DSM 4 / DSM 5 Differences Research Paper

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A DIMENSIONAL APPROACH

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Christopher A. Kearney University of Nevada, Las Vegas

Timothy J. Trull University of Missouri, Columbia

Abnormal Psychology

& Life

Abnormal Psychology and Life: A Dimensional Approach, Third Edition Christopher A. Kearney and Timothy J. Trull

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Printed in Canada Print Number: 01 Print Year: 2016

To my wife, Kimberlie, and my children, Derek and

Claire, for their great patience and support.

—CHRISTOPHER A. KEARNEY

To my wife, Meg, for her love and support.

To Molly, Janey, and Neko for their smiles and laughter.

—TIMOTHY J. TRULL

Christopher A. Kearney, Ph.D., is Distinguished Professor of Psychol- ogy, Chair of the Department of Psychology, and Director of the UNLV Child School Refusal and Anxiety Disorders Clinic at the University of Nevada, Las Vegas. He is a Fellow of the American Psychological Association, a licensed clinical psychologist, and the author of numerous journal articles, book chapters, and books related to school refusal behavior, social anxi- ety, shyness, and selective mutism in youth. He has also published a work on general child psychopathology, Casebook in Child Behavior Disorders (Cengage), and is or has been on the editorial boards of Journal of Con- sulting and Clinical Psychology, Behavior Therapy, Journal of Clinical Child and Adolescent Psychology, Journal of Abnormal Child Psychology, Journal of Psychopathology and Behavioral Assessment, Journal of Anxiety Disor-of Psychopathology and Behavioral Assessment, Journal of Anxiety Disor-of Psychopathology and Behavioral Assessment, Journal of Anxiety Disor ders, and Journal of Gambling Studies. Dr. Kearney has received several awards for his research, teaching, and mentoring, including the Harry Reid Silver State Research Award among others. In addition to his clinical and research endeavors, Dr. Kearney works closely with school districts and mental health agencies to improve strategies for helping children attend school with less distress.

Timothy J. Trull, Ph.D., is Professor of Psychological Sciences at the University of Missouri, Columbia. Dr. Trull received his Ph.D. from the University of Kentucky and completed his internship at New York Hospital– Cornell Medical Center. His research interests are in the areas of diagno- sis and classi�cation of mental disorders, borderline personality disorder, substance use disorders, clinical assessment, professional issues in clinical psychology, and ambulatory assessment methods. Dr. Trull has received several awards and honors for his teaching and mentoring, including Psi Chi Professor of the Year, the Robert S. Daniels Junior Faculty Teaching Award, and most recently the MU Graduate Faculty Mentor Award. He enjoys teaching Abnormal Psychology and Introduction to Clinical Psychol- ogy; his textbook Clinical Psychology (Wadsworth) is used in classes across the United States and internationally. Dr. Trull is a licensed psychologist, and he continues to train future clinical psychologists in the assessment, prevention, and treatment of psychological disorders.

ABOUT THE AUTHORS

BRIEF CONTENTS

PREFAREFAREF CE xxvi

1 Abnormal Psychology and Life 3

2 Perspectives on Abnormal Psychology 21

3 Risk and Prevention of Mental Disorders 51

4 Diagnosis, Assessment, and Study of Mental Disorders 73

5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders 99

6 Somatic Symptom and Dissociative Disorders 141

7 Depressive and Bipolar Disorders and Suicide 173

8 Eating Disorders 215

9 Substance-Related Disorders 243

10 Personality Disorders 281

11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria 313

12 Schizophrenia and Other Psychotic Disorders 351

13 Developmental and Disruptive Behavior Disorders 383

14 Neurocognitive Disorders 423

15 Consumer Guide to Abnormal Psychology 453

APPENDIX: STRESS-RELATED PROBLEMS 477

GLOSSARY G-0

REFERENCES R-1

NAME INDEX I-1

SUBJECT INDEX I-17

CONTENTS

1 Abnormal Psychology and Life Abnormal Psychology and Life 3

C Travis / What Do You Think? 4

Introduction to Abnormal Psychology 4

What Is a Mental Disorder? 4 C Treva Throneberry / What Do You Think? 5 Deviance from the Norm 5 Dif�culties Adapting to Life Demands 6 Experience of Personal Distress 7 De�ning Abnormality 7 Dimensions Underlying Mental Disorders Are Relevant

to Everyone 8 INTERIM SUMMARY 11 REVIEW QUESTIONS 11

History of Abnormal Psychology 11 Early Perspectives 12 Early Greek and Roman Thought 12 Middle Ages 12 Renaissance 13 Reform Movement 13 Modern Era 13 INTERIM SUMMARY 14 REVIEW QUESTIONS 14

Abnormal Psychology and Life: Themes 14 Dimensional Perspective 14 Prevention Perspective 14 Consumer Perspective 15 Diversity 16 Stigma 16 INTERIM SUMMARY 17 REVIEW QUESTIONS 18

FINAL COMMENTS 18 KEY TERMS 19

Special Features

• 1.1 FOCUS ON DIVERSITY: Emotion and Culture 7

CONTINUUM FIGURE 1.2 Continuum of Emotions, Cognitions, and Behaviors 10

• 1.2 FOCUS ON LAW AND ETHICS: Heal Thyself: What the Self-Help Gurus Don’t Tell You 15

Personal Narrative 1.1 Alison Malmon 18

Preface xxvi

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2 Perspectives on Abnormal Psychology 21

C Mariella / What Do You Think? 22

Introduction 22

The Biological Model 23 Genetics 23 Nervous Systems and Neurons 24 Brain 24 Biological Assessment and Treatment 25 Evaluating the Biological Model 25 INTERIM SUMMARY 25 REVIEW QUESTIONS 27

The Psychodynamic Model 28 Brief Overview of the Psychodynamic Model 29 Psychodynamic Assessment and Treatment 30 Evaluating the Psychodynamic Model 32 INTERIM SUMMARY 32 REVIEW QUESTIONS 32

The Humanistic Model 32 Abraham Maslow 33 Carl Rogers 34 Rollo May 34 Humanistic Assessment and Treatment 35 Evaluating the Humanistic Model 35 INTERIM SUMMARY 35 REVIEW QUESTIONS 36

The Cognitive-Behavioral Model 36 Behavioral Perspective 36 Cognitive Perspective 37 A Cognitive-Behavioral Model 38 Cognitive-Behavioral Assessment and Treatment 38 Evaluating the Cognitive-Behavioral Model 40 INTERIM SUMMARY 40 REVIEW QUESTIONS 40

The Sociocultural Model 40 Culture 41 Gender 42 Neighborhoods and Communities 43 Family 43 Sociocultural Assessment and Treatment 44 Evaluating the Sociocultural Model 44 INTERIM SUMMARY 45 REVIEW QUESTIONS 45

FINAL COMMENTS 47 KEY TERMS 47

Special Features

• 2.1 FOCUS ON VIOLENCE: A More Complex Approach 28

• 2.2 FOCUS ON LAW AND ETHICS: Dangerousness and Commitment 33

• 2.3 FOCUS ON GENDER: A More Complex Approach 41

Personal Narrative 2.1 An Integrative Psychologist: Dr. John C. Norcross 46

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3 Risk and Prevention of Mental Disorders Risk and Prevention of Mental Disorders 51

C DeShawn / What Do You Think? 52

The Diathesis-Stress Model 52 Diathesis, Stress, and Mental Health 52 Diathesis-Stress: The Big Picture 53 Diathesis-Stress: The Little Picture 53 Implications of the Diathesis-Stress Model 54 INTERIM SUMMARY 54 REVIEW QUESTIONS 54

Epidemiology: How Common Are Mental Disorders? 54 Prevalence of Mental Disorders 55 Treatment Seeking 57 Treatment Cost 58 INTERIM SUMMARY 58 REVIEW QUESTIONS 59

Risk, Protective Factors, and Resilience 59 C Jana / What Do You Think? 59 Risk Factors 59 Protective Factors 61 INTERIM SUMMARY 63 REVIEW QUESTIONS 63

Prevention 63 Prevention on a Continuum 64 Three Types of Prevention 64 Prevention Programs for Mental Disorders 66 INTERIM SUMMARY 69 REVIEW QUESTIONS 69

FINAL COMMENTS 70 KEY TERMS 71

Special Features

• 3.1 JOHN SNOW: A Pioneer in Epidemiology and Prevention 55

• 3.2 FOCUS ON COLLEGE STUDENTS: Suicide 60

• 3.3 FOCUS ON VIOLENCE: Prevention of Femicide 64

• 3.4 FOCUS ON LAW AND ETHICS: Constructs Related to Insanity 69

Personal Narrative 3.1 Kim Dude and the Wellness Resource Center 70

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4 Diagnosis, Assessment, and Study of Mental Disorders 73

C Professor Smith / What Do You Think? 74

De�ning Abnormal Behavior and Mental Disorder 74 Dimensions and Categories 74 DSM 75DSM 75DSM Advantages of Diagnosis 75 INTERIM SUMMARY 76 REVIEW QUESTIONS 76

Classifying and Assessing Abnormal Behavior and Mental Disorder 76 Assessing Abnormal Behavior and Mental Disorder 76 Reliability, Validity, and Standardization 77 Interview 80 Intelligence Tests 80 Personality Assessment 81 Behavioral Assessment 85 Biological Assessment 87 Psychophysiological Assessment 88 Neuropsychological Assessment 89 INTERIM SUMMARY 90 REVIEW QUESTIONS 90

Culture and Clinical Assessment 90 Culture and the Development of Mental Disorders 90 Culture and Clinical Assessment 91 INTERIM SUMMARY 92 REVIEW QUESTIONS 92

Studying Abnormal Behavior and Mental Disorder 92 Experiment 92 Correlational Studies 94 Quasi-Experimental Methods 94 Other Alternative Experimental Designs 94 Developmental Designs 96 Case Study 96 Consuming the Media’s Research 96 INTERIM SUMMARY 96 REVIEW QUESTIONS 97

FINAL COMMENTS 97 KEY TERMS 97

Special Features

• 4.1 FOCUS ON DIVERSITY: Culture and Diagnosis 77

Personal Narrative 4.1 Anonymous 78

• 4.2 FOCUS ON LAW AND ETHICS: Who Should Be Studied in Mental Health Research? 93

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5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders 99

C Angelina / What Do You Think? 100

Worry, Anxiety, Fear, and Anxiety; Obsessive- Compulsive; and Trauma-Related Disorders: What Are They? 101

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 103 Panic Attack 103 Panic Disorder 104 Social Phobia 105 Speci�c Phobia 106 Generalized Anxiety Disorder 106

C Jonathan / What Do You Think? 108 Obsessive-Compulsive Disorder 108 Obsessive-Compulsive-Related Disorders 108 Posttraumatic Stress Disorder and Acute Stress Disorder 109

C Marcus / What Do You Think? 109 Separation Anxiety Disorder and School Refusal

Behavior 114 Epidemiology of Anxiety, Obsessive-Compulsive, and

Trauma-Related Disorders 114

Stigma Associated with Anxiety, Obsessive- Compulsive, and Trauma-Related Disorders 117 INTERIM SUMMARY 118 REVIEW QUESTIONS 118

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention 118 Biological Risk Factors for Anxiety, Obsessive-Compulsive,

and Trauma-Related Disorders 118 Environmental Risk Factors for Anxiety, Obsessive-Compulsive,

and Trauma-Related Disorders 122 Causes of Anxiety, Obsessive-Compulsive, and Trauma-Related

Disorders 124 Prevention of Anxiety, Obsessive-Compulsive, and Trauma-

Related Disorders 126 INTERIM SUMMARY 127 REVIEW QUESTIONS 127

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 127 Assessment of Anxiety, Obsessive-Compulsive, and Trauma-

Related Disorders 127 Biological Treatment of Anxiety, Obsessive-Compulsive, and

Trauma-Related Disorders 130 Psychological Treatments of Anxiety, Obsessive-Compulsive, and

Trauma-Related Disorders 131 What If I Have Anxiety or an Anxiety-Related Disorder? 136 Long-Term Outcome for People with Anxiety, Obsessive-

Compulsive, and Trauma-Related Disorders 137 INTERIM SUMMARY 137 REVIEW QUESTIONS 137

FINAL COMMENTS 138 THOUGHT QUESTIONS 138 KEY TERMS 139

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Special Features

CONTINUUM FIGURE 5.1 Worry, Anxiety, and Fear Along a Continuum 102

CONTINUUM FIGURE 5.2 Continuum of Emotions, Cognitions, and Behaviors Regarding Anxiety-Related Disorders 102

• 5.1 FOCUS ON COLLEGE STUDENTS: Trauma and PTSD 116

• 5.2 FOCUS ON GENDER: Are There True Gender Differences in Anxiety-Related Disorders? 116

• 5.3 FOCUS ON DIVERSITY: Anxiety-Related Disorders and Sociocultural Factors 117

V THE CONTINUUM VIDEO PROJECT Darwin / PTSD 125

Personal Narrative 5.1 Anonymous 128

• 5.4 FOCUS ON LAW AND ETHICS: The Ethics of Encouragement in Exposure-Based Practices 138

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6 Somatic Symptom and Dissociative Disorders Somatic Symptom and Dissociative Disorders 141

Somatic Symptom and Dissociative Disorders: A Historical Introduction 142

Somatization and Somatic Symptom Disorders: What Are They? 142 C Gisela / What Do You Think? 142

Somatic Symptom Disorders: Features and Epidemiology 144 Somatic Symptom Disorder 144 Illness Anxiety Disorder 145 Conversion Disorder 146 Factitious Disorder and Malingering 146 Epidemiology of Somatic Symptom Disorders 147

Stigma Associated with Somatic Symptom Disorders 148 INTERIM SUMMARY 148 REVIEW QUESTIONS 149

Somatic Symptom Disorders: Causes and Prevention 149 Biological Risk Factors for Somatic Symptom Disorders 149 Environmental Risk Factors for Somatic Symptom

Disorders 149 Causes of Somatic Symptom Disorders 151 Prevention of Somatic Symptom Disorders 152 INTERIM SUMMARY 152 REVIEW QUESTIONS 153

Somatic Symptom Disorders: Assessment and Treatment 153 Assessment of Somatic Symptom Disorders 153 Biological Treatment of Somatic Symptom Disorders 154 Psychological Treatments of Somatic Symptom Disorders 154 What If I or Someone I Know Has a Somatic Symptom

Disorder? 155 Long-Term Outcome for People with Somatic Symptom

Disorders 155 INTERIM SUMMARY 155 REVIEW QUESTIONS 155

Dissociative Disorders 156 C Erica / What Do You Think? 156

Normal Dissociation and Dissociative Disorders: What Are They? 157

Dissociative Disorders: Features and Epidemiology 157 Dissociative Amnesia 157 Dissociative Identity Disorder 158 Depersonalization/Derealization Disorder 160 Epidemiology of Dissociative Disorders 161

Stigma Associated with Dissociative Disorders 162 INTERIM SUMMARY 162 REVIEW QUESTIONS 162

Dissociative Disorders: Causes and Prevention 163 Biological Risk Factors for Dissociative Disorders 163 Environmental Risk Factors for Dissociative Disorders 164 Causes of Dissociative Disorders 165 Prevention of Dissociative Disorders 166 INTERIM SUMMARY 166 REVIEW QUESTIONS 167

Dissociative Disorders: Assessment and Treatment 167 Assessment of Dissociative Disorders 167 Biological Treatment of Dissociative Disorders 167 Psychological Treatments of Dissociative Disorders 168 What If I or Someone I Know Has a Dissociative Disorder? 169 Long-Term Outcome for People with Dissociative Disorders 169 INTERIM SUMMARY 169 REVIEW QUESTIONS 169

FINAL COMMENTS 170 THOUGHT QUESTIONS 170 KEY TERMS 170

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Special Features

CONTINUUM FIGURE 6.1 Continuum of Somatization and Somatic Symptom Disorders 144

• 6.1 FOCUS ON COLLEGE STUDENTS: Somatization 148

• 6.2 FOCUS ON VIOLENCE: Terrorism and Medically Unexplained Symptoms 152

CONTINUUM FIGURE 6.4 Continuum of Dissociation and Dissociative Disorders 158

Personal Narrative 6.1 Heather Pate 160

• 6.3 FOCUS ON COLLEGE STUDENTS: Dissociation 161

• 6.4 FOCUS ON LAW AND ETHICS: Recovered Memories and Suggestibility 162

• 6.5 FOCUS ON DIVERSITY: Dissociation and Culture 163

• 6.6 FOCUS ON VIOLENCE: Dissociative Experiences and Violence Toward Others 166

V THE CONTINUUM VIDEO PROJECT Lani and Jan / Dissociative Identity Disorder 169

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7 Depressive and Bipolar Disorders and Suicide Depressive and Bipolar Disorders and Suicide 173

C Katey / What Do You Think? 174

Normal Mood Changes and Depression and Mania: What Are They? 174

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 175 Major Depressive Episode 175 Major Depressive Disorder 177 Persistent Depressive Disorder (Dysthymia) 178 Other Depressive Disorders 179 Manic and Hypomanic Episodes 179 Bipolar I Disorder 181 Bipolar II Disorder 185 Cyclothymic Disorder 185 Suicide 186 Epidemiology of Depressive and Bipolar Disorders 187 Epidemiology of Suicide 189

Stigma Associated with Depressive and Bipolar Disorders 190 INTERIM SUMMARY 190 REVIEW QUESTIONS 191

Depressive and Bipolar Disorders and Suicide: Causes and Prevention 191 Biological Risk Factors for Depressive and Bipolar Disorders

and Suicide 191 Environmental Risk Factors for Depressive and Bipolar Disorders

and Suicide 194 Causes of Depressive and Bipolar Disorders and Suicide 198 Prevention of Depressive and Bipolar Disorders and Suicide 199 INTERIM SUMMARY 200 REVIEW QUESTIONS 200

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 200 Interviews and Clinician Ratings 201 Self-Report Questionnaires 202 Self-Monitoring and Observations from Others 203 Laboratory Assessment 203 Assessment of Suicide 203 Biological Treatment of Depressive and Bipolar Disorders and

Suicide 204 Psychological Treatments for Depressive and Bipolar Disorders

and Suicide 207 What If I Am Sad or Have a Mood Disorder? 210 Long-Term Outcome for People with Depressive and Bipolar

Disorders and Suicide 210 INTERIM SUMMARY 211 REVIEW QUESTIONS 211

FINAL COMMENTS 212 THOUGHT QUESTIONS 212 KEY TERMS 212

Special Features

CONTINUUM FIGURE 7.1 Continuum of Sadness and Depression 176

CONTINUUM FIGURE 7.2 Continuum of Happiness, Euphoria, and Mania 176

Personal Narrative 7.1 Karen Gormandy 180

• 7.1 FOCUS ON GENDER: Forms of Depression Among Women 182

• 7.2 FOCUS ON COLLEGE STUDENTS: Depression 195

V THE CONTINUUM VIDEO PROJECT Emilie / Bipolar Disorder 200

• 7.3 FOCUS ON LAW AND ETHICS: Ethical Dilemmas in Electroconvulsive Therapy 206

• 7.4 FOCUS ON DIVERSITY: Depression in the Elderly 208

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8 Eating Disorders Eating Disorders 215

C Sooki / What Do You Think? 216

Weight Concerns, Body Dissatisfaction, and Eating Disorders: What Are They? 216

Eating Disorders: Features and Epidemiology 217 Anorexia Nervosa 217 Bulimia Nervosa 218

C Lisa / What Do You Think? 218 Binge-Eating Disorder 220 Epidemiology of Eating Disorders 221

Stigma Associated with Eating Disorders 224 INTERIM SUMMARY 225 REVIEW QUESTIONS 225

Eating Disorders: Causes and Prevention 225 Biological Risk Factors for Eating Disorders 225 Environmental Risk Factors for Eating Disorders 227 Causes of Eating Disorders 230 Prevention of Eating Disorders 230 INTERIM SUMMARY 231 REVIEW QUESTIONS 231

Eating Disorders: Assessment and Treatment 231 Assessment of Eating Disorders 231 Treatment of Eating Disorders 234 Biological Treatments of Eating Disorders 234 Psychological Treatments of Eating Disorders 236 What If I Have Weight Concerns or an Eating Disorder? 238 Long-Term Outcome for People with Eating Disorders 238 INTERIM SUMMARY 240 REVIEW QUESTIONS 240

FINAL COMMENTS 240 THOUGHT QUESTIONS 240 KEY TERMS 241

Special Features

CONTINUUM FIGURE 8.1 Continuum of Body Dissatisfaction, Weight Concerns, and Eating Behavior 218

Personal Narrative 8.1 Kitty Westin (Anna’s mother) 220

• 8.1 FOCUS ON COLLEGE STUDENTS: Eating Disorders 223

• 8.2 FOCUS ON GENDER: Why Is There a Gender Difference in Eating Disorders? 223

V THE CONTINUUM VIDEO PROJECT Sara / Bulimia Nervosa 227

Personal Narrative 8.2 Rachel Webb 232

• 8.3 FOCUS ON LAW AND ETHICS: How Ethical Are Pro-Ana (Pro-Anorexia) Websites? 237

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9 Substance-Related Disorders Substance-Related Disorders 243

C Elon / What Do You Think? 244

Normal Substance Use and Substance-Related Disorders: What Are They? 244

Substance-Related Disorders: Features and Epidemiology 245 Substance Use Disorder 245 Substance Intoxication 246 Substance Withdrawal 246 Types of Substances 247 Epidemiology of Substance-Related Disorders 256

Stigma Associated with Substance-Related Disorders 258 INTERIM SUMMARY 259 REVIEW QUESTIONS 259

Substance-Related Disorders: Causes and Prevention 259 Biological Risk Factors for Substance-Related Disorders 259 Environmental Risk Factors for Substance-Related

Disorders 262 Causes of Substance-Related Disorders 266 Prevention of Substance-Related Disorders 267 INTERIM SUMMARY 268 REVIEW QUESTIONS 269

Substance-Related Disorders: Assessment and Treatment 269 Interviews 269 Psychological Testing 269 Observations from Others 271 Laboratory Testing 272 Biological Treatment of Substance-Related Disorders 273 Psychological Treatment of Substance-Related Disorders 274 What If I or Someone I Know Has a Substance-Related Problem

or Disorder? 276 Long-Term Outcome for People with Substance-Related

Disorders 276 INTERIM SUMMARY 276 REVIEW QUESTIONS 278

FINAL COMMENTS 278 THOUGHT QUESTIONS 278 KEY TERMS 278

Special Features

CONTINUUM FIGURE 9.1 Continuum of Substance Use and Substance-Related Disorders 246

• 9.1 The Sam Spady Story 252

• 9.2 The “Meth” Epidemic 254

• 9.3 FOCUS ON GENDER: Date Rape Drugs 256

• 9.4 FOCUS ON VIOLENCE: Alcohol and Violence 264

V THE CONTINUUM VIDEO PROJECT Mark / Substance Use Disorder 264

• 9.5 FOCUS ON COLLEGE STUDENTS: Substance Use 268

Personal Narrative 9.1 One Family’s Struggle with Substance- Related Disorders 270

• 9.6 FOCUS ON LAW AND ETHICS: Drug Testing 273

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10 Personality Disorders Personality Disorders 281

C Michelle / What Do You Think? 282

Personality Traits, Unusual Personality, and Personality Disorder: What Are They? 283

Organization of Personality Disorders 284

Odd or Eccentric Personality Disorders: Features and Epidemiology 285 Paranoid Personality Disorder 285 Schizoid Personality Disorder 285 Schizotypal Personality Disorder 285

C Jackson / What Do You Think? 286 Epidemiology of Odd or Eccentric Personality Disorders 287 INTERIM SUMMARY 288 REVIEW QUESTIONS 288

Dramatic Personality Disorders: Features and Epidemiology 288 C Duane / What Do You Think? 288 Antisocial Personality Disorder 288 Borderline Personality Disorder 289 Histrionic Personality Disorder 289 Narcissistic Personality Disorder 290 Epidemiology of Dramatic Personality Disorders 291 INTERIM SUMMARY 293 REVIEW QUESTIONS 293

Anxious/Fearful Personality Disorders: Features and Epidemiology 293 Avoidant Personality Disorder 293 Dependent Personality Disorder 294

C Betty / What Do You Think? 294 Obsessive-Compulsive Personality Disorder 294 Epidemiology of Anxious/Fearful Personality Disorders 295

Stigma Associated with Personality Disorders 295 INTERIM SUMMARY 296 REVIEW QUESTIONS 296

Personality Disorders: Causes and Prevention 296 Biological Risk Factors for Odd or Eccentric Personality

Disorders 297 Environmental Risk Factors for Odd or Eccentric Personality

Disorders 297

Causes of Odd or Eccentric Personality Disorders 297 Biological Risk Factors for Dramatic Personality Disorders 298 Environmental Risk Factors for Dramatic Personality

Disorders 298 Causes of Dramatic Personality Disorders 299 Biological Risk Factors for Anxious/Fearful Personality

Disorders 299 Environmental Risk Factors for Anxious/Fearful Personality

Disorders 299 Causes of Anxious/Fearful Personality Disorders 300 Prevention of Personality Disorders 300 INTERIM SUMMARY 301 REVIEW QUESTIONS 302

Personality Disorders: Assessment and Treatment 303 Assessment of Personality Disorders 303 Biological Treatments of Personality Disorders 304 Psychological Treatments of Personality Disorders 304 What If I or Someone I Know Has a Personality Disorder? 307 Long-Term Outcomes for People with Personality Disorders 307 INTERIM SUMMARY 310 REVIEW QUESTIONS 310

FINAL COMMENTS 310 THOUGHT QUESTIONS 310 KEY TERMS 311

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Special Features

CONTINUUM FIGURE 10.1 Continuum of Normal Personality and Personality Disorder Traits Related to Impulsivity 282

• 10.1 FOCUS ON COLLEGE STUDENTS: Personality Disorders 292

• 10.2 FOCUS ON VIOLENCE: Personality Disorders and Violence 292

• 10.3 FOCUS ON GENDER: Mirror Images of Personality Disorders? 296

• 10.4 FOCUS ON LAW AND ETHICS: Personality and Insanity 305

V THE CONTINUUM VIDEO PROJECT Tina / Borderline Personality Disorder 307

Personal Narrative 10.1 Anonymous 308

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11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria 313

Normal Sexual Behavior and Sexual Dysfunctions: What Are They? 314 C Douglas and Stacy / What Do You Think? 314

Sexual Dysfunctions: Features and Epidemiology 315 Male Hypoactive Sexual Desire Disorder 315 Female Sexual Interest/Arousal Disorder 315 Erectile Disorder 316 Female Orgasmic Disorder 316 Delayed Ejaculation 317 Premature (Early) Ejaculation 317 Genito-Pelvic Pain/Penetration Disorder 318 Epidemiology of Sexual Dysfunctions 318

Stigma Associated with Sexual Dysfunctions 321 INTERIM SUMMARY 321 REVIEW QUESTIONS 322

Sexual Dysfunctions: Causes and Prevention 322 Biological Risk Factors for Sexual Dysfunctions 322 Psychological Risk Factors for Sexual Dysfunctions 322 Causes of Sexual Dysfunctions 323 Prevention of Sexual Dysfunctions 323 INTERIM SUMMARY 323 REVIEW QUESTIONS 324

Sexual Dysfunctions: Assessment and Treatment 325 Assessment of Sexual Dysfunctions 325 Biological Treatment of Sexual Dysfunctions 325 Psychological Treatments of Sexual Dysfunctions 326 What If I or Someone I Know Has a Sexual Dysfunction? 327 Long-Term Outcomes for People with Sexual Dysfunctions 328 INTERIM SUMMARY 328 REVIEW QUESTIONS 328

Normal Sexual Desires, Paraphilias, and Paraphilic Disorders: What Are They? 329

Paraphilic Disorders: Features and Epidemiology 329 Exhibitionistic Disorder 330

C Tom / What Do You Think? 330

Fetishistic Disorder 331 Frotteuristic Disorder 331 Pedophilic Disorder 332 Sexual Masochism and Sexual Sadism 333 Transvestic Disorder 333 Voyeuristic Disorder 334 Atypical Paraphilic Disorders 334 Epidemiology of Paraphilic Disorders 334 INTERIM SUMMARY 337 REVIEW QUESTIONS 337

Paraphilic Disorders: Causes and Prevention 337 Biological Risk Factors for Paraphilic Disorders 337 Environmental Risk Factors for Paraphilic Disorders 337 Causes of Paraphilic Disorders 338 Prevention of Paraphilic Disorders 339 INTERIM SUMMARY 339 REVIEW QUESTIONS 339

Paraphilic Disorders: Assessment and Treatment 340 Assessment of Paraphilic Disorders 340 Biological Treatment of Paraphilic Disorders 340 Psychological Treatment of Paraphilic Disorders 341 What If I or Someone I Know Has a Paraphilic Disorder? 342 Long-Term Outcomes for People with Paraphilic Disorders 342 INTERIM SUMMARY 342 REVIEW QUESTIONS 342

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Normal Gender Development and Gender Dysphoria: What Are They? 342 C Austin / What Do You Think? 343

Gender Dysphoria: Features and Epidemiology 343

Gender Dysphoria: Causes and Prevention 344

Gender Dysphoria: Assessment and Treatment 345 Assessment of Gender Dysphoria 345 Biological Treatment of Gender Dysphoria 345 Psychological Treatment of Gender Dysphoria 345 What If I or Someone I Know Has Questions About Gender or

Gender Dysphoria? 345 Long-Term Outcomes for People with Gender Dysphoria 346 INTERIM SUMMARY 347 REVIEW QUESTIONS 347

FINAL COMMENTS 348 THOUGHT QUESTIONS 348 KEY TERMS 348

Special Features

CONTINUUM FIGURE 11.1 Continuum of Sexual Behavior and Sexual Dysfunctions 314

• 11.1 FOCUS ON GENDER: Gender Biases in Sexual Dysfunctions and Disorders 319

• 11.2 FOCUS ON COLLEGE STUDENTS: Sexual Dysfunctions 322

CONTINUUM FIGURE 11.4 Continuum of Sexual Behavior and Paraphilic Disorders 328

• 11.3 FOCUS ON COLLEGE STUDENTS: Sexual Fantasies and Paraphilic Interests 336

• 11.4 FOCUS ON VIOLENCE: Rape 336

• 11.5 FOCUS ON LAW AND ETHICS: Sex Offender Notification and Incarceration 341

Personal Narrative 11.1 Sam 346

V THE CONTINUUM VIDEO PROJECT Dean / Gender Dysphoria 346

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12 Schizophrenia and Other Psychotic Disorders Schizophrenia and Other Psychotic Disorders 351

C James / What Do You Think? 352

Unusual Emotions, Thoughts, and Behaviors and Psychotic Disorders: What Are They? 352

Psychotic Disorders: Features and Epidemiology 353 Schizophrenia 353 Phases of Schizophrenia 357 Schizophreniform Disorder 359 Schizoaffective Disorder 359 Delusional Disorder 361

C Jody / What Do You Think? 362 Brief Psychotic Disorder 362 Epidemiology of Psychotic Disorders 363

Stigma Associated with Schizophrenia 365 INTERIM SUMMARY 365 REVIEW QUESTIONS 366

Psychotic Disorders: Causes and Prevention 367 Biological Risk Factors for Psychotic Disorders 367 Environmental Risk Factors for Psychotic Disorders 370 Causes of Psychotic Disorders 371 Prevention of Psychotic Disorders 373 INTERIM SUMMARY 373 REVIEW QUESTIONS 374

Psychotic Disorders: Assessment and Treatment 374 Interviews 374 Behavioral Observations 374 Cognitive Assessment 375 Physiological Assessment 375 Biological Treatments of Psychotic Disorders 376 Psychological Treatments of Psychotic Disorders 377 What If I or Someone I Know Has a Psychotic Disorder? 379 Long-Term Outcome for People with Psychotic Disorders 380 INTERIM SUMMARY 380 REVIEW QUESTIONS 380

FINAL COMMENTS 381 THOUGHT QUESTIONS 381 KEY TERMS 381

Special Features

CONTINUUM FIGURE 12.1 Continuum of Unusual Emotions, Cognitions, and Behaviors and Psychotic Disorder 354

Personal Narrative 12.1 John Cadigan 360

• 12.1 FOCUS ON DIVERSITY: Ethnicity and Income Level in Schizophrenia 364

• 12.2 FOCUS ON COLLEGE STUDENTS: Psychotic Symptoms 365

• 12.3 FOCUS ON VIOLENCE: Are People with Schizophrenia More Violent? 366

V THE CONTINUUM VIDEO PROJECT Andre / Schizophrenia 373

• 12.4 FOCUS ON LAW AND ETHICS: Making the Choice of Antipsychotic Medication 376

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13 Developmental and Disruptive Behavior Disorders 383

Developmental and Disruptive Behavior Disorders 384 C Robert / What Do You Think? 384

Normal Development and Developmental Disorders: What Are They? 385

Developmental Disorders: Features and Epidemiology 385 Intellectual Disability 385 Autism Spectrum Disorder 387 Learning Disorder 389

C Alison / What Do You Think? 389 Epidemiology of Developmental Disorders 390

Stigma Associated with Developmental Disorders 391 INTERIM SUMMARY 392 REVIEW QUESTIONS 392

Developmental Disorders: Causes and Prevention 392 Biological Risk Factors for Developmental Disorders 392 Environmental Risk Factors for Developmental Disorders 396 Causes of Developmental Disorders 396 Prevention of Developmental Disorders 396 INTERIM SUMMARY 398 REVIEW QUESTIONS 398

Developmental Disorders: Assessment and Treatment 398 Cognitive Tests 398 Achievement Tests 399 Interviews 400 Rating Scales 400 Behavioral Observation 400 Biological Treatment for Developmental Disorders 400 Psychological Treatments for Developmental Disorders 401 What If I Think Someone Has a Developmental Disorder? 403 Long-Term Outcome for People with Developmental

Disorders 403 INTERIM SUMMARY 403 REVIEW QUESTIONS 404

Normal Rambunctious Behavior and Disruptive Behavior Disorders: What Are They? 404 C Will / What Do You Think? 405

Disruptive Behavior Disorders: Features and Epidemiology 405 Attention-De�cit/Hyperactivity Disorder 405 Oppositional De�ant Disorder and Conduct Disorder 406 Epidemiology of Disruptive Behavior Disorders 407

Stigma Associated with Disruptive Behavior Disorders 408 INTERIM SUMMARY 409 REVIEW QUESTIONS 410

Disruptive Behavior Disorders: Causes and Prevention 410 Biological Risk Factors for Disruptive Behavior Disorders 410 Environmental Risk Factors for Disruptive Behavior

Disorders 411 Causes of Disruptive Behavior Disorders 413 Prevention of Disruptive Behavior Disorders 413 INTERIM SUMMARY 414 REVIEW QUESTIONS 414

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Disruptive Behavior Disorders: Assessment and Treatment 414 Interviews 415 Rating Scales 415 Behavioral Observation 415 Biological Treatments for Disruptive Behavior Disorders 415 Psychological Treatments for Disruptive Behavior Disorders 416 What If I Think a Child Has a Disruptive Behavior

Disorder? 417 Long-Term Outcome for Children with Disruptive Behavior

Disorders 417 INTERIM SUMMARY 419 REVIEW QUESTIONS 419

FINAL COMMENTS 420 THOUGHT QUESTIONS 420 KEY TERMS 421

Special Features

CONTINUUM FIGURE 13.1 Continuum of Normal Development and Developmental Disorder 384

• 13.1 FOCUS ON COLLEGE STUDENTS: Autism 392

• 13.2 FOCUS ON LAW AND ETHICS: Key Ethical Issues and Developmental Disorders 394

• 13.3 FOCUS ON DIVERSITY: Testing for People with Developmental Disorders 399

V THE CONTINUUM VIDEO PROJECT Whitney / Autism Spectrum Disorder 401

CONTINUUM FIGURE 13.4 Continuum of Disruptive Behavior and Disruptive Behavior Disorder 406

• 13.4 FOCUS ON COLLEGE STUDENTS: ADHD 410

• 13.5 FOCUS ON VIOLENCE: Juvenile Arrests and “Diversion” 417

Personal Narrative 13.1 Toni Wood 418

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14 Neurocognitive Disorders 423

C William and Laura / What Do You Think? 424

Normal Changes During Aging and Neurocognitive Disorders: What Are They? 425

Neurocognitive Disorders: Features and Epidemiology 426 Delirium 426 Dementia and Major and Mild Neurocognitive Disorder 428 Alzheimer’s Disease 428 Lewy Bodies 430 Vascular Disease 431 Parkinson’s Disease 432 Pick’s Disease 432 Other Problems 433 Epidemiology of Neurocognitive Disorders 434

Stigma Associated with Neurocognitive Disorders 435 INTERIM SUMMARY 436 REVIEW QUESTIONS 436

Neurocognitive Disorders: Causes and Prevention 437 Biological Risk Factors for Neurocognitive Disorders 437 Environmental Risk Factors for Neurocognitive Disorders 440 Causes of Neurocognitive Disorders 441 Prevention of Neurocognitive Disorders 442 INTERIM SUMMARY 443 REVIEW QUESTIONS 443

Neurocognitive Disorders: Assessment and Treatment 443 Assessment of Neurocognitive Disorders 443 Biological Treatments of Neurocognitive Disorders 445 Psychological Treatments of Neurocognitive Disorders 446 What If Someone I Know Has a Neurocognitive Disorder? 448 Long-Term Outcome for People with Neurocognitive

Disorders 449 INTERIM SUMMARY 449 REVIEW QUESTIONS 450

FINAL COMMENTS 450 THOUGHT QUESTIONS 450 KEY TERMS 451

Special Features

CONTINUUM FIGURE 14.1 Continuum of Thinking and Memory Problems and Neurocognitive Disorder 426

• 14.1 FOCUS ON COLLEGE STUDENTS: Delirium 434

• 14.2 FOCUS ON VIOLENCE: Maltreatment of the Elderly 436

V THE CONTINUUM VIDEO PROJECT Myriam / Alzheimer’s Disease 437

• 14.3 FOCUS ON GENDER: Grief in the Spouse Caregiver 448

• 14.4 FOCUS ON LAW AND ETHICS: Ethical Issues and Dementia 449

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15 Consumer Guide to Abnormal Psychology Consumer Guide to Abnormal Psychology 453

Introduction to the Consumer Guide 454

Becoming a Mental Health Professional 454 Types of Therapists and Quali�cations 454 Preparing to Be a Mental Health Professional 455

Becoming a Client 458

Treatment at the Individual Level 459 Active Ingredients of Treatment 459 Process Variables in Treatment 460 Does Treatment Work? 462 Prescriptive Treatment 462 INTERIM SUMMARY 463 REVIEW QUESTIONS 463

Treatment at the Community Level 463 Self-Help Groups 463 Aftercare Services for People with Severe Mental Disorders 464 Residential Facilities for People with Developmental

Disorders 465 Criminal Justice System 466 Public Policy and Mental Health 466 INTERIM SUMMARY 466 REVIEW QUESTIONS 467

Limitations and Caveats About Treatment 467 Client-Therapist Differences 467 Cultural Differences 467 Managed Care 468 Differences Between Clinicians and Researchers 468 Quick Fixes 468 Misuse of Research 468 Weak Research and How to Judge a Research Article 468 Negative Therapist Characteristics 469 Lack of Access to Treatment 470

Ethics 470 General Principles 470 Assessment 470 Treatment 471 Public Statements 472 Research 472 Resolving Ethical Issues 472 INTERIM SUMMARY 473 REVIEW QUESTIONS 473

FINAL COMMENTS 473 THOUGHT QUESTIONS 473 KEY TERMS 474

Special Features

• 15.1 FOCUS ON GENDER: Graduate School and Mentors 459

Personal Narrative 15.1 Julia Martinez, Graduate Student in Clinical Psychology 460

Personal Narrative 15.2 Tiffany S. Borst, M.A., L.P.C. 464

• 15.2 FOCUS ON LAW AND ETHICS: Rights of Those Hospitalized for Mental Disorder 466

• 15.3 FOCUS ON DIVERSITY: Lack of Diversity in Research 467

Personal Narrative 15.3 Christopher A. Kearney, Ph.D. 469

• 15.4 FOCUS ON LAW AND ETHICS: Sexual Intimacy and the Therapeutic Relationship 472

Appendix: Stress-Related Problems 476

Glossary G-0

References R-1

Name Index I-1

Subject Index I-17

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When we, the authors, decided to write this textbook, we wanted to create something different for our students. We wanted to create a book that appealed to students by helping them understand that symptoms of psychological problems occur in many people in different ways. We wanted to avoid character- izing mental disorders from a “yes–no” or “us–them” perspective and focus instead on how such problems affect many people to varying degrees in their everyday lives. In essence, we wanted to illustrate how abnormal psychology was really about the strug- gles that all of us face in our lives to some extent. We represent this approach in our title: Abnormal Psychology and Life.

Abnormal psychology is one of the most popular courses on college campuses. Students are eager to learn about unusual behavior and how such behavior can be explained. Many stu- dents who take an abnormal psychology course crave a scien- ti�c perspective that can help prepare them well for graduate school and beyond. Other students take an abnormal psychol- ogy course because they are curious about themselves or people they know and thus seek application and relevance of the course information to their daily lives. Our book is designed to appeal to both types of students. The material in the book re�ects state- of-the-art thinking and research regarding mental disorders but also emphasizes several key themes that increase personal relevance. These themes include a dimensional and integrative perspective, a consumer-oriented perspective, and emphases on prevention and cultural diversity. Personal relevance is also achieved by providing information to reduce the stigma of men- tal disorder; by illustrating comprehensive models of mental disorder that include biological, psychological, and other risk factors; and by employing various pedagogical aids, visually appealing material, and technological utilities.

A Dimensional and Integrative Perspective A focus on how abnormal psychology is a key part of life comes about in this book in different ways. One main way is our focus on a dimensional perspective toward mental disorder. We believe that thoughts, feelings, and behaviors associated with mental disorders are present, to some degree, in all of us. Everyone experiences some level of anxiety, sadness, odd physical symp- toms, worry about sexual behavior, and memory problems from time to time, for example. Throughout our chapters we vividly illustrate how different mental disorders can be seen along a continuum of normal, mild, moderate, severe, and very severe emotions, thoughts, and behaviors. We also provide examples along this continuum that parallel common scenarios people face, such as interactions with others and job interviews.

Our dimensional perspective is discussed within the context of an integrative perspective that includes an extensive discus- sion of risk and protective factors for various mental disorders. Such factors include biological (e.g., genetic, neurochemical, brain changes), personality, psychological (e.g., cognitive, learn- ing, trauma), interpersonal, family, cultural, evolutionary, and other domains. We emphasize a diathesis-stress model and pro- vide sections that integrate risk factors to present comprehen- sive models of various mental disorders. We also provide an appendix of medical conditions with contributing psychological factors that includes a biopsychosocial perspective to explain the interplay of physical symptoms with stress and other key contributing variables.

A Consumer-Oriented Perspective Our book is also designed to recognize the fact that today’s stu- dent is very consumer-oriented. Students expect textbooks to be relevant to their own lives and to deliver information about diagnostic criteria, epidemiological data, brain changes, and assessment instruments in visually appealing and technologi- cally sophisticated ways. This textbook adopts a consumer approach in several ways. The chapters in this book contain suggestions for those who are concerned that they or someone they know may have symptoms of a speci�c mental disorder. These suggestions also come with key questions one could ask to determine whether a problem may be evident. In addition, much of our material is geared toward a consumer approach. In our discussion of neurocognitive disorders such as Alzheimer’s disease, for example, we outline questions one could ask when considering placing a parent in a nursing home.

The consumer orientation of this book is also prominent in the last chapter when we discuss topics such as becoming a men- tal health professional, becoming a client in therapy, treatments available at the community level such as self-help groups, and how to judge a research article, among other topics. Throughout our chapters, we also focus special attention on issues of gen- der, ethnicity, law and ethics, and violence in separate boxes. In addition, we have separate sections that speci�cally address symptoms of mental disorder in college students. We offer visually appealing examples of a dimensional model for each major mental disorder, brain �gures, and engaging tables and charts to more easily convey important information. The book is also linked to many technological resources and contains 15 chapters, which �ts nicely into a typical 15-week semester.

We also include several pedagogical aids to assist students during their learning process. The chapters are organized in a

PREFACE

similar fashion throughout, beginning with initial sections on normal and unusual behavior and followed by discussions of features and epidemiology, stigma, causes and prevention, assess- ment, treatment, and prognosis. The chapters contain interim summaries and review questions at periodic intervals to help students check their understanding of what they just learned. Bold key terms are placed throughout the chapters and correspond- ing de�nitions are placed in the margin. What Do You Think? questions appear after the chapter-opening case study, which help students focus on important aspects of the case. Boxes that direct readers to related videos from the Continuum Video Project are featured in the disorder chapters (Chapters 5–14). More information on the Continuum Video Project, available in MindTap, is on page xxix. Final comments are also provided at the end of each chapter to link material to previous and future chapters. Broad-based thought questions are also at the end of each chapter to challenge students to apply what they have learned to their daily lives. The writing style of the book is designed to be easy to follow and to succinctly convey key information.

Prevention Another important theme of this book is prevention. Most col- lege students function well in their environment, but everyone has some level of risk for psychological dysfunction or distress. We thus emphasize research-based ways to prevent the onset of psychological problems throughout this textbook. We offer spe- ci�c sections on prevention and provide a detailed discussion of risk factors for mental disorder and how these risk factors could be minimized. We also provide a discussion of protective factors and strategies that could be nurtured during one’s life to prevent psychological problems. Examples include anxiety and stress management, emotional regulation, appropriate coping, healthy diet, and adaptive parenting.

Much of our discussion in this area focuses on primary and secondary prevention, which has great appeal for students. Many prevention programs target those who have not developed a mental disorder or who may be at risk due to individual or environmental factors. A focus on prevention helps students un- derstand what they could do to avert problematic symptoms or to seek help before such symptoms become more severe. Pre- vention material in the book also focuses on tertiary prevention and relapse prevention, so students can understand what steps people can take to continue healthy functioning even after the occurrence of a potentially devastating mental disorder. The pre- vention material in this book thus has broad appeal, relevance, and utility for students.

Cultural Diversity Mental health professionals have made a more concerted effort to achieve greater cultural diversity in their research, to apply �ndings in laboratory settings to greater numbers of people, and to shine a spotlight on those who are traditionally underserved. We emphasize these greater efforts in this textbook. In addition

to the special boxes on diversity, we provide detailed informa- tion about cultural syndromes; how symptoms and epidemiology may differ across cultural groups; how certain cultural factors may serve as risk and protective factors for various disorders; how diagnostic, assessment, and treatment strategies may need to be modi�ed for different cultural groups; and how cultural groups may seek treatment or cope differently with symptoms of mental disorder.

Our discussion of cultural diversity applies to various eth- nic and racial groups, but diversity across individuals is repre- sented in many other ways as well. We focus heavily on gender differences, sexual orientation, sociocultural factors, migrant populations, and changes in symptoms as people age from childhood to adolescence to adulthood to late adulthood. Our emphasis on cultural and other types of diversity is consistent with our life-based approach for the book: Symptoms of mental disorder can occur in many people in many different ways in many life stages.

Stigma A focus on a dimensional approach to mental disorder helps us advance another key theme of this book, which is to reduce stigma. Stigma refers to socially discrediting people because of certain behaviors or attributes that may lead to them being seen as undesirable in some way. People with schizophrenia, for example, are often stigmatized as people who cannot function or who may even be dangerous. Adopting a dimensional per- spective to mental disorder helps reduce inaccurate stereotypes and the stigma associated with many of these problems. You will also see throughout this book that we emphasize people �rst and a mental disorder second to reduce stigma. You will not see us use words or phrases such as schizophrenics or bulimics or the learning disabled. Instead, you will see phrases such as people with schizophrenia, those with bulimia, or children with learning disorder. We also provide special sections on stigma throughout the chapters as well as boxes that contain informa- tion to dispel common myths about people with mental disor- ders that likely lead to negative stereotyping.

Clinical Cases and Narratives Our dimensional perspective and our drive to reduce stigma is enhanced as well by extensive use of clinical cases and personal narratives throughout the book. Clinical cases are presented in chapters that describe a particular mental disorder and are often geared toward cases to which most college students can relate. These cases then reappear throughout that chapter as we dis- cuss features of that disorder as well as assessment and treat- ment strategies. We also include personal narratives from people who have an actual mental disorder and who can discuss its symptoms and other features from direct experience. All of these cases reinforce the idea that symptoms of mental disorder are present to some degree in many people, perhaps including those easily recognized by a student as someone in his or her life.

xxvii

PREFACE

New to the Third Edition The third edition contains many new and exciting changes. Readers will see that the most obvious change is that ongo- ing research has adapted to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM), DSM the DSM-5. State-of-the-art research and citations are thus presented. The chapters remain aligned as they were previ- ously to enhance teaching in a typical semester and to re�ect empirical work that has been done for each set of disorders. DSM-5 criteria and other information are presented to help illuminate symptoms of mental disorders for students and to convey various dimensional aspects as well. Examples include continua based on severity, number of symptoms or behav- ioral episodes, body mass index, and personality traits, among many others.

The third edition also contains many boxes devoted to gen- der, diversity, violence, and law and ethics. In addition, separate sections have been added regarding how symptoms of mental disorders often manifest themselves in college students. Up- dated sections on stigma also illustrate our commitment to this important topic and present fascinating research with respect to others’ views of someone with a mental disorder and treatment and other strategies that have been developed to reduce stigma toward those with mental disorder.

An important process as well has been a thorough review of the material to ensure that students continue to be presented with state-of-the-art research and most current thinking regard- ing mental disorders, including epidemiology. Many sections of the book have thus been redone or reworked to re�ect new data, and hundreds of new citations have been added, most of which are very current. One thing that has not changed, however, is our deep devotion and commitment to this work and to our students and their instructors.

A brief summary of key changes and additions for each chapter in the third edition is provided here. This is not an exhaustive list but provides some general guidance for those familiar with the second edition.

Chapter 1: Abnormal Psychology and Life

• New information regarding worldwide epidemiology of mental disorders.

• Revamped stigma sections to re�ect recent �ndings. Chapter 2: Perspectives on Abnormal Psychology

• Updated citations and enhanced clari�cation of certain sections.

• Enhanced boxes on violence, law and ethics, and gender, including material on dangerousness and commitment.

Chapter 3: Risk and Prevention of Mental Disorders

• Updated information on epidemiology and a new world map in this regard.

• Revamped sections on demographic risk factors and resilience.

• Updated and new information on prevention, including primary prevention of alcohol use disorders on college campuses and selective prevention of eating disorders in college students.

• Updated information on suicide in college students. Chapter 4: Diagnosis, Assessment, and Study of Mental Disorders

• Updated information on all assessment information. • New culture and diagnosis example: ghost oppression. Chapter 5: Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

• Updated and enhanced information regarding epidemiology.

• Updated heritability and other etiology information and a revamped gender box.

• Updated assessment and treatment information, such as transdiagnostic treatments.

• New box on anxiety in college students. Chapter 6: Somatic Symptom and Dissociative Disorders

• Updated information regarding new somatic symptom disorders, including features and epidemiology.

• Updated and revamped sections on risk factors, assessment, and treatment throughout.

• New boxes on somatic symptoms and dissociative experiences in college students.

Chapter 7: Depressive and Bipolar Disorders and Suicide

• Updated information, including features and epidemiol- ogy, of the mood disorders.

• Revamped sections on suicide, stigma, genetics, neuro- chemical features, stressful life events, and interpersonal factors, among other sections.

• New box on depression in college students. Chapter 8: Eating Disorders

• Updated information, including features and epidemiol- ogy, of eating disorders.

• Revamped stigma and family sections, among others, on eating disorders.

• New box on eating disorder symptoms in college students.

Chapter 9: Substance-Related Disorders

• Updated information throughout and especially with respect to recent �gures regarding substance use.

• Revamped sections on stigma, prevention, and long-term outcome of substance use disorders, among other sections.

• New box on treatment of substance use disorders in college students.

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PREFACE

Chapter 10: Personality Disorders

• Updated information, including features and epidemiol- ogy, of personality disorders.

• Revamped stigma, assessment, and long-term outcome of personality disorders sections, among others.

• New box on features of borderline personality disorder in college students.

Chapter 11: Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria

• Updated information, including features and epidemiol- ogy, of sexual dysfunctions, paraphilic disorders, and gender dysphoria.

• Revamped sections on stigma, cultural factors, psycholog- ical interventions, and long-term follow-up, among other sections.

• New boxes on sexual dysfunctions and sexual fantasies in college students.

Chapter 12: Schizophrenia and Other Psychotic Disorders

• Updated information, including features and epidemiol- ogy, of psychotic disorders.

• Revamped sections on stigma, genetics, cognitive clusters, and long-term outcome of psychotic disorders, among other sections.

• New box on attenuated psychotic symptoms in college students.

Chapter 13: Developmental and Disruptive Behavior Disorders

• Updated information, including features and epidemiology, of developmental and disruptive behavior disorders.

• Revamped sections on stigma, genetics, and long-term outcome of developmental and disruptive behavior disor- ders, among other sections.

• New boxes on autism and attention-de�cit/hyperactivity disorder in college students.

Chapter 14: Neurocognitive Disorders

• Updated information, including features and epidemiol- ogy, of neurocognitive disorders.

• Revamped sections on genetics, alcohol and tobacco use, medication, and long-term outcome for neurocogni- tive disorders, among other sections.

• New box on delirium in college students. Chapter 15: Consumer Guide to Abnormal Psychology

• Editing throughout to enhance clarity as well as reference updating.

• Revamped sections on group therapy, misuse of research, and lack of diversity in research, among other sections.

Appendix: Stress-Related Problems

• New prevalence information. • Revised section and study regarding stressful life events

and trauma among college students.

• Key updates regarding risk factors.

MindTap for Kearney and Trull’s Abnormal Psychology and Life MindTap is a personalized teaching experience with relevant assign- ments that guide students to analyze, apply, and improve thinking, allowing you to measure skills and outcomes with ease.

• Guide Students: A unique learning path of relevant readings, media, and activities that moves students up the learning taxonomy from basic knowledge and comprehension to analysis and application.

• Personalized Teaching: Becomes yours with a Learning Path that is built with key student objectives. Control what students see and when they see it. Use it as-is or match to your syllabus exactly—hide, rearrange, add and create your own content.

• Promote Better Outcomes: Empower instructors and motivate students with analytics and reports that provide a snapshot of class progress, time in course, engagement and completion rates.

In addition to the bene�ts of the platform, MindTap for Kearney and Trull’s Abnormal Psychology and Life includes:Abnormal Psychology and Life includes:Abnormal Psychology and Life

• Pro�les in Psychopathology, an exciting new product that guides users through the symptoms, causes, and treatments of individuals who live with mental disorders.

• Videos, assessment, and activities from the Continuum Video Project.

• Concept Clip Videos that visually elaborate on speci�c dis- orders and psychopathology in a vibrant, engaging manner.

• Case studies to help students humanize psychological disorders and connect content to the real world.

Supplements Continuum Video Project The Continuum Video Project provides holistic, three-dimensional portraits of individuals dealing with psychopathologies. Videos show clients living their daily lives, interacting with family and friends, and displaying—rather than just describing—their symp- toms. Before each video segment, students are asked to make observations about the individual’s symptoms, emotions, and behaviors and then rate them on the spectrum from normal to severe. The Continuum Video Project allows students to “see” the disorder and the person as a human; and helps viewers under- stand abnormal behavior can be viewed along a continuum.

Pro�les in Psychopathology In Pro�les of Psychopathology, students explore the lives of indi- viduals with mental disorders to better understand the etiology,

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PREFACE

symptoms and treatment. Each of the ten modules focuses on one type of disorder. Students learn about six individuals— historical and popular culture �gures—and then match the in- dividual to the disorder that best explains their symptoms and causes. The experiences of a real-life person from the population- at-large is also featured, with video footage of that individual discussing their experience with psychopathology.

Instructor Resource Center Everything you need for your course in one place! This collec- tion of book-speci�c lecture and class tools is available online via www.cengage.com/login. Access and download PowerPoint pre- sentations, images, instructor’s manual, videos, and more.

Online Instructor’s Manual with Test Bank Available online for instructors, the Instructor’s Manual with Test Bank offers a convenient and thorough overview of each chapter and a wealth of teaching suggestions developed around the chapter content. And the Test Bank section is an extensive collection of multiple-choice questions for objective tests, all closely tied to the text chapters. We’re con�dent that you will �nd this to be a dependable and usable resource. [ISBN 9781337278232]

Cengage Learning Testing Powered by Cognero Cengage Learning Testing Powered by Cognero is a �exible, on- line system that allows you to:

• author, edit, and manage test bank content from multiple Cengage Learning solutions

• create multiple test versions in an instant • deliver tests from your LMS, your classroom or wherever

you want.

Online PowerPoint Slides These vibrant, Microsoft PowerPoint lecture slides for each chapter assist you with your lecture, by providing concept cover- age using images, �gures, and tables directly from the textbook!

All of these instructor supplements are available online for download.

[ISBN 9781337288125]

Acknowledgments Producing this book required the joint efforts of Cengage and Graphic World Publishing Services. We thank our editors, Tim Matray and Carly McJunkin, and our content developer, Tangelique Williams-Grayer. We thank Cassie Carey at Graphic World for management of the book’s production. We are grateful for Kimiya Hojjat and Katie Chen, product assistants; Ruth Sakata Corley, content production manager; and Vernon Boes, art director. We also appreciate the work of Jennifer Levanduski, marketing director; and James Findlay, market- ing manager.

We would like to recognize and thank Ileana Arias, Marianne Ta�inger, Jaime Perkins, and Kate Barnes for their help with this text’s initial development.

We also thank those who agreed to contribute their personal stories for this book. Their narratives were essential to this book and helped bring the material to life.

The feedback and comments from the reviewers were extremely helpful. First, we thank the instructors who responded to the Third Edition survey:

Nicole Brandt, Columbus State Community College Andrew Blair, Palm Beach State College Acacia Parks, Hiram College Elizabeth DenDekker, Silver Lake College Andrea Phronebarger, York Technical College Nina Slota, Northern State University Jennifer Spychalski, College of Charleston Bettina Veigel, College of Charleston Sherry Molock, George Washington University Patti Lou Watkins, Oregon State University Marie D. Sjoberg, University of West Florida Anna Ciao, Western Washington University Brenda Ingram-Wallace, Albright College Angela Spaniolo-DePouw, Muskegon Community College David M. Feldman, Barry University

We also thank the following First and Second Editions re- viewers, as well as those who wished to remain anonymous:

Craig Abrahamson, James Madison University; Dave Alfano, Community College of Rhode Island; Randolph Arnau, University of Southern Mississippi; Stephen Balsis, Texas A&M University; Kira Banks, St. Louis University; Ollie Barrier, Park University at Parkville; Lee Ann Bartolini, Dominican University of California; Evelyn Behar, University of Illinois–Chicago; Kathryn Bell, Northern Illinois University–Dekalb; Laurie Berkshire, Erie Community College; James Bexendale, Cayuga Community College; Amy Badura Brack, Creighton University; Nicole Bragg, Mount Hood Community College; Jo Anne Brewster, James Madison University; Seth Brown, University of Northern Iowa; Emily Bullock, University of Southern Mississippi; David Carpenter, Texas State University; Sherri Chandler, Muskegon Community College; Bryan Chochran, University of Montana; Brian Cowley, Park University–Parkville; Trina Cyterski, University of Georgia; Dale Doty, Monroe Community College; Anthony Drago, East Stroudsburgh University; Wendy Dunn, Coe College; Christopher Echkhardt, Purdue University at West Lafayette; Georg Eifert, Chapman University; Carlos A. Escoto, Eastern Connecticut State University; Joe Etherton, Texas State University; Gabriel Feldmar, Nassau Community College; Meredyth Fellows, West Chester University; David Fresco, Kent State University; Gina Golden-Tangalakis, California State University, Long Beach; Barry Greenwald, University of Illinois–Chicago; Ron Hallman, Emmanuel Bible College; Julie Hanauer, Suffolk Community College at Ammerman; Kevin Handley, Germanna Community College; April Hess, Southwest Virginia Community College; Cecil Hutto, University of Louisiana–Monroe; Robert Rex Johnson, Delaware Community College; Samuel Joseph, Luzerne County Community College; Guadalupe King, Milwaukee Area Technical College–Downtown; Laura Knight, Indiana University of Pennsylvania; Victor Koop, Goshen College; Martha Lally, College of Lake County; Steve Lee, University of California, Los

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Angeles; David Lester, The Richard Stockton College of New Jersey; Don Lucas, Northwest Vista College; Polly McMahon, Spokane Falls Community College; Susan Meeks, University of Louisville; Rafael Mendez, Bronx Community College; Paul Moore, Quinnipiac University; Regan Murray, Briar Cliff University; Francis P. O’Neill, Montgomery County Community College–West Campus; Leanne Parker, Lewis-Clark State College; Deborah S. Podwika, Kankakee Community College; Skip Pollack, Mesa Community College; Jay Pope, Fresno Paci�c University; Frank J. Provenzano, Greenville Technical College; Kelly Quinn, East Texas Baptist University; Barry Ries, Minnesota State University at Mankato; Eric Rogers, College of Lake County; John Roop, North Georgia College & State University; Patricia Sawyer, Middlesex Community College; Kerry Schwanz, Coastal Carolina University; Norman A. Scott, Iowa State University; William Scott, Liberty University; Laura Seligman, University of Toledo; Nancy Simpson, Trident Technical College; Ashlea Smith, Paradise Valley Community College; Randyl Smith, Metropolitan State College of Denver; Scott Stehouwer, Calvin College; Stephanie Stein, Central

Washington University; Betsy Stern, Milwaukee Area Technical College–Downtown; Joanne Hoven Stohs, California State University, Fullerton; Diane Tarricone, Eastern Connecticut State University; Ronald Theobald, SUNY–Jefferson Community College; Ayme Turnbull, Hofstra University; Michelle Vanbuskirk, Monroe Community College; Fabian Vega, Baltimore City Community College at Liberty Campus; J. Celeste Walley-Jean, Clayton State University; Stephen Weiss, Adams State College; Adam Wenzel, Saint Anselm College; Gene White, Salisbury University; Fred Whitford, Montana State University at Bozeman; Beth Wiediger, Lincoln Land Community College; Amy Williamson, Moraine Valley Community College.

In addition, we thank those who helped us create the supplements for this text, including the Instructor’s Manual, Test Bank, and PowerPoint preparers.

Finally, we thank all of the instructors who use this text- book, as well as the students who take their courses. As al- ways, we welcome your comments and suggestions regarding the book.

PREFACE 1

Special Features

• 1.1 Emotion and Culture

CONTINUUM FIGURE 1.2 Continuum of Emotions, Cognitions, and Behaviors

• 1.2 Heal Thyself: What the Self-Help Gurus Don’t Tell You

Personal Narrative 1.1 Alison Malmon

C / What Do You Think?

Introduction to Abnormal Psychology

What Is a Mental Disorder?

History of Abnormal Psychology

Abnormal Psychology and Life: Themes

FINAL COMMENTS

KEY TERMS

CHAPTER 1 Abnormal Psychology and Life4

Some of us may also be asked to help a friend or sibling strug- gling with symptoms of a mental disorder. In addition, all of us are interested in knowing how to improve our mental health and how to prevent mental disorders so we can help family members and friends.

In this book, we provide information to help you recognize mental problems and understand how they develop. We also ex- plore methods used by professionals to prevent and treat mental distress and disorder. Knowing this material will not make you an expert, but it could make you a valuable resource. Indeed, we will present information you can use to make informed deci- sions and direct yourself and others to appropriate sources of support and help. Based on information in Chapters 5 and 7, for example, you will become knowledgeable about how anxiety and depression affect health and behavior in yourself and others as well as ways of dealing with these common problems.

What Is a Mental Disorder?

As we mentioned, a mental disorder is a group of emotional (feelings), cognitive (thinking), or behavioral symptoms that cause distress or signi�cant problems. Abnormal psychol- ogy is the scienti�c study of problematic feelings, thoughts, and behaviors associated with mental disorders. At �rst glance, de�ning problematic or abnormal behavior seems fairly straight- forward—isn’t abnormal behavior simply behavior that is not normal? In a way, yes, but then we �rst must know what normal

Introduction to Abnormal Psychology

You and your classmates chose to take this course for many reasons. The course might be required, or perhaps you thought learning about abnormal, deviant, or unusual behav- ior was intriguing. Or you might be interested in becoming a mental health professional and thought this course could help prepare you for such a career. Whatever the reason, you have likely known or will eventually know someone with a mental disorder. A mental disorder is a group of emotional (feelings), cognitive (thinking), or behavioral symptoms that cause distress or signi�cant problems. About 29.2 percent of adults worldwide have had a mental disorder in their lifetime (Steel et al., 2014). Students in our abnormal psychology classes often tell us that they know at least one person with a mental disorder. These students often say that they or an immediate family member— such as a parent, sibling, or child—had a disorder. A commonly reported disorder is depression, a problem that Travis seemed to be experiencing.

Abnormal psychology is the scienti�c study of problematic feelings, thoughts, and behaviors associated with mental disor- ders. This area of science is designed to evaluate, understand, predict, and prevent mental disorders and help those who are in distress. Abnormal psychology has implications for all of us. Everyone has feelings, thoughts, and behaviors, and occasion- ally these become a problem for us or for someone we know. Travis’s situation at the beginning of the chapter represents some daily experiences people have with mental disorders.

Travis is a 21-year-old college junior who has been struggling recently. He and his longtime girlfriend broke up 2 months ago, and he took this very hard. Travis and his girlfriend had been together for 17 months, and she was his �rst serious romantic relationship. However, the couple eventually became emotionally distant from one another and mutually decided to split following several arguments. Travis initially seemed �ne after the breakup but then became a bit sullen and withdrawn about a week later. He began to miss a few classes and spent more time in his dorm room and on his computer.

Since the breakup several weeks ago, Travis seems to be getting worse each day. He rarely eats, has trouble sleeping, and stays in bed much of the day. He “zones out” by play- ing video games, watching television, or staring out the window for hours per day. Travis has lost about 10 pounds in recent weeks and looks tired

and pale. He has also been drinking alcohol more in recent days. In addition, his classroom attendance has declined signi�cantly, and he is in danger of failing his courses this semester.

Travis says little about the breakup or his feelings. His friends have tried everything they can think of to help him feel better, with no suc- cess. Travis generally declines their offers to go out, attend parties, or meet other women. He is not mean-spirited in his refusals to go

out but rather just shakes his head. Travis’s friends have become worried that Travis might hurt himself, but they cannot be with him all the time. They have decided that Travis should speak with someone at the psychological ser- vices center on campus and plan on escorting him there today.

What Do You Think? 1. Which of Travis’s emotional or behavioral

problems concern you the most? Why? 2. What do you think Travis should do? 3. What would you do if you had a friend who

was experiencing dif�culties like Travis? 4. What emotional or behavioral problems

have you encountered in yourself or in others over the past year?

5. Are you surprised when people you know experience emotional or behavioral problems? Why or why not?

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Deviance from the Norm Treva’s actions are certainly not typical of most teenagers or young adults. Because Treva’s behavior is so different from others—so different from the norm—her behavior would be considered abnormal. De�ning abnormal behavior based on its difference or deviance from the norm is common and has some mass appeal—most people would agree Treva’s behaviors are abnormal. Do you? Mental health professionals also rely on deviance from the norm to de�ne abnormal behavior, but they often do so statistically by measuring how frequently a behavior occurs among people. Less frequent or less probable behaviors are considered to be abnormal or statistically deviant. Suddenly disappearing from home and assuming a new identity, as Treva did, is a very infrequent behavior that is statistically far from normal behavior.

An objective, statistical method of de�ning abnormality involves determining the probability of a behavior for a pop- ulation. Note the bell curve in Figure 1.1. This curve shows how likely a behavior is based on its frequency in large groups of people. In this case, a 0 to 100 rating scale indicates level of physical activity among 10-year-olds during a 30-minute recess period. In this graph, 0 � no physical activity and 100 � con- tinuous physical activity. The left axis of the scale shows how many children received a certain activity score: you can see that almost all children received scores in the 20 to 80 range. Based on this distribution of scores, we might statistically de�ne and label the physical activity of children scoring 0 to 19 or 81 to 100 as “abnormal.” Note that extremely low and extremely high scores are considered abnormal. Some physical activity is the norm, but too little or too much is not. A mental health profes- sional might thus focus on underactive and overactive children in her scienti�c studies.

Statistical deviance from the norm is attractive to research- ers because it offers clear guidelines for identifying emotions,

behavior is. We often refer to normal behavior as that which characterizes most people. One normal behavior for most peo- ple is to leave home in the morning to go to school or work and to interact with others. If a person was so afraid of leav- ing home that he stayed inside for many weeks or months, this might be considered abnormal—the behavior differs from what most people do.

But what do we mean by most people? How many people must engage in a certain behavior for the behavior to be con- sidered normal? And which group of people should we use to decide what is normal—women, men, people of a certain eth- nicity, everyone? You can see that de�ning normal and abnormal behavior is more complicated than it might appear. Consider the following case:

case Treva Throneberry was born in Texas. Her sisters describe their family as a peaceful and loving one, but Treva paints a different picture. At age 15 years, Treva accused her father of sexual molestation. She later recanted her accu- sation but was removed from her parents’ home and placed in foster care. At age 17 years, Treva ran away from her foster home and was found wandering alone by a roadside before spending time in a mental hospital. A year later, Treva moved into an apartment but soon vanished from town. Years later, she was charged by Vancouver police with fraud and forgery. Her �ngerprints matched those of Treva Throneberry, who was born 30 years before, but Treva said she was an 18-year-old named Brianna Stewart. She had been attending Evergreen High School in Vancouver for the past two years, where everyone knew her as Brianna Stewart. This was the basis for the fraud and forgery charges.

Since her disappearance from Texas, Treva had been known by many other names in places across the country. In each town, she initially pre- sented herself as a runaway 15- or 16-year-old in need of shelter who then left suddenly before her new identity turned 18 years old. She would then move to another town and start again as a 15- or 16-year-old. Her foster care mother said Treva could not envision living beyond age 18.

Treva was examined by a psychiatrist and found competent to stand trial. At her trial, Treva represented herself. She would not plea-bargain because she insisted she was Brianna Stewart and not Treva Throneberry. She argued in court that she was not insane and did not have a mental disorder that caused her to distort reality or her identity. Despite her claims, however, Treva was convicted of fraud and sentenced to a 3-year jail term. She continues to insist she is Brianna Stewart.

You may think Treva’s behavior is abnormal, but why? To address this question, we may consider one of three criteria commonly used to determine whether an emotion, thought, or behavior is abnormal: (1) deviance from the norm, (2) dif-dif-dif �culties adapting to life’s demands or dif�culties functioning effectively (including dangerous behavior), and (3) experience of personal distress.

FIGURE 1.1 A STATISTICAL METHOD A STATISTICAL METHOD A ST OF DEFINING ABNORMALITY. Extremely low and extremely high levels of activity are considered abnormal from a statistical perspective.

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chapter, you can see his depression kept him from interacting with others and could even lead to self-harm. Indeed, dangerous behavior toward oneself or others clearly interferes with an ability to function effectively.

Everyone occasionally has feelings of sadness and discour- agement, especially after a tough event such as a breakup. Most people, however, are eventually able to focus better on school, work, or home regardless of these feelings. For other people like Travis, however, feelings of sadness or discouragement become maladaptive. A maladaptive behavior is one that interferes with a person’s life, including ability to care for oneself, have good relationships with others, and function well at school or at work. Feelings of sadness and discouragement, which at �rst can be normal, can lead to maladaptive behaviors such as trouble getting out of bed, concentrating, or thinking.

Think about Sasha, who has been very worried since her mother was diagnosed with breast cancer last year. Her mother is currently doing well, and the cancer seems to be in remission, but Sasha cannot stop worrying that her mother’s cancer will return. These worries cause Sasha to be so anxious and upset that she can- not concentrate on her schoolwork, and she �nds herself irritable and unable to spend much time with her friends. Sasha’s worries and behavior, which were understandable at �rst, have become maladaptive. According to the dif�culties-adapting-to-life-demands criterion, Sasha’s behaviors might be considered abnormal. Her continual thoughts about her mother’s health, coupled with irrita- bility and trouble concentrating, prevent her from functioning well as a family member, student, and friend. In fact, Sasha may bene�t from some professional intervention at this point. In this case, the focus is not on deviance or norms but on the extent to which a behavior or characteristic interferes with daily functioning.

One advantage of this approach is that problems in daily living—as in school, work, or relationships—often prompt peo- ple to seek treatment. Unfortunately, the difference between good

functioning and maladaptive behavior is not always easy to measure. In addition, the difference be- tween good functioning and maladaptive behavior

differs from person to person. Another prob- lem with this criterion is that different people may view a certain behavior dif- ferently. Sasha’s family members might see her behaviors as caring and thought- ful, but one of her professors might see her behavior as laziness. Mental health professionals often struggle with how to determine whether a person’s behavior is maladaptive or truly interferes with a person’s daily functioning.

Another problem with the criterion of dif�culties adapting to life demands is that people may engage in odd behaviors but experience little interference in daily functioning. Consider Henry, a telemar- keter living alone in Seattle. He never leaves home because of fear of contamina- tion by airborne radioactivity and bacterial

thoughts, or behaviors as normal or abnormal. However, this ap- proach has some disadvantages. One major disadvantage is that people who differ signi�cantly from an average score are techni- cally “abnormal” or “disordered.” But does this make sense for all behaviors or characteristics? Think about intelligence. Using a deviance-from-the-norm criterion, people who score extremely high on an intelligence test would be considered abnormal! But high intelligence is certainly not a disorder. In fact, high intelli- gence is valued in our society and often associated with success instead of failure. A deviance approach to de�ning abnormality is thus easy to apply but may fall short for determining what is abnormal.

Another disadvantage of the deviance-from-the-norm crite- rion is that cultures differ in how they de�ne what is normal. One culture might consider an extended rest period during the workday to be normal, and another culture might not. Likewise, symptoms of mental disorders differ from culture to culture. We often consider self-critical comments and expressions of sadness as indicators of depression, but such behaviors are not always viewed the same way in East Asia (see Box 1.1). This is impor- tant for mental health professionals to consider when treating someone. Mental health professionals must recognize their own cultural biases and refrain from applying these views inappro- priately to someone from another culture. Mental health profes- sionals must also understand that deviance within a culture can change over time—what was considered deviant 50 years ago may be acceptable today.

A �nal problem with the deviance-from-the-norm criterion is that deciding the statistical point at which a behavior is abnor- mal can be arbitrary and subject to criticism. The method does not tell us what the correct cutoff should be. Refer again to Figure 1.1. If a child has an activity score of 81, she might be considered abnor- mal. Realistically, however, is a score of 80 (normal) much different from a score of 81 (abnormal)? Where should the cutoff be, and how do we know if that cutoff point is meaningful?

Dif�culties Adapting to Life Demands Because several problems exist with the deviance-from-the-norm criterion, other judgments are sometimes made to de�ne abnormal behavior. One key judgment often made by mental health professionals is whether a behavior interferes with a person’s ability to func- tion effectively. One could argue that Treva’s behaviors greatly interfered with her ability to function effectively. She continued to behave in ways that prevented her from adopting an adult role and that eventually landed her in jail. In the case of Travis presented at the beginning of the

Using a statistical de�nition of deviance, Albert Einstein would be considered “abnormal” because of his high intelligence.

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not be particularly distressed about his actions but may be referred to treatment by his parents.

A personal-distress de�nition of abnormality has strengths and weaknesses. Personal distress is a hallmark feature of many mental disorders and often prompts people to seek treatment. In addition, most people can accurately assess whether they expe- rience signi�cant emotional and behavioral problems and can share this information when asked. However, some people (like Henry, mentioned earlier) do not report much personal distress even when exhibiting unusual behavior. And, even if a person is distressed, no clear guidelines exist for establishing a cutoff point that indicates an abnormal behavior. How much personal distress is too much personal distress?

De�ning Abnormality As you can see, these three approaches to de�ning abnormality have several strengths and weaknesses. A successful approach to de�ning abnormality has thus been to combine the perspec- tives to merge their strengths and minimize their weaknesses (see Table 1.1). At least one of three characteristics must be present for abnormality to be de�ned as such. We refer to emo- tions, thoughts, or behaviors as abnormal when they

• violate social norms or are statistically deviant (like Treva’s unusual behavior, insisting she was another person),

spores released by the Central Intelligence Agency. Henry does not consider himself dysfunctional because he works at home, gets things delivered to him, and communicates to friends or family via telephone and e-mail. Most would agree Henry limits his options by not leaving home and that his thinking is quite peculiar and un- realistic. But is Henry experiencing interference in daily function- ing if he is happy the way things are for him? Hasn’t he adapted well to his environment? Does he truly need treatment?

Experience of Personal Distress Maladaptive behavior is not always a source of concern for people like Henry, so they may not seek treatment. Therefore, another criterion used by mental health professionals to de�ne abnormal behavior is experience of personal distress. Consider Margarette, who has irrational fears of entering tunnels or bridges while traveling by car or bus. She is extremely distressed by this and recognizes that these fears are baseless. Unfortu- nately, Margarette must travel through tunnels or bridges given her residence in Manhattan. She is desperate for treatment of these irrational fears because they cause her so much distress. In Margarette’s case, extreme levels of distress created by a behav- ior such as fear may be important for de�ning her behavior as abnormal. In other cases, a behavior could cause great distress for others, which may prompt them to initiate treatment for a person. A child with highly disruptive behavior in school may

addition, expressions of depression are more likely labeled abnormal by Amer-addition, expressions of depression are more likely labeled abnormal by Amer-addition, expressions of depression are more likely labeled abnormal by Amer icans, but anger is more likely labeled abnormal by East Asians. Expressions of anxiety—especially over �tting in with a group—may be more common or nor-anxiety—especially over �tting in with a group—may be more common or nor-anxiety—especially over �tting in with a group—may be more common or nor mal in East Asians, but expressions of anger—especially when asserting one’s individual rights—may be more common or normal in Americans. If deviance from the norm is used to de�ne abnormal behavior, then cultural identity must be considered. An American psychologist should not, for example, apply her norms regarding emotional expression to someone from East Asia.

Focus on

Emotional experience and expression are clearly in�uenced by culture (Lagattuta, 2014). Pride is promoted in the United States, an individualist (Lagattuta, 2014). Pride is promoted in the United States, an individualist (Lagattuta, 2014). Pride is promoted in the United States, an individualist culture, through praise, encouragement, and awards for personal accom- plishments. As a result, Americans may be more self-focused and individual- achievement oriented. In contrast, non-Western collectivist cultures, as in East Asia, prioritize modesty, social obligations, and interpersonal harmony. People are expected to �t in with others and avoid behaviors that bring individual attention or that create group con�ict. An Ameri- can student asked to present a top-notch paper to her class may quickly accept this invitation and invite friends to her presentation. A Japanese student, however, may be less receptive to such a prospect. The Ameri- can student came from a culture that promotes individual achievement and recognition, whereas the Japanese student came from a culture that promotes group belongingness and not individual recognition.

Consider another example. Expression of self-criticism is more typical of East Asian culture and does not necessarily indicate a mental disorder. In

Diversity Emotion and Culture

1.1

Public expressions of anger are less common, and more likely to be seen as deviant, in certain cultures.

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TABLE 1.1

De�nitions of Abnormal Psychology

De�nition Advantages Limitations

Deviance from the norm • We use our own judgment or gut feeling. • Once statistical or objective cutoff scores

are established, they are easy to apply.

• Different cultures have different ideas about what normal behavior is.

• “Statistically deviant” behaviors may be valued (e.g., high intelligence).

• Arbitrary cutoffs (e.g., is a score of 80 much different from a score of 81?).

Dif�culties adapting to life’s demands • Typically easy to observe if someone is having dif�culty.

• Often prompts people to seek psycho- logical treatment.

• Unclear who determines impairment or whether a consensus about impairment is required.

• Thresholds for impairment not always clear.

Experience of personal distress • Hallmark of many forms of mental disorder.

• Individuals may be able to accurately report this.

• Some psychological problems are not associated with distress.

• Thresholds or cutoffs for distress are not always clear.

This man has not left his home in two years, but he functions fairly normally and is not distressed. Is his behavior abnormal?

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• interfere with functioning (like Sasha’s worries that kept her from performing well at school), or

• cause great personal distress (like Margarette’s fears of tunnels and bridges).

Agreeing on a de�nition of “mental disorder” is important to psychopathologists, who study mental problems to see how disorders develop and continue and how they can be prevented or treated. A lack of consensus on a de�nition of abnormal be- havior can have adverse consequences. Consider intimate part- ner violence (IPV), a signi�cant problem in the United States. Much research has been conducted by psychologists and other mental health professionals to identify causes of IPV so effective treatments can be designed. Some researchers, however, de�ne IPV as physical violence, whereas others work from a broader de�nition that includes physical, emotional, or sexual violence against an intimate partner. A standard or consistent de�nition of IPV is important because individuals who are physically vio- lent against a partner may differ from those who are emotion- ally or sexually violent. Likewise, individuals using one form of violence may differ from those using multiple forms of violence against intimate partners. If so, treatments that are effective for one type of perpetrator may not be effective for other types of perpetrators. Varying de�nitions of a problem can thus impede our understanding of abnormal psychology.

Dimensions Underlying Mental Disorders Are Relevant to Everyone Our discussion to this point might suggest a person’s behavior is either abnormal or not, but this is not really so. Along with

many experts in abnormal psychology, we view the abnormal- ity of emotions, thoughts, or behaviors as a matter of degree, not of kind. In other words, emotions, thoughts, and behaviors associated with mental disorders are present, to some degree, in all of us. This statement may seem strange or even shock- ing to you at �rst, but let’s explore it a little more. Abnormal behaviors are not simply present or absent but exist along a continuum in everyone to some degree. Think about sex drive, motor coordination, anxiety, or sadness. Each characteristic is present to some degree in everyone at different times. We all have some sex drive and coordination, and we all become anx- ious or sad at times. These characteristics may also change over time—it’s likely you are more coordinated now than you were at age 5! Different people also show different levels of these characteristics—you may know people who tend to be more anxious or sad than others.

Deciding whether a behavior is different or deviant from the norm is a matter of degree. Earlier we discussed children’s activity level—children may be underactive, overactive, and even hyperactive. Deciding whether a behavior is maladaptive also is a matter of degree. Some students concerned about their parents’ health cope better than others. Even personal distress is displayed in different degrees. Some people are much more distressed about driving through tunnels than others. All these differences make us unique in some way, which is a good thing. The important thing to remember is that anxiety, sadness, anger, and other emotions and behaviors can be best described along a dimension or continuum from extremely low to extremely high levels. Sometimes we do make pronouncements about people who are “anxious” or “depressed,” but this is just a convention of language. These features—like all emotions, thoughts, and behaviors—exist on a continuum. Figure 1.2 is an example of the full range of emotions, thoughts, and behaviors that might follow from problems in college. Think about where Travis might be on this continuum.

The idea that emotions, thoughts, and behaviors exist in varying degrees on a continuum in people has important implica- tions. When a mental health professional evaluates an individual for symptoms of mental disorder, these three dimensions— emotion, thought, and behavior—�gure prominently. Various forms of mental disorder comprise emotions such as anxious or depressed mood, thoughts such as excessive worry, and behaviors such as avoidance of others or hyperactivity.

To explore this continuum idea more deeply, consider Figure 1.3. Ricardo started a job as a �nancial analyst 6 months ago and has been feeling anxious, worried, and overwhelmed for the past 3 weeks. His overall mood, or emotional state, has been highly anxious—he has great dif�culty eating, sleeping, and interacting with friends. His cognitive style can be charac- terized by intense worry—almost all his thoughts involve what he is doing wrong at his new job and fear that his coworkers and friends will discover the dif�cult time he is having at work. Because of his anxiety and worry, Ricardo has started to avoid coworkers and friends. This avoidance behavior is causing prob- lems for Ricardo, however, because he must meet with clients almost every day.

Consider Yoko as well. Yoko is a young adult with many symptoms related to anxiety. After college, she was hired as a writer for a large software company. Yoko has dealt with bouts of anxious mood for most of her life—she almost always feels “on edge” and sometimes has physical symptoms that suggest her body is “on high alert,” such as rapid heartbeat, muscle ten- sion, and sweating. These anxiety symptoms worry Yoko, and she often wonders if something is physically wrong with her. Because of her job, however, Yoko can work at home and spends most days without much human contact. This suits Yoko �ne because she has never felt completely comfortable around other people and prefers to be alone. Her job requires her to meet with her boss only at the beginning and end of each project. Yoko can tolerate this relatively infrequent contact without much dif- �culty. Her preference and choice to be alone most of the time therefore does not cause major problems for her.

The combination of psychological symptoms exhibited by Ricardo characterizes social anxiety disorder, which we discuss in Chapter 5. As you can see, though, the emotions, thoughts, and behaviors associated with this disorder exist on a con- tinuum. As this example illustrates, mental disorders include characteristics found among most, if not all, people. Only when levels of these characteristics cross a threshold—when they are statistically deviant, associated with maladaptiveness, or cause great distress—are they considered abnormal. At one time or an- other, you have certainly felt anxious, had worrisome thoughts, or had the desire to be alone—similar emotions and thoughts, and their accompanying behaviors, are present to some degree in all of us. In Ricardo’s case, however, the degree to which these features are present over the past 3 weeks hinders his daily life.

Figure 1.3 visually depicts this perspective and focuses on several important features of abnormal psychology. Each dimen- sion of abnormality is shown along a continuum, be it emotional (e.g., anxious mood), cognitive (e.g., worry intensity), or behav- ioral (e.g., avoidance of others) features. Other factors associ- ated with abnormality can be understood from a dimensional perspective as well. The degree to which one is distressed or experiences interference in daily functioning, for example, can be represented on a continuum. As Figure 1.3 shows, Ricardo and Yoko show similar levels of anxious mood, worry intensity, and avoidance behavior. On a scale of 0 (none) to 100 (extremely high), their anxious mood can be rated 85 (very high), their worry intensity can be rated 50 (moderate), and their avoidance can be rated 70 (high). In Yoko’s case, however, these symptoms are associated with lower levels of distress (rating � 45) and impairment (rating � 50). As we noted, Ricardo’s level of dys- function is severe enough to warrant a diagnosis of social anxiety disorder, a mental disorder that is characterized by avoidance of social situations, intense anxiety, and clinically signi�cant impairment in functioning. Yoko, however, does not warrant this or any other anxiety diagnosis because her symp- toms are not associated with signi�cant impairment in daily functioning. Indeed, she copes with her symptoms so they do not cause her great personal distress.

You might be wondering whether the literature and re- search on anxiety disorders is relevant to Ricardo, Yoko, and

CHAPTER 1 Abnormal Psychology and Life10

even people with much lower levels of anxious symptoms. The answer is yes, absolutely! Features of mental disorder, personal distress, and impairment are all dimensional or continuous in nature. In fact, research suggests that the same causal factors are responsible for these anxiety-related symptoms whether the symptoms are mild, moderate, or severe. Because everyone will experience some of the symptoms discussed in this textbook or know someone who has or will experience these symptoms, abnormal psychology is relevant to all of us. Abnormal psychol- ogy is a part of life.

As you read this textbook and understand more that ab- normal psychology is a part of life, you will identify with some of the symptoms and disorders we discuss. This does not mean, however, that you or someone you know has a mental disorder. Some people, for example, are extremely neat and tidy and do not like things to be disorderly. In fact, they may feel uncomfortable when things are not lined up and organized. If this applies to you or someone you know, you may be tempted to believe you or the person has obsessive- compulsive disorder (Chapter 5). You might share an interest in neatness with someone who has obsessive-compulsive disorder, but you are probably able to tolerate this need for neatness and order and can function even if you were pre- vented from keeping everything organized. People with very high levels of a characteristic, like a need for neatness, are indeed at risk for developing a condition such as obsessive- compulsive disorder, especially under conditions of high

FIGURE 1.3 RICARDO AND YOKO. Ricardo and Yoko have similar levels of anxious mood, worry intensity, and avoidance behavior. However, they differ on amount of distress experienced and levels of impairment created by their symptoms. (Photos courtesy of © 2010 Design Pics/Jupiterimages Corporation [Yoko]; ©Istockphoto.com/Carole Gomez [Ricardo].)

Yoko 85

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Ricardo 50

Worry intensity (cognitive style)

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Ricardo 70

Avoidance (behavior)

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Ricardo 90

Distress

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Ricardo 90

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1.2 Continuum of Emotions, Cognitions, and Behaviors

NORMAL MILD

Emotions Good alertness and positive emotional state.Good alertness and positive emotional state. Feeling sad or down temporarily, but not for long.Feeling sad or down temporarily, but not for long.Feeling sad or down temporarily, but not for long.

Cognitions “I’m not getting the grades I want this semester, but “I’m not getting the grades I want this semester, but I’ll keep trying to do my best.” I’ll keep trying to do my best.”

“I’m struggling at school this semester. I wish I could study “I’m struggling at school this semester. I wish I could study “I’m struggling at school this semester. I wish I could study better, or I’ll fail.” better, or I’ll fail.”

Behaviors Going to classes and studying for the next round of tests. Talking to professors.

Going to classes with some trouble studying. Less contact with others.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

CONTINUUM FIGURE

•

• -

•

➲ Review Questions 1. -

History of Abnormal Psychology

Knowing a little about the history of abnormal psychology will help you better understand some of the ideas and forces that have shaped how we view and treat mental disorders. The model a society uses to understand mental disorder will in�uence how that disorder is treated. Historically, not much emphasis was placed on research and the scienti�c method to understand mental health or well-being. In addition, ideas about

stress. We hope to make you more aware of who is vulner- able for a mental disorder and what can be done to maximize mental health. In doing so, we also emphasize prevention of mental disorder, or how people can lower the probability of developing mental disorders.

➲ Interim Summary •

•

If people cannot overcome fears they experience when performing an everyday activity such as taking the subway, the fear may be abnormal.

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MODERATRATE MENTAL DISORDER—LESS SEVERE MENTAL DISORDER—MORE SEVEREMENTAL DISORDER—LESS SEVERE MENTAL DISORDER—MORE SEVEREMENTAL DISORDER—LESS SEVERE MENTAL DISORDER—MORE SEVEREMENTAL DISORDER—LESS SEVERE MENTAL DISORDER—MORE SEVERE

Feeling sad, but a strong positive experience Feeling sad, but a strong positive experience such as a good grade could lift mood. such as a good grade could lift mood.

Intense sadness most of the day with some trouble Intense sadness most of the day with some trouble Intense sadness most of the day with some trouble concentrating and some loss of appetite. concentrating and some loss of appetite.

Extreme sadness all the time with great trouble Extreme sadness all the time with great trouble concentrating and complete loss of appetite. concentrating and complete loss of appetite.

“These bad grades really hurt. This may set me back for a while. I’m really worried.”

“I’m so worried about these grades that my stomach “I’m so worried about these grades that my stomach “I’m so worried about these grades that my stomach hurts. I don’t know what to do.hurts. I don’t know what to do.

“These bad grades just show what a failure I am “These bad grades just show what a failure I am at everything. There’s no hope; I’m not doing at everything. There’s no hope; I’m not doing anything today.”

Skipping a few classes and feeling somewhat unmotivated to study.

Avoiding contact with professors and classmates.

Skipping most classes and unable to maintain eye Skipping most classes and unable to maintain eye contact with others. Strong lack of motivation. contact with others. Strong lack of motivation.

Unable to get out of bed, eat, or leave the house. Lack of energy and frequent crying.

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forces and instead look to things that can be observed, known, and measured as potential causes of events. Particularly in�u- ential in moving forward the �eld of abnormal psychology was Hippocrates (460–377 B.C.), a Greek physician known as the father of modern medicine. Hippocrates rejected demons and evil spirits as causes of abnormal behavior. He believed the brain was the central organ of the body and that abnormal behavior resulted from brain disorders or dysfunctions.

Hippocrates recommended treatments for abnormal behav- ior that would restore brain functioning, including special diets, rest, abstinence from alcohol, regular exercise, and celibacy. Hippocrates’ work had great impact on later Greek and Roman physicians. Throughout Greece and Rome, physicians empha- sized a scienti�c approach to learning about causes of abnormal behavior. Because of limited knowledge about human anatomy and biology—experimentation on humans and dissection of human cadavers was illegal—questionable practices such as bleeding and purging were employed. However, treatment of ab- normal behavior focused primarily on creating therapeutic envi- ronments that included healthy diets, regular exercise, massage, and education. These treatments remain good ideas even today.

Middle Ages The scienti�c aspects and advances of Greek medicine contin- ued in the Middle East. However, the fall of the Roman Empire brought a return to supernatural theories in Europe. Demon possession again became a prominent explanation of abnormal behavior, and treatment focused on prayer, holy objects or relics, pilgrimages to holy places, con�nement, and exorcism. A dramatic emergence of mass madness in Europe also appeared during the last half of the Middle Ages. Groups of individuals would be af�icted at the same time with the same disorder or abnormal behaviors.

An example of mass madness was a dancing mania in Italy known as tarantism. In tarantism, individuals became victims

mental health and disorders were often shaped by social, politi- cal, and economic forces. During times of political conservatism or economic hardship, for example, people tend to emphasize individual and physical causes of abnormal behavior as well as biological treatments such as psychosurgery and medication. During times of political liberalism or economic strength, people tend to emphasize environmental causes of abnormal behavior as well as psychological treatments or sociocultural approaches (Horowitz & Grob, 2011). In the next few sections, we exam- ine the development of abnormal psychology over time, which helps us understand modern-day attitudes and conceptualiza- tions of abnormal behavior as well as treatments.

Early Perspectives Early writings of the Egyptians, Chinese, Greeks, and Hebrews identify patterns of, and concerns about, treating abnormal behavior. Early theoreticians frequently attributed abnormal behavior to supernatural causes such as possession by demons or evil spirits. The behavior was viewed spiritually, so the pri- mary form of treatment was exorcism, or an attempt to cast out a spirit possessing an individual. Various exorcism techniques were used, including magic, noisemaking, incantations, prayer, �ogging, starvation, and medicinal techniques or potions. These techniques were designed to make a person an unpleasant, un- comfortable, or painful host for the spirit or demon. Another ancient technique, called trephination, involved cutting a hole in a person’s skull to help release a harmful spirit.

Early Greek and Roman Thought The development of medicine and medical concepts among Egyptians and Greeks helped replace ancient supernatural the- ories with natural ones. Natural theories reject supernatural

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Early treatments for mental disorder attempted to make a person an unpleasant, uncomfortable, or painful host for a possessive spirit or demon.

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Pinel’s reforms in France soon spread to other places. William Tuke (1732–1822) created the York Retreat in England and Benjamin Rush (1745–1813) encouraged humane treatment of people with mental disorder in the United States. Dorothea Dix (1802–1887) is credited with making the most signi�cant changes in treating those with mental disorder and in chang-

ing public attitudes about these conditions in America. She raised awareness, funds, and political support

and established more than 30 hospitals. The humane type of care emphasized during the

reform movement period, sometimes re- ferred to as moral treatment, paved the way for the modern approach to mental disorders.

Modern Era The modern approach to abnormal psychology includes accepting those with mental disorder as people who need professional attention; scien- ti�c, biomedical, and psychological methods are used to understand and treat mental disorder. Of special note

in this regard was the mental hy- giene movement that emerged from

Clifford Beers’s 1908 book, A Mind That Found Itself. In the book, Beers described Found Itself. In the book, Beers described Found Itself

his own experiences with mental disorder and his subsequent treatment in an institu- tion. His description of maltreatment while hospitalized sparked a mental health reform movement in the United States and later across the world. After his recovery, Beers

of a tarantula’s “spirit” after being bitten. The possession led to raving, jumping, dancing, and convulsions. Lycanthropy also developed in some groups; this is a belief that a person has been transformed into a demonic animal such as a werewolf. Another form of mass madness, St. Vitus’s dance, or rapid, un- coordinated jerking movements, spread to Germany and other parts of Europe. What caused these and other instances of mass hysteria remains unclear. One possibility is that people in highly emotional states tend to be suggestible. High levels of fear and panic may have led some to believe they had been “taken over” by an outside force or spirit and that these odd behaviors were contagious. Another possibility is that people inadvertently ate substances such as fungi on food that led to odd beliefs and visions.

Renaissance A rebirth of natural and scienti�c approaches to health and human behavior occurred at the end of the Middle Ages and beginning of the Renaissance. Once again, physicians focused on bodily functioning and medical treatments. In addition, Para- celsus (1490–1541), a Swiss physician, introduced the notion of psychic or mental causes for abnormal behavior and proposed a treatment initially referred to as bodily magnetism and later called hypnosis. Another new approach to treating mental disor- ders during the Renaissance involved special institutions known as asylums. Asylums were places set aside for people with mental disorder. Unfortunately, asylums were originally created simply to remove people with mental disorder from the general population because they were not able to care for themselves. As such, early asylums did not provide much treatment, and living con- ditions for residents were usually poor.

Reform Movement The conditions of asylums or men- tal hospitals in Europe and America were generally deplorable and in need of great change. A key leader of change was Philippe Pinel (1745–1826), who was in charge of a Paris mental hospital called La Bicêtre. Shocked by the living conditions of the patients, Pinel in- troduced a revolutionary, experimen- tal, and more humane treatment. He unchained patients, placed them in sunny rooms, allowed them to exercise, and required staff to treat them with kind- ness. These changes produced dramatic re- sults in that patients’ mental states generally improved and order and peace was restored to the hospital. Pinel later assumed charge of a similar facility, La Salpêtrière, and replicated changes and effects seen at La Bicêtre.

Philippe Pinel advocated more humane treatment of persons with mental problems.

Activist Dorothea Dix is credited with helping to reform treatment of persons with mental disorder in the United States.

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CHAPTER 1 Abnormal Psychology and Life14

2. -

Abnormal Psychology and Life: Themes

When we developed plans for this textbook, we wanted to take When we developed plans for this textbook, we wanted to take Wa speci�c approach to abnormal psychology. In particular, we wanted to focus on how abnormal psychology applies to your daily life. You will notice in the following chapters that we try to maximize the personal relevance of the textbook material. We also adopted several other themes for this book that are highlighted here, including a focus on dimensions of abnormal psychology as well as prevention. We hope you keep these themes in mind as you read, think about, and apply material we present in later chapters.

Dimensional Perspective You may recall we discussed dimensions, or a continuum, of emotions, thoughts, and behaviors that characterize mental dis- order. This theme is worth highlighting again because it is a core principle that guides our text. An important implication of a dimensional perspective is that research on emotions, thoughts, and behavior is relevant to all of us. Everyone, you may recall, feels anxious or sad at times—this is normal. When these nor- mal emotions or thoughts become frequent or severe, however, a mental disorder may be present. Many people are sometimes nervous about driving, especially in a new place. If a person is so anxious when driving that he or she cannot go to school, however, then the anxiety might be considered abnormal. A dimensional perspective thus involves the notion that people differ only in their degree of symptoms.

Prevention Perspective The average college student functions pretty well, but many students may be at some risk for mental dysfunction or dis- tress. Therefore, we emphasize prevention of mental disorder throughout this textbook. Prevention stems from the concept of mental hygiene, or the science of promoting mental health and thwarting mental disorder through education, early treatment, and public health measures. You may recall this approach was developed and promoted by Clifford Beers about a century ago. Prevention and mental hygiene have greatly in�uenced modern approaches to understanding and treating mental disorders.

We hope this emphasis on prevention will help you recog- nize symptoms of mental disorder, become aware of early warn- ing signs or risks for these problems, and take steps to prevent psychological distress in yourself or others. Risk and protective factors associated with speci�c mental disorders will be identi�ed in later chapters. We also present strategies for responding to, or coping with, these risk factors.

Clifford Beers’s autobiography recounted his experiences as a patient in a mental institution and helped launch the mental hygiene movement in the United States.

founded the Connecticut Soci- ety for Mental Hygiene in 1908 and the National Committee for Mental Hygiene in 1909. These groups were designed to improve quality of care for those with mental disorder, help prevent mental disorder, and disseminate information to the public about mental dis- order. These goals are just as relevant and important today as they were a century ago.

Several theoretical per- spectives were developed dur- ing the late 19th century and throughout the 20th century

to guide work on understanding and treating mental disorders. These perspectives include biological, psychodynamic, cognitive, behavioral, sociocultural, and other theories of abnormal behav- ior. Each perspective has important applications for determin- ing causes and appropriate treatments of mental disorder. These perspectives are somatogenic (emphasizing physical, bodily somatogenic (emphasizing physical, bodily somatogenic causes of behavior) and psychogenic (emphasizing psychologipsychogenic (emphasizing psychologipsychogenic - cal or mind-related causes of behavior). Major perspectives of abnormal behavior are presented in Chapter 2 in more detail.

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not yet developed a mental disorder. Health promotion efforts to reduce excessive substance use are one example. Other primary prevention examples include programs to reduce job discrimina- tion, enhance school curricula, improve housing, teach parent- ing skills, and provide educational assistance to children.

Secondary prevention involves addressing emerging problems while they are still manageable and before they be- come resistant to intervention. A good example of secondary prevention is early detection and treatment of college students with potentially damaging drinking problems. In this case, peo- ple at risk for a particular problem are addressed to prevent a full-blown disorder.

Finally, tertiary prevention involves reducing the sever- ity, duration, and negative effects of a mental disorder after it has occurred. Tertiary prevention differs from primary and sec- ondary prevention in that its aim is to lessen the effects of an already diagnosed disorder. Examples include various medical and psychological treatments for mental disorders. Throughout this textbook, we emphasize primary and secondary prevention in addition to treatments for already existing mental disorders.

Consumer Perspective Another major theme of this book is a consumer perspective. Our goal is to help you become a more informed consumer of scienti�c information on mental health that is often presented in the popular press. For example, recent reports suggest that certain antidepressant medications, in some highly publicized cases, increased suicidal thoughts and behaviors in children and

A prevention approach is consistent with a public health model that focuses on promoting good health and good health practices to avert disease. This model applies well to abnormal psychology. Different aspects of our lifestyles contribute greatly to poor physical and mental health and even death. Examples include poor diet and insuf�cient exercise, social isolation, and unhealthy interpersonal relationships. In addition, mental disor- ders discussed in this textbook have been linked to declines in physical health. Public health practitioners and researchers are thus motivated to address psychological health and functioning to improve overall quality of life.

In Chapter 3, we further discuss the important topic of pre- vention and how this concept applies to mental health. At this point, we brie�y discuss how prevention interfaces with the study of abnormal psychology. Historically, emphasis has been placed on treating mental disorder once it developed, and certainly this is an important focus. However, the �eld of abnormal psychology has advanced enough to allow the identi�cation of risk factors that help produce many mental disorders. This textbook presents what is currently known in this regard. Information about risk factors can also inform us about what makes someone vulner- able to psychological problems, what can be done to prevent symptoms of mental disorder, and what methods can be used to ameliorate these symptoms if they do develop.

Types of Prevention Three types of prevention are commonly considered within abnormal psychology. Primary prevention involves targeting large groups of people, sometimes the entire public, who have

has been thrust upon you. The logical extension of this viewpoint is that you have no personal responsibility for your problem. According to Salerno (2005), victimization dominated from the 1960s through the 1980s and is now manifested in a culture of blame—misfortunes are not your fault and society “owes you one.” Self-help books and programs that capitalize on victimization are successful because they make individuals feel less guilty about their problems. Conversely, the empowerment approach to self-help emphasizes that everything is under your control. In other words, you can do it—with willpower! This viewpoint has dominated American culture over the past decade and emphasizes building self-esteem. Just listen to an interview with an athlete (“If I just put my mind to it, I know we will win”) and witness the rising popularity of “life coaches.”

The potential harm caused by adopting these perspectives is that victim- ization may lead you to accept no personal responsibility, whereas empower-ization may lead you to accept no personal responsibility, whereas empower-ization may lead you to accept no personal responsibility, whereas empower ment may lead you to be overly con�dent in your abilities. Either perspective is likely to lead to problems and negative feelings. If you do not get better after adopting the self-help gurus’ prescriptions (which may have dubious value), victimization suggests you are still a slave to your problem or disease. On the other hand, empowerment suggests your “failure” re�ects a lack of desire or effort. You lose either way, and that must mean it is time for the next book, show, or program to �gure out why. Or not—you choose.

Focus on

We all try to help ourselves. In Western societies such as the United States, the notion of personal responsibility is common, even in the area of mental health. Imagine watching television, listening to the radio, or browsing in a bookstore without being exposed to advice from “Dr. So-and-So” (usually a �rst name!) about how to deal with family or relationship problems, stress, or some kind of drug, food, sex, or Internet ad- diction. But does advice from these so-called experts work? Some argue that the passive approach of the self-help movement should be paired with more active therapeutic strategies in many cases (L’Abate, 2011).

The self-help industry promotes victimization and empowerment. Victim- ization is the idea that your current state results from factors beyond your control. A common example is thinking about a problem as a “disease” that

Law and Ethics Heal Thyself: What the Self-Help

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CHAPTER 1 Abnormal Psychology and Life16

though their illness is no fault of their own. Such stigma can also apply to mental disorders. Children with a learning disorder are sometimes treated differently by teachers, and adults with social anxiety disorder are sometimes ridiculed by coworkers. Indeed, stigma is often associated with discrimination and social avoidance. Stigma is also a major reason why people do not seek treatment for mental distress (Clement et al., 2015). This is so alarming that public health programs are often designed to reduce the stigma associated with seeking treatment for psy- chological problems (Henderson, Evans-Lacko, & Thornicroft, 2013). In speci�c sections throughout the textbook, we discuss what may lead to stigma, the effects of stigma, and ways to com- bat stigma associated with particular mental disorders.

Stigma and mental disorder are aligned for various reasons. Stigma likely arises from a stereotype that people with a men- tal disorder are unpredictable, dangerous, violent, incompetent, or responsible for their own fate (Corrigan & Penn, 2015). As you read this textbook, however, you will see that these stereo- types are inaccurate and often based on infrequent and isolated events. The vast majority of people with a mental disorder are not much different from you or your classmates, as a dimen- sional approach to mental disorder suggests. People with mental disorder generally are not violent, unpredictable, incompetent, or to blame for their plight.

Stigma also occurs when government or other institutional policies negatively affect opportunities for people who may be seen as threatening, dangerous, or less deserving of support. One example of this structural stigma can be seen in state laws that limit health insurance coverage for mental health problems. Stereotypes and public misperceptions about mental disorder also come from the media via newspaper stories and editorials, television reports and shows, and movies (Corrigan, 2015). The media’s focus on negative aspects and consequences of mental disorder, whether accurate or not, promotes prejudice and dis- crimination. Conversely, media emphasis on well-being in men- tal health stories may help combat stigma (Kenez, O’Halloran, & Liamputtong, 2015).

Effects of Stigma Stigma affects people in different ways (Figure 1.4). One type of stigma is public stigma, which refers to the general disgrace the public confers on people with mental disorder that can result in prejudice, stereotyping, and discrimination. People with mental disorder, for example, may experience dif�culty securing employment, housing, and health care coverage. Pub- lic stigma can also hinder treatment of mental disorders by restricting opportunities for care and by limiting insurance bene�ts. Think about neighborhood complaints that arise when an agency wants to build a group home for people with intellec- tual disability (Chapter 13). In a sense, public stigma is a type of social injustice (Corrigan, 2015).

Another way stigma can affect people is self-stigma, which refers to disgrace people assign themselves because of public stigma (Corrigan, 2015). Some people adopt the public notion that a mental disorder is something to be ashamed of; this can affect self-esteem or cause an individual to deny a problem

adolescents. We hope material presented in Chapter 7 will in- form you about features of depression, how these features vary across age groups, and how these features can be treated using research-supported biological and psychological methods. We also hope to help you see through the media hype and under- stand the true nature of various disorders and their treatment.

Another goal as authors is to show how you can apply research-based information to your own life. Throughout this textbook, for example, you will �nd strategies for improving emotional regulation, intimate relationships, and coping abili- ties. Doing so is also consistent with the prevention theme we discussed earlier. We also present information on how mental disorders speci�cally relate to college students. In addition, some of you may have enrolled in this course because you are interested in certain mental health professions. Once you have learned about different mental disorders, Chapter 15 will help you navigate the �eld of mental health professions. Consistent with our consumer theme, we also present material in Chapter 15 about seeking a therapist should you ever decide to do so.

Diversity Diversity involves differences across males and females, people of assorted racial or ethnic backgrounds, and those with vari- ous sexual identities or orientations, among other groups. Great progress has been made in recent years with respect to under- standing how mental disorders vary across these groups. For example, we know that depression tends to be more common among women than men (Chapter 7) and that certain immi- grant populations of ethnic minority status are at increased risk for psychotic disorder (Chapter 12). Multicultural psychology refers to examining the effect of culture on the way people think, feel, and act (Hall, 2016). Multicultural psychology is important, among other reasons, for understanding what causes mental disorders and how to better and more speci�cally assess and treat mental disorders.

Diversity and multicultural psychology are important parts of this textbook. For each major mental disorder, we discuss group differences that have been reported by researchers. In ad- dition, we have special “focus on diversity” and “focus on gen- der” boxes throughout the textbook that further highlight cultural and gender differences. We also have detailed sections on cul- ture and the sociocultural model of mental disorder (Chapter 2), gender and race and culture as risk factors for mental disorder (Chapter 3), and culture and clinical assessment (Chapter 4). Our goal is to help you understand how cultural, gender, and other group variations in�uence the presentation, assessment, and treatment of mental disorders.

Stigma Another important aspect of this textbook, and one related to a dimensional perspective of abnormal behavior, is stigma. Stigma is a characterization by others of disgrace or reproach based on an individual characteristic. People with certain medi- cal disorders are sometimes shunned or rejected by others even

Finally, a unique feature of this textbook is use of narra- tives (like Alison Malmon’s narrative presented in this chapter). These features are �rst-person accounts of people who experi- ence and deal with symptoms of mental disorder in themselves or family members. Common themes throughout these narra- tives are that stigma directed toward those with mental disorder is inappropriate and that we all have a vested interest in advo- cating for those with mental disorder. We trust these accounts will be informative, make these conditions more personally rel- evant, and inspire all of us to advocate for the rights and needs of those with mental disorder.

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exists. Self-stigma can lead as well to damaging behaviors such as re- luctance to seek treatment. You can imagine that self-stigma is especially pertinent to children. Imagine a child who is told he has a learning disorder— how might this knowledge affect his motivation to work in the classroom? Others have found as well that sub- stantial personal stigma often prevents college students from seeking help for mental health issues (Cheng, Kwan, & Sevig, 2013).

Fighting Stigma Stigma can be fought in two key ways: education and promoting personal contact. Educational efforts to combat stigma range from distributing mate- rials that present factual information about mental disorder to online and di- rect courses regarding the truth about mental disorder (Corrigan, Morris, Michaels, Rafacz, & Rusch, 2012). Edu- cational efforts to combat stigma do have short-term effects on participants’ at- titudes, although less support is avail- able for long-term effects (Friedrich et al., 2013; Papish et al., 2013).

Promoting personal contact involves increased contact with someone with a mental disorder to dispel myths and stereotypes. Methods of promoting personal contact include encouraging volunteer activities in mental health settings and providing classroom experiences in which individuals whose lives are touched by mental disorder present their stories. These encounters have signi�cant effects on attitudes about mental disorder (Michaels et al., 2014). Indirect contact with mental health consumers via video has also been shown to reduce stigma and is part of the reason we developed many video case studies of persons with mental disorder in conjunction with this textbook (Nguyen, Chen, & O’Reilly, 2012).

This textbook strives to �ght stigma in several ways. First, by providing factual information about mental disorders, we hope to dispel many myths about them. Second, we empha- size that symptoms of mental disorders are present to some degree in all of us. Indeed, material in this textbook is likely to be personally relevant to your life or the lives of people you know because mental disorders are so prevalent. Third, we emphasize people �rst and mental disorders second. Through- out this book, we refer to people with schizophrenia (not “schizophrenics”), children with a learning disorder (not “the learning disabled”), and individuals with mental disorder (not “the mentally ill”). After all, if someone you know has can- cer, you would not call her a “cancer”! People should not be viewed by the disorder they have but by their own singular characteristics.

FIGURE 1.4 PUBLIC STIGMA AND SELF-STIGMA. Public stigma may lead some people to avoid the label of mental disorder by not seeking services that might be helpful. Self-stigma may lead people with mental disorder to feel incompetent and unworthy of help. (From Corrigan, P. How stigma interferes with mental health care. American Psychologist, 59, 614–625, Figure 1. Copyright © 2004 by the American Psychological Association. Reprinted by permission.)

Self-stigma

Stereotypes: “All people with mental illness are incompetent.”

Prejudices: “I have a mental illness, so I must be incompetent.”

Discrimination: “Why should I even get a job? I’m an incompetent mental patient.”

Public stigma

Stereotypes: “All people with mental illness are dangerous.”

Prejudice: “I agree, all people with mental illness are dangerous, and so I am afraid of them.”

Discrimination: “I don’t want to be near such people. Do not hire them at my job.”

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CHAPTER 1 Abnormal Psychology and Life18

➲ Review Questions 1.

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I was 18 years old when my world crumbled. Shortly after spring break in my freshman year of college, I got a call from my mother that for- ever changed our lives. “Ali, Brian shot him- self,” she said. “He’s dead.” Brian was my only sibling. Born 4 years and 4 days before me, he was an extraordinary child. He rose to the top of our high school, taking all Advanced Placement classes. He was captain of the debate team, soloist in the annual Rock and Roll Revival show, announcer for school football games, and a columnist for our local paper. He had friends, was smart and funny, and was my role model.

There was no question in Brian’s mind that he wanted to go to college in New York City—he had fallen in love with the city a few years earlier and was determined to one day own one of its infamous tall black buildings. So as I entered high school, Brian was on his way to Columbia University. Four years later, he had stormed Columbia just as he did in high school: He had joined an a cappella group and become

president. He was also a columnist for, and sports editor of, the Columbia daily newspa- per and the star of the school’s Varsity Music and Comedy show. In ad- dition, he was on the Dean’s List every semester, pursuing a political science degree with a strong focus on journalism, with plans to go on to law school.

So when Brian came home for a weekend in November of his senior year to “de-stress,” I wasn’t too surprised. But that weekend quickly turned into a week, a week into a month, and a month into the rest of the semester. Before I knew it, Brian was home for basically my entire senior year of high school. He began seeing a psychiatrist, and only then did we discover Brian was suffering from schizoaffec- tive disorder (Chapter 12) and had been since

February of his freshman year at Columbia. He had been hearing voices typical of schizophrenia and experienc- ing depressive episodes for

almost 3 years. He had been walking the streets at night, and

packing up his dorm room in boxes, because voices told him to. He had been sleeping days at a time and hated to leave

his dorm room because he was so depressed. But he never told anyone. In retrospect, his friends at school remember that he “sometimes went into a funk,” but no one ever confronted him about it.

By the time he sought help and came home, Brian had already lost hope. He suffered through what was supposed to be the best time of his life in pain, fear, and complete isolation; no matter how much therapy and medications he tried once he came home, the pain was too much to bear. During my freshman year at the

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Final Comments The goal of this chapter has been to introduce the �eld of abnormal psychology and important relevant concepts. Major de�nitions of abnormal psychology have advantages and disadvantages, and no gold standard exists to de�ne what is abnormal. However, each of these de�nitions taps an important facet of abnormal behavior that “rings true” to some extent. In addition, emotions, thoughts, behaviors, distress, and impairment from abnormal behavior are dimensional and thus present to some degree in all of us. As authors, we advocate the public health model as a viable and effective way to conceptualize, prevent, and treat mental disorders. Throughout this book, we emphasize themes of dimensionality of abnormal behavior, prevention of mental disorders, a consumer perspective, diversity, and stigma. We hope you �nd the material engaging and useful not just today but throughout your lifetime.

Alison Malmom

University of Pennsylvania, Brian took his own life. He was just 22.

I can’t even try to describe what it was, and continues to be, like since Brian’s death. I lost my big brother, my other half; I am now an only child. My family has been torn apart and our entire fabric has had to be rewoven as well as we know how. A loss to suicide is truly some- thing only other suicide survivors can under- stand. I live every day with the “what ifs?”—the guilt, and the devastation. The unbearable pain has lessened and I am able to get through each day a little easier, but my life will never be the same. Brian was such a promising young man with so much of his life ahead of him. I simply feel sad for anyone whose life he did not have the chance to touch.

When Brian �rst died, one of the most sa- lient emotions I felt was fear. I became scared thinking that, had I been in his situation and began suffering from a mental disorder in col- lege, I probably would have done exactly what Brian had. I would have felt responsible, kept

me. But you can get help for what you’re going through, and you can feel better.”

This idea of education and discussion to reduce stigma was extremely well supported at my school and within the mental health com- munity. Just 18 months after starting that group at Penn, I formed my own nonpro�t organiza- tion with the goal to introduce this concept to young adults nationwide. I now work full time as the executive director of the organization Active Minds, Inc., developing and supporting chapters of Active Minds at high schools and colleges around the country, and helping to give a voice to young adults in this �eld. Every time a young person shares her story, or con- centrates his energy to combat stigma he has encountered, our voice is strengthened.

I would give anything to have my brother Brian back with me today. But since I can’t, I will do everything in my power to ensure no other young adult has to suffer in silence like he did, and no other sister has to lose her big brother to suicide.

my symptoms to myself, and suffered in si- lence. Nobody was talking about mental health issues on my campus; no one was educating students about signs and symptoms of various disorders, where they could get help, and that they could get better. The stigma surrounding the issues was causing too many people to suf- fer in shame and isolation. And I knew that if I would have kept quiet like Brian did, too many of my peers were also suffering in silence.

So I formed a campus group called Ac- tive Minds (www.activeminds.org) to educate my peers about these issues and get people talking. With more young adults talking, shar- ing what they and their family and friends had gone through, we would break down walls of silence and more of my peers might feel com- fortable getting help they deserved. We were the ones suffering. We were the ones watching our friends suffer. It was time for young adults to be engaged in and educated about mental health issues and to tell each other: “This can happen to you. I know, because it happened to

personal narrative

Key Terms mental disorder 4 abnormal psychology 4 maladaptive behavior 6 psychopathologists 8 trephination 12 exorcism 12

mass madness 12 asylums 13 mental hygiene movement 13 public health model 15 primary prevention 15 secondary prevention 15

tertiary prevention 15 multicultural psychology 16 stigma 16 public stigma 16 self-stigma 16

Used with permission

Special Features

• 2.1 A More Complex Approach

• 2.2 Dangerousness and Commitment

• 2.3 A More Complex Approach

Personal Narrative 2.1 An Integrative Psychologist: Dr. John C. Norcross

C / What Do You Think?

Introduction

The Biological Model

The Psychodynamic Model

The Humanistic Model

The Cognitive-Behavioral Model

The Sociocultural Model

FINAL COMMENTS

KEY TERMS

CHAPTER 2 Perspectives on Abnormal Psychology22

food. Mental health professionals use models to help explain unusual behavior or mental disorders in people like Mariella. Five main models to explain mental disorders are described in this chapter:

• The biological model focuses on genetics, neurotransmit- ters, brain changes, and other physical factors.

• The psychodynamic model focuses on internal personality characteristics.

• The humanistic model focuses on personal growth, choice, and responsibility.

• The cognitive-behavioral model focuses on speci�c thoughts and learning experiences.

• The sociocultural model focuses on external environmental events and includes the family systems perspective.

Introduction

If Mariella had lived centuries ago, demonic possession might have been a common explanation for her problems. Scientists and mental health professionals today, however, focus on a per- son’s biology, environment, and other factors to help people like Mariella. Scientists and mental health professionals develop perspectives or models—ways of looking at things—to piece together why someone like Mariella has problems.

Perspectives or models are systematic ways of viewing and explaining what we see in the world. When you try to explain high prices for an item, you might think about the economic model of supply and demand to conclude everyone wants the item but supplies are limited. Or if a friend of yours is sick, you might think about the disease model of germ theory to ask whether she was around a sick person or if she ate spoiled

Mariella, a 19-year-old college freshman, has been repeatedly asking herself, “What’s going on?” and “What should I do?” Something was not right. Mariella was outgoing, bright, and cheery in high school but was now fatigued, blue, and pessimistic in college. She was start- ing her second semester and thought the tough college adjustment period her friends and family talked about should be over by now. Were her feelings of fatigue and discontent just a tempo- rary “funk,” or was something seriously wrong?

Mariella’s fatigue and discontent began early in her �rst semester and worsened toward �nals week. She enrolled in �ve courses and was soon overwhelmed by extensive reading assignments, large classes, and fast-approaching deadlines. She struggled to �nish her work, often seemed isolated from others, and felt unimportant in the huge academic setting. Mariella believed no one cared whether she was in class, and she longed for days in high school when she interacted with a close-knit group of teachers and friends. Her college professors seemed to treat her like a number and not a student, and her classmates always seemed to be rush- ing about with little time to talk.

Mariella was an “A” student in high

school but was now struggling to get Cs in her college classes. She had great trouble concen- trating on what she read, which led to low test scores. Mariella did talk to her friends and fam- ily members back home about her troubles, but no one truly understood what she was going through. Instead, they thought Mariella was experiencing simple, normal homesickness that would soon end.

Mariella began spending more time alone as her �rst semester approached mid-November. She often slept, watched television, listened to music, and went online. She no longer found much enjoyment doing things that used to ap- peal to her, such as going to the movies and playing the guitar. Mariella declined invitations from others to go out, and her roommate noticed that Mariella seemed sad and lonely. Unfortu- nately, no one took the time to ask Mariella if something serious might be wrong.

Mariella also lost signi�cant weight her �rst semester. When she went home for Thanksgiving, her family

members were surprised at how she looked. Mariella had noticed no

major change except for oc- casional hunger, but in fact

she had lost 10 pounds from her 120-pound

frame. Unfortunately, she received �attering

comments on how she looked, so the larger prob- lem of her sad mood went undetected. Her con- centration and eating problems continued when she returned to school to �nish her �rst semester, and Mariella struggled to �nish her �nal examina- tions and receive passing grades.

Mariella was happy to return home for the winter break and hoped her feelings of fatigue and discontent were simply related to school. Unfortunately, she remained sad, did not regain lost weight from the previous semester, and con- tinued to sleep much of the day. She dreaded returning to school but felt pressure from oth- ers to do so. Mariella became quite despondent when she returned to school in mid-January. She knew something would have to change to endure this second semester, but she felt con- fused and unsure. Once again she was asking, “What’s going on?” and “What should I do?”

What Do You Think? 1. Why do you think Mariella feels the way

she does? 2. What should Mariella do? What would you

do if in her situation? 3. Which aspects of Mariella’s story concern

you most? 4. Do you know people who have had similar

experiences? What did they do? 5. What should Mariella’s friends and family

do to help?

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are commonly described within the syndrome of depression (Chapter 7). Kraepelin believed, as do many psychiatrists and other mental health professionals today, that syndromes and symptoms have biological causes. Kraepelin proposed two major types of mental disorders, each with different biological causes: dementia praecox (similar to schizophrenia, discussed in Chapter 12) and manic-depressive psychosis (similar to bipo- lar disorder, discussed in Chapter 7).

Kraepelin also believed syndromes to be separate from one another, like mumps and measles, and that each syndrome has unique causes, symptoms, and outcomes. In Mariella’s case, her symptom of sadness seemed partly caused by her separation from home and led to outcomes such as poor grades. Kraepelin and many psychiatrists also believe each syndrome has its own biological cause. A psychiatrist may feel Mariella’s sadness was caused by depression that ran in her family (genetics), by a chemical (neurotransmitter) imbalance, or by some brain change. We discuss these biological causes next.

Genetics Do you think Mariella’s sadness may have been present as well in some of her family members? Many mental disorders such as depression do seem to run in families. Genetic material may be involved when symptoms of a mental disorder are passed from parents to children. Genetic material refers to molecular “codes” contained in the nucleus of every human cell (Ahuja, 2014). Genes are the smallest units of inheritance that carry informa- tion about how a person will appear and behave. Genes carry information about hair and eye color, weight and height, and even vulnerability to diseases such as lung cancer or mental disorders such as depression. Human genes are located on 46 chromosomes or threadlike structures arranged in 23 pairs.

A person’s chromosomes come half from the biological mother and half from the biological father.

The genetic composition of a person is known as a genotype and is �xed at birth. Genotypes produce characteristics such as eye color that do not change over time. An observ- able characteristic of a person is known as a phenotype, which can change over time. Observable characteristics can include in- telligence, as well as symptoms of a mental disorder such as dif�culty concentrating. Phe- notypes can change because they result from genetic and environmental in�uences. Your intelligence is partly determined by genetics from your parents but also by the type of edu- cation you received as a child. Scientists are interested in knowing which genetic and en- vironmental in�uences impact the develop- ment of emotions, cognitions, and behavior (O’Connor, 2014). This research specialty is known as behavior genetics.

Behavior geneticists are interested in the degree to which a mental disorder is

These models dominate the mental health profession today and in�uence the way we think about, assess, and treat mental disorders (see Figure 2.1). Each model has strengths and weak- nesses, but each provides mental health professionals with ways of understanding what is happening to someone like Mariella. In this chapter, we show how each model could be used to explain Mariella’s problems and help her. Many mental health profes- sionals also integrate these models to study and explain mental disorders.

The Biological Model

The biological model rests on the assumption that mental states, emotions, and behaviors arise from brain func- tion and other physical processes. This model has been in use for centuries and is stronger than ever today. Read a newspaper or magazine, watch television, or go online—countless articles, documentaries, and advertisements are avail- able about medications and other substances to treat mental conditions. Some drug or herb always seems available to cure depression, anxiety, or sexual dysfunction. Despite the incessant advertising, however, the biological model of mental disorder, including the use of medications, is supported by scienti�c re- search that links genetics, neurochemistry, and brain changes to various psychological problems.

The biological model of mental dis- order was pioneered by Emil Kraepelin (1856–1926), who noticed various syn- dromes or clusters of symptoms in people. Mariella had a cluster of symptoms that included concentration problems, oversleep- ing, sadness, and weight loss. Her symptoms

Model explains

Causes of mentalCauses of mental disordersdisorders

Assessment of mentalAssessment of mentalAssessment of mentalAssessment of mental disordersdisorders

Prevention and treatment of mental disordersof mental disorders

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Emil Kraepelin is considered by many to be the father of psychiatric classi�cation and a key contributor to the biological model.

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FIGURE 2.1 THE USE OF MODELS. Models or perspectives affect the way we think about causes of mental disorder, our methods of assessment, and our methods of prevention and treatment.

CHAPTER 2 Perspectives on Abnormal Psychology24

Nervous Systems and Neurons Physical structures in our body are affected by genetics, and this can contribute to mental disorder. The central nervous system includes the brain and spinal cord and is responsible for pro- cessing information from our sensory organs such as eyes and ears and prompting our body into action. The peripheral ner- vous system helps control muscles and voluntary movement, regulates the cardiovascular and endocrine (hormone) systems, assists with digestion, and adjusts body temperature. The ner- vous systems are composed of billions of neurons, or nerve cells, that have four major components: cell body, dendrites, axon, and terminal buttons (see Figure 2.3).

A small gap called the synapse exists between neurons. Neurons communicate with each other using neurotransmit- ters, or chemical messengers that allow information to cross the synapse. Not all neurotransmitters released into the synapse are used, so an unused neurotransmitter is reabsorbed and recycled in a process called reuptake. Medications in�uence neurotrans- mitter systems to treat mental disorders. Medications may block synapses to decrease neurotransmitter levels or block reuptake to increase neurotransmitter levels. People with depression of- ten take drugs such as Prozac or Paxil to increase availability of certain neurotransmitters for improved energy and mood. Six major neurotransmitters are discussed throughout this textbook: serotonin, norepinephrine, dopamine, gamma-aminobutyric acid (GABA), acetylcholine, and glutamate. Table 2.1 lists func- tions associated with each.

Brain The brain is our most complex and important organ and com- prises about 86 billion neurons (Lent, Azevedo, Andrade-Moraes, & Pinto, 2012). The brain consists of two cerebral hemispheres that are mirror images of each other. The right hemisphere conright hemisphere conright hemisphere - trols movement for the left side of the body, in�uences spa- tial relations and patterns, and affects emotion and intuition. The left hemisphere controls movement for the right side of the left hemisphere controls movement for the right side of the left hemisphere body, in�uences analytical thinking, and affects grammar and

determined by genetics. Heritability refers to the amount of variation in a phenotype attributed to genetic factors, often expressed as a number ranging from 0 to 1. Some mental dis- orders such as anxiety-related disorders have modest heritabil- ity, but many major mental disorders have more substantial genetic in�uences in their development (see Figure 2.2). Disorders with particularly high heritability include bipolar disorder and schizophrenia (Pearlson, 2015).

Behavior geneticists also focus on what speci�c genes are inherited and how these genes help produce a mental disorder. Researchers in the �eld of molecular genetics analyze deoxy- ribonucleic acid (DNA)—the molecular basis of genes—to iden- tify associations between speci�c genes and mental disorders. Molecular genetics is quite challenging for several reasons. First, most mental disorders are in�uenced by multiple genes, not just one. When you hear a media report that researchers found a gene for Alzheimer’s disease, keep in mind they likely found only one of many genes. Second, the same symptoms of a mental disorder may be caused by different genes in differ- ent people. Third, it is estimated that there are about 20,000 to 25,000 human protein-coding genes, so �nding speci�c ones related to a certain disorder is like �nding a needle in a haystack. Despite these challenges, advances in molecular genetics will likely lead to �ndings that help scientists deter- mine how and if disorders are genetically distinct from one another. Knowledge of speci�c genes can also help researchers determine how genes in�uence physical changes in the body, which we discuss next.

.34

Major depression

Bipolar disorder

Anxiety- related

disorder

Substance use disorder

Schizo- phrenia

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Terminalrminal buttonbuttonFIGURE 2.2 HERITABILITY OF MAJOR MENTAL DISORDERS. Adapted

from Merikangas, K.R., & Risch, N. (2005). Will the genomics revolution revolutionize psychiatry? In N.C. Andreasen (Ed.), Research advances in genetics and genomics: Implications for psychiatry (pp. 37-61). Washington, DC: American Psychiatric Publishing; Kendler, K.S., Chen, X., Dick, D., Maes, H., Gillespie, N., Neale, M.C., & Riley, B. (2012). Recent advances in the genetic epidemiology and molecular genetics of substance use disorders. Nature Neuroscience, 15, 181-189.

FIGURE 2.3 BASIC PARTS OF A NEURON. Adapted from Josephine F. Wilson, Biological foundations of human behavior, Fig. 2.6, p. 30. Reprinted by permission of the author.

Biological Assessment and Treatment How can knowledge about genetics, neurotransmitters, and brain changes be used to evaluate and treat people with mental disor- ders? A biologically oriented mental health professional such as a psychiatrist would �rst give a diagnostic interview (Chapter 4) to better understand a person’s problems. Biologically oriented health professionals also use assessment methods to obtain images of brain structure and functioning. Magnetic resonance imaging (MRI) provides high-quality brain images to reveal tuimaging (MRI) provides high-quality brain images to reveal tuimaging - mors, blood clots, and other structural abnormalities. Figure 2.5 (page 28) compares MRI images of a youth with autism to a youth without autism. Other methods for brain imaging are described in Chapter 4.

Biologically oriented mental health professionals decide on treatment once a comprehensive evaluation is complete. Psychiatric medications are commonly used to treat mental disorders by affecting neurotransmitter systems. Medica- tions that decrease dopamine generally have antipsychotic effects to ease symptoms of schizophrenia. Medications that increase norepinephrine or serotonin often have antidepres- sant effects. Medications that increase GABA often have antianxiety effects.

Evaluating the Biological Model The biological model is respected because genetics, neu- rotransmitters, and brain areas clearly in�uence problems such as anxiety (Chapter 5), depression and bipolar disor- der (Chapter 7), schizophrenia (Chapter 12), intellectual disability and autism (Chapter 13), and Alzheimer’s disease (Chapter 14). Findings from this model have led to better knowledge about which genes are inherited, how neurotrans- mitter effects and medications can help treat mental disorder, and how brain changes over time lead to abnormal behavior. The biological perspective comprises much of the material in this textbook.

The biological perspective also has some limitations. First, biological factors do not provide a full account of any form of mental disorder. Some disorders have substantial genetic contributions, such as schizophrenia or bipolar disorder, but environmental or nonbiological factors are clearly in�uential as well. An exclusive focus on biological factors would also deny crucial information about cultural, family, stress, and other factors that in�uence all of us. Second, we do not know yet exactly how biological factors cause mental disorder. We can only say biological changes appear to be signi�cant risk factors for mental disorder. Biological risk factors also clearly interact with environmental risk factors, as we discuss through- out this textbook.

➲ Interim Summary •

vocabulary. The two hemispheres do communicate with each other, however. Complex behaviors such as playing a piano or using language are in�uenced by both hemispheres.

The cerebral cortex covers much of each hemisphere and is largely responsible for consciousness, memory, attention, and other higher-order areas of human functioning. The brain itself is divided into four main lobes (see left side of Figure 2.4). The frontal lobe is in the front portion of the brain and has many important functions such as movement, planning and organi- zation, inhibiting behavior or responses, and decision making. The frontal lobe is thus a central focus of many mental health researchers. The parietal lobe is behind the frontal lobe and is associated with touch. The temporal lobe is at the base of the brain and is associated with hearing and memory. The occipital lobe is behind the parietal and temporal lobes and is associated with vision.

The brain may also be organized along the forebrain, mid- brain, and hindbrain. The forebrain contains the limbic system (see right side of Figure 2.4), which regulates emotions and impulses and controls thirst, sex, and aggression. The limbic sys- tem is important for several mental disorders and is composed of the hippocampus, cingulate gyrus, septum, and amygdala. Farther down the forebrain, the basal ganglia help control pos- ture and motor activity. The thalamus and hypothalamus are at the crossroads of the forebrain and midbrain and relay informa- tion between the forebrain and lower brain areas. The midbrain also contains the reticular activating system, which is involved in arousal and stress or tension. The hindbrain includes the medulla, pons, and cerebellum. These structures are involved in breathing, heartbeat, digestion, and motor coordination.

TABLE 2.1

Major Neurotransmitter Systems Associated with Mental Disorders

Neurotransmitter system Functions

Serotonin Processing of information; regulation of mood, behavior, and thought processes

Norepinephrine Regulation of arousal, mood, behavior, and sleep

Dopamine In�uences novelty-seeking, sociability, pleasure, motivation, coordination, and motor movement

Gamma-aminobutyric acid (GABA)

Regulation of mood, especially anxiety, arousal, and behavior

Acetylcholine Important in motor behavior, arousal, reward, attention, learning, and memory

Glutamate In�uences learning and memory

CHAPTER 2 Perspectives on Abnormal Psychology26

• --

•

ParietalParietal lobelobe

Central fissure

Temporal lobe

FrontalFrontal lobelobe

Insula (embedded under surface)

LateralLateral fissufissure

Occipital lobe

Left hemisphere Right

hemispherehemisphere

Central fissure

Frontal lobeFrontal lobe Longitudinal fissure

Parietal lobe

OccipitalOccipital lobelobeCortexCortex

Subcortical tissue

Fissure

Lateral view Superior view

Transverse section through the cerebral cortex

Central �ssure

Cerebellum

Cerebral cortex

Frontal lobe

Hemisphere (left)

Hemisphere (right)

Lateral �ssure

Longitudinal �ssure

Occipital lobe

Parietal lobe

Prefrontal cortex

Subcortical tissue

Temporal lobe

Deep valley in the cerebral cortex that divides the frontal lobe from the rest of the brain

Located within the hindbrain; coordinates muscle movement and balance

Outer-most layer of the brain. Covers almost all of each hemisphere of the brain; referred to as the grey matter of the brain (named after its characteristic coloring).

Located in the front of the brain (in front of the central fissure). The frontal lobe is the seat of a number of very important functions, including controlling movement, planning, organizing, inhibiting behavior or responses, and decision-making.

Controls the right half of the body, is typically responsible for analytic thinking, and is responsible for speech

Controls the left side of the body, is involved in the determination of spatial relations and patterns, and is involved in emotion and intuition

Deep valley in the cerebral cortex that is above the temporal lobe

Deep valley in the cerebral cortex that divides the left and right hemispheres of the brain

Located behind the parietal and temporal lobes of the brain; associated with vision

Located behind the frontal lobe of the brain and above the lateral fissure; associated with the sensation of touch.

Controls attention and impulse control; used in problem solving and critical thinking

Brain tissue immediately below the cerebral cortex

Located below the lateral fissure of the brain; associated with auditory discrimination.

Structure Location and Description

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FIGURE 2.4 MAJOR FEATURES OF THE HUMAN BRAIN.

➲ Review Questions 1.

Amygdala

Basal ganglia

Corpus callosum

Hindbrain

Hypothalamus

Hippocampus

Limbic system

Medulla

Pituitary gland

Pons

Reticular formation

Spinal cord

Thalamus

Structure in the limbic system that is involved in emotion and in aggression

Brain structures that control posture, motor activity, and anxiety level

A band of nerve fibers that connects the two hemispheres of the brain, allowing for communication between the right and left sides of the brain.

Most posterior part of the brain; includes the medulla, pons, and cerebellum; these structures are involved in important “automatic” activities of the body like breathing, heartbeat, and digestion. In addition, the cerebellum controls motor coordination.

Regulates basic biological needs like hunger, thirst, and body temperature

Part of the limbic system involved in memory and learning

Regulates emotions and impulses, and is also responsible for basic drives like thirst, sex, and aggression. The limbic system consists of several structures that are implicated in psychological disorders: the hippocampus, cingulate gyrus, septum, and amygdala.

Located in the hindbrain; involved in regulating breathing and blood circulation

Regulates other endocrine glands and controls growth; sometimes called the “master gland.”

Located in the hindbrain; involved in sleep and arousal

Internal structures within the midbrain that are involved in arousal and stress or tension

Transmits information between the brain and the rest of the body; controls simple reflexes

Relay signals to and from the cerebral cortex to other brain structures

Structure Location and Description

HypothalamusHypothalamus

Sagittal view

Limbic system

Corpus callosumcallosum

Basal ganglia Thalamus

CerebellumCerebellum

Spinal cordSpinal cord Medulla

ReticularReticular formationformation

Pons

Pituitary glandPituitary gland

Cingulate gyrusCingulate gyrus

Thalamus

Hypothalamus

Mamillary body

Amygdala

Hippocampus

Olfactory bulbOlfactory bulb

FIGURE 2.4—cont’d

CHAPTER 2 Perspectives on Abnormal Psychology28

contributions to the mental health �eld; its in�uence permeates our culture. Psychodynamically oriented words or phrases such as ego, unconscious, and Freudian slip have become part of our common vernacular. You may have even come across aspects of Freudian thought in art, literature, �lms, and textbooks.

Several basic principles comprise the psychodynamic per- spective (Gabbard, 2014). One basic principle is that childhood experiences shape adult personality. The belief that childhood development in�uences adult behavior is almost universally ac- cepted. You can likely identify certain childhood experiences that shaped who you are today. You are a product of your biology, youthful experiences, and events happening now. Ignoring any of these factors means we lose much information about your personality and history with others. Imagine if we focused only on Mariella’s problems for the past few months—we would lose other information, such as her high school experiences that may in�uence her current symptoms.

A second key principle of the psychodynamic perspective is that causes and purposes of human behavior are not always obvi- ous but partly unconscious. Unconscious means the part of the mind where mental activity occurs but of which a person is un- aware. Scientists in disciplines such as neuroscience have found that certain mental and behavioral processes do not appear to be under cognitive control (MacDonald, Naci, MacDonald, & Owen, 2015). The implication is that realms of emotion, cogni- tion, and behavior exist of which we are not consciously aware. These hidden realms of emotion, thought, and behavior may also affect motives that drive us to act in certain ways. This is known as unconscious motivation. Healthy behavior is considered behavior for which a person understands the motivation (do you know why you are doing what you are doing?). Un- healthy behavior results when we do not fully understand the

The Psychodynamic Model

The biological model focuses on internal physical structures related to mental disorder. The psychodynamic model also focuses on internal structures but mental ones rather than physi- cal. The psychodynamic model comes from Freudian theory that assumes mental states and behaviors arise from motives and con�icts within a person. The term intrapsychic refers to intrapsychic refers to intrapsychic psychological dynamics that occur within a person’s mind, so this term is often used to describe the psychodynamic model. The psychodynamic model represents one of the most sweeping

FIGURE 2.5 MRI SCANS FROM THE CEREBELLAR AREAS OF A 16-YEAR-OLD BOY WITH AUTISM (A) AND A 16-YEAR-OLD BOY WITHOUT AUTISM (B). Note the somewhat smaller cerebellar area in the youth with autism, which may contribute to abnormal motor movements and cognitive impairments often seen in people with autism. From Palmen, J.M.C., van Engeland, H., Hof, P.R., & Schmitz, C. 2004. Neuropathological �ndings in autism. Brain, 127, 2572-2583.

and social problems, which can lead to association with deviant peers in middle or high school. If parents’ supervision declines during this time, then the child may not develop adequate social skills to control anger and aggression. In this scenario, many contributing factors are involved, including biological, psychological, and social factors (Hyde, Shaw, & Hariri, 2013).

A more in-depth approach may be necessary to explain forms of vio- lence in adulthood as well. Intimate partner violence is a signi�cant problem among college students but one that cannot be fully explained just by learn- ing or sociocultural factors. One group of researchers examined college stu- dents in dating relationships who recorded daily instances of interpersonal violence and other behaviors. Students were much more likely to engage in physical or psychological interpersonal violence on days they were drinking alcohol, using marijuana, or were more angry, hostile, or irritable (negative affect). The study also revealed that multiple factors can interact in various ways to in�uence different kinds of violence. For example, number of alco- holic drinks consumed in addition to negative affect was most closely related to physical violence (Shorey, Stuart, Moore, & McNulty, 2014).

Focus on

Violence and aggression are complex behaviors that cannot necessarily be explained by single models such as a biological one. Instead, a more complex and developmental approach is often needed. One example is aggression in adolescents with delinquent behavior or conduct disorder (Chapter 13). Some youth have certain biological qualities that may pre- dispose them to conduct problems such as aggression, although not all youth with these qualities necessarily become aggressive. Those who are more likely to become aggressive tend to experience harsh parental dis- cipline, emotional neglect, lack of teaching from parents, and con�icts with aggressive peers. These experiences then interact with academic

Violence A More Complex Approach

2.1

as soon as possible. This process is the pleasure principle. The id propels us to meet demands of hunger, thirst, aggression, or sexual or physical pleasure as soon as possible. The id is thus hedonistic and without values, ethics, or logic. Think about a baby who cries when she wants something and does not want to wait for it. Babies, and maybe even some adults you know, have “id-oriented” personalities.

The id uses a primary process form of thinking if grati�ca- tion is not immediate—this involves manufacturing a fantasy or mental image of whatever lessens the tension. You might want to date someone but are convinced he or she will reject your invitation, so you simply fantasize about being with that person. Or you might think about food when you are hungry. Dream- ing is also a form of primary process. Primary processes cannot provide real grati�cation such as a date or food, however, so we must develop a second personality structure to help us address real-life demands—the ego.

The ego is an organized, rational system that uses higher- order thinking processes to obtain grati�cation. The ego is the executive of the personality and operates along the reality prin- ciple, or need to delay grati�cation of impulses to meet environ- mental demands. If you badly want an iPad, then your id might urge you to steal one. This would land you in trouble, however, so the ego tries to mediate demands of the id and demands of the environment. The ego uses secondary process to do this. Secondary process involves learning, perception, memory, plan- ning, judgment, and other higher-order thinking processes to plan a workable strategy. The ego might plan to schedule some overtime shifts at work so you can earn extra money to buy the iPad. The id thus receives what it wants eventually but in a socially acceptable way. A strong ego is often considered by psychodynamic theorists to be the hallmark of mental health.

unconscious causes of our behavior. The goal of psychodynamic therapy is thus to make the unconscious more conscious.

A third key principle of the psychodynamic perspective is that people use defense mechanisms to control anxiety or stress. Defense mechanisms are strategies to cope with anxiety or stressors such as con�ict with others. Psychodynamic theorists believe most humans can adapt to challenges and stressors by using healthy defense mechanisms. Some people with a mental disorder over-rely on less effective defense mechanisms, or de- fense mechanisms do not work well for them and they become quite stressed.

A fourth key principle of the psychodynamic model is that everything we do has meaning and purpose and is goal-directed. This is known as psychic determinism. Mundane and bizarre behavior, dreams, and slips of the tongue all have signi�cant meaning in the psychodynamic model. Behaviors may in fact have different meanings. Think about Mariella’s weight loss: Was her behavior motivated by a simple desire to lose weight, or was it a signal to others that she needed help?

Brief Overview of the Psychodynamic Model We now provide an overview of the major concepts of the psy- chodynamic model. This includes a description of the structure of the mind, as well as an explanation of psychosexual stages and defense mechanisms.

Structure of the Mind A major component of the psychodynamic model of personal- ity and mental disorders is structure of the mind. According to Freud and other psychodynamic theorists, the mind (and hence personality) is composed of three basic structures in our un- conscious: id, ego, and superego (see Figure 2.6). The id is the portion of the personality that is present at birth. The purpose of the id is to seek immediate grati�cation and discharge tension

Superego Ego

Guiding principle: morality Tasks: develop conscience; block id impulses

Guiding principle: realityGuiding principle: reality Tasks: mediate demands ofTasks: mediate demands of id and superego; cope id and superego; cope id and superego; cope with r with real world

Guiding principle: pleasure Tasks: attain gratifTasks: attain gratifTasks: at ication of wants, needs, and impulses

The roots of the psychodynamic model can be traced back to the life and times of the Viennese physician Sigmund Freud (1856–1939).

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FIGURE 2.6 FREUD’S STRUCTURE OF THE MIND. Adapted from Rathus, Psychology: Concepts and Connections, 9th ed., Fig. 11.1, p. 402. Copyright © 2005 Wadsworth, a part of Cengage Learning. Reproduced by permission. www.cengage.com/permissions.

CHAPTER 2 Perspectives on Abnormal Psychology30

anal stage may compensate in adulthood by being overly neat or compulsive. A psychodynamic theorist might say Mariella’s basic needs of nurturance and safety were unsatis�ed during her oral stage of development, and so she remained �xated at this stage. Her depression may thus be a signal to others that she craves social attention and comfort.

Defense Mechanisms The ego experiences anxiety when the id urges it to seek im- pulsive grati�cation or when the superego imposes shame and guilt. Anxiety is a painful emotion that warns the ego to quell the threat and protect the organism. The ego uses secondary processes of memory, judgment, and learning to solve problems and stave off external threats. But these measures are less useful when internal threats arise from the id or superego. What then? The ego has at its disposal various tactics called defense mecha- nisms, which are unconscious mental processes used to fend off con�ict or anxiety.

We all use defense mechanisms, such as when we claim we did not really want to date someone who just turned down our invitation. Use of defense mechanisms becomes a problem, however, when we use them excessively or when we use a se- lect few defense mechanisms exclusively. If we constantly deny reality and continue to ask out people who are likely to reject us, then we may get depressed. Moderation and variety are im- portant for mental health, including use of defense mechanisms.

Table 2.3 lists many defense mechanisms proposed by psy- chodynamic theorists. Let’s discuss some of the primary ones. Repression is a basic ego defense that occurs when a person banishes from consciousness threatening feelings, thoughts, or impulses, like a strong sexual desire for a stranger. Regression involves returning to a stage that previously gave a person much grati�cation—think of a middle-aged man under stress who be- gins to act as if he were a teenager. Reaction formation occurs when an unconscious impulse is consciously expressed by its behavioral opposite. “I love you” is thus expressed as “I hate you,” a phenomenon common among tweens who like some- one but who are afraid of rejection. Projection occurs when unconscious feelings are attributed to another person. A spouse who feels guilty about cheating on her husband may accuse her husband of in�delity.

Psychodynamic Assessment and Treatment Psychodynamic theorists believe symptoms of mental disorders are caused by unresolved con�icts. A psychodynamically ori- ented therapist treating Mariella’s depression might explore a history of loss, such as loss of important relationships. Mariella’s relationships with friends and family at home were indeed affected by attending college. Psychodynamic theorists also be- lieve we unconsciously harbor anger and resentment toward those we love. Mariella may have been unconsciously jealous of, and angry at, her friends and family members who did not move far away and who did not fully appreciate her problems in college. Perhaps she internalized feelings of resentment by directing the feelings toward herself—anger turned inward.

The third component of the personality is the superego. The superego develops in early childhood and represents soci- etal ideals and values conveyed by parents through rewards and punishments. The superego is essentially one’s sense of right and wrong. Punished behavior becomes part of one’s conscience, and rewarded behavior becomes a part of one’s ego ideal. The conscience punishes individuals by making them feel guilty or worthless for doing something wrong, whereas the ego ideal rewards individuals by making them feel proud and worthy for doing something right. The role of the superego is to block unac- ceptable id impulses, pressure the ego to pursue morality rather than expediency, and generate strivings toward perfection. Your superego might punish you by using guilt, shame, and worry if you decide to steal an iPad.

Freud’s Psychosexual Stages Not all psychodynamic theorists adhere strictly to Freudian prin- ciples, but they do agree childhood is extremely important in shaping a person’s character and personality. Freud himself pro- posed that each person progresses through psychosexual stages of development. These stages occur early in life and are marked by erogenous zones, or areas of the body through which hedo- nistic id impulses are expressed. Table 2.2 provides a description of each stage.

Severe dif�culties experienced by a child at a psychosexual stage may be expressed later in life as symptoms of mental dis- orders. These dif�culties are marked by excessive frustration or overindulgence at a psychosexual stage and can result in �xation, or delayed psychosexual development. The particular stage at which such frustration or overindulgence is encoun- tered will determine the nature of later symptoms. A child neglected or deprived during the oral stage of development may compensate in adulthood by engaging in excess oral behaviors such as smoking, talkativeness, or drinking too much alcohol. A child overindulged by parents during toilet training in the

TABLE 2.2

Freud’s Psychosexual Stages of Development

Stage Age Focus

Oral stage 0–6 months Mouth is the chief means of reaching satisfaction.

Anal stage 6 months– 3 years

Attention becomes centered on defecation and urination.

Phallic stage 3–6 years Sexual organs become the prime source of grati�cation.

Latency stage 6–12 years Lack of overt sexual activity or interest.

Genital stage 12 years to adulthood

Mature expression of sexuality.

(TAT). However, we present next an overview of projective assessment within the context of Mariella’s case.

A psychodynamic theorist might expect a depressed client like Mariella to respond to projective tests in ways that indicate underlying anger and hostility. Such �ndings would support the psychodynamic explanation of depression as “anger turned in- ward” in response to loss. Mariella might be given an inkblot from the Rorschach and asked, “What might this be?” or asked to develop a story about characters depicted in the TAT. Mariella could reveal unconscious material about herself because she must impose some structure, organization, and interpretation onto ambiguous materials. She may respond to an inkblot by saying it represents “two bears �ghting with each other” or de- velop a story from a TAT card about a woman who is mad at a friend. A psychodynamic theorist might conclude from these re- sponses that Mariella is “projecting” her anger and hostility onto the neutral stimulus of an inkblot or TAT card. This “projected” anger and hostility is considered to be unconscious material.

Psychodynamic theorists also use other techniques to ac- cess unconscious material. Free association means asking a client to say whatever comes to mind during the session, with- out exercising censorship or restraint. This is not easy (try it) because the client must stop censoring or screening thoughts that may seem ridiculous, aggressive, embarrassing, or sexual. A psychodynamic therapist is looking for slips of the tongue, or Freudian slips, that reveal quick glimpses of unconscious mate- rial. Mariella could be speaking during free association and “ac- cidentally” say she has always resented her mother for pushing her to do things outside the home.

A related technique is dream analysis. Dreams are thought to reveal unconscious material because ego defenses are low- ered during sleep. The manifest content of a dream is what actually happens during the dream. The manifest content of a dream may be, for example, that the dreamer is confronted with two large, delicious-looking ice cream cones. The latent content of a dream, however, is its symbolic or unconscious meaning. Dreaming about ice cream cones may symbolically represent a longing to return to the mother’s breast.

How might psychodynamic theorists use information from projective tests, free association, and dreams to treat Mariella? A key goal of psychodynamic treatment is to help clients gain in- sight into their current problems. sight into their current problems. sight Insight means understanding the unconscious determinants of irrational emotions, thoughts, or behaviors that create problems or distress. The need for defense mechanisms and psychological symptoms should disap- pear once these unconscious reasons are fully confronted and understood. A psychodynamic theorist believes Mariella can improve by understanding the true, underlying reasons for her depression, including feelings of anger turned inward.

Psychodynamic theorists interpret past experiences and information from projective assessments to help accomplish in- sight. Interpretation is a cornerstone of psychodynamic therapy and the method by which unconscious meanings of emotions, thoughts, and behavior are revealed. A mental health profes- sional will “translate” for a client what may be causing current symptoms involving emotions, thoughts, or behaviors. Signi�cant

This may have led to symptoms of depression such as low self- esteem and sadness. Mariella’s depression may have been caused by this unconscious con�ict of emotions.

How does a psychodynamic theorist know what uncon- scious material exists for a client? A psychodynamic mental health professional often assesses unconscious motivations and con�icts using projective techniques. Projective techniques are based on the projective hypothesis, or an assumption that people project unconscious needs and con�icts onto ambiguous stimuli such as inkblots. People impose their own structure on unstructured stimuli and thus reveal something of themselves. Unconscious material is thus uncovered. In Chapter 4, we discuss two major projective tests used to access unconscious material—the Rorschach and the Thematic Apperception Test

TABLE 2.3

Examples of Defense Mechanisms

Defense mechanism Description

Denial Refusing to accept or acknowledge reality

Displacement Expressing one’s unacceptable feelings onto a different object or person than the one that is truly the target of the feelings

Fantasy Imagining some unattainable desire

Identi�cation Modeling another person’s behavior or preferences to be more like them

Intellectualization Providing an in-depth intellectual analysis of a traumatic or other situation to distance oneself from its emotional content

Overcompensation Emphasizing strength in one area to bal- ance a perceived weakness in other area

Projection Attributing one’s own unacceptable motives or impulses to another person

Rationalization Developing a speci�c reason for an action, such as justifying why one did not purchase a particular car

Reaction formation Expressing an unconscious impulse by engaging in its behavioral opposite

Regression Returning to an earlier psychosexual stage that provided substantial grati�cation

Repression Keeping highly threatening sexual or aggressive material from consciousness

Sublimation Transforming emotions or sexual or aggres- sive material into more acceptable forms such as dancing or athletic or creative activity

Undoing Reversing an unacceptable behavior or thought using extreme means

CHAPTER 2 Perspectives on Abnormal Psychology32

mainstream appeal, but a short-term therapy approach based on the theory remains popular among some mental health profes- sionals (Driessen et al., 2015).

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➲ Review Questions 1.

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The Humanistic Model

Biological and psychodynamic perspectives focus primarily on internal factors such as genetics and unconscious con- �icts. Some theorists have reacted to these models with disdain because the models do not emphasize personal growth, free will, or responsibility. Biological and psychodynamic theorists concentrate heavily on how factors such as genetics and un- conscious con�icts automatically shape human behavior. Other theorists, however, focus more on how people can make choices that in�uence their environment and how they can take respon- sibility for their actions.

One group of theorists that emphasize human growth, choice, and responsibility adopt a humanistic model of psychology.

insight or behavioral change rarely comes from a single interpre- tation but rather a slow process in which meaning behind cer- tain emotions, thoughts, and behaviors is repeatedly identi�ed in one context after another. A psychodynamic therapist might point out Mariella’s various child, adolescent, and adult experi- ences, as well as projective assessment responses to illustrate a history of becoming angry with others but bottling up such anger and becoming depressed. Certain dreams and Freudian slips would be instructive as well.

A client’s behavior with a therapist can also illuminate the unconscious and reveal con�icts with others. Transference is a key phenomenon in psychodynamic therapy that occurs when a client reacts to a therapist as if the latter is an important �gure from childhood. Positive and negative feelings can be transferred. Con�icts and problems that originated in childhood are thus reinstated in the therapy room. Mariella might one day yell at her therapist to re�ect anger toward her mother.

Client–therapist interactions provide important clues about the nature of a client’s problems but are also an opportunity for the therapist to carefully and supportively interpret transference in an immediate and vital situation. A client will, ideally, then recognize the irrational nature and origins of transference feel- ings and cope with these in more rational ways. The client can begin to control such reactions in real-world settings and to use them as a basis for further interpretation and analysis.

Evaluating the Psychodynamic Model As mentioned, the most in�uential principle of the psychody- namic perspective may be that childhood experiences greatly affect adult functioning. The in�uence of this principle can be seen in popular media as well as in psychology and psychiatry. Think about how we value the health, welfare, and education of children. We also emphasize the negative consequences of child maltreatment, poor parenting, and inadequate education. Chil- dren are not little adults who can roll with the punches or easily avoid the stress of a dysfunctional family or dangerous home or neighborhood. Psychodynamic theory has certainly helped us focus on providing better environments for our children. The psychodynamic theory of defense mechanisms also makes intui- tive sense. Many of us use defenses to ward off anxiety and cope with psychological threats in our environment.

A strict view of the psychodynamic perspective does reveal some limitations, however. Perhaps the biggest weakness is that little empirical support exists for many of the major proposi- tions and techniques of the perspective. Psychodynamic theory was mostly formed from anecdotal evidence, and many con- cepts such as the id are abstract and dif�cult to measure. If we cannot measure an important variable reliably and with con- �dence, then its usefulness is questionable. Psychodynamic theorists were accused for many years of being “antiscienti�c” because they accepted Freud’s propositions as simple truth. This stance, predictably, divides people into believers and non- believers. Believers thought empirical research was unneces- sary, and nonbelievers saw no point to empirically testing the theory. Psychodynamic theory has thus lost much of its broad,

and include air, food, water, sex, sleep, and other factors that promote homeostasis, or maintenance of the body’s internal en- vironment. We feel anxious or irritable when these needs are not met but feel a sense of well-being when the needs are met and when we have achieved homeostasis. These needs must be largely ful�lled before a person can meet other needs. Safety needs include shelter, basic health, employment, and family and �nancial security. Love and belongingness needs include intimacy with others and close friendships—a strong social support network. Esteem needs include con�dence in oneself, self-esteem, achievement at work or another important area, and respect from others. These needs are thought to apply to everyone and have even been adapted to the care of intensive care and dying patients (Jackson et al., 2014).

The highest level of need is self-actualization, de�ned as striving to be the best one can be. Maslow believed humans naturally strive to learn as much as they can about their environ- ment, seek beauty and absorb nature, create, feel close to others, and accomplish as much as possible. Self-actualized people are also thought to be moral beings who understand reality and can view things objectively. Pursuit of self-actualization normally occurs after other basic needs have been met, although some people may value other needs such as respect from others more highly than self-actualization.

Maslow believed healthy people are motivated toward self-actualization and become mature in accepting others, solv- ing problems, seeking autonomy, and developing deep-seated

The humanistic model was developed in the 1950s and retains some relevance today. A main assumption of the humanistic model is that people are naturally good and strive for personal growth and ful�llment. Humanistic theorists believe we seek to be creative and meaningful in our lives and that, when thwarted in this goal, become alienated from others and possibly develop a mental disorder. A second key assumption of the model is that humans have choices and are responsible for their own fates. A person with a mental disorder may thus enhance his recovery by taking greater responsibility for his actions.

Humanistic theorists adopt a phenomenological approach, which is an assumption that one’s behavior is determined by perceptions of herself and others. Humanistic theorists believe in a subjective human experience that includes individual awareness of how we behave in the context of our environment and other people. To fully understand another person, therefore, you must see the world as he sees it and not as you see it. We all have different views of the world that affect our behavior. Humanistic theory was shaped greatly by the works of Abraham Maslow, Carl Rogers, and Rollo May. We explore these theorists next to expand on our discussion of the humanistic model.

Abraham Maslow Abraham Maslow (1908–1970) believed humans have basic and higher-order needs they strive to satisfy during their life- time (see Figure 2.7). The most basic needs are physiological

dangerous to the general population has become an accepted practice. Civil commitment refers to involuntary hospitalization of people at serious risk of harming themselves or others or people who cannot care for themselves (Slate, Buf�ngton-Vollum, & Johnson, 2013). Commitment in this regard can occur on an emergency basis for a few days or more emergency basis for a few days or more emergency formally for extended formally for extended formally periods by court order.

Criminal commitment refers to involuntary hospitalization of people charged with a crime. A person may be hospitalized to determine her com- petency to stand trial or after acquittal by reason of insanity. Competency to stand trial refers to whether a person can participate meaningfully in his own defense and can understand and appreciate the legal process. Such competency is often questioned for people who commit crimes while expe- riencing intellectual disability, psychotic disorders, dementia, or substance use problems (Greene & Heilbrun, 2014).

Insanity is a legal term that refers to mental incapacity at the time of a crime, perhaps because a person did not understand right from wrong or because the person was unable to control personal actions at the time of the crime. A person judged to be insane is not held criminally responsible for an act but may be committed as a dangerous person, sometimes for extensive periods of time. The insanity defense has always been controversial, but very few defendants (about 1 percent) actually use this defense. This may be complicated, however, by the number of people with intellectual disability in the criminal justice system (Sakdalan & Egan, 2014).

Focus on

Determining whether someone is dangerous to oneself or others is extremely dif�cult. Behaviors such as suspiciousness, excitability, uncooperativeness, and tension are not good predictors of dangerousness. Making the task more dif�cult is that a large majority of people with mental disorders are not dangerous (Peterson, Skeem, Kennealy, Bray, & Zvonkovic, 2014). A psy- chologist’s ability to predict dangerous behavior may be better in the short term than the long term, although errors still occur. Some variables may help predict dangerousness, including psychopathy (Chapter 10), school and work maladjustment, excessive substance use, violent criminal history, early age of onset of violent behaviors, injury to victims, and psychotic symptoms (Chapter 12) (Bonta, Blais, & Wilson, 2014; Parry, 2013).

The issue of predicting dangerousness relates to committing someone to a mental hospital against his will. The con�ict between individual rights to be free versus societal rights to be protected from dangerous people has been an issue for centuries. Detaining and separating people perceived as

Law and Ethics Dangerousness and Commitment

2.2

CHAPTER 2 Perspectives on Abnormal Psychology34

who feel a sense of loss of control over life events do indeed seem to be at risk for anxiety disorders (Chapter 5).

Unconditional positive regard refers to an environment in which a person is fully accepted as she is and allowed to pursue her own desires and goals. Someone like Rachel who is given freedom to choose her own way in life is more predisposed toward self-actualization and psychological health than Colby. Mariella might also have felt less sad if her family members recognized her signs of depression and offered different ideas about what she could do in her life.

Rogers developed client-centered therapy that relies heav- ily on unconditional positive regard and empathy. A client- centered therapist establishes a therapeutic environment in which a client is completely accepted and unjudged. Uncondi- tional positive regard in therapy refers to respecting a client’s feelings, thoughts, and actions and providing a sympathetic understanding of the client’s statements. Many client-centered therapists allow clients to speak freely without assigning blame, criticism, or even feedback about what to do. The therapist in- stead concentrates on trying to see the world as the client sees it and often re�ects a client’s statements so the client can develop his own solution to a problem. Consider the following exchange between a client-centered therapist and Colby:

Colby: I’ve been feeling so down lately, I get so tired of my life. Therapist: It sounds as though things are upsetting you. Colby: Yeah, my parents are always on my case to be a

lawyer because my dad and grandfather were lawyers. Therapist: That sounds like a lot of pressure. Colby: It is a lot of pressure. Sometimes I just want to tell

them to leave me alone so I can do whatever I want. Therapist: I can understand that. Tell me more about that. Colby: I think I need to have a heart-to-heart talk with my

dad. I just can’t take this anymore.

The client-centered therapist in this exchange did not tell Colby what to do but instead displayed empathy and allowed Colby to speak freely without worrying about being judged. The therapist also re�ected Colby’s feelings and statements so he could arrive at his own solution. Client-centered therapists believe many mental problems result from other-centeredness, or oversensitivity to demands, criticisms, and judgments of oth- ers. Colby’s therapist treated him as a responsible adult who needed to become more person-centered and �nd his way back to a path of self-actualization (Wedding & Corsini, 2014). Client- centered therapists believe clients are their own best experts of their problems and that healthy functioning requires more autonomous decision making.

Rollo May Rollo May (1909–1994) adopted a similar approach to human- istic psychology. May’s existential psychology is heavily based on the concept of authenticity, or how closely one adheres to one’s personality. Someone who is authentic is true to his nature and honest in his interactions with others. Someone who is not

feelings of compassion and empathy for others. Unhealthy people, however, experience personal or other obstacles to self- actualization and may develop mental problems as a result. Compare Rachel, who takes whatever classes she wants and excitedly pursues her degree, with Colby, who is pressured by his parents toward a career in which he has no interest. Colby is more likely to experience frustration in his goal toward per- sonal self-actualization and become depressed. Recall as well that Mariella felt considerable pressure from family members to return to college for her second semester. Her feelings of sadness may have been related to diversion from more desired life goals.

Carl Rogers Carl Rogers (1902–1987) expanded on Maslow’s work to become one of the leading proponents of the humanistic model of psy- chology. Rogers also believed humans strive for self-actualization and that frustration toward this goal could lead to mental prob- lems such as depression. Rogers believed people raised in the right environment could work toward self-actualization and a strong self-concept in which one feels differentiated from others self-concept in which one feels differentiated from others self-concept in a positive way. Think of someone who is rightfully proud to be the �rst in her family to graduate from college.

What is the right environment for self-actualization? Rogers presented the concepts of conditional and unconditional posi- tive regard. Conditional positive regard refers to an environ- ment in which others set the conditions or standards for one’s life. Think about someone like Colby whose major life decisions are made by parents, teachers, or other in�uential people. Peo- ple like Colby may feel a sense of loss of control over events and thus feel helpless to change anything. Their drive toward self- actualization and psychological health is thus thwarted. People

Challenging projects, opportunities foropportunities for innovation and creativity,innovation and creativity, learning and creating atlearning and creating at a high levela high level

Important projects, recognition fromrecognition from others, prestige andothers, prestige and statusstatus

Acceptance, be part ofAcceptance, be part of a group, identificationa group, identification with a successful teamwith a successful team

Physical safety, economicPhysical safety, economic security, freedom fromsecurity, freedom from threatsthreats

Physical survival needs:Physical survival needs: water, food, sleep,water, food, sleep, warmth, exercise, etc.warmth, exercise, etc.

Self- actualizationactualizationactualizationactualization

Ego (esteem)

Social (belonging)

Safety/security

Physiological

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FIGURE 2.7 MASLOW’S HIERARCHY OF NEEDS.

external agent of behavior change. Psychodynamic theorists focus on personality models of mental disorder, so treatment usu- ally involves better insight with the help of a therapist. Human- istic theorists, however, emphasize that clients themselves must take responsibility for their recovery. Such an approach would seem useful for people with disorders such as anxiety, depression, and substance use. People who actively participate in treatment often have better outcomes than those who participate less (Weinstein, 2014).

Rogers’s client-centered approach has also contributed greatly to the way therapists approach their clients in session. Many therapists, especially in the �rst few sessions of therapy, develop a warm, supportive environment for their clients to en- hance self-disclosure. We discuss in Chapter 15 different process variables that contribute to treatment success. Process variables are factors common to all treatments that seem to help clients. One particularly helpful process variable is a therapeutic envi- ronment based on respect, empathy, and full acceptance of cli full acceptance of cli full acceptance - ent expressions. A client must feel free to communicate private thoughts without fear of rejection or ridicule. Humanistic thera- pies may thus be helpful for people who need to express grief or discuss dif�cult personal issues (Piazza-Bonin, Neimeyer, Alves, Smigelsky, & Crunk, 2016). Nondirective treatment may also be useful for clients highly mistrustful of, or hostile toward, a therapist.

The humanistic perspective is partly represented in ethical guidelines that psychologists adhere to when treating clients (Schneider et al., 2015). Psychologists are expected to refrain from biases from possible prejudices toward people of a different culture, sexual orientation, age, gender, or political af�liation, among other factors. Psychologists are expected to respect a client’s dignity and rights, including the right to self-determination. If a psychologist feels he cannot be unbiased with a client and this interferes with his ability to conduct therapy, then a referral to another therapist should be made.

The humanistic approach has several limitations as well. The theory is an unscienti�c one that largely lacks empirical support. Concepts such as self-actualization are dif�cult to de�ne and test. Many factors other than human perceptions of the world also in�uence behavior and mental disorder. Client-centered therapy has been criticized as well for less applicability to people with a severe mental disorder, such as schizophrenia or those who are suicidal or in pain (Angus, Watson, Elliott, Schneider, & Timulak, 2015). The therapy is also more effective for people who are verbal, social, intelligent, and willing to talk. Several groups of people, such as children and people with intellectual disability, are thus not good candidates for this kind of therapy.

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authentic may develop a façade and act like someone else in social situations. Perhaps you know someone who tries to be extroverted when really he is introverted or someone who con- forms to the “in” crowd so she will be liked. People who are not authentic are thought to be at risk for alienation from others. We discuss several personality disorders in Chapter 10 that involve odd behaviors that often result in social isolation.

Existential theorists believe people are alone in the world and may therefore develop a sense of meaninglessness. People who feel meaningless in their world and who are not authen- tic may be at risk for anxiety and other problems. Existential therapists help their clients discover reasons for their anxiety, manage their anxiety in healthier ways, seek social support from others, develop strong moral values, and act more honestly with others (Spinelli, 2014). For example, someone who is introverted could acknowledge that he is less willing to talk in social situa- tions and develop friendships through good listening and other nonverbal support.

Humanistic Assessment and Treatment Humanistic theorists believe in a qualitative model of assessqualitative model of assessqualitative - ment. Qualitative assessment focuses on unique characteristics of an individual and often includes general questions about one’s perceptions of the world. Humanistic theorists do not group peo- ple together to identify common characteristics and often shun formal psychological testing (Chapter 4; Schneider, Pierson, & Bugental, 2015). A client-centered therapist interviewing Colby would focus on how Colby perceives his world and might thus ask certain questions such as “How might you speak to your father about your concerns?” Speci�c questions for Colby would not likely be used for Mariella, however, because Mariella’s way of viewing the world is completely different from Colby’s.

Treatment from a humanistic perspective is nondirective, meaning the therapist does not adopt a paternalistic or com- manding tone for therapy. A psychiatrist might tell you what medication to take, and a psychodynamic therapist might tell you what your dream means, but a nondirective therapist does not impose her worldview or opinions onto her client. The therapist instead engages in re�ective listening so a client can develop solutions, relieve tension, and resume a path toward self-actualization. Nondirective treatments are sometimes con- sidered to be pretherapy, or actions taken �rst in treatment to develop a good relationship with a client (Wedding & Corsini, 2013). Nondirective treatments thus �t well with most other kinds of therapy.

Evaluating the Humanistic Model The humanistic model has several strengths, particularly its focus on human choice and growth. The humanistic model is optimistic and tied to contemporary positive psychology, which refers to the study of what factors allow people to thrive in their environments. The humanistic model also emphasizes respon- sibility. Biological theorists focus on disease models of mental disorder, so treatment usually involves medication or some

CHAPTER 2 Perspectives on Abnormal Psychology36

such as id and unconscious were dif�cult to measure and not important to mental health outcomes. The behavioral perspec- tive instead focuses on environmental stimuli and behavioral responses—variables that can be directly observed and measured. The behavioral perspective is based on the assumption that all behavior—normal or abnormal—is learned. The behavioral model dominated psychology in the mid-20th century because learning principles received much empirical support and applied to many topics of psychological research. Treatment approaches from a behavioral perspective were also found to be quite effective for many problems such as anxiety disorders and intel- lectual disability. The behavioral perspective is based heavily on a learning approach, so a discussion of key learning principles is important.

Learning Principles Two key learning principles are critical to the behavioral perspective: classical conditioning and operant conditioning. Classical conditioning essentially refers to learning by associaClassical conditioning essentially refers to learning by associaClassical conditioning - tion and was studied initially by Ivan Pavlov (1849–1936), a Russian physiologist. Pavlov was interested in the digestive system but made some interesting observations during his experiments with dogs. Pavlov gave meat powder repeatedly to dogs to produce salivation, and he found the dogs often sali- vated beforehand, such as when hearing approaching footsteps! Pavlov was intrigued and explored the nature of this reaction. He rang a bell immediately before a dog received meat powder. This was repeated several times and resulted in dogs salivating after the bell but before the meat powder. The dogs learned to before the meat powder. The dogs learned to before salivate to a stimulus, in this case a ringing bell that should not by itself cause salivation. The dogs had learned by association: the bell meant food.

This important experiment led ultimately to classical con- ditioning theory (“conditioning” means learning). Learning occurs when a conditioned stimulus (CS; bell) is paired with an unconditioned stimulus (UCS; meat powder) so future pre- sentations of the CS (bell) result in a conditioned response (CR; salivation). Classical conditioning theory also suggests that problems such as trauma-based disorders might develop because classical conditioning once took place. Posttraumatic stress disorder (Chapter 5) involves avoiding situations or people that remind someone of a traumatic experience. Rape victims with this disorder often avoid certain parts of a city associated with the assault, or may feel anxious when they see someone who reminds them of their attacker. These behav- ioral and emotional reactions might be understood via classical conditioning: a location or physical feature (CS) was paired with an assault (UCS), and now the CS produces the classically conditioned response (CR) of intense fear and avoidance (see Figure 2.8).

Operant conditioning is based on the principle that behav- ior followed by positive or pleasurable consequences will likely be repeated, but behavior followed by negative consequences, such as punishment, will not likely be repeated (McSweeney & Murphy, 2014). Reinforcement is thus an important aspect of operant conditioning. Positive reinforcement involves giving a

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The Cognitive-Behavioral Model

The psychodynamic and humanistic perspectives we have covered so far focus speci�cally on internal variables, lack empirical support, or seem not to apply well to many people with a mental disorder. Another perspective of mental disorders focuses on external as well as internal factors, has good empirical support, and is relevant to many people with a mental disorder. The behavioral perspective focuses on external acts and thebehavioral perspective focuses on external acts and thebehavioral perspective cog- cog- cog nitive perspective focuses on internal thoughts. Some theorists nitive perspective focuses on internal thoughts. Some theorists nitive perspective discuss these perspectives separately, but many contemporary researchers and therapists understand the limitations of working within just one model. Many mental health professionals now combine these perspectives into a singular cognitive-behavioral model. We discuss these perspectives next and then note how combining the two provides a good explanation for mental disorders and treatment.

Behavioral Perspective The behavioral perspective developed in reaction to psycho- dynamic theory that dominated psychology in the early 20th century. Many psychologists were concerned that variables

Cognitive Perspective The cognitive perspective arose from the behavioral perspective because people often behave in ways that have little to do with reinforcement. How did Tony develop an intense fear of heights when he never had a traumatic experience involving heights? An understanding of thoughts, perceptions, and emotions may better account for Tony’s fear and avoidance. Not everything can be explained by simple principles of classical and operant con- ditioning. The cognitive perspective instead suggests that emo- tions and behavior are in�uenced by how we perceive and think about our present and past experiences. Learning principles help comprise the behavioral perspective, but other principles comprise the cognitive perspective. These are discussed next.

Cognitive Principles Each of us actively processes and interprets our experiences. Such processing and interpretation is in�uenced by cognitive schemas, or beliefs or expectations that represent a network of accumulated knowledge. We go into many situations with some expectation of what may happen. Think about the unwrit- ten script that occurs when you enter a restaurant. You wait to be seated, place your order, eat, pay, and leave. If a restaurant conducted this script in a different order, you might be a little confused. Our schemas or expectations about events affect our behavior and emotional experiences. College students told they are drinking a beverage with alcohol—when in fact they are drinking a nonalcoholic beverage—often report feeling intoxi- cated. They talk loudly or become silly as though they are intox- icated. Their expectancies of what they are like when intoxicated in�uence their behavior, even when not drinking alcohol!

Cognitive distortions are another important principle of the cognitive perspective and refer to irrational, inaccurate thoughts people have about environmental events. Aaron Beck’s cognitive theory (Beck & Haigh, 2014) holds that mental disorder may result if one has negative views of oneself (“I’m not good at anything”), other people in the world (“No one cares about anyone except himself”), and the future (“Things will never get easier for me”).

Cognitive distortions often come in the form of arbitrary inference, which means reaching a conclusion based on little evidence. A professor may see that 2 out of 50 students fell asleep during one lecture and assume she is a bad teacher. The professor ignored the greater evidence that most people did pay attention and instead focused on the two who did not. As professors, we also see students who agonize over one or two mistakes at the expense of seeing the greater value of their examination or project.

Another common cognitive distortion is personalization, or erroneously blaming oneself for events. If a coworker refused to speak to you one day, you might personalize the event by wondering what offense you committed. You are ignoring other, more reasonable explanations for what happened—perhaps your coworker just had a �ght with her spouse or was worried about a sick child. Cognitive distortions are common to many mental disorders such as anxiety, depressive, eating, and sexual disorders. Indeed, we discuss them throughout this textbook.

pleasant event or consequence after a behavior. A child praised or rewarded for cleaning his room is likely to repeat the behavior in the future. Positive reinforcement can also maintain maladap- tive behavior, as when someone with depression receives sym- pathy from others or when parents allow a child to miss school and play video games.

Negative reinforcement involves removing an aversive event following a behavior, which also increases the future likelihood of the behavior. Why do you wear deodorant? You likely do not do so for all the wonderful compliments you get during the day but rather to avoid negative com- ments about body odor! Negative reinforcement can also explain why some fears are maintained over time. Someone afraid of spiders may avoid closets because spiders like to live in dark places. Such avoidance is reinforced because spiders are not encountered and so the aversive event of fear is re- moved. Such avoidance is also likely to continue in the future (see Figure 2.9).

Behavior can also be “shaped” through reinforcement. Students might shape a professor’s teaching style by reward- ing more interesting lectures. Students might provide strong reinforcement by maintaining eye contact, asking questions, or saying, “That is really interesting!” when a professor pro- vides multiple examples or case illustrations. You can see where this is headed. When students reinforce successive ap- proximations of this lively lecture style, they have the power to make the class more engaging, fresh, and interesting. If you try this on your professors, please do not let them know the source of the idea, and please do not keep them completely under your control!

Unconditioned stimulus (UCS)

Conditioned response (CR)

*UCS and CS are paired.

*After the UCS and CS are paired, the CS produces the conditioned response (CR), or avoidance.

Conditioned stimulus (CS)

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CHAPTER 2 Perspectives on Abnormal Psychology38

Avoidance conditioning combines classical and operant conditioning and accommodates an in- ternal state like fear as a motivating or driving factor that in�uences befactor that in�uences befactor - havior. This internal state is the cognitive aspect of phobia development.

Consider Shawn’s �ying phobia (see Figure 2.10). A neutral stimulus such as �ying on an airplane becomes paired with an unpleasant uncon- ditioned stimulus such as nausea—classical con- ditioning. Shawn later avoids �ying because in- ternalized fear of experifear of experifear - encing nausea drives him to do so. The internalized state that drives Shawn’s future avoidance could not be explained by sim- ple classical or operant conditioning. The inter-

nalized state or cognitive component instead provides a more complete account of why Shawn’s phobia continued over time.

Contemporary models of mental disorders often include a combination of learning principles and cognitive in�uences such as expectancies and motivations. Substantial research also supports the idea that cognitive schemas and distortions in�u- ence forms of mental disorder. The combination of behavioral/ learning and cognitive principles has also led to many impor- tant assessment and treatment strategies, some of which are discussed next.

Cognitive-Behavioral Assessment and Treatment Behavior therapy represented a novel way of treating mental disorders when introduced in the 1950s and initially included treatments based on principles of classical and operant con- ditioning. The scope of behavior therapy has since expanded to include other forms of treatment such as cognitive therapy (Beck & Dozois, 2014). Many mental health professionals today endorse a cognitive-behavioral orientation that recognizes the importance of classical and operant conditioning as well as cognitive theories of mental disorders.

A key assessment approach within the cognitive-behavioral perspective is functional analysis. Functional analysis refers to evaluating antecedents and consequences of behavior, or what preceded and followed certain behaviors. This is often done by observing a person. A mental health professional might note that Mariella’s depressive symptoms were preceded by

A Cognitive-Behavioral Model The cognitive perspective highlights the idea that information processing and learning are active, not passive, processes. Con- temporary psychologists have generally combined behavioral and cognitive approaches into a cognitive-behavioral model. This model rests on the assumption that learning principles and cog- nitions interact to in�uence a person’s behavior. This assumption is evident when considering modeling, which refers to learning by observing and imitating others. People often learn by watch- ing others, such as when they watch others operate a piece of machinery or use drugs. We process this information, judge how good someone is modeling the behavior, and decide to practice the behavior ourselves. Modeling, also known as vicarious con- ditioning, implies that cognitive mechanisms such as thoughts, beliefs, or perceptions in�uence learning. A combined cognitive- behavioral perspective helps explain why certain behaviors are learned through observation and not simple reinforcement.

Learning principles and cognitions also interact to help explain speci�c disorders. Many people are afraid of airplanes even though airplanes are not typically dangerous or threaten- ing. Classical and operant conditioning may help explain why fear in these situations is maintained, but why do people start avoiding harmless objects or situations in the �rst place? People who avoid a harmless stimulus internalized something that now motivates or drives subsequent avoidance behavior. A type of learning called avoidance conditioning is thus often proposed.

Behavior Repetition of behavior is more likely

Positive reinforcement: pleasant event or reward

such as payment for chores

Behavior Repetition of behavior is more likely

Negative reinforcement: removal of an aversive

event such as injury in a car accident

Positive reinforcement

Negative reinforcement

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FIGURE 2.9 PRINCIPLES OF OPERANT CONDITIONING.

3. Mariella might engage in assertiveness training and role- playing to improve her social and conversational skills.

4. Mariella might be asked to identify thoughts such as “I can’t do anything right” that occur before or during feelings of depression.

5. The reality or accuracy of Mariella’s thoughts might be ex- amined by gently challenging their validity (“So you don’t think there is anything you can do right?”).anything you can do right?”).anything

6. Mariella might be taught to avoid personalizing events for which she is not to blame. She may be shown that her class- mates’ busy behaviors re�ect their own hectic lives and not attempts to rebuff Mariella.

7. Mariella could be helped to �nd alternative solutions to her problems instead of giving up.

A common therapeutic technique from this perspective is cognitive restructuring, or helping someone think more real- istically in a given situation. How might cognitive restructuring help Mariella? Recall that Mariella was distancing herself from family, friends, and enjoyable activities. She felt her friends did not understand her or care about her. A therapist using cog- nitive restructuring might help Mariella see the situation more realistically. The therapist might help her understand her friends are not avoiding her, but rather she is avoiding them. Mariella is not giving her friends the opportunity to support and care for her because Mariella is isolating herself. A therapist using cognitive restructuring will be quite direct with Mariella, us- ing discussions and making arguments that Mariella is viewing her situation irrationally. Irrational beliefs such as “My friends don’t care about me” are unfounded and lead to depression. The therapist may also try to teach Mariella to “modify her internal sentences.” Mariella might be taught when feeling depressed to pause and ask herself what her immediate thoughts are. The therapist would then ask Mariella to objectively evaluate these thoughts and make corrections. The therapist might thus have her imagine particular problem situations and ask her to think more realistically in these situations.

Other cognitive-behavioral techniques are used to treat men- tal disorders as well. Systematic desensitization is an approach used to treat fear-related concerns. A client is �rst taught to relax, typically via progressive muscle relaxation techniques. The therapist and client then construct a hierarchy of situations or objects related to the feared stimulus. Items at the bottom of the hierarchy arouse fear at low levels; for a person afraid of dogs, for example, this might mean watching a dog in a �lm. More fear-provoking items are further along the hierarchy. Contact with an actual feared situation, such as petting a dog, is at the top of the hierarchy. Clients reach a state of relaxation and pro- gressively encounter each object or situation on the hierarchy. If a client becomes too fearful, the procedure is halted so the client can once again become relaxed. Progression along the hierarchy is then restarted. A person is thus desensitized to the previously feared stimulus or situation. From a classical conditioning per- spective, the client has learned to respond to a previously feared stimulus with relaxation instead of excessive arousal.

school-based stressors and loneliness and followed by rewards such as greater attention from family members and friends.

Cognitive variables must also be considered during assess- ment. Mariella may have certain cognitive distortions, such as believing her troubles in school were related to lack of ability, that others did not care about her, and that things would not im- prove in the future. Her symptoms may have been at least partly caused by these kinds of cognitive schemas or beliefs that are linked to depression. A therapist would assess for these cogni- tive processes as well during a functional analysis.

How might a cognitive-behavioral therapist treat Mariella’s symptoms? Cognitive-behavioral therapy refers to a large col- lection of treatment techniques to change patterns of thinking and behaving that contribute to a person’s problems. These techniques have much empirical support and are among the most effective forms of therapy. Cognitive-behavioral therapy has been shown to be equal or superior to alternative psycholog- ical or psychopharmacological treatments for adults and youth (Hofmann, 2013; Nathan & Gorman, 2015).

Aaron Beck has been a pioneer in developing cognitive- behavioral treatments for various clinical problems. His model uses cognitive and behavioral techniques to modify problematic thinking patterns. Under this model, the following techniques might be used to treat Mariella’s depression:

1. Scheduling activities to counteract her inactivity and her focus on depressive feelings. Mariella might be given “homework assignments” to go to the movies with friends or play the guitar before others.

2. Mariella might be asked to imagine successive steps leading to completion of an important task, such as attending an exercise class, so potential barriers or impediments can be identi�ed, anticipated, and addressed. This is called cogni- tive rehearsal.

Shawn flies on airplane

Shawn feels nauseous

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getting sick when

he flies

Shawn then avoids flying and takes the bus instead

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avoidance behavior

Operant conditioning —Operant conditioning — Avoidance of flying

reduces fear (negative reinforcement)

Classical conditioning —

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nausea

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CHAPTER 2 Perspectives on Abnormal Psychology40

cause Mariella’s depression, or did these cognitive patterns result from her depression?

The cognitive-behavioral perspective appears less able to provide clear and comprehensive historical accounts of how problematic behavior developed in the �rst place. The cognitive- behavioral perspective seems best suited to explain and address current functioning and highlight targets of change that can be current functioning and highlight targets of change that can be current used in treatment. The perspective is particularly good for iden- tifying speci�c symptoms that need change, such as Mariella’s isolated behavior and cognitive distortions.

➲ Interim Summary •

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•

➲ Review Questions 1.

3. -

The Sociocultural Model

The models of mental disorder we have discussed so far in this chapter—biological, psychodynamic, humanistic, and cogni- tive-behavioral—focus primarily on individuals and their personal characteristics. We do not live in a vacuum, however—many out- side factors affect how we feel, think, and behave. Biological, psy- chodynamic, humanistic, and cognitive-behavioral perspectives do acknowledge some environmental role in psychological prob- lems. The sociocultural perspective differs from these models in

A key element of systematic desensitization is exposure treatment, which involves directly confronting a feared stimu- lus. This can be done gradually or, in the case of �ooding, the client does not relax in advance but is instead exposed immedi- ately to a feared stimulus. Exposure treatment can be done by having clients imagine the presence of a feared stimulus or by facing the feared stimulus or situation in real life. Clients are understandably fearful in these situations, but if they continue to stay in the presence of the stimulus, fear diminishes. A non- fearful response becomes associated with a previously feared stimulus or situation through repeated exposure sessions.

Systematic desensitization and exposure treatment are based on classical conditioning, but other behavior therapy tech- niques are based on operant conditioning, which emphasizes reinforcement. A relatively simple application is when a mental health professional stops reinforcing a problematic behavior and reinforces more adaptive and acceptable behavior. Or a therapist might help parents manage consequences for their children to increase positive behavior such as completing homework and decrease negative behavior such as aggression.

Operant conditioning principles are also apparent in token economies to modify behaviors of institutionalized populations such as people with intellectual disability or schizophrenia. A token economy is a reinforcement system for certain behaviors in which tokens or points are given for positive behaviors and exchanged later for tangible rewards. Someone with schizo- phrenia on an inpatient hospital unit may earn points for posi- tive behaviors such as attending group therapy sessions and showering. These points could later be exchanged for privileges such as day passes from the hospital. Token economies are also used to improve social and academic skills and other behaviors in children.

Evaluating the Cognitive-Behavioral Model The cognitive-behavioral perspective has contributed greatly to our understanding and treatment of mental disorders. The be- havioral approach and its emphasis on learning principles revo- lutionized the study and treatment of mental disorders following psychodynamic theory. The model has been broadened to in- clude thought processes, expectancies, and other internal states. A combined cognitive-behavioral model is among the most in- �uential for conceptualizing the development and maintenance of problematic behavior. The perspective also offers a broad array of treatment choices for many mental disorders. These cognitive-behavioral treatments often have been shown to be effective and ef�cient, often requiring fewer than 20 sessions.

Limitations of the cognitive-behavioral model should be noted, however. Most problematic might be the model’s con- cept of how mental disorders �rst develop. Many cognitive- behavior theorists reduce complex behaviors such as depression to simple learning history or cognitive schemas, but this does not seem plausible. Many biological, personality, and social factors also contribute to depression and other disorders. The “chicken and egg” problem is also relevant to cognitive- behaviorism: Did problematic thoughts, beliefs, or expectancies

rather socially de�ned. Culture includes but is not limited to concepts of ethnicity and race, and culture is learned from others and passed on to succeeding generations.

Culture can contribute to mental disorder in several ways. First, culture might serve as a distant but direct cause of mendirect cause of mendirect cause - tal disorders. Culturally shared beliefs and ideas can lead to particular forms of stress that, in turn, lead to speci�c forms of problems called cultural syndromes (American Psychiatric Association [APA], 2013). Dhat syndrome, for example, is an anxiety-related belief observed in Indian men that one is “losing” semen through nocturnal emissions, masturbation, or urina- tion. The cultural belief driving the fear is that excessive semen loss results in illness (Udina, Foulon, Valdes, Bhattacharyya, & Martin-Santos, 2013).

Culture can help cause mental disorder but can also in�u- ence the way individuals cope with stressful situations. Two ex- amples are amok and family suicide (Hagan, Podlogar, & Joiner, 2015). Amok is a condition in South Asian and Paci�c Islander cultures in which a person attacks and tries to kill others. Cultures in which this condition is observed are often character- ized by passivity and nonconfrontation, so amok is seen as a failure to cope with extreme stress. The English phrase “running amok” is derived from this condition (although its meaning is not literal!). Family suicide is sometimes observed in Japanese Family suicide is sometimes observed in Japanese Family suicide culture when parents and children commit suicide together. This act may be preceded by �nancial debt or a disgraceful event that causes extreme stress. Family suicide is seen as a coping response, albeit a maladaptive one, because cultural values dis- courage living disgracefully after a shameful event.

Culture can also in�uence mental disorders by shaping the content of symptoms. Examples include anthrophobia and brain fag. Anthrophobia, a phobia of interpersonal relations, is observed in Japanese culture and involves fears of one’s body

its greater emphasis on environmental factors; its core assumption is that outside in�uences play a major role in creating a person’s major role in creating a person’s major psychological problems. The sociocultural perspective focuses on in�uences that social institutions and other people have on a person’s mental health.

Many sociocultural factors potentially in�uence the devel- opment, symptom expression, assessment, and treatment of mental disorders. We highlight here several prominent examples of sociocultural in�uences on mental health. This is not an ex- haustive list, but these examples best highlight this perspective and current areas of investigation. We begin with more global in�uences, such as culture and gender and neighborhoods, and �nish with a topic closer to home—family.

Culture Culture refers to the unique behavior and lifestyle shared by a group of people. Culture is composed of viewpoints, beliefs, val- ues, and preferences that are evident in rituals, food, customs, laws, art, music, and religion. Culture is not innate but external, learned, and transmitted to others. Culture is not the same as eth- nicity, which refers to clusters of people who share cultural traits and who use those traits to distinguish themselves from others. Culture is also different from race, which refers to a category typi- cally based on physical characteristics (Ferraro & Andreatta, 2014).

One difference between ethnicity and race is that ethnic groups identify themselves as such. The concept of race, how- ever, evolved from early attempts to categorize people based on physical characteristics such as skin color, hair texture, and facial features. However, analyses of genetic material (DNA) actually reveal more differences within racial groups than be- tween racial groups (Berg, Tymoczko, Gatto, & Stryer, 2015). This reinforces the idea that race is not biologically based but

negative life events as well as biological, cognitive, and emotional factors (Auerbach, Ho, & Kim, 2014; Xia & Yao, 2015). For example, a girl may experience sexual maltreatment as a child, develop a negative cognitive style, experience increased biological arousal, and display emotional dif- �culties into adulthood that include depression. These factors may pertain more to girls than boys, which may help explain gender differences in adult depression.

Another problem that differs by gender is excessive alcohol use, which is much more common in males than females by late adolescence. Single models such as the humanistic or sociocultural perspective cannot fully ac- count for this difference. Instead, an integrative model may be best. Early in life, certain biological and psychological factors that predispose alcohol use appear to be similar for boys and girls. During adolescence, however, some important changes may take place. Boys may become more impulsive and sensation seeking, experience later brain maturation, and be more sensitive to peer in�uences than girls (Kuhn, 2015). These factors may predispose boys to disruptive drinking more than girls.

Focus on

Different models are useful for understanding symptoms, causes, and treatment of mental disorder. The use of a single model to describe a mental disorder can be a problem, however, when gender differences arise. For example, a well-established �nding is that female and male children experience similar rates of depression but female adults experi- ence depression at twice the rate of male adults. To explain this �nd- ing using just a psychodynamic or cognitive-behavioral model would be dif�cult. Instead, researchers generally develop integrative models to help explain gender differences. Some have proposed models that focus on

Gender A More Complex Approach

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CHAPTER 2 Perspectives on Abnormal Psychology42

likely to have antisocial personality and substance use disor- der, but women are more likely to have anxiety-related and depressive disorders (APA, 2013). Gender differences may be ex- plained by differences in biology, gender identity, socialization, and social situations in which women and men �nd themselves (Aneshensel, Phelan, & Bierman, 2013). Biological differences in sex hormones may help explain why more men than women have sexual disorders (Chapter 11).

Gender identity refers to one’s awareness of being male or female or perceived degree of masculinity or femininity. Gender identity is in�uenced by parenting style and interactions with others and can be related to mental disorder. People who are an- drogynous in their personality, as opposed to strictly masculine or feminine, tend to have fewer symptoms of eating disorders (Strother, Lemberg, Stanford, & Turberville, 2012).

Men are also less likely to �nd themselves in certain situa- tions compared with women, especially as victims of domestic violence and sexual assault. This may help explain why men have fewer anxiety-related disorders than women (Chapter 5). Our ex- pectations of men and of women, or socialization differences, also play a role in developing symptoms of mental disorders. We gen- erally expect men to be less emotionally expressive. Men who are anxious and depressed may thus be more likely to use alco- hol and other drugs to self-medicate their symptoms, whereas women may be more likely to talk to friends or see a therapist.

Gender differences are most evident for depression, where women have much higher rates than men, and social support seems to be a key factor. Women generally have more social sup- port than men with respect to number of close relationships and level of intimacy of these relationships. If social support suffers, however, women may be more susceptible to depression because they rely more on social support for their well-being (Kendler & Gardner, 2014). Recall that Mariella’s separation from family members and friends near home was related to her sadness.

Women may be more likely than men to respond to stress by “tending-and-befriending” (Bodenmann et al., 2015). Women

odor, �ushing or blushing, and eye contact. These symptoms re�ect the culture’s hypersensitivity to being looked at or look- ing at others as well as concern about how one’s own behavior is viewed by others. Brain fag involves symptoms of intellectual Brain fag involves symptoms of intellectual Brain fag and visual impairment and other body complaints in Nigerian and Ugandan cultures. This condition develops during periods of intensive reading and study, such as before an academic examination, and appears in�uenced by a culture that promotes family-oriented education. This places intense pressure on a student to be academically successful for the family’s sake (Tseng & Zhong, 2012).

Disorders found primarily in Western societies also contain unique symptoms and features. Multiple personality disorder, now termed dissociative identity disorder (APA, 2013), is one dissociative identity disorder (APA, 2013), is one dissociative identity disorder example. Someone with this disorder may not report being “pos- sessed” by animals or spirits (as is the case in other cultures) but reports being possessed by other selves or personalities that control his behavior. Culture thus in�uences the possession source: in non-Western cultures possession may be by animals or spirits, but in Western cultures, possession may be by other personalities (Tseng & Zhong, 2012).

Anorexia nervosa (Chapter 8) involves excessive concern Anorexia nervosa (Chapter 8) involves excessive concern Anorexia nervosa about being overweight and severe weight loss that threatens one’s health. This condition is often observed in American and European cultures but is relatively absent in Samoa and the Paci�c Islands where food is scarce or where being overweight is considered attractive. A sociocultural theory stipulates that an- orexia nervosa is more prevalent in food-abundant societies that stress an “ideal body” as thin (Fitzsimmons-Craft et al., 2014). Culture thus affects the development of psychological problems in various ways (see Table 2.4).

Gender Mental disorders affect men and women, but some problems seem more common in one gender than the other. Men are more

Culture can in�uence such problems as anthrophobia.

TABLE 2.4

How Does Culture Contribute to Mental Disorders?

Method Examples

Direct cause: culturally shared belief leads to stress, and then to symptoms of mental disorder

Dhat syndrome

In�uences the way individuals cope with stress

Amok

Family suicide

Shapes the content of the symptoms or the symptoms themselves

Anthrophobia

Brain fag

Dissociative identity disorder

Anorexia nervosa

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Why do certain neighborhood characteristics relate to poor mental health? A common theme appears to be stress (Senn, Walsh, & Carey, 2014). Certain neighborhoods generate many stressful life events. People from these neighborhoods also have few resources to handle these stressors, so their ability to cope is taxed. Individual differences exist, however, with respect to how able and how well one can cope with such stressors. Some people are “resilient” to such stressors, and psychologists have focused more on features and mechanisms of this resilience. Knowledge about resilience can help psychologists prevent negative mental health outcomes even for people who live under adverse conditions. We discuss resilience in more detail in Chapter 3 within the context of risk and prevention.

Family Many theorists believe that positive family relationships de- crease risk for psychological problems but that family con�ict can increase risk. A family systems perspective assumes that each family has its own rules and organizational structure, or hierarchy of authority and decision making. When family members keep this organization and obey the rules, a sense of homeostasis or stability is created. Dysfunctional families, how- ever, experience problems and distress because the structure and rules are not optimal (Zvara et al., 2014). Some problematic family relationships and environmental variables are discussed next.

Problematic Family Relationships In�exible families are overly rigid and do not adapt well to In�exible families are overly rigid and do not adapt well to In�exible changes within or outside the family. This can lead to substan- tial con�ict, especially as a child reaches adolescence and wants more independence. Enmeshed families are characterized by family members who are overly involved in the private lives of other family members—everything is everyone’s business. This can lead to overdependence of family members on one another and feelings of being controlled by others. A family systems the- ory of anorexia nervosa suggests some individuals try to regain control over their lives by refusing to eat in reaction to parents’ excessive involvement and control.

Disengaged families are characterized by family members who operate independently of one another with little parental supervision. This family structure might predispose children to develop conduct problems or get into legal trouble. Families can also be characterized by triangular relationships, or situations in which parents avoid talking to each other or addressing marital con�icts by keeping their children involved in all conversations and activities.

Problematic Family Environment Family environment refers to features or dimensions of family Family environment refers to features or dimensions of family Family environment functioning. One feature of family environment is family affect, or the degree to which a family is cohesive, organized, and free of con�ict. Another feature is family activity, or the degree to which families engage in cultural, recreational, and religious ac- tivities together. Family control is the degree to which a family is

often respond to stress by nurturing and protecting offspring (tend) and by af�liating with others to reduce risk of harm (befriend). Doing so may have an evolutionary component. When a threat existed, quieting offspring and blending into the environment was adaptive because one was not seen as a threat. Af�liating with a social group following a threat also increased the chance one would be protected. This tending and befriend- ing pattern has also been linked to neurobiological systems that characterize attachment to others and caregiving, and these are speci�c to women. This theory and related �ndings illustrate that understanding gender differences can help us explain men- tal disorders and develop treatments. Mariella could volunteer to help others to help reduce her social isolation and depression.

Neighborhoods and Communities Another in�uence on our mental well-being is our surrounding neighborhoods and communities. Several neighborhood charac- teristics are associated with poorer mental health (Poole, Higgo, & Robinson, 2014). First, neighborhoods with high rates of pov- erty, turnover among residents, and families headed by single parents often have high rates of juvenile delinquency and child- hood maltreatment. Second, people in neighborhoods character- ized by physical (abandoned buildings, vandalism) and social (public drunkenness, gangs, disruptive neighbors) decline often have substantial anxiety, depression, and physical complaints. Third, neighborhoods characterized by noise, crowding, and pollution are often associated with high rates of depression, aggression, and childhood behavior problems.

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CHAPTER 2 Perspectives on Abnormal Psychology44

for social stressors, social support, and family environment, but few measures are available for features of culture, gender role, and neighborhood or community variables. A mental health profes- sional, therefore, may be limited to using an unstructured interview when conducting these assessments. (Unstructured interviews are problematic assessment tools; we discuss this in Chapter 4.)

Treatment from a sociocultural perspective focuses on ad- dressing a person’s dif�culties at global and individual levels. Globally, sociocultural interventions focus on decreasing or preventing stress created for people through sexism, racism, or age or religious discrimination. Consider discrimination based on race or ethnicity, which places additional burden and stress on people and may lead to economic hardship and limited re- sources for education, health care, and employment. People who experience discrimination because of lack of economic re- sources are also likely to live in stressful neighborhoods or com- munities—neighborhoods with high rates of unemployment, poverty, crime, and substance use problems. Unremitting stress from these circumstances can have a signi�cant negative impact on a person’s mental health. Racial and ethnic disparities also exist with respect to access to physical and mental health care (Le Cook et al., 2014).

A comprehensive program is clearly needed to address the in�uence of racial and ethnic discrimination on mental health and access to services. This would include programs to make community members aware of the discrimination, public policy and laws to prevent such discrimination, and efforts to decrease disparities in employment, housing, and economic well-being.

Treatment from a sociocultural perspective also focuses on addressing a person’s dif�culties at individual levels. Family therapy or couples therapy—in which multiple family members meet with a therapist at the same time—are used by various kinds of mental health professionals (Goldenberg & Goldenberg, 2013). These therapies allow for better assessment of a fam- ily’s problems and provide the opportunity to intervene with all members. Many family and couples therapists directly coach individuals on what to say to other family members and provide feedback about their interactions.

Family and couples therapists also identify and �x problems in communication. Therapists emphasize that nothing is wrong with the family or dyad itself but instead focus on particular re- lationship issues or communication patterns. One family mem- ber might be exhibiting more emotional distress or behavioral problems than others, but this is thought to re�ect problems within a family or couple. All family members must thus engage in treatment and change the way they interact with other family members.

Evaluating the Sociocultural Model The sociocultural perspective has much strength for under- standing mental disorders. First, the perspective highlights the importance of social in�uences on emotions, cognitions, and behaviors. Humans are indeed social beings and so our mental health is clearly in�uenced by people and institutions around

rigid or �exible when adapting to new situations or challenges (Goldenberg & Goldenberg, 2013).

Family environment does seem to in�uence the mental health of individual family members. For example, expressed emotion is the degree to which family interactions are marked by emotional overinvolvement, hostility, and criticism. A parent in a family with high expressed emotion might say to his son: “You never get out of the house. You are never going to amount to anything if you keep it up.” Communications like this, al- though perhaps intended to motivate the son, likely lead to stress and negative feelings of self-worth. People with schizophrenia living in families with high expressed emotion, especially criti- cism, are at greater risk for relapse compared with people living in families with low expressed emotion (Cechnicki, Bielanska, Hanuszkiewicz, & Daren, 2013). Interventions have thus been developed to help family members understand how their actions can negatively affect someone who has, or who is at risk for, a mental disorder.

Sociocultural Assessment and Treatment Socioculturalists believe psychological problems largely develop because of the impact of social institutions and other people. What sociocultural factors may have affected Mariella, who was Latina? Mariella’s culture is typically collectivist, meaning less emphasis on the self and more emphasis on interdependence with others such as friends and family members. Social sup- port is thus likely quite important for Mariella, and her isola- tion at school may have in�uenced her sadness and pessimism. The importance of Mariella’s academic achievement from a cultural and family perspective is also important to consider. Mariella may have experienced intense pressure to do well at college, which in turn led to added stress. Her family’s dismis- sive reaction to her depressive symptoms when she was home for Thanksgiving may have led to further pessimism and self- criticism as well.

Mariella’s identity as a Latina may have in�uenced her col- lege experience. Latinas, compared with their male counterparts, may be more passive and less competitive. Mariella may have been experiencing some ambivalence about pursuing advanced academic training given her gender as well. Overall, many potential cultural, gender role, and familial issues may have in�uenced the development and maintenance of Mariella’s depressive symptoms.

Clinicians should thus conduct a thorough assessment of an individual’s culture. A cultural assessment does not simply include race but also a person’s self-de�ned ethnicity, sources of social support, af�liations and interactions with social insti- tutions, and larger worldview factors such as religious prefer- ence. A person’s gender role within a cultural context as well as important neighborhood and community factors should also be assessed. A thorough evaluation of family structure, dynam- ics, and environment is necessary for understanding a person’s mental health as well.

Sociocultural assessment methods are less advanced than those of other models of mental disorder. Measures are available

•

➲ Review Questions 1.

2. -

4. -

us. Second, the sociocultural perspective provides a good un- derstanding of different sources of stress that have an impact on a person and how that person copes with stress. Sources of stress may occur at global and in- dividual levels. Finally, the socio- cultural perspective emphasizes the critical role that family mem- bers have in in�uencing mental health.

Limitations of the sociocul- tural model should be noted, however. First, evidence linking social, cultural, or environmental factors to mental health is largely correlational. Whether these fac- tors cause symptoms of mental disorders is unclear. Second, we do not yet know why people exposed to adverse in�uences have various outcomes: Some will develop various psychologi- cal problems, and some will not. Why does one child living in a poor neighborhood and raised by a dysfunctional family become delinquent but another be- comes depressed? Why does one child with abusive parents commit suicide but his sibling succeeds in college with few psychological effects? The sociocultural perspective has great strength, but its account of how psychological problems de- velop remains incomplete.

➲ Interim Summary •

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Family therapy is a commonly used treatment in the sociocultural model of mental disorder.

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CHAPTER 2 Perspectives on Abnormal Psychology46

TABLE 2.5

Perspectives to Explain Mental Disorder

Biological

Mental disorder is related to brain or neurochemical changes or genetics.

Psychodynamic

Mental disorder is related to internal mental structures and childhood experiences.

Humanistic

Mental disorder is related to choices people make in their environment and how satis�ed they are with their real self.

Cognitive-Behavioral

Mental disorder is a learned behavior and is in�uenced by how people perceive and think about their environment.

Sociocultural

Mental disorder is related to outside in�uences such as social institutions or family members.

Biopsychosocial

Mental disorder is related to a variety of biological, individual, and social environmental risk factors that interact with one another.

In the early days of psychotherapy, an ideologi- cal cold war reigned as clinicians were separated into rival schools—biological, psychodynamic, cognitive-behavioral, humanistic, sociocultural, and so on. Clinicians traditionally operated from within their own theoretical frameworks, often to the point of being blind to alternative concep- tualizations and potentially superior treatments.

As the �eld of psychotherapy has matured, integration has emerged as a clinical reality and the most popular approach. Clinicians now acknowledge the inadequacies of any one theoretical school and the potential value of many perspectives. Rival therapy systems are increasingly viewed not as adversaries but as partners; not as contradictory but as complementary.

My practice and research is devoted to integration: a dissatisfaction with single-school

approaches and a concomi- tant desire to look across school boundaries to see how patients can bene�t from other ways of conduct- ing treatment. The goal is to enhance the effectiveness and applicability of psychotherapy by tailoring it to the singular needs of each client. Clients frequently require an eclectic mix or hybrid of different perspectives.

Applying identical treatments to all patients is now recognized as inappropriate and prob- ably unethical. Imagine if a physician delivered the same treatment—say, neurosurgery or an antibiotic—to every single patient and disorder. Different folks require different strokes. That’s the mandate for integration.

How do we select treat- ment methods and rela- tionship stances that �t? On the basis of research evidence, clinical experi-

ence, and patient prefer- ences. A client who denies

the existence of an obvious problem (the precontempla- tion stage), for example, will

pro�t from a different relationship and treatment than a client who is committed to changing her behavior right now (the action stage). Or a client who seeks more insight into the early childhood antecedents of a problem, for another example, will probably secure better results in psychodynamic therapy than one who seeks psychoactive medication (biological therapy) or speci�c skills in restructuring thoughts

2.1

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(cognitive therapy). And a client who responds negatively to external guidance and direct ad- vice (high reactance) will surely require a dif- ferent treatment than one who enjoys them (low reactance). Decades of research can now direct us in making better marriages between some treatments and certain disorders and client characteristics.

The integrative psychotherapist leads by fol- lowing the client. An empathic therapist works toward an optimal relationship that enhances collaboration and results in treatment success. That optimal relationship is determined by both patient preferences and the therapist’s knowl- edge of the client’s personality and preferenc- es. If a client frequently resists, for example, then the therapist considers whether she is pushing something that the client �nds incom- patible (preferences), or the client is not ready

of the Buddha: “anything that can help to alleviate human suffering.”

As a university professor teaching abnormal psychology and clinical psychology, I �nd that my students naturally favor integration. Theo- retical purity, they remind me, is for textbooks, not people. And as a clinical psychologist in part-time independent practice, I �nd my cli- ents overwhelmingly require an integrative or eclectic approach. Rigid therapy, they teach me, is bad therapy.

Integrative therapy brings evidence-based �exibility and empathic responsiveness to each clinical encounter. Integrative therapy offers the research evidence and clinician �exibility to meet the unique needs of individual patients and their unique contexts. For these reasons, integration will assuredly be a therapeutic mainstay of the 21st century. Come join us!

to make changes (stage of change), or is un- comfortable with a directive style (reactance).

Integration refers typically to the synthesis Integration refers typically to the synthesis Integration of diverse systems of psychotherapy, but we need not stop there. We can combine thera- py formats—individual, couples, family, and group. We frequently integrate medication and psychotherapy, also known as combined treat- ment. Integration gets us beyond either/or to both/and.

In practice, integrative psychologists are committed to the synthesis of practically all effective, ethical change methods. These include integrating self-help and psycho- therapy, integrating Western and Eastern perspectives, integrating social advocacy with psychotherapy, integrating spirituality into psychotherapy, and so on. When asked about my doctrine, I reply with the words

personal narrative

Key Terms models 22 biological model 23 syndromes 23 genotype 23 phenotype 23 behavior genetics 23 molecular genetics 24

central nervous system 24 peripheral nervous system 24 neurons 24 synapse 24 neurotransmitters 24 reuptake 24 cerebral cortex 25

frontal lobe 25 parietal lobe 25 temporal lobe 25 occipital lobe 25 limbic system 25 basal ganglia 25 thalamus 25

Final Comments You might wonder which major perspective of abnormal behavior is the best one, especially when each one provides such a different view of mental disorder (Table 2.5). Each perspective has its own strengths and limitations and none provides a complete and comprehensive account of all psychological problems. Many mental health professionals thus adopt the notion of a biopsychosocial model to mental disorder. A biopsychosocial model stipulates that mental disorder can be attributed to many biological (e.g., genetic, brain changes), psychological (thought, emotional changes), and social (family, societal) variables. These variables work in tandem to produce healthy or unhealthy behavior.

In Chapter 3, we present a general theoretical model, the diathesis-stress model, that resembles the biopsychosocial model and addresses the issue of how mental health problems develop. This model incorporates notions of diathesis, or predisposition or vulnerability to mental disorder, and stress, which can be environmental, interpersonal, or psychological. This model, because of its �exible, wide-ranging de�nition of diathesis and stress, can accommodate the �ve perspectives covered in this chapter as well as combinations of these perspectives. The diathesis-stress model is perhaps the best way to think about mental health issues. Chapter 3 begins with a detailed description of this model and its implications for studying, treating, and preventing psychological problems.

Source: Reprinted by permission of the author.

CHAPTER 2 Perspectives on Abnormal Psychology48

hypothalamus 25 psychodynamic model 28 unconscious motivation 28 defense mechanisms 29 psychic determinism 29 id 29 pleasure principle 29 primary process 29 ego 29 reality principle 29 secondary process 29 superego 30 psychosexual stages of

development 30 �xation 30 repression 30 regression 30 reaction formation 30 projection 30 projective hypothesis 31

free association 31 dream analysis 31 manifest content 31 latent content 31 insight 31 interpretation 31 transference 32 humanistic model 32 civil commitment 33 criminal commitment 33 competency to stand trial 33 insanity 33 phenomenological approach 33 self-actualization 33 conditional positive regard 34 unconditional positive regard 34 client-centered therapy 34 behavioral perspective 36 classical conditioning 36 operant conditioning 36

positive reinforcement 36 negative reinforcement 37 cognitive perspective 37 cognitive schemas 37 cognitive distortions 37 modeling 38 avoidance conditioning 38 functional analysis 38 cognitive-behavioral therapy 39 cognitive restructuring 39 systematic desensitization 39 exposure treatment 40 token economy 40 sociocultural perspective 40 culture 41 ethnicity 41 race 41 cultural syndromes 41 family systems perspective 43 expressed emotion 44

Special Features

• 3.1 John Snow: A Pioneer in Epidemiology and Prevention 55

• 3.2 Suicide

• 3.3 Prevention of Femicide

• 3.4 Constructs Related to Insanity

Personal Narrative 3.1 Kim Dude and the Wellness Resource Center

C / What Do You Think?

The Diathesis-Stress Model

Epidemiology: How Common Are Mental Disorders?

Risk, Protective Factors, and Resilience

Prevention

FINAL COMMENTS

KEY TERMS

CHAPTER 3 Risk and Prevention of Mental Disorders52

discussing its implications for studying, treating, and preventing mental disorders.

Diathesis, Stress, and Mental Health A diathesis is a biological or psychological predisposition to disorder. Diatheses are often genetic or biological, but some diatheses are psychological. Some people expect alcohol use to make them more sociable and fun to be around. These people are more likely than others to drink alcohol. This expectancy is thus a psychological predisposition to use alcohol excessively. DeShawn expected that drinking would make him more socia- ble, so he is more likely to drink and use alcohol excessively.

Another psychological predisposition is impulsivity, or act- ing too quickly without thinking of the consequences. Impulsive people may predispose themselves to dangerous situations such

The Diathesis-Stress Model

Why do some college students like DeShawn develop prob-lems with alcohol use but others do not? College is stress- ful for most students, but not everyone develops a drinking problem. Did DeShawn have a certain genetic structure, an oral �xation, or a maladaptive cognitive schema that led to his drink- ing problems? Or was some combination of these factors within a stressful college environment responsible?

We discussed different models of mental disorder in Chapter 2 that have various strengths and limitations. We also introduced the diathesis-stress model as a way of integrating these models to explain mental disorders. The diathesis-stress model not only integrates perspectives but is consistent with a continuum of mental health and mental disorder. We thus begin this chapter by examining the diathesis-stress model in detail and

DeShawn is a 21-year-old business major who has been attending a large public university for 3 years. DeShawn was initially anxious about at- tending college because no one else in his family had done so. He thought the transition to college was going to be tough and unlike anything he had experienced previously. His actual transition to college was a “mixed blessing.” On one hand, DeShawn was invigorated by his classes and by meeting so many new people. He liked interact- ing with his professors and looked forward to graduating with an eye toward an MBA.

On the other hand, DeShawn had never been to so many parties. His experience was far beyond his expectations about the party scene

at college. His experience began during his �rst semester when DeShawn was invited to a party at the dorm room of a new acquain- tance. The beverage that night was “trash-can punch” that

tasted good and had plenty of alcohol. DeShawn thus felt poorly the next day when he

woke up around noon, but he could not turn down an invitation for another party later that evening. DeShawn kept telling himself he would eventually slow down, but that was 3 years ago. DeShawn did not drink every night but seemed to attend a party at least 4 nights a week—every sporting and campus event and weekend was an opportunity for someone to throw a big party.

DeShawn met hundreds of people at these parties in 3 years, but there was a clear down- side. DeShawn’s drinking increased over the years to the point where he could get tipsy only after 6 to 10 drinks. Of course, DeShawn did not usu- ally stop at 6 to 10 drinks and so felt miserable the next day. Over time he tried to schedule his classes in the late afternoon or early evening to ac- commodate his “social” activities, but even these classes he often skipped because they con�icted with “Happy Hour.” DeShawn’s studying suffered tremendously, and he almost failed school his �rst semester, �rst year, and two semesters since then. He accumulated only three semesters worth of credits during his 3 years at school.

DeShawn’s parents were unhappy about their son’s progress. He did his best to hide his grades, but the registrar regularly informed parents about poor academic performance. DeShawn’s parents could not understand why their son was doing so poorly in college because he had been a straight- A student in high school. They did not know about the parties, however, and DeShawn was

certainly not going to tell them about his social life. DeShawn thus rarely went home on weekends— too many parties to miss, and who wants to get “grilled” by their parents?—but promised his parents via telephone and e-mail that he would concentrate better and improve his grades.

DeShawn felt he had things under control until he looked in his rearview mirror one night to see �ashing lights. He had been drinking heavily and was weaving across lanes. He was a bit confused and even wondered if he had accidentally hurt someone. He was processed at the police station, and DeShawn knew he faced his greatest challenge. What was he going to tell his parents about this “driving under the in�u- ence” charge? They were going to go ballistic. He had trouble believing what was happening but resigned himself to the possibility that his college days might be over.

What Do You Think? 1. Do you think DeShawn has a problem with

alcohol? Why or why not? 2. Why do you think DeShawn is drinking so

much? 3. What should DeShawn do? Should he tell his

parents? To whom should he turn for help? 4. Do you know people who have had similar

experiences? What did they do? 5. Do you think DeShawn’s situation could

have been prevented? If so, how?

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mental disorder. DeShawn and Kira’s college stress is likely similar, but their predispositions for high alcohol use are quite different. Many soldiers in Afghanistan developed posttraumatic stress disorder (Chapter 5), but many did not. Why? Because soldiers (and people in general) differ considerably with respect to their vulnerability to posttraumatic stress disorder.

Diatheses such as impulsivity are clearly important but in- teract with stressors that can also be viewed along a continuum (Figure 3.1). Two people with the same level of impulsivity may show different outcomes based on level of stress. Mariella may have been troubled because signi�cant college stress triggered her predisposition for depression. Her friend Gisela, however, who had the same type of predisposition but who stayed home after high school, showed no symptoms of depression.

Diathesis-Stress: The Little Picture Let’s also examine the little picture of the diathesis-stress model by showing how diatheses and stressors can interact in sub- tle ways. One example is that a diathesis or predisposition can in�uence a person’s perception of stress. Stress is subjective, and so one event can be perceived and experienced as much more stressful by one person than another who has a different level of diathesis or vulnerability. Mariella’s cognitive predisposition for depression—viewing the world as disappointing, unsympa- thetic, and unforgiving—likely affects her internal de�nition of a stressful event and her experience of the event as stressful. Mariella’s rejection or lack of support from friends is more likely to be seen as stressful and lead to depression than someone without such a worldview. We therefore must recognize that stress varies from person to person and can actually depend on level and type of diathesis or predisposition.

Our predispositions also in�uence our life course and choice of experiences. Someone predisposed toward a shy tempera- ment may choose over time to have fewer friends and engage

as drinking too much and then driving. Cognitive schemas can also be considered psychological diatheses or predispositions. Recall Mariella from Chapter 2. Her negative views or schemas about herself, the world, and the future can be viewed as a diathesis or predisposition for her depression.

Biological or psychological diatheses do not guarantee one do not guarantee one do not guarantee will develop disorders like alcoholism or depression. A diathesis is a vulnerability—you can be vulnerable to a certain disorder, but this does not mean you will necessarily develop it. Many people have a genetic predisposition for lung cancer but never develop the disease. Why? Because they never smoke tobacco! DeShawn’s expectancies about alcohol or Mariella’s cognitive style predispose them toward certain disorders but do not guar- antee these disorders will occur. Something must trigger these trigger these trigger predispositions, such as smoking cigarettes or experiencing the stress of college life. Traumatic experiences such as assault are another stressor linked to many of the mental disorders we discuss in this textbook.

A combination of predisposition and stress produces psy- chological problems according to the diathesis-stress model. Stress can be environmental, interpersonal, or psychological, but it must interact with a predisposition for a disorder to occur. interact with a predisposition for a disorder to occur. interact Predispositions and stressors also occur on a continuum from weak to strong (or low to high). This is consistent with current research and this textbook’s dimensional approach to mental health. We need to examine the diathesis-stress model in gen- eral (the big picture) and more speci�cally (the little picture) to understand it better.

Diathesis-Stress: The Big Picture Let’s examine the big picture of the diathesis-stress model using DeShawn as an example. Figure 3.1 illustrates predisposition, stress, and a potential psychological problem involving alcohol use on a continuum. This model shows the interaction of a pre- disposition (impulsivity) with stress along a continuum as they contribute to levels of alcohol use. Predisposition to be impul- sive is on a continuum because people are impulsive to vary- ing degrees. Some people may even have no impulsivity traits (labeled Predisposition to impulsivity absent in Figure 3.1). One Predisposition to impulsivity absent in Figure 3.1). One Predisposition to impulsivity absent of DeShawn’s friends, Kira, is quite conscientious about her life and always considers decisions carefully. Kira is not impulsive and would not likely develop alcoholism even when faced with substantial stress.

Most people have some degree of diathesis or predisposisome degree of diathesis or predisposisome - tion or vulnerability, whether low or high. Most of us are im- pulsive to some extent, and this is illustrated in Figure 3.1 as some extent, and this is illustrated in Figure 3.1 as some multiple lines bracketed by Predisposition to impulsivity present. Each line represents a different impulsivity level. Higher levels of a predisposition— impulsivity in this case—even with smaller amounts of stress result in more alcohol use. Lower levels of impulsivity, even with high stress, result in less alcohol use. However, the combination of strong predisposition and high stress results in the most alcohol use.

This model helps us understand why two people exposed to the same level of stress do or do not develop a certain

FIGURE 3.1 A DIATHESIS-STRESS MODEL OF ALCOHOL USE.

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CHAPTER 3 Risk and Prevention of Mental Disorders54

➲ Interim Summary •

•

➲ Review Questions 1.

Epidemiology: How Common Are Mental Disorders?

Epidemiology is the study of patterns of disease or disorder in the general population. Epidemiology can involve any physical or mental condition related to poor health or mortal- ity among children and adults. Epidemiologists are scientists who investigate the extent of a public health problem such as a mental disorder by making observations, surveying people, and using other methods. Box 3.1 presents a famous example of epidemiology: John Snow’s discovery of the cause of a chol- era outbreak and subsequent prevention of new disease cases. Prevention is an important application of information gathered from epidemiological research.

Epidemiologists often focus on incidence and prevalence of mental disorder. Incidence refers to new cases of a men- tal disorder within a speci�c time period such as a month or year. A 1-year incidence of a mental disorder is the percent- age of people who, for the �rst time, developed that disorder in the previous 12 months. Prevalence refers to all cases of a mental disorder, including new and existing cases, within a speci�c time period such as a month or year. A 1-year prevalence of depression includes all cases of existing depres- sion during the previous 12 months, regardless of when the disorder began.

Epidemiologists also provide lifetime prevalence estimates of mental disorders. Lifetime prevalence refers to the propor- tion of those who have had a certain mental disorder at any time in their life up to the point they were assessed. Lifetime time in their life up to the point they were assessed. Lifetime time in their life prevalence indicates risk for certain disorders over the entire life span, whereas smaller prevalence times such as a year provide a

in more solitary activities. The person’s choice of life experi- ences is guided, at least in part, by his diathesis. Our predis- positions can affect the preferences we have and the decisions we make. The type of friends or romantic partners we choose, the experiences we seek, the jobs we take, and the places we choose to live are likely in�uenced by diatheses. These choices and experiences also in�uence the people, places, and events we encounter in life and thus affect our life course. A diathesis will partly determine the range and varieties of life events we experience, and some of these may be seen as stressful. A shy person who surrounds himself with only a few close friends may be more likely than others to feel deliberately alienated at work.

DeShawn’s impulsivity may have predisposed him to quickly attending parties and drinking as well as a prefer- ence for encountering new people and exciting environments. These preferences helped expose him to certain environments and experiences where excessive alcohol use is more likely to occur. Some of these experiences may also have created stress from poor grades and nagging parents, which may have led to more drinking to cope with the stress. The diathesis of high impulsivity affects a person’s life choices and life course. The opposite is also true—less impulsive people will not seek these experiences and will not be exposed to some of these stressors.

Implications of the Diathesis-Stress Model The diathesis-stress model has many implications for studying, treating, and preventing psychological problems. A key implica- tion is that we must study certain diatheses or vulnerabilities to mental disorder to fully understand why and how these dis- orders develop. We must understand the etiology, or cause, of mental disorders. A diathesis-stress model does so by includ- ing aspects of all theoretical models discussed in Chapter 2. All possible diatheses are considered, such as genetics, neuro- chemical and brain changes, unconscious processes, learning experiences, thought patterns, and cultural and family factors. Knowing these diatheses is also important for treating mental disorders when they occur and for preventing mental disorders before they begin.

Diatheses or vulnerabilities are risk factors for mental disor- ders. Risk factors are discussed later in this chapter and all chap- ters describing mental disorders. Researchers study risk factors by comparing people with many symptoms of a disorder to peo- ple with few or no symptoms of a disorder. Differences between these groups may represent risk factors or vulnerabilities for the disorder. People like DeShawn with excessive alcohol use can be compared to people like Kira with less alcohol use. We may �nd key differences such as genetic structure, impulsivity, and stress, and some of these differences could be useful for treat- ment and prevention. College freshmen found to be impulsive and stressed could undergo an awareness program to decrease excessive alcohol use. The search for risk factors intersects with the study of patterns of mental disorder in the general popula- tion, a topic we turn to next.

students, do not seek a mental health professional during the �rst year of their diagnosis (Eisenberg, Hunt, & Speer, 2012). Friends, peers, or family members may not even know about a person’s symptoms. Many symptoms of mental disorders are not obvious, such as sadness, so other people may not recog- nize a person has a serious problem. Such may have been the case for Mariella.

Second, mental disorders differ with respect to severity and many people show only mild symptoms. This point re- inforces a major theme of this textbook: Symptoms of mental disorders are present to some extent in all of us and can be represented along a continuum. People with certain symptoms or diagnoses are not qualitatively different from those without. Mariella’s symptoms of depression are something we all feel from time to time. Her symptoms may be more severe than ours at the moment, but the symptoms are something with which we can identify.

NCS-R data included serious, moderate, and mild levels of severity (Kessler, Chiu, et al., 2005). Each level was de�ned by certain features associated with a disorder. For example, serious severity was de�ned by features such as suicide attempt with lethal intent, occupational disability, psychotic symptoms, or

snapshot of whether people have recently been diagnosed with a speci�c disorder. Both prevalence types help us understand the likelihood of mental disorder and are discussed in more detail next and throughout this textbook.

Prevalence of Mental Disorders Epidemiologists help determine the prevalence of mental disorders. A major epidemiological survey of Americans, the National Comorbidity Survey-Replication (NCS-R), is a represen- tative, community-based survey of about 10,000 people aged 18 years and older. The survey included structured interviews to assess people for major mental disorders and serves as the basis for the next several sections.

Overall Prevalence and Severity NCS-R data revealed that 46.4 percent of Americans experience a mental disorder at some point in their life (Kessler, Berglund, Demler, Jin, & Walters, 2005). This percentage may seem high, but keep two key points in mind. First, not everyone who meets criteria for a mental disorder is in treatment. Most peo- ple who experience psychological symptoms, including college

John Snow: A Pioneer in Epidemiology and Prevention John Snow (1813–1858) is often referred to as the “Father of Epidemiology.” His investigation of a catastrophe is considered classic among epidemiologists, and his simple intervention is a �ne example of prevention. An outbreak of cholera occurred in 1854 London pri- marily among people living near Cambridge and Broad Streets; 500 deaths were reported in this area over a 10-day period. Snow thought people were contracting cholera from a contaminated water source, so he obtained information on cholera deaths from the General Register Of�ce. He used this information and surveyed the scene of the deaths to determine that nearly all deaths occurred a short distance from the Broad Street pump (a water source for this area). He went to each ad- dress of the deceased and calculated the distance to the nearest water pump, which was usually the Broad Street pump. He also determined that some of the deceased recently drank from this pump. These data supported his theory of the spread of cholera through water, and he concluded that the water source for the Broad Street pump was con- taminated. Snow presented his �ndings to local authorities, the handle to the pump was removed, and the local cholera outbreak ended. This is a great example of epidemiological �ndings leading to a preventive intervention—one that saved untold lives.

The map featured here shows the distribution of cholera deaths in a London area. The circles represent the way the deaths were concen- trated in one region, leading John Snow to question whether the source of the outbreak originated there.

3.1

Map showing the distribution of deaths from cholera in an area of London.

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CHAPTER 3 Risk and Prevention of Mental Disorders56

Comorbidity Comorbidity refers to the presence of two or more disorders in a person and is a signi�cant concern for mental health pro- fessionals. This is so because recovery among people with two or more mental disorders is less likely than among people with one mental disorder. According to the NCS-R, 27.7 per- cent of Americans will have more than one mental disorder in their lifetime, and 11.8 percent will have had more than one mental disorder in the past year (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). A signi�cant percentage of Americans thus experience more than one mental disorder. Comorbidity is also clearly related to severity of mental disor- der. Data from Figure 3.2 indicate that a much higher percent- age of those with three or more disorders (49.9 percent) were classi�ed as serious severity than those with only one disorder (9.6 percent).

Age of Onset A unique aspect of the NCS-R was that questions were asked about the onset of mental disorder. People who received a onset of mental disorder. People who received a onset diagnosis for a mental disorder at some point in their lives were asked if they could remember when their symptoms started and how their symptoms progressed. Several interesting �ndings emerged (see Figure 3.4). First, the median age of onset for a mental disorder is 14 years. Second, anxiety-related disorders have an earlier onset (age 11 years) than substance use (age 20 years) or mood (age 30 years) disorders. Not everyone diagnosed with these disorders has these exact ages of onset, of

intense violence. Figure 3.2 illustrates percentage of severity levels for some major mental disorders. Mental disorder was generally classi�ed as serious (22.3 percent), moderate (37.3 percent), or mild (40.4 percent) in severity. Serious severity was most evident with respect to mood (i.e., depressive and bipolar) disorders (45.0 percent).

Speci�c Prevalence Rates Prevalence information for speci�c disorders is crucial so we know where to assign treatment and prevention resources. Figure 3.3 outlines lifetime and 12-month prevalence rates for some major mental disorders. Lifetime prevalence rates for anxiety-related disorders (28.8 percent), including speci�c phobia (12.5 percent) and social phobia (12.1 percent), are substantial. Mood disorders (20.8 percent) are also relatively common. Lifetime prevalence for substance use disorders in general was 14.6 percent and for alcohol use disorder in par- ticular was 13.2 percent.

The NCS-R also provided 12-month prevalence rates, which are lower than lifetime prevalence rates because of the shorter time frame. Researchers found that more than one-fourth of Americans (26.2 percent) had one or more mental disorders over the previous year (Kessler, Chiu, et al., 2005). Anxiety-related (18.1 percent), mood (9.5 percent), and substance use (3.8 percent) disorders were quite common (Figure 3.3).

AnyAny anxiety-relatedanxiety-related

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0 50 5 10 15 20 25

Rates

30 35 40 45 5030 35 40 45 50

Lifetime 12-monthLifetime 12-monthLifetime 12-month

20.8 9.5

14.6 3.8

27.7 11.8

17.3 6.0

46.4 26.2

FIGURE 3.2 SEVERITY OF 12-MONTH MAJOR MENTAL DISORDERS. Rates indicate the proportion of people in the United States with the mental disorder at each level of severity (serious, moderate, mild). Adapted from Kessler, Chiu, et al. (2005).

FIGURE 3.3 LIFETIME AND 12-MONTH PREVALENCE OF MAJOR MENTAL DISORDERS. Lifetime and Lifetime and Lifetime 12-month rates represent the proportion of U.S. 12-month rates represent the proportion of U.S. 12-month rates residents with the mental disorder. Adapted from Kessler, Berglund, et al. (2005); Kessler, Chiu, et al. (2005).

of mental disorder than older people. Mental disorders can be of varying severity, and even people without a formal diagnosis may experience symptoms to some degree. Mental disorders and their symptoms are dimensional, and this is why the study of abnormal psychology is a key part of life in general. The high prevalence of mental disorder also means people often seek treatment, which is discussed next.

Treatment Seeking The NCS-R researchers asked people with anxiety-related, mood, or substance use disorders about their use of mental health services in the previous year (Wang, Lane, et al., 2005). Many (41.1 percent) used services, including 21.7 percent who used mental health services, 22.8 percent who used general medical services, and 13.2 percent who used non–health care services such as alternative medicine (some used two or more types of service). People who sought treatment were gener- ally younger than age 60 years, female, from a non-Hispanic white racial background, previously married, more af�uent, and living in urban areas. People who sought treatment also tended to have more severe mental disorders or two or more mental disorders.

course, but these estimates do indicate that many mental disor- ders �rst appear in adolescence or young adulthood.

Cohort Effects and Children Cohort effects are signi�cant differences in disorder expres- sion depending on demographic features such as age or gender. Younger Americans may be more likely to develop substance use disorders compared with older Americans. Why? One possible reason is that alcohol was not as available to adoles- cents 30 years ago as it is today. Our views on underage college drinking have also changed over the years, and the behavior may be more tolerated now than in the past. Attention-de�cit de�cit/hyperactivity disorder is also diagnosed more now than in the past. Another example is addiction to online gambling such as poker. Which group might have this problem more— older Americans with less expertise about computers or college students raised in a technological era?

Figure 3.5 presents NCS-R data on mental disorders by age. People aged 18 to 59 years have higher lifetime rates of some major (anxiety-related, mood, substance use) mental disorders than people aged 60 years or older. Why these age differences exist is unclear. Higher lifetime prevalence rates for younger people may be due to greater willingness to admit psychological problems, or adults may underreport or forget symptoms as they get older and further from their disorder onset.

What about youth? Epidemiologists estimate that about 40 percent of American children and adolescents have a men- tal disorder. Children and adolescents are most likely to be diagnosed with anxiety-related, disruptive, mood, and sub- stance use problems (Kessler, Avenevoli, et al., 2012). Many children are also reported by their parents to have emotional or behavioral dif�culties that interfere with family, academic, and social functioning (Sellers, Maughan, Pickles, Thapar, & Collishaw, 2015).

Mental disorders will generally affect about half of us in our lifetime, and many of these disorders begin in adolescence or early adulthood. Many of us will experience more than one mental disorder, and younger people tend to report higher rates

AnyAny anxiety-relatedanxiety-related

disorderdisorder 11

AnyAny moodmood

disorderdisorder

AnyAny substancesubstance

use disorderuse disorder

AnyAny disorderdisorder

0 5 10 15 20 25 30

Age of onset

FIGURE 3.4 MEDIAN AGE OF ONSET OF MAJOR MENTAL DISORDERS. Adapted from Kessler, Berglund, et al. (2005); Kessler, Chiu, et al. (2005).

AnyAny anxiety-relatedanxiety-relatedanxiety-related

disorderdisorder

30.2

30.8 15.3

35.1

21.4

22.9 11.9

24.6

16.7

15.3 6.3

18.0

52.4

46.5 26.1

55.0

33.9

27.0 11.6

34.0

22.3

15.9 5.3

22.5

AnyAny moodmood

disorderdisorder

AnyAny substancesubstance

use disorderuse disorder

AnyAny disorderdisorder

Two or moreor more

disordersdisorders

ThreeThree or moreor more

disordersdisorders

0 5 10 15 20 25 30 35 40 45 50 55 6010 15 20 25 30 35 40 45 50 55 60

18-29 30-4418-29 30-4418-29 30-44 Ages:

Lifetime rates

45-59 6045-59 6045-59 60+

FIGURE 3.5 LIFETIME PREVALENCE OF MENTAL DISORDERS BY AGE. Lifetime rates represent the proportion of U.S. residents with a mental Lifetime rates represent the proportion of U.S. residents with a mental Lifetime rates disorder. Adapted from Kessler, Berglund, et al. (2005).

CHAPTER 3 Risk and Prevention of Mental Disorders58

•

Many people with a mental disorder do eventu- ally seek treatment. Unfor- tunately, a lengthy delay often occurs between onset of a disorder and �rst treat- ment contact. Less than half of those with a men- tal disorder seek treatment within the �rst year of onset (Wang, Lane, et al., 2005). The typical delay be- tween diagnosis and treat- ment for many disorders was 10 years or more. Less delay was evident for mood disorders but greater delay was evident for anxiety- related disorders. Younger people are more likely to seek treatment, and a later age of onset is linked to more timely treatment con- tact. This may re�ect the idea that younger people are more open to seeking treatment than their par- ents or grandparents.

Treatment Cost Many people seek treatment for mental disorder, but the price of such care can be steep. The cost for mental health and sub- stance abuse treatment is estimated at $57.5 billion. In addi- tion, individuals nationwide spend about 10 percent of their family’s annual income out of pocket for mental health and substance use treatment (Agency for Healthcare Research and Quality, 2014).

Mental health and substance use services thus represent a signi�cant proportion of the overall health care economy. Other, indirect costs compound this issue. Indirect costs of mental disorders include lost productivity at work, home, and school due to disability and impairment or premature death. Mental and substance use disorders account for substantial years of life lost to premature mortality and years lived with disability (Whiteford et al., 2013). This rate of disability far exceeds that of cardiovascular disease, respiratory disease, and cancer (see Figure 3.6).

➲ Interim Summary •

•

Epidemiological studies show that some mental disorders, such as alcohol use disorder, are most prevalent among young adults.

Most people eventually seek treatment for their psychological problems but only after a delay of many years.

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Risk, Protective Factors, and Resilience

•

➲ Review Questions 1.

How do mental health professionals understand problems like Jana’s? A diathesis-stress model helps us understand factors involved in the development of mental disorder. Some factors are diatheses or vulnerabilities: features or attributes within a person. Other factors comprise the “stress” part of the model and are typically seen as “environmental”: outside a person and perhaps more transient in nature. Diatheses and stressors may be risk factors for a mental disorder, but, as we have seen, not everyone with a predisposition for a mental disorder necessarily develops one. Something must therefore protect some people from developing a mental disorder. We next protect some people from developing a mental disorder. We next protect discuss further the concepts of risk and protective factors.

Risk Factors A risk factor is an individual or environmental characteristic that precedes a mental disorder and is correlated with that dis- order. Risk factors can be biological, psychological, or social. Jana’s severe childhood sexual maltreatment is a risk factor for problems she experienced in adulthood. Risk factors are associ- ated with an increased probability a disorder will develop, but they do not imply cause. Jana has a mental disorder called bor-bor-bor derline personality disorder (Chapter 10). A childhood history derline personality disorder (Chapter 10). A childhood history derline personality disorder of severe sexual maltreatment is more common in people with borderline personality disorder than those without the disor- der. Recall that risk factors are often identi�ed by comparing prevalence of the risk factor in those with and without a certain disorder. Factors more common in people with a mental disor- der may be the ones that place them “at risk” for developing the disorder.

FIGURE 3.6 MENTAL DISORDERS ARE THE LEADING CAUSE OF DISABILITY. Adapted from President’s New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Mental disordersMental disorders

SubstanceSubstance use disordersuse disorders

Alzheimer’s diseaseAlzheimer’s disease and dementiasand dementias

MusculoskeletalMusculoskeletal diseasesdiseases

RespiratoryRespiratory diseasesdiseases

CardiovascularCardiovascular diseasesdiseases

Sense organSense organ diseasesdiseases

Injuries (disabling)Injuries (disabling)

DigestiveDigestive diseasesdiseasesdiseases

CommunicableCommunicable diseasesdiseases

Cancer (malignantCancer (malignant neoplasms)neoplasms)

DiabetesDiabetes

MigraineMigraine

All other causesAll other causes of disabilityof disability

0 4 8 12

Percent with each disability

16 20 24

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case Jana is a 22-year-old college student with a long history of psychological problems. Jana often feels depressed and anxious, has trouble controlling her moods, and can lash out at others for no reason. This has affected her relationships because many people are afraid they might “set her off.” Jana has frequently cut herself with razor blades when under stress or when she is angry at herself. Jana has wanted to die many times and has made several suicide attempts over the past 10 years. She tends to make bad decisions and does so impulsively, which has landed her in legal trouble for shoplifting and writing bad checks. Jana has also struggled with excessive alcohol and other drug use for years. Her friends say Jana often “zones out” for 30 min- utes or so when she gets upset, as though she is not really there. Jana has seen many mental health professionals over the years. When they ask what may have caused her problems, Jana points to her childhood, when an uncle maltreated her sexually.

CHAPTER 3 Risk and Prevention of Mental Disorders60

factor for his excessive alcohol use. Excessive alcohol use in- stead led to skipping classes and poor grades. For someone else, however, poor grades could trigger stress that then leads to ex- cessive alcohol use. For this person, poor grades are a risk factor.

Identifying risk factors can lead to better treatment and pre- vention (see Box 3.2). Childhood sexual maltreatment is a risk factor for borderline personality disorder, as with Jana, so those seeking to prevent borderline personality disorder might focus on preventing such maltreatment. This might be accomplished by educating parents and children about appropriate and inap- propriate intimacy and by informing parents and children about resources available to them if problems occur (such as a state Department of Family and Protective Services). We discuss how identifying risk factors can lead to prevention efforts later in this chapter. We next discuss several key risk factors identi�ed for various mental disorders.

Gender Risk of mental disorder is different for men and women. A con- sistent �nding is that males are more likely than females to have substance use, antisocial personality, sexual, and developmen- tal disorders (Chapters 9, 10, 11, and 13, respectively). Women are at greater risk for developing anxiety-related disorders and depression (Chapters 5 and 7, respectively). They are also more likely to have neurocognitive disorders such as Alzheimer’s dis- ease because they live longer than men (Chapter 14). Women are also more likely than men to have more than one mental disorder at any point in time (Eaton et al., 2012; Halladay et al., 2015; Mielke, Vemuri, & Rocca, 2014).

Age Age is also a signi�cant risk factor for mental disorders, especially during the period moving from adolescence to early adulthood (Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015; Figure 3.5). For example, 75 percent of anxiety disorders occur by age 21 years, 75 percent of substance use disorders occur by age 27 years, and 75 percent of mood disorders occur by age 43 years (Jones et al., 2013). Unfortunately, earlier onset of a

Some risk factors are “�xed,” such as gender or family history of a disorder. Other risk factors are dynamic and can change over time, such as social support. Risk factors can also vary across age, gender, or culture. Risk factors for excessive alcohol use in a 21-year-old African American college student like DeShawn are not the same as those for a 45-year-old Euro- pean American businessman. Many risk factors also exist for a particular mental disorder and may interact with each other in complex ways to in�uence the development of the disorder.

Risk factors must precede the development of a condiprecede the development of a condiprecede - tion, so the mental disorder itself cannot cause its risk factors. We would not consider DeShawn’s college struggles to be a risk

Women are at greater risk for developing anxiety-related and depressive disorders. Men are at greater risk for developing antisocial personality disorder and substance use disorders.

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sexual assault. These stressors may create new psychological dif�culties or exacerbate existing ones. Signi�cant risk factors for college student suicide include having an existing mental disorder such as depression, alcohol or other drug use, history of trauma, major physical illness, lack of social support and access to care, stigma associated with seeking help, and iden- ti�cation as lesbian, gay, or bisexual. Conversely, however, protective fac- tors include resilience, access to appropriate care, family and community support, good problem-solving and con�ict resolution skills, positive beliefs about the future, and cultural and religious beliefs that discourage sui- cide (Shadick, Dagirmanjian, & Barbot, 2015; Taub & Thompson, 2013). Research regarding risk and protective factors is important for develop- ing good assessment strategies and for targeting prevention and treatment efforts (King et al., 2015).

Focus on

One of the leading causes of death among young adults is suicide, espe- cially those in college (Centers for Disease Control and Prevention, 2015). One explanation may be the stress of college, combined with negative life events (Rowe, Walker, Britton, & Hirsch, 2013). Such stress may come from leaving family and peers, facing new academic demands, or even

College Students Suicide

3.2

2005). A summary of risk factors for mental disorder is found in Table 3.1.

Other Risk Factors Other risk factors seem to represent more general vulnerabilities to mental disorder. Individual risk factors include genetic pre- disposition, low birth weight and premature birth, neuropsycho- logical de�cits, language disabilities, chronic physical illness, below-average intelligence, and history of child maltreatment. Family risk factors include severe marital discord, overcrowd- ing or large family size, paternal criminality, maternal mental disorder, and admission to foster care. Community or social risk factors include violence, poverty, community disorganization, inadequate schools, and racism, sexism, and discrimination (Curtis et al., 2013). We also covered many other risk factors in Chapter 2 when discussing biological, psychodynamic, human- istic, cognitive-behavioral, and sociocultural models of mental disorder. Understanding these many risk factors is important for developing effective treatments and preventing mental disorders before they start. This is also true for protective factors, which are discussed next.

Protective Factors We must identify risk factors to determine who is vulnerable to mental disorder, but we must also identify protective factors as- sociated with lower risk of mental disorder. Protective factors are the �ip side of risk factors. Poor social support is a risk factor for depression, therefore strong social support can be thought of as a protective factor. Those with strong social support from friends and family are less likely to develop depression than those with poor social support. Perhaps you have been thanked by a friend for being caring and supportive during a dif�cult period in her life. Your support, and the support of others, may have protected her from becoming severely depressed.

disorder can be related to poorer chance for recovery (Costello & Maughan, 2015). Other disorders, however, such as dementia, tend to occur at later ages (Prince et al., 2013).

Race and Ethnicity The extent to which race and ethnicity are risk factors for men- tal disorder has been dif�cult to establish. European Americans have been found in general to have higher lifetime prevalence rates for anxiety-related, mood, and substance use disorders than African Americans, Asians, and Latinos (Holzer & Copeland, 2013). Most studies of race and ethnicity focus on more nuanced aspects of mental disorder, however. For example, rates of posttraumatic stress disorder tend to be higher among African Americans who may have greater exposure to certain traumatic events (Benitez et al., 2014). In addition, mood disorders tend to be higher among Hispanic adolescents than non-Hispanic whites (Avenevoli, Swendsen, He, Burstein, & Merikangas, 2015). Alcohol use disorder is most frequent among Native Americans (Grant et al., 2015). Some speci�c differences may be evident, but we cannot yet conclude that race and ethnicity are general risk factors for mental disorder. We discuss speci�c racial and ethnic differences in greater detail for each disorder throughout this textbook.

Education, Socioeconomic Status, and Marital Status Less education, low socioeconomic status, and poverty are well- established risk factors for mental disorder (Lund et al., 2011; Reiss, 2013). Marital status is a signi�cant and consistent risk factor for mental disorder as well. Entry into marriage is gen- erally associated with enhanced psychological well-being and less distress, whereas divorce and widowhood are strongly as- sociated with substantial declines in mental health (Umberson, Thomeer, & Williams, 2013). Marital disruption is most strongly associated with a higher risk for anxiety-related, mood, and sub- stance use disorders, as well as suicide (Kessler, Berglund, et al.,

TABLE 3.1

Summary of Risk Factors for Mental Disorders

Risk factor Findings

Age The highest rates of mental disorders are in adolescence and early adulthood.

Education Individuals who do not complete high school are signi�cantly more likely to be diagnosed with a mental disorder, especially substance use disorders, than those who complete or go beyond high school.

Employment Individuals who are unemployed are more likely to develop psychological problems than those who are employed.

Gender Men are at greater risk for antisocial personality disorder and substance use disorders.

Women are at greater risk for anxiety-related and depressive disorders.

Women are more likely than men to be diagnosed with more than one mental disorder at any point in time.

Marital status Marital disruption (divorce or separation) is associated with mental disorders in general and with anxiety-related, mood, and substance use disorders in particular.

Race and ethnicity Research has demonstrated mixed results in general, with some speci�c differences.

CHAPTER 3 Risk and Prevention of Mental Disorders62

mental disorder (Johnson & Wood, 2016; Layous, Chancellor, & Lyubomirsky, 2014).

Resilience Recall from Chapter 2 that some people function well even in terrible circumstances, such as poverty and maltreatment. Some people adapt well in these circumstances because of resilience, or the ability to withstand and rise above extreme adversity (Fletcher & Sarkar, 2013). Resilient people can adapt and prosper despite odds against them. Psychologists have become increas- ingly interested in studying factors associated with resilience, especially among children at risk for negative outcomes due to unfavorable environments such as war, domestic violence, or poverty (see Figure 3.7).

Resilience was originally studied among children of parents with schizophrenia (Chapter 12). A child with a biological par- ent with schizophrenia is at genetic and environmental risk for schizophrenia, but many children with these risk factors do not develop the disorder and actually adapt quite well (Hameed & Lewis, 2016). These children are exposed to several risk factors for schizophrenia, but they can still thrive.

The study of resilience has since expanded to include trau- matic events or adverse environmental or social situations. Many people developed symptoms of posttraumatic stress disorder following the 9/11 terrorist attacks. They became anx- ious, depressed, lost sleep, and had great dif�culty concentrat- ing. These symptoms were very distressing and caused many people to wonder if their mental health would ever improve. But not everyone exposed to these tragic events developed posttraumatic stress disorder. What characterized people who adapted well despite exposure to such tragic events? What were their resiliency factors?

Key resiliency factors among children include good social and academic competence and effectiveness in work and play situations. Key resiliency factors among minority populations

Research on protective factors has not been as extensive as that for risk factors, but Table 3.2 provides some examples. Like risk factors, protective factors can be biological, psycho- logical, or social and can operate at individual, family, or com- munity levels. Happily married people have the lowest lifetime and 1-year prevalence rates of mental disorder. Social support or contact with friends and others, and level of satisfaction with these social contacts, are important protective factors as well (Holt-Lunstad & Uchino, 2015). Personality and psychological factors such as self-ef�cacy, problem-solving skills, hopeful- ness, and a focus on positive events also protect people against

One epidemiological study found European Americans to have higher lifetime prevalence rates for anxiety-related, mood, and substance use disorders than African Americans and Latinos. Some speci�c ethnic differences like these are evident, but we cannot yet conclude that race and ethnicity are general risk factors for mental disorder.

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FIGURE 3.7 TYPICAL PATTERNS OF DISRUPTION IN NORMAL FUNCTIONING ACROSS TIME AFTER A TRAUMATIC EVENT. Adapted from G.A. Bonanno, American Psychologist, 59, Fig. 1, p. 21. Copyright © 2004 by the American Psychological Association. Used with permission.

TABLE 3.2

Protective Factors Against Mental Disorders and Problems

Individual Positive temperament

Above-average intelligence

Social competence

Spirituality or religion

Family Smaller family structure

Supportive relationships with parents

Good sibling relationships

Adequate monitoring and rule-setting by parents

Community or social

Commitment to schools

Availability of health and social services

Social cohesion

One year later Two years later

Chronic

Delayed

Recovery

Resilience

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Prevention

Our discussion of risk factors and protective factors such as resilience leads naturally to a focus on one of the main themes of this textbook—prevention. Prevention refers to thwarting the development of later problems and may be more ef�cient and effective than individual treatment after a mental disorder occurs. Those engaging in prevention often use risk and protective factors to identify people who need more help before major problems develop. Prevention is therefore a guiding prin- ciple of many public health programs.

Many prevention programs aim to reduce risk and increase protective factors regarding mental disorder. Child maltreat- ment, such as that Jana experienced, is a key risk factor for several mental disorders. Many prevention programs therefore try to reduce the prevalence of childhood maltreatment. Pre- vention programs may also aim to enhance protective factors. Protective factors for children include good social and academic competence and growing up in a positive home environment. Prevention programs could thus be designed to help kids make friends and do well in school and educate parents about proper child-rearing methods. Prevention programs often focus on chil- dren and families who are “at risk” for certain disorders based on these kinds of characteristics.

include supportive families and communities as well as spir- ituality and religion. Spirituality and religion are also linked to greater life satisfaction and well-being (Lewis & Rudolph, 2014; Van Cappellen, Toth-Gauthier, Saroglou, & Fredrickson, 2015). African Americans report higher levels of religiosity than other racial or ethnic groups, and religiosity seems to protect against higher rates of psychological problems. But how does religiosity or spirituality provide an advantage? Perhaps people with strong religiosity or spirituality adhere to healthier life- styles (such as not smoking or drinking alcohol), provide and receive higher levels of social support (such as a church com- munity), or promote positive, optimistic beliefs related to faith (Lavretsky, 2014).

Resiliency factors are associated with good outcome, but whether they cause good outcome remains unclear. Still, strong cause good outcome remains unclear. Still, strong cause attachments or bonds with family members and the community, as well as good problem-solving and coping skills, seem to buf- fer people against adverse circumstances. Studies of resilience and competence also help mental health professionals in several practical ways. These studies guide the development of inter- ventions to prevent or eliminate risk factors, build resources, en- hance relationships, and improve self-ef�cacy and self-regulation (Khanlou & Wray, 2014; Macedo et al., 2014).

➲ Interim Summary •

•

➲ Review Questions 1.

Spirituality and religion may serve as a protective factor against psychological problems.

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CHAPTER 3 Risk and Prevention of Mental Disorders64

mental disorder in which interventions are given after signi�after signi�after - cant problems develop. Universal prevention is similar to pri- mary prevention in that large groups of people not affected by a particular problem are targeted to reduce new cases of a disor- der (Figure 3.8). Advertisements to educate the public about the dangers of excessive alcohol and other drug use are an example. Universal prevention interventions target everyone, however, so they can be costly.

Other examples of primary or universal prevention are also available. Newborn children are regularly screened for phenylke- tonuria (PKU), a disorder that can result in intellectual disabil- ity (Chapter 13). Children with PKU can be placed on a special diet that prevents intellectual disability from occurring. Other examples of primary prevention include mandatory car seats for preschoolers to prevent accident fatalities and parenting classes to prevent child maltreatment (Table 3.3). Primary prevention also includes programs to reduce job discrimination, enhance school curricula, improve housing, and help children in single- parent homes. Some primary prevention programs work fairly well, such as school-based programs for bullying (Evans, Fraser, & Cotter, 2014). Other primary prevention programs work less well, however, such as for sexual violence perpetration (DeGue et al., 2014).

Secondary and Selective Prevention Secondary prevention refers to addressing problems while they are manageable and before they are more resistant to treatment (Aneshensel et al., 2013). Secondary prevention is designed to “nip a problem in the bud” before it progresses to a full-blown disorder. Secondary prevention programs promote the early identi�cation of mental health problems as well as treatment at an early stage so mental disorders do not develop.

A secondary prevention approach suggests that many peo- ple will be screened for early signs of mental health problems.

Table 3.3 presents various techniques to prevent child maltreatment in children in high-risk families. This particular program emphasizes different aspects of parenting and caring for a child that may serve to “protect” against maltreatment. The program provides basic education and training in positive parenting, problem-solving skills, and anger management. The hope is that a successful program such as this one will lead to less maltreatment.

Prevention on a Continuum The basis of prevention is to build mental health and limit the scope of problems, including mental health problems, before they occur or worsen. Individuals do bene�t from prevention and treatment programs along a continuum of intervention for mental disorders (Nathan & Gorman, 2015). This continuum is represented in the following way: prevention occurs before a disorder develops, treatment occurs after a disorder develops (or treatment occurs after a disorder develops (or treatment as a disorder is developing), and maintenance occurs long after maintenance occurs long after maintenance a disorder has developed for people whose symptoms require ongoing attention (see Figure 3.8).

Three Types of Prevention Mental health professionals have adopted three major ap- proaches to prevention. These approaches were introduced in Chapter 1 and are discussed in more detail next.

Primary and Universal Prevention The purest form of prevention is primary prevention, where an intervention is given to people with no signs of a disorder (Bloom & Gullotta, 2014). Primary prevention practices are admin- istered to prevent new cases of a disorder. This type of preven- tion is a radical departure from traditional ways of addressing

leads from physical maltreatment to homicide. This is a foundation for prevention efforts.

Campbell and colleagues have studied many factors associated with femicide. Several factors appear to distinguish femicide perpetrators from abusive men, including unemployment, excessive drug use, and access to guns. Other factors include a stepchild biologically related to the victim but not the perpetrator, previous separation from the perpetrator after cohabita- tion, and leaving a physically abusive partner for another partner. Protective factors include previous arrests of the perpetrator for domestic violence and never living together. These results may help health professionals in- tervene and perhaps prevent femicide in women in an abusive relationship by assessing a perpetrator’s access to guns, encouraging women to contact police and use domestic violence resources, and advising women to avoid the perpetrator when leaving the relationship (Messing, Campbell, Wilson, Brown, & Patchell, 2015; Sabri, Campbell, & Dabby, 2015).

Focus on

Femicide, the murder of women, is a leading cause of premature death among females. Intimate partner homicide overall accounts for 13.5 percent of homicides worldwide (Stockl et al., 2013). American women are killed by intimate partners more frequently than any other type of perpetrator, and physical maltreatment of the woman by the man often precedes the homicide. Identifying risk factors for femicide in abusive relationships may thus help us understand what

Violence Prevention of Femicide

3.3

TABLE 3.3

A Sample Plan for Preventing Child Maltreatment in High Risk Families

Basic problem-solving training Learn to recognize and de�ne typical life problems

Positive parenting: enjoying the child • Gain education on the child’s development and how to enjoy the child’s unfolding abilities • See the world through the child’s eyes • Learn activities for parent and child together: child-led play and mutual reinforcement

Parenting skills Learn general skills such as how to:

• De�ne behaviors and goals • Recognize developmentally appropriate goals • Identify antecedents and consequences • Identify rewards • Identify a reasonable level of control

Learn request skills such as how to:

• Make requests to ensure compliance (alpha commands) • Make reasonable requests

Learn how to reduce the frequency of undesirable behaviors:

• Ignore • Reward the absence of negative behaviors • Implement time-out • Get past the “testing the limits” phase

Learn how to increase desirable behaviors:

• Use praise • Use explicit rewards: appropriate rewards, token economy

Extending parenting Learn about child safety, especially the following:

• Discipline and maltreatment—how discipline can slip into maltreatment, outcomes of maltreatment

• Responsibility for selecting safe care agents • Other kinds of injury, “child proo�ng” • Supervision • Child as precious to parent: work to protect

Anger management Learn how to see oneself through the child’s eyes:

• Recall one’s own parents and parental anger • Characterize how being the focus of anger feels

Learn to control your own emotions:

• See your anger as a feeling, a color, or a state

Learn behavioral treatments:

• Power to alter your state • Relaxation • Becoming aware of anger triggers • Safety valves • Self-esteem

Learn to see successful parenting as anger reducing

Adapted from “Integrating Child Injury and Abuse-Neglect Research: Common Histories, Etiologies, and Solutions” by L. Peterson and D. Brown, 1994, Psychological Bulletin, 116, 293-315. Copyright © 1994 by the American Psychological Association. Reprinted with permission.

CHAPTER 3 Risk and Prevention of Mental Disorders66

job training to increase competence, and (3) teaching independent living skills to help someone be more self-reliant. A person recovering from an episode of schizophre- nia might need help in these areas to avoid rehospitalization.

A key goal of tertiary prevention is to prevent additional problems from occur- ring. Tertiary prevention programs are not much different from traditional treatment of individuals with mental disorders. The focus remains, however, on preventing other problems; thus, tertiary prevention other problems; thus, tertiary prevention other does share something in common with pri- mary and secondary prevention. The goal of each prevention form is to reduce prob- lems associated with mental disorder on a community- or population-wide basis.

Indicated prevention targets indi- viduals (not groups) who are at very high risk for developing extensive problems in the future (Figure 3.8). These “high-risk” individuals are identi�ed as having many risk factors and few protective factors for

a certain mental disorder. Unlike tertiary prevention, indicated prevention focuses on people who have not yet developed a full-blown mental disorder.

Prevention Programs for Mental Disorders Prevention programs have been quite successful or promising in areas such as school adjustment, learning and health problems, injuries from accidents, pregnancy, and child maltreatment. Areas of limited success include prevention of complex problems such as excessive substance use and delinquency in adolescents (Gullotta & Bloom, 2014). A key advantage of prevention is that enormous resources can be saved that otherwise would go to- ward future treatment, hospitalization, and/or incarceration of people with mental disorder (van Zoonen et al., 2014). Speci�c examples of prevention programs to address problems com- monly experienced by young adults are presented next.

Primary/Universal Prevention of Alcohol Use Disorders on College Campuses DeShawn’s problems at college come as little surprise given that excessive alcohol use is widespread on college campuses today. DeShawn often engaged in what is known as binge drinking, which means consuming �ve or more drinks on one occasion for men and four or more drinks on one occasion for women. Binge drinking is associated with poorer academic performance, risk for violence or physical injury, risky sexual behavior, and health problems, among other things. About 39.1 percent of college students aged 18 to 22 years engaged in binge drink- ing in the past month (White & Hingson, 2014). Because binge drinking among college students is a major problem, efforts to prevent it are a top priority.

These people are not necessarily seeking help and may not even appear to be at risk. Such screening may be conducted by community-service personnel such as psychologists, physicians, teachers, clergy, police, court of�cials, social workers, or others. May 1 of each year is set aside as National Anxiety Disorders Screening Day, which helps provide quick assessment for those who may be struggling with initial panic or other anxiety symp- toms. Early identi�cation of problems is followed, of course, by appropriate referrals for treatment.

Selective prevention is similar to secondary prevention in that people at risk for a particular problem are targeted (Figure 3.8). Selective prevention practices target individuals or subgroups of the population who are more likely than the general population to develop a particular mental disorder. Targeted individuals are identi�ed on the basis of biological, psychological, or social risk factors associated with the onset of a disorder. A program to �nd and help youth genetically predisposed to schizophrenia would be an example of selective prevention. Selective prevention has been recommended espe- cially for high-risk problems such as depression and suicide (Okereke, 2015).

Tertiary and Indicated Prevention Tertiary prevention refers to reducing the duration and addi- tional negative effects of a mental disorder after onset. Tertiary prevention differs from primary and secondary prevention in that new cases of mental disorder are not reduced. Instead, the goal is to stabilize symptoms, provide rehabilitation, prevent relapse, improve a person’s quality of life, and lessen effects of an exist- ing mental disorder (Fernandez, Gold, Hirsch, & Miller, 2015). ing mental disorder (Fernandez, Gold, Hirsch, & Miller, 2015). ing Tertiary prevention programs often focus on (1) educating peers and family members to reduce stigmatization, (2) providing

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FIGURE 3.8 PREVENTION EXISTS ON A CONTINUUM OF INTERVENTION FOR MENTAL HEALTH PROBLEMS. Source: Adapted from Institute of Medicine, Summary: Reducing risks for mental disorders: Frontiers for preventive intervention research, Fig. 2.1, p. 8. Washington, DC: National Academy Press.

many substance use prevention programs. This approach is based on the assumption that students often overestimate how much other students drink and that students drink in amounts they perceive others to drink. Programs like the WRC correct this misperception by educating students about the actual amount of alcohol their peers drink. Survey data reveal that Missouri students believed 60 percent of their peers drink three times a week or more, but actual data from students themselves reveal that only 33 percent do so. The WRC corrects students’ norms for drinking by placing weekly ads in the student newspaper, distributing written materials across campus, giving away book- marks, and placing mouse pads with this information in student computer labs.

Many college campuses have pre- vention programs to curb excessive or binge drinking. These programs can be thought of as primary or uni- versal prevention programs because all students, not just those at risk for alcohol use disorder, are exposed to these efforts. These programs include general education during freshman orientation, special events during the academic year such as “Alcohol Awareness Week,” and peer education programs in which students them- selves support their peers’ healthy attitudes and lifestyle choices regard- ing alcohol use (Scott-Sheldon, Carey, Elliott, Garey, & Carey, 2014).

The Wellness Resource Center (WRC) at the University of Missouri sponsors a prevention program targeting excessive alcohol use. Major compo- nents of the program include promot- ing responsible decision making and providing accurate information about how much alcohol is consumed by col- lege students (called social norming). social norming). social norming Peers provide much of the information about drinking and its related prob- lems to fellow students. The WRC’s responsible decision-making program is administered by trained peer educa- tors who visit residence halls, fraternity and sorority houses, classrooms, and junior high and high schools to speak about alcohol and other drug issues and making healthy lifestyle choices about eating, exercising, and smoking.

For example, one peer presenta- tion introduces participants to the Virtual Bar, an interactive computer program that demonstrates the effect of alcohol on the body. Participants decide whether the character sips, drinks, or slams a range of alcoholic drinks to see how this affects blood alcohol content (BAC). In addition, participants learn to con- sider time, alcohol content, gender, and weight when making decisions about alcohol use. Another presentation focuses on the increasingly popular tradition of having 21 drinks on one’s 21st birthday. The program emphasizes the danger of such a practice (alcohol poisoning and death), and promotes safe, re- sponsible drinking. Finally, START (Student Alcohol Respon- sibility Training) is an online training program that educates participants in planning and hosting a fun and safe party. Top- ics covered include general party safety, alcohol consumption by guests, preventing MIPs (minors in possession), and legal responsibilities. Social norming is an important component of Social norming is an important component of Social norming

This screenshot from the University of Missouri Wellness Resource Center illustrates attempts to educate students about the facts regarding college drinking.

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CHAPTER 3 Risk and Prevention of Mental Disorders68

behavior. SOS participants show fewer suicide attempts, greater knowledge of depression, and more adaptive attitudes about depression and suicide than nonparticipants. This program has also been adapted for graduating seniors who are college- bound, emphasizing how to access resources on campus and in the community. A program like SOS might have helped Jana learn about her signs of depression and distress, realize suicidal behavior is not a good way to cope with depression or stress, and develop a plan for getting social support when she felt overwhelmed. These skills may have reduced Jana’s suicidal behaviors.

Secondary/Selective Prevention of Eating Disorder Symptoms Researchers have also evaluated secondary prevention pro- grams for college students. Stice and colleagues (2012) con- ducted such a program to prevent eating disorder symptoms and unhealthy weight gain in female college students. Healthy Weight is a selective prevention program that focuses on healthy Weight is a selective prevention program that focuses on healthy Weight dietary intake and appropriate physical activity in women with body image concerns. Body image refers to beliefs about one’s appearance, how one feels about his or her body, and one’s sense of control over one’s body. Concerns about body image may be a risk factor for eating disorders (Chapter 8). Recall that secondary or selective prevention targets people who do not currently have a certain mental disorder but who may be at risk for developing additional symptoms of the disorder. Students targeted by the researchers thus appeared to be at risk for developing an eating disorder.

Healthy Weight is a four-session program that begins with Healthy Weight is a four-session program that begins with Healthy Weight education about how participants can make small but lasting healthy changes to diet and physical activity to ensure that their energy intake and output are balanced. Participants are encouraged to pursue a healthy ideal, not a thin ideal, by using adaptive choices such as starting meals with high-�ber foods, reducing portion sizes, and not having unhealthy foods at home. Scheduled and creative exercise routines are discussed as well. Participants keep eating and exercise diaries to maintain moti- vation toward a healthy body weight. They are also encouraged to discuss possible future obstacles in this regard and develop ways of overcoming barriers to healthy behavior change.

Most students (67 percent) attended all four sessions (4 hours total) of the Healthy Weight program. Compared with Healthy Weight program. Compared with Healthy Weight controls, students in the Healthy Weight intervention displayed Healthy Weight intervention displayed Healthy Weight fewer eating disorder symptoms, increased exercise, less diet- ing, and less body dissatisfaction. Intermittent dieting is often considered a risk factor for eating disorders, so the program helped reduce behaviors that may have led to a full-blown diag- nosis. Intervention effects were strongest for students who had more eating disorder symptoms and who felt more pressure to be thin. The results suggested that a brief group intervention can be a powerful preventative strategy for such a devastat- ing disorder. Prevention programs can thus successfully “buf- fer” young people from developing psychological problems. We present many examples of primary, secondary, and tertiary prevention of mental disorders throughout this textbook.

The WRC also sponsors prevention organizations such as PARTY (Promoting Awareness and Responsibility Through You), a peer education organization that promotes responsible deci- sion making; GAMMA (Greeks Advocating the Mature Manage- ment of Alcohol), an organization of fraternity/sorority students who promote responsible alcohol use; and CHEERS, a statewide program of student volunteers who work with local bars and restaurants to provide designated drivers with free soft drinks. You can see this prevention program is quite comprehensive and extensive.

Primary/Universal Prevention of Suicidal Behavior in High School Students Earlier in the chapter we saw that Jana, a 22-year-old col- lege student, had been suicidal many times over the past few years. Suicidal behavior among teenagers and college students is not as rare as you might think. Suicide is one of the leading causes of death among 15- to 24-year-olds. In ad- dition, 6 percent of undergraduates and 4 percent of gradu- ate students have seriously considered suicide in the past 12 months (King et al., 2015). Thus the need for early and effective suicide prevention programs is clear. These programs may help people like Jana who struggle with thoughts of sui- cide and self-harm.

Signs of Suicide (SOS) is a school-based prevention program with two main components (Schilling, Lawless, Buchanan, & Aseltine, 2014). An educational component involves the review of a video and a discussion guide. These materials highlight the link between suicide and depression, show that suicidal behav- ior is not a normal reaction to emotional distress, and provide

guidelines for recognizing signs and symptoms of de- pression in oneself and oth- ers. Students are also taught what to do (ACT) if signs of depression are present in a peer: acknowledge (A) the acknowledge (A) the acknowledge signs and take them seri- ously, let the person know you care (C), and care (C), and care tell (T) a responsible adult about the situation. The video has in- terviews of people who have been touched by suicide and provides ways of reacting if a peer has signs of depres- sion or suicide. The second component involves a self- screening: Individuals eval- uate themselves for signs of depression and suicidal thoughts and are prompted to seek help if necessary.

The SOS program ap- pears to be successful at helping to prevent suicidal

The Signs of Suicide (SOS) prevention program helps prevent suicide attempts and increase knowledge about depression.

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➲ Interim Summary •

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➲ Review Questions 1.

Another important historical standard is the irresistible impulse or con- trol rule. In this situation, one could argue for an insanity defense if a trol rule. In this situation, one could argue for an insanity defense if a trol person had a mental disorder that did not allow him to control his actions during a crime. A person may have known the difference between right and wrong but still could not exercise behavioral control. In addition, the Durham rule refers to the idea that a person may not be responsible for a criminal act if the act was due to a “mental disease or defect.” Both of these standards, however, have been criticized as being too broad (Kolla & Brodie, 2012).

The American Law Institute (ALI) attempted to address this concern by American Law Institute (ALI) attempted to address this concern by American Law Institute blending the M’Naghten and irresistible impulse concepts. The ALI recom- mended that a person could use an insanity defense if a mental disorder prevented him from knowing right from wrong or prevented him from be- ing able to control his actions. The American Psychiatric Association (APA) later recommended paring the ALI de�nition to include only the �rst part (i.e., to the M’Naghten rule). Many states and the federal government use the APA distinction today, although some states have eliminated the insan- ity defense altogether.

Focus on

Recall from Chapter 2 that insanity is a legal term that refers to meninsanity is a legal term that refers to meninsanity - tal incapacity at the time of a crime. The concept of insanity has been shaped by some key historical standards. One standard is the M’Naghten rule, which refers to the idea that a criminal defendant is not guilty by reason of insanity if, at the time of the crime, he did not know the nature or quality of his actions or did not know the difference between right and wrong. The M’Naghten rule means that defendants must have the cognitive ability to know right from wrong. If a defendant did not know the difference, such as someone experiencing a psychotic episode (Chapter 12) or someone with severe intellectual disability (Chapter 13), then this could be the basis for an insanity defense.

Law and Ethics Constructs Related to Insanity

3.4

CHAPTER 3 Risk and Prevention of Mental Disorders70

I began my student affairs career in residential life where my role was to encourage students to be successful by helping them make healthy, safe, and responsible decisions in all aspects of their lives. I wrote a grant to the U.S. Department of Education to create an alcohol and drug abuse of�ce and became the Director of ADAPT (Alcohol and Drug Abuse Prevention Team). The mission of ADAPT later expanded, and it became the Wellness Resource Center (WRC).

The students and staff of the Wellness Resource Center realize that one single ap- proach or one single event is not suf�cient in helping college students make responsible de- cisions concerning alcohol or other aspects of their health. Four theoretical models guide the WRC’s prevention efforts: (1) responsible deci- sion making, (2) social norming, (3) harm re- duction, and (4) environmental management. It takes a comprehensive yearlong effort to have an impact on student behavior.

The responsible decision-making approach is used through peer educator presentations and major campus-wide events such as Alcohol Responsibility Month, Safe Spring Break, Safe

Holiday Break, and Well- ness Month. The WRC challenges students to make informed, respon- sible decisions regard- ing all aspects of their health, and presents be- tween 150 and 200 outreach programs per year.

The WRC implements a social norms approach. Social norms theory sug- gests that students’ misperceptions and over- estimations of their peers’ alcohol and drug use increase problem behaviors and decrease healthy behaviors because students are acting in accordance with what they think is “normal.” Our research on University of Missouri students indicates a signi�cant difference between stu- dent perceptions and the reality of peer alcohol and other drug use. By correcting mispercep- tions of the norm, the WRC has decreased problem behavior and seen an increase in healthy behavior. The WRC’s social norming efforts are comprehensive and incorporate not only an extensive marketing campaign but also

educational outreach programs and training.

A harm reduction approach accepts that students some- times make risky choices and

that it is important to create safety nets to keep them from

hurting themselves or someone else. The WRC created and supports Project

CHEERS, a designated-driver program in which more than 50 bars in Columbia give free soda to designated drivers. Additionally, the WRC provides an educational intervention called BASICS (Brief Alcohol Screening In- tervention for College Students) for students caught in violation of the alcohol and drug poli- cies of the university and/or for students who are concerned about their use. The program is composed of a 2-hour interactive workshop and a 1-hour individual follow-up session led by two PhD-level counseling psychology graduate students.

The WRC also takes an environmental management approach by actively working to in�uence the campus and community

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Final Comments The diathesis-stress model is a useful way of thinking about various in�uences on mental disorders. Diatheses (predispositions) and stressors can be thought of as risk factors for mental disorders. Most mental disorders begin in adolescence or early adulthood when the burden of mental disorder is high. This highlights the need for early prevention efforts to address risk factors and thwart disorder development. Prevention programs are more ef�cient and cost-effective in the long run than traditional treatment because enormous costs related to disability and tertiary care can be lessened. We discuss effective treatments but also contemporary and personal approaches for preventing various psychologi- cal problems throughout this textbook. Examples include suggestions for reducing anxiety and sadness (Chapters 5 and 7), enhancing prenatal care to prevent intellectual disability (Chapter 13), and improv- ing memory to limit cognitive decline (Chapter 14). We turn our attention in Chapter 4 to methods used by mental health professionals to assess, diagnose, classify, and study mental disorders. This discussion will further provide the foundation for understanding the mental disorders we discuss in Chapters 5 through 14.

environment through the campus and com- munity coalition called the Access to Alcohol Action Team. The Columbia Tobacco Preven- tion Initiative works with all three high schools in Columbia as well as Columbia College and Stephens College on the tobacco control issues. The WRC has also created two state- wide coalitions called Missouri Partners In Prevention and Partners In Environmental Change, composed of the 13 state colleges and universities in Missouri. Both PIP and PIEC provide technical assistance, training, and programmatic support for the campus, and are funded by the Missouri Division of Alcohol and Drug Abuse.

My professional journey has been �lled with many challenges. Our society glamorizes the misuse and abuse of alcohol through the me- dia, movies, television, music, magazines, and even campus traditions. We have faced a long list of obstacles including the lack of power to make signi�cant change, strong campus orga- nizations that revolve around alcohol, territory issues with other professionals, and the opin- ions that student alcohol abuse is simply a rite of passage. Additionally, because the WRC is

each a simple question. “Excuse me sir, what are you doing?” The �rst man said he was lay- ing bricks, the second man said he was build- ing a wall, and the third man stated proudly that he was building a great cathedral. All three men were doing the same task and yet each viewed it differently. Ultimately, we are all play- ing a part in building a great cathedral. Some days we may feel like we are just laying bricks, but we are part of a much bigger picture. We are taking part in the great task of building a community that encourages and supports good decision making by all. My philosophy in life is embodied in this quote from Leon Joseph Cardinal Suenens: “Happy are those who dream dreams and are ready to pay the price to make them come true.”

Kim Dude was recognized by the U.S. Department of Education’s Network: Ad- dressing Collegiate Alcohol and Other Drug Issues as the recipient of the Outstanding Contribution to the Field award in 2003. Kim has also been honored by the Phoenix Pro- grams in Columbia, Missouri, with the Buck Buchanan Lifetime Service Award for her prevention efforts.

more than 80 percent grant funded, securing and maintaining funding has been one of the biggest obstacles we have faced.

Another great challenge is trying to change the environment. The WRC cannot do this alone. As the saying states, “It takes a village to raise a child.” Everyone in the community needs to be part of the solution: parents, law enforcement, community leaders, educators, business owners, etc. I was taught that if you are not part of the solution, you are part of the problem. We all need to be part of the solution and help change laws, policies, and practices so that we have an environment that supports and encourages good decision making.

I am proud to say that the WRC has been successful over the years despite its obstacles and has been recognized as one of the top prevention programs in the country. So much of our survival and our success is the result of a positive attitude and the desire to never give up. I want to share a story that I love. A woman was walking down a street in a large city past a construction site. She came across three construction workers and asked them

personal narrative

Key Terms diathesis 52 etiology 54 epidemiology 54 epidemiologists 54 incidence 54 prevalence 54 lifetime prevalence 54

comorbidity 56 cohort effects 57 risk factor 59 protective factors 61 resilience 62 prevention 63 primary prevention 64

universal prevention 64 secondary prevention 64 selective prevention 66 tertiary prevention 66 indicated prevention 66

Source: Used with permission.

Special Features

• 4.1 Culture and Diagnosis 77

Personal Narrative 4.1 Anonymous 78–79

• 4.2 Who Should Be Studied in Mental Health Research?

C / What Do You Think?

De�ning Abnormal Behavior and Mental Disorder

Classifying and Assessing Abnormal Behavior and Mental Disorder

Culture and Clinical Assessment

Studying Abnormal Behavior and Mental Disorder

FINAL COMMENTS

KEY TERMS

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders74

De�ning Abnormal Behavior and Mental Disorder

Professor Smith’s case illustrates how certain symptoms can limit someone’s ability to live comfortably, maintain a career, and even talk to others. These symptoms are indeed quite dis- tressing to him and seem out of the ordinary. Professor Smith has consulted a psychologist to �nd out what is wrong and what can be done to help. What do mental health professionals do when they address people with mental disorder? Mental health professionals de�ne, classify, assess, and study mental disor- ders; we discuss these endeavors in this chapter, starting with de�nition.

Dimensions and Categories Mental health professionals often focus on dimensions and categories to de�ne abnormal behavior and mental disorder. A dimensional approach refers to de�ning abnormal behav- ior along a continuum or spectrum. Recall three de�nitions of abnormal behavior from Chapter 1: (1) behavior that deviates from the norm, (2) behavior associated with dif�culty adapting to life’s demands, and (3) behavior accompanied by personal distress. Each de�nition lies on a continuum. Some behaviors deviate a little from the norm and involve slight adaptation

problems or distress, and some behaviors deviate substantially from the norm and involve signi�cant adaptation problems and distress. Recall from Chapter 2 how Mariella’s symptoms of depression re�ected to some extent a normal reaction to being separated from family and friends but also that some of her de- pressive symptoms seemed problematic. Recall from Chapter 3 our discussion of mild, moderate, and severe intensity of symp- toms. These examples show abnormal behavior on a continuum or from a dimensional perspective.

One way to think about abnormal behavior from a dimen- sional perspective is to consider its many forms. Abnormal be- havior actually consists of emotional states, cognitive styles or ways of thinking, and physical behavior. We can view each form along a continuum or dimensional perspective. Professor Smith experiences emotional sadness, cognitive worry, and cognitive worry, and cognitive behavioral avoidance. His symptoms are severe, but all of us become sad and worrisome and avoid things from time to time. We show emotions, thoughts, and behaviors along a spectrum of intensity or oddity.

A different way of de�ning abnormal behavior or mental disorder is a categorical approach. A category is a large class of frequently observed syndromes (mental disorders) composed of abnormal behaviors or features that occur in a person. Many chapters in this book represent broad categories of mental disor- der, such as anxiety, depressive, psychotic, personality, develop- mental, and neurocognitive disorders.

Forty-�ve-year-old Professor Smith could not understand what had been happening to him over the past 6 months. He had been experi- encing strange sensations throughout his body, including chest pains and headaches. He felt short of breath, light-headed, shaky, and hot throughout his chest and arms during these

episodes. These symptoms came on abruptly, sometimes even during sleep, but ended within 15 minutes. Professor Smith had a number of recent setbacks, including denial for promotion to full professor, so this was the last thing he needed.

What could be wrong? Professor Smith had several medical tests to rule out heart problems, a brain tumor, and other maladies. His physician reassured him nothing was medically wrong, but the symptoms persisted. Professor Smith found it harder to concentrate on his work and his career seemed to be on hold. Despite looming deadlines, he struggled to read books and jour- nals and could not concentrate long enough to write a paragraph. His teaching was suffering as well, and he cancelled several classes because of his physical symptoms.

Professor Smith felt he needed to know what was happening but had no clear answer. Even worse, these symptoms and problems at work were creating a strain on his fam- ily and friendships. Those who cared about

him wanted to help but had trouble doing so because Professor Smith became more iso- lated, frustrated, and depressed. This depres- sion seemed to worsen recently as he had trouble sleeping, felt fatigued much of the day, and lost 20 pounds. Finally, he agreed to see a clinical psychologist after constant pleas from his wife and at the suggestion of his physician. He was skeptical, but what harm could it do at this point?

What Do You Think? 1. Is Professor Smith’s behavior abnormal? Do

you think he has a mental disorder? 2. Do you know anyone with problems like

Professor Smith’s? 3. What other information about his condition

would be useful to know? 4. What do you think would be the best way to

�nd out more about his problems? Do you think interviews, psychological evaluations, or other medical tests would help?

5. What kind of treatment might give Professor Smith some relief?

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Depression is a widely recognized syndrome or mental dis- order that often includes sad mood, sleep and appetite distur- bance, and suicidal thoughts. A certain number of symptoms must be present from a categorical perspective before a person’s behavior can be considered abnormal—for depression, �ve of nine main symptoms must be present. Someone with only three or four symptoms of depression would not be considered to have a mental disorder. A diagnosis from a categorical perspec- tive is de�ned by rules that outline how many and what features of a mental disorder must be present.

The categorical approach can be thought of as a “yes–no” approach: One either has or does not have a mental disorder. The approach is derived from a medical model that makes sense when you consider a disease such as measles. We can guarantee you either have measles right now or you do not (pick one!). A “yes–no” approach works well for physical disorders but per- haps less well for mental disorders. Imagine if someone visited a psychologist and complained of sad mood, trouble sleeping, suicidal thoughts, and no other symptoms. This person has no mental disorder from a strict categorical perspective because not mental disorder from a strict categorical perspective because not mental disorder enough symptoms of depression are evident. But doesn’t the person have a problem that should be treated?

We have indicated throughout this textbook that we can best view abnormal behavior along a continuum. Still, many men- tal health professionals adopt a common categorical approach to classifying mental disorder, and we describe this approach next. Our approach throughout this textbook will be to organize mental disorders by general categories but explain the dimen- sional aspects of each category in detail.

DSM A categorical approach to mental disorder commonly used in the United States and much of the world is the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychi- atric Association [APA], 2013). General features of mental dis- order according to the DSM include the following:DSM include the following:DSM

• A group of emotional, cognitive, or behavioral symptoms, called a syndrome, that occur within a person.

• These symptoms are usually associated with emotional dis- tress or disability (impairment) in life activities.

• The syndrome is not simply an expected or culturally approved response to a speci�c event, such as grief and sadness following death of a loved one.

• The symptoms are considered to re�ect dysfunction in psy- chological, biological, or developmental processes.

A syndrome (or mental disorder or diagnosis) includes a group of abnormal behaviors or number of symptoms associ- ated with distress, signi�cant work or interpersonal problems, or likelihood of future problems. Recall Ricardo and Yoko from Chapter 1 who had symptoms of anxiety. Ricardo quali�ed for a DSM diagnosis of social phobia because his symptoms interfered DSM diagnosis of social phobia because his symptoms interfered DSM with daily functioning. Yoko’s anxiety symptoms, however, were not accompanied by signi�cant impairment in daily functioning, and so she did not qualify for a diagnosis.

This description of syndrome or mental disorder incorpo- rates de�nitions of abnormal behavior from Chapter 1 and this chapter. The description focuses on behavior that deviates from the norm, behavior associated with dif�culty adapting to life’s demands, and behavior accompanied by distress. The DSM de�nition of mental disorder is restrictive because it focuses on clusters of abnormal behaviors associated with distress or dis- ability. Several abnormal behaviors must be present at the same time and cause signi�cant problems for someone to qualify for a diagnosis of a mental disorder.

Advantages of Diagnosis Several advantages do exist regarding diagnoses, however. A primary advantage of diagnosis is communication—a wealth of information can be conveyed in a single term. A colleague once referred a person with a diagnosis of schizophrenia to one of your authors, Tim. A symptom pattern immediately came to Tim’s mind even though he knew nothing about the person: de- lusions, hallucinations, severe social/occupational dysfunction, and continuous symptoms for at least 6 months. You can think of a diagnosis as “verbal shorthand” for describing features of a mental disorder. We do not have to ask so many questions about a person’s symptoms when we know his or her diagnosis.

A second advantage of diagnosis is that standard rules are provided for de�ning mental disorders and for seeking the cause of these disorders. We must group people based on symptoms they share to study the cause of a mental disorder. Important comparisons between groups can then be made about develop- mental characteristics, personality features, performance on ex- perimental tasks, or other variables that could shed light on risk factors and cause. We mentioned in Chapter 3 that childhood sexual maltreatment is a risk factor for borderline personality disorder. A reliable and systematic way of de�ning borderline personality disorder was necessary �rst, however, to even reach this conclusion. Use of diagnoses assists this process.

A third advantage of diagnosis is that, because everyone uses the same system, clinicians can �nd useful assessment strategies, such as questionnaires for depression, and research- ers can examine prevalence rates of a certain mental disorder at local, state, and national levels. Managed care agencies also rely on diagnostic codes to reimburse people for mental health ser- vices. Diagnoses are most important because they may suggest which treatment is most effective. A diagnosis of schizophrenia, for example, suggests that antipsychotic medication is likely to be more effective than psychodynamic therapy. More than one treatment is often effective for mental disorders, however.

Diagnoses thus serve many useful functions, and research- ers and practitioners commonly use them to understand mental disorder. Laypeople also use diagnoses to understand what is wrong. If you were diagnosed with a strange-sounding disease, you would likely “Google” it to get more information. Diagnoses also ease the sense of uniqueness or loneliness people feel when something is wrong. Professor Smith learned his condition was called “panic disorder” and that the problem can be successfully treated. How do you think he felt once he learned this?

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders76

➲ Interim Summary •

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• DSMDSMDSM

• -

➲ Review Questions 1.

2. DSM

3. DSM

Classifying and Assessing Abnormal Behavior and Mental Disorder

Recall that mental health professionals de�ne, classify, assess, and study mental disorders. We have discussed de�nition. Classi�cation is next and refers to arranging men- tal disorders into broad categories or classes based on similar features. The DSM is a primary method of classi�cation with DSM is a primary method of classi�cation with DSM criteria and research-based information about mental disorders listed in the manual (DSM-5; APA, 2013).

Some of the diagnostic categories discussed in this textbook may be familiar to you because of their prevalence and media coverage. You may have heard a lot about anxiety, depression, attention-de�cit/hyperactivity disorder, Alzheimer’s disease, alco- hol use disorder, and anorexia nervosa. Other diagnoses may be less familiar to you, such as somatic symptom disorder and para- philic disorders. Researchers have studied these disorders in one form or another for decades and the disorders are often the focus of clinical attention because of their prevalence and severity.

The DSM-5 relies on categories to organize mental disorder but also encourages clinicians to use dimensional assessments in addition to diagnoses. Recall that “dimensional” means viewing

behavior or symptoms along a continuum. One type of dimen- sional assessment might include ratings of a person’s symptoms as mild, moderate, or severe in intensity. Another dimensional assessment could involve a person’s degree of insight into, or rec- ognition of, his mental condition. Dimensional assessments allow clinicians to consider �uctuations in symptoms, to track a client’s progress in therapy, and to evaluate all of a client’s symptoms, not simply those that are part of an assigned diagnosis. Other types of dimensional assessments are discussed throughout the textbook.

How might such a categorical and dimensional approach work for Professor Smith? Professor Smith’s therapist assigned two diagnoses based on his symptoms. The primary diagnosis (initial focus of treatment) was panic disorder. Professor Smith’s “episodes” suggest he has periodic panic attacks with chest pain, shaking, breathlessness, hot �ashes, and light-headedness (Chapter 5). These attacks are recurrent and unexpected, and Professor Smith has been concerned about additional attacks and their implications (“Am I having a heart attack?”). Profes- sor Smith also received a diagnosis of major depressive disorder (Chapter 7). He has had sad mood, insomnia, dif�culty concen- trating, fatigue, weight loss, and poor appetite for more than 2 weeks. These symptoms characterize depression.

Professor Smith’s therapist also used dimensional assess- ments. One type of dimensional assessment involved symp- tom intensity ratings along a continuum (i.e., mild, moderate, severe). For example, some of Professor Smith’s anxiety and depressive symptoms were mild to moderate in nature. These included his headaches and sad mood. In contrast, some of his anxiety and depressive symptoms were severe in nature. These included his shortness of breath, light-headedness, trouble sleeping, and fatigue.

Another dimensional assessment involved the impact of Pro- fessor Smith’s symptoms on different areas of his life. Professor Smith’s symptoms such as his inability to concentrate or �nish projects had the greatest negative impact on his career. His symp- toms also had some impact on his marriage, but his wife was supportive of him during this dif�cult time. These dimensional assessments allowed the therapist to concentrate treatment �rst on those symptoms that caused Professor Smith the most amount of distress and that seemed most urgent. You can see that a dimensional approach adds substantial information to a simple diagnosis. We continue to emphasize this dimensional ap- proach as we discuss mental disorders throughout this textbook.

Assessing Abnormal Behavior and Mental Disorder De�ning and classifying mental disorder are important tasks that involve detailed clinical assessment. Clinical assessment involves evaluating a person’s strengths and weaknesses and understanding the problem at hand to develop a treatment (Trull & Prinstein, 2013). This may include providing a diagnosis for the person. We describe in this next section assessment proce- dures implemented in clinics, hospitals, and of�ces of mental health professionals.

The clinical assessment process begins with a referral. Someone—perhaps a parent, teacher, spouse, friend, judge, or a

person himself—asks a question: “Why is Samantha struggling at her job?” “Why are my child’s moods so unstable?” “Why do I feel anxious all the time?” “Why does Professor Smith keep canceling his classes?” People may then be referred to a thera- pist who might provide a DSM-5 diagnosis but who will also examine emotional, cognitive, personality, and biological issues that must be addressed. Mental health professionals try to un- derstand precisely what a client seeks or needs and use a wide array of procedures and measures to do so.

Reliability, Validity, and Standardization An important expectation of mental health professionals is that they use assessment measures that are strong psychometrically. This means the measures should be reliable, valid, and stan- dardized. We discuss each of these concepts separately.

Reliability Reliability refers to consistency of scores or responses. Three main ways of evaluating reliability include test–retest, interrater, and in- ternal consistency reliability (see Table 4.1). Each type of reliability is used to examine consistency of assessment data. Test–retest reliability is the extent to which a person provides similar answers reliability is the extent to which a person provides similar answers reliability

to the same test items across time. If Karl provides different scores on the same anxiety questionnaire on two consecutive Mondays, then the data may not be very useful. If we interview someone and �nd that her diagnosis changes from week to week, this would demonstrate poor test–retest reliability for the interview. Recall

Joey’s experiences and beliefs may seem quite unusual or even evi- dence of a serious mental disorder like schizophrenia. However, there may be cultural explanations that account, at least partially, for his experience. One possible Chinese indigenous explanation is a form of sleep paralysis called “ghost oppression” (guai ya chun; “ghost presses bed”). However, this does not seem to �t Joey’s report in that he did not report an inabil- ity to move while awakening. However, seeing ghosts is not an uncommon experience among Chinese people, and thus does not necessarily indicate psychotic symptoms like hallucinations or delusions. But why did Joey feel that the ghosts might hurt him or his family? Clinicians that evaluated Joey and his family attributed these feelings to the stress of immigration for both Joey and his family. Treatment focused on supporting Joey and his family in their adjustment to life in the United States as well as encouraging the family to spend more time together to strengthen their bond. Over time, Joey’s primary symptoms of seeing ghosts at bedtime improved and the family reported better functioning.

Joey’s case highlights the importance of considering culture when eval- uating psychological symptoms. The DSM-5 includes a Cultural Formulation DSM-5 includes a Cultural Formulation DSM-5 Interview to help mental health professionals gain information about how a person’s culture may affect his symptoms and treatment (APA, 2013). Questions surround how a person understands and explains his condition, what social stressors and supports he may have, whether his cultural back- ground or identity affects his symptoms, what cultural factors may in�uence his ability to cope and to seek help, and concerns about his therapist or the mental health setting. Mental health professionals are also encouraged to be aware of how a person’s culture can in�uence risk factors and the course of a disorder (Kleinman, 2012).

Focus On

Culture has an impact on our thoughts, personal perspectives and world- views, emotional expression, and behavior. Culture must be considered when a person is evaluated for psychological problems, and mental health professionals must be aware of their own biases when they evaluate people of other cultures. What may be considered unusual in one culture may not be in another culture. Consider Joey, a 10-year-old boy of Chinese descent who moved to the United States with his parents 4 years earlier (Fang, Lee, & Huang, 2013). Joey was referred to a mental health clinic by his pediatrician after reports of seeing ghosts at bedtime on a daily basis for the past 2 years. Joey stated that he actually sees ghosts (does not dream about them), they appear to be teenagers, and they intend to hurt his family. Joey goes to bed each night with a stick and a �ashlight ready to defend himself and his family if necessary. However, over time, he has become less scared of the ghosts and simply watches them but does not interact with them. Joey reports that he has no trouble falling asleep, and he is functioning well at school and at home. Joey’s parents began to wonder if Joey might possess some special powers to connect to the spiritual world, which according to some Chinese customs naturally interact with humans. Those with this gift are considered to be more vulnerable to “spirit attack.”

Diversity Culture and Diagnosis

4.1

Type of reliability De�nition

Test–retest reliability Consistency of test scores or diagnoses across some period of time

Interrater reliability Agreement between two or more raters or judges about level of a trait or presence/ absence of a feature or diagnosis

Internal consistency reliability

Relationship among test items that measure the same variable

TABLE 4.1

Types of Reliability for Psychological Tests and Structured Interviews

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders78

that Professor Smith received a primary diagnosis of panic disor- der. If he came back the next week for a follow-up interview and no longer met criteria for panic disorder, how useful would this interview be? Panic disorder does not come and go this rapidly.

Test–retest reliability is important, but the consistency of scores or diagnoses will naturally diminish as time between test and retest grows longer. This may re�ect actual change. Profes- sor Smith may not meet criteria for panic disorder 2 years from now, but this may re�ect the fact that he received treatment and no longer shows symptoms of the disorder.

Interrater reliability is the extent to which two raters or observers agree about their ratings or judgments of a person’s behavior. Interrater reliability is often used to examine the use- fulness of a diagnostic interview. Two mental health profes- sionals may give Professor Smith the same diagnostic interview on the same day and arrive at the same diagnosis. This would re�ect good interrater reliability.

Internal consistency reliability refers to whether items on a test appear to be measuring the same thing. You would expect items on a test of anxiety to generally relate to one another. If they do not, then the items may not be measuring the same

I glanced at the clock on the opposite wall, tak- ing a break from staring at a worn patch in the carpet near my feet. It was nearly 5 PM; the last time I looked up was about 1 PM. My only mo- tivation was to determine where we were in the rhythm of the day, to see how much longer I had to bear before I could retreat to my room. There, my eyes heavy from sleeping pills and emotional exhaustion, I could succumb to the only thing that brought relief from my depression: sleep. It had not taken me long to discover that the most time- consuming activity on psychiatric units was doing nothing other than waiting for something to hap- pen. Waiting to see your psychiatrist. Your social worker. Your nurse. Waiting for a therapy group. For art therapy. Pet therapy (if you’re lucky). Wait- ing for a shower. To brush your teeth. Waiting for morning meds. Afternoon meds. Evening meds. Night meds. Breakfast. Lunch. Dinner. How did I get here?

My depression during my sophomore year in college was not my �rst episode. I had gone through periods of depression twice during high school, received antidepressant treatment and counseling, and recovered. I took having a depressive disorder seriously and was diligent about seeking and getting help. I did not share

my condition with other people, but I did not feel stigmatized. In an age of depressed Zoloft balls bouncing on the TV screen, depression seemed common in society. A little like having mild asth- ma or high blood pressure. I never thought of myself as someone who was truly “sick”—I saved that term for people with schizophrenia or bipolar disorder, people I assumed spent most of their lives in secluded state institutions, receiving anti- psychotics and getting “shock therapy.” If some- one suggested I would know someday what it’s like to be in a hospital, to take a plethora of drugs, and to be considered severely and chronically disordered, I would have found the notion bizarre and comical, if not impossible. That was not me.

Near the end of my sophomore year, I no- ticed some familiar feelings that, in the past, heralded depression. Over the course of a few weeks, I lost my appetite. Things I nor- mally found engaging—reading, being with friends, participating in groups on campus— had no allure. I lacked the concentration to read more than a page or two or even follow a conversation. As my mood sunk, family and friends became concerned. I became increas- ingly depressed and despondent over a mat- ter of weeks, and even though I recognized the

symptoms and was educated about treatments, I did not want to admit that I was experiencing a relapse of the disorder I thought had ended with my adolescence.

Ultimately, a close friend realized what was happening. Fearing for my safety, he made an urgent appointment with a local psychiatrist; I did not have the energy to protest. The psy- chiatrist spoke with me about my history, my current symptoms and thoughts of suicide, and determined that I needed to be hospitalized. My recollections of this decision, my admission, and the �rst few days in the hospital are foggy. My primary emotional response was shock and bewilderment, tempered only by the deadening apathy that engulfed my mood. I couldn’t quite get my head around how things had gotten “this far.” I was on a locked unit with severely disordered men and women, many acutely psychotic. I was watched constantly by an aide, denied access to my shoelaces, and allowed to make calls only from a phone in the “day room.” But despite the indignities and trauma of this experience, I can say now it saved my life. I was discharged after a few weeks, not completely over my depression but on the way to feeling well again. I had started treatment and begun to feel optimistic about my

4.1

thing or may be measuring something else. Some child self- report measures of anxiety have been criticized for measuring depression more than anxiety. For us to consider them useful, test items should have high internal consistency reliability.

Validity Validity is the extent to which an assessment technique measures what it is supposed to measure. Key types of validity include con- tent, predictive, concurrent, and construct validity (see Table 4.2). Content validity is the degree to which test or interview items actually cover aspects of the variable or diagnosis under study. If a test of depression contained items only about sad mood, the test would not have high content validity because depression also involves problematic thinking patterns and withdrawn behavior.

Predictive validity refers to whether test or interview re- sults accurately predict some future behavior or event. A test of future behavior or event. A test of future school success has good predictive validity if current scores relate to children’s school achievement 2 years from now. Concurrent validity refers to whether current test or interview results relate to an important present feature or characteristic. A child’s diagnosis present feature or characteristic. A child’s diagnosis present of conduct disorder should re�ect his current level of misbehavior.

Construct validity refers to whether test or interview results relate to other measures or behaviors in a logical, theoretically expected fashion. Recall DeShawn’s impulsivity and alcohol problems from Chapter 3. A valid test of impulsivity might be expected to correlate with a diagnosis of alcohol use disorder, school or work problems, and lower levels of the neurotransmit- ter serotonin. If this test does so, then we can be more con�- dent in its construct validity. If people with problems similar to DeShawn’s scored high on this test of impulsivity, this would also support the test’s construct validity.

Standardization Standardization refers to administering or conducting assess- ment measures in the same way for everyone. When you took the SAT or ACT, you may have noticed all the rules and guide- lines for administering, scoring, and interpreting the test. Proc- tors gave the test in a standardized or similar way for all high school students in the country.

Assessment measures can be standardized in several ways. First, the same test items and testing procedures, such as time limits or item order, can be used for everyone. Second, the way

future. Within a month of getting back to school, I truly felt all this sadness and strife was behind me, and I never imagined that things could be- come even more challenging and complicated.

Right before my junior year I experienced symptoms that, unlike those during my depressions, I did not �nd troubling. I was always someone who needed a good 9 hours of sleep to feel well rested, but I started getting by on dramatically less. Some nights I would not touch the bed (if I was even home), other nights I would fall asleep for 2 or 3 hours and then jolt awake, energized and ready to go. My waking hours became �lled with fren- zied activity—I never felt smarter, more able, or more con�dent. My thinking was swift and sharp and seemed to reach near superhu- man perfection. These feelings continued, but the ecstasy soon devolved into agitation. Every annoyance seemed like a concerted, even conspiratorial, effort to thwart my plans. When my psychiatrist saw me in his of�ce, he knew immediately what was wrong. I was experiencing a manic episode. An ambulance was called and I was brought to the hospi- tal. I was enraged and scared at the same time, but eventually acquiesced to treatment. New medications—antipsychotics and mood

strength. I began to see medications and thera- py as my toolbox for maintaining a stable life in which I could achieve my goals. This involved tinkering to �nd the best combination of medi- cines and trade-offs in terms of putting up with some side effects if my overall health was good.

Coming to terms with having bipolar disor- der and learning how to effectively take care of myself has been a process of peaks and val- leys. After 3 years of feeling well, I relapsed and experienced episodes of mania and depres- sion. Both required hospitalization and medi- cation changes. Experiencing relapse after a few years of feeling great was a wake-up call. I secretly felt I was somehow “past” that sort of thing. Since then I’ve tried to be optimistic while still recognizing I have a chronic disorder, and the chance of having more episodes in the future is very high. Thankfully, when I am sta- ble, I have no lingering symptoms. My goal is no longer to avoid getting sick again but to keep myself stable and healthy for as long a stretch as possible. Despite my disorder, I’ve graduated college and entered graduate school. I’ve had lasting and meaningful relationships. I live on my own and have traveled widely. My disorder hasn’t de�ned my life, and despite the inevita- ble challenges ahead, I don’t believe it ever will.

stabilizers this time—were used to control my mood. Most of my symptoms abated within a few weeks, but the medications left me sedated and feeling somewhat dull. New medications for a new diagnosis: bipolar I disorder.

I came away from this traumatic experience dismayed and disheartened, my self-image shattered. I had already come to terms with be- ing a “psychiatric patient” and acknowledged that my �rst hospitalization was necessary (although at the time I had no doubt it would be my last). But during my �rst manic episode, I was “publicly” sick in a way I hadn’t been before. I was embarrassed and humiliated. Being told I had a disorder only “other people” got—“other people” being unfortunates who lived their lives in drug-induced stupors in institutions or group homes—compounded my feelings of defeat.

As I recovered, I reevaluated some of these feelings and saw things more realistically. I also met other young adults, through a support group, who struggled with the same disorder. It was enlightening and heartening to hear many of their stories, and they provided invaluable ad- vice and support. My ideas as to what it meant to have a mental disorder shifted largely as a result of these conversations, allowing me to ap- proach my own situation with more hope and

personal narrative

Type of validity De�nition

Content validity How well test or interview items adequately measure various aspects of a variable, construct, or diagnosis

Predictive validity How well test scores or diagnoses predict and correlate with behavior or test scores that are observed or obtained at some future point

Concurrent validity How well test scores or diagnoses correlate with a related but independent set of test scores or behaviors

Construct validity How well test scores or diagnoses correlate with other measures or behaviors in a logical and theoretically consistent way

TABLE 4.2

Common Types of Validity

Source: Used with permission.

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders80

the test is scored can be the same for everyone. Everyone’s SAT verbal scores are based on the same scoring system. Third, our interpretation of test scores can be standardized by collecting normative data from large groups of people across age, gender, and race. Test scores can thus be compared among members of these groups. Scores obtained by a 25-year-old Latina student, for example, can be compared with typical scores obtained by Latina students in this age range. We can then interpret these scores by seeing whether they are higher or lower than average scores obtained by members of the appropriate normative group.

Reliability, validity, and standardization are important for developing and re�ning clinical assessment techniques. We next explore different methods of clinical assessment. We begin with a discussion of interviews, which mental health professionals use to gather information about a person’s concerns, symptoms, and history.

Interview The interview is the most common assessment technique and is used to solicit a wide range of information about mental dis- orders. Interviewers often ask questions about the frequency and nature of symptoms of different mental disorders. Interview questions also focus on events or experiences that preceded symptom onset, such as child maltreatment or death of a par- ent. Interviews have a range of applications and can be easily adapted to match a person’s situation.

Interviews differ in two key ways. First, interviews differ with respect to purpose. The purpose of one interview may be to evalu- ate the history and concerns of a person seeking psychological help for the �rst time, but another interview might focus solely on DSM-5 diagnoses. Second, interviews may be unstructured or unstructured or unstructured structured. Unstructured interviews allow an interviewer to ask any question that comes to mind in any order. This type of in- terview is often unreliable because two clinicians evaluating the same person may arrive at different ideas of what is happening. Structured interviews require an interviewer to ask standardized questions in a speci�ed sequence. Interviewers ask people the same questions, so two clinicians who evaluate the same person are more likely to arrive at the same diagnosis or conclusion.

Several structured diagnostic interviews are available. The Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2015) is a popular structured diagnostic inter- view for major mental disorders. The SCID-5 gives clear instruc- tions to the interviewer about what questions to ask and in what order to ask them. Structured interviews like the SCID-5 stan- dardize questions to be asked and help interviewers obtain rele- vant information. Structured interviews are available for various mental disorders as well as many psychological and other vari- ables such as personality and family history of mental disorder.

Diagnoses and ratings from structured diagnostic interviews are generally reliable across raters and have high content validity be- cause they are based on speci�c criteria. Many structured interviews appear to have high construct validity as well. Structured interview diagnoses or ratings usually relate to scores and ratings from other psychological, behavioral, or biological tests in expected ways.

A disadvantage of structured diagnostic interviews is the time necessary to administer and score them. These interviews

are comprehensive and can take several hours to conduct. In many clinical settings, clients are seen for only an hour at a time and often for only a few sessions, so these interviews may be less attractive as assessment devices. Structured diagnostic interviews are thus particularly common to research settings.

Intelligence Tests Intelligence tests are probably the most common form of clini- cal assessment after the interview. Intelligence tests assess cogni- tive functioning and provide estimates of a person’s intellectual ability. Mental health professionals are interested in assessing cognitive processes such as memory, language, comprehension, reasoning, and speed with which we process and interpret in- formation. Many people associate intelligence tests with assess- ment of learning disorder and brain dysfunction, but information provided by these tests can also be used to understand symp- toms of mental disorders such as schizophrenia or depression.

Most intelligence tests include multiple subscales or sub- tests to measure speci�c aspects of cognitive functioning such as memory, arithmetic, mastery of general information, or visual-perceptual organization. Some subtests require a person to answer direct questions, but other subtests require people to complete tasks or solve problems. Scores on these subtests are typically combined and compared with normative data from peo- ple of similar age and gender. This form of standardization allows an individual’s scores to be interpreted as low, average, or high.

The Wechsler Adult Intelligence Scale—Fourth Edition (WAIS-IV; Wechsler, 2008) is one of the most popular intelligence tests. Items regarding a particular domain such as arithmetic are placed in one section (subtest) and arranged in order of increas- ing dif�culty. Item scores from each subtest are converted to scaled scores, which represent standardized scores within an age group. Scaled scores are added to derive intelligence quotients (IQs), which are general measures of intellectual functioning. Several WAIS-IV subtests are described in Table 4.3 and a simu- lated WAIS-IV item is illustrated in Figure 4.1.

Intelligence quotients often include full-scale, verbal, and performance IQs. The full-scale IQ may be most familiar to performance IQs. The full-scale IQ may be most familiar to performance you; it gives an estimate of overall intellectual ability. Verbal IQ speci�cally represents use and comprehension of language,

The clinical interview is the most commonly used assessment technique.

Ph ot

og ra

ph ee

.e u/

Fo to

lia L

and performance IQ speci�cally represents spatial reasoning. In- dividual IQs are calculated in relation to normative data. The score of a 20-year-old male, for example, is compared with the scores of other 20-year-old males. To make scores easier to inter- pret, the mean for each age group is 100; this makes the IQ scale consistent across age groups.

Intelligence test scores can give mental health professionals a sense of a person’s strengths and weaknesses. This informa- tion is important for diagnosing, assessing, and treating psycho- logical problems. Some disorders, such as Alzheimer’s disease, are de�ned primarily by cognitive de�cits that may be assessed by intelligence tests. Other disorders have cognitive and behav- ioral features that intelligence tests can at least tap. Intelligence tests are therefore administered to many clients in clinical and research settings.

Intelligence test scores must be interpreted with caution. IQ scores do not indicate how smart a person is but rather how well she is likely to do in future academic work. Most intelligence tests focus on verbal and spatial ability but do not measure other forms of competence such as social skill, creativity, and mechanical ability. Intelligence tests have also been criticized for bias because people across cultures think differently. A test that is completely “culture-free” has not been developed, but researchers have identi�ed nonverbal intelligence subtests that may be “culture-fair” because scores differ less between ethnic groups (Cockcroft, Alloway, Copello, & Milligan, 2015).

Personality Assessment A clinical assessment measure that may be more familiar to you is personality assessment. Personality assessment refers to in- struments that measure different traits or aspects of our charac- ter. Most of us could name or describe at least one personality or psychological test based on what we have read in books or seen on television shows or �lms. Many of us have seen a movie or television show that portrayed the “inkblot test” as a measure of personality. Thousands of other personality assessment mea- sures are available, however. These can be divided into objective and projective tests.

Objective Personality Measures Objective personality measures involve administering a stan- dard set of questions or statements to which a person responds using set options. Objective tests often use a true/false or true/false or true/false yes/no response format, but others provide a dimensional scale such as dimensional scale such as dimensional scale 0 � strongly disagree, 1 � disagree, 2 � neutral, 3 � agree, and 4 � strongly agree. Self-report, paper-and-pencil questionnaires are popular objective tests of general or limited aspects of personality, and many types are discussed throughout this textbook. Examples include the Social Phobia and Anxiety Inventory (Chapter 5) and Social Phobia and Anxiety Inventory (Chapter 5) and Social Phobia and Anxiety Inventory Beck Depression Inventory (Chapter 7). These questionnaires are Beck Depression Inventory (Chapter 7). These questionnaires are Beck Depression Inventory economical, impartial, simple to administer and score, and more reliable and standardized than other assessment methods.

We brie�y illustrate here the Minnesota Multiphasic Personality Inventory—2 (MMPI-2), which clinicians have used for more than 60 years and is still considered the most important general person- ality questionnaire (Butcher, 2011). Thousands of studies using the MMPI/MMPI-2 have been published (Friedman, Bolinskey, Levak, & Nichols, 2015), and scores from the scale have been used to mea- sure everything from psychosis to marriage suitability.

The developers of the original MMPI believed the content of a test item mattered less than whether people with the same mental disorder endorsed the same items. Do people with de- pression endorse the item “I like mechanics magazines” more

FIGURE 4.1 SIMULATED ITEM FROM THE WAIS-IV PICTURE COMPLETION SUBTEST. Can you �nd what’s missing in this picture? Simulated items similar to those found in the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV). Copyright © 2008 NCS Pearson, Inc. Reproduced with permission. All rights reserved. “Wechsler Adult Intelligence Scale” and “WAIS” are trademarks, in the United States and/or other countries, of Pearson Education, Inc. or its af�liates.

Vocabulary The examinee must de�ne words. For example, “What does the word impede mean?”impede mean?”impede

Similarities The examinee must explain how two objects are alike. For example, “How are a wheel and wheel and wheel ski alike?”ski alike?”ski

Digit span Two lists of digits are read aloud by the examiner. For the �rst list, the examinee must repeat the digits in the order they were read. For example, “2-8-3-9-6.” For the second list, the digits must be repeated backward.

Source: Wechsler (2008).

TABLE 4.3

Simulated Examples of Wechsler Adult Intelligence Scale Subtests

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders82

so than people without depression? If so, then the item might appear on a scale of depression. An item that does not appear on the surface to be related to depression may thus become an item on the depression scale.

The MMPI-2 includes 567 items to which a person answers “True,” “False,” or “Cannot Say.” The MMPI-2 can be adminis- tered to people aged 13 years or older, to those who can read at an eighth-grade level, and to individuals or groups. An ado- lescent version (MMPI-A) is also available (Williams & Butcher, 2011). The MMPI-2 is usually computer-scored.

A potential problem with questionnaires such as the MMPI-2 is susceptibility to distortion. Some people might wish to place themselves in a favorable light, and others may “fake bad” to receive aid, sympathy, or a military discharge. Other people tend to agree with almost any item regardless of content. If a mental health professional is unaware of these response styles in a given client, the test can be misinterpreted. The following MMPI-2 validity scales are used to detect people who are trying to look a certain way or who are defensive or careless when taking the test:

1. ? (cannot say) scale: This is the number of items left unanswered.

2. F (infrequency) scale: These items are seldom answered a certain way (“true” or “false”) by people. A high F score may suggest unusual approaches to taking the test or the presence of odd emotional states, thinking patterns, and behavior.

3. L (lie) scale: Endorsing these items places someone in a very positive light. People are unlikely, however, to endorse too many items such as, “I like everyone I meet.”

4. K (defensiveness) scale: These items suggest defensiveness in admitting certain problems. Items such as “Criticism from others never bothers me” purportedly detect “faking good” but are more subtle than L or F items.

Validity scales help us understand someone’s motives and test- taking attitudes. Attempts to present oneself in an overly favorable light will likely be detected by the Lie or Lie or Lie Defensiveness scale and a tendency to exaggerate one’s problems or symptoms usually results in an elevated F (Infrequency) scale. A mental health professional might disregard the test as well under these circumstances.

Scores on 10 MMPI-2 clinical scales are also calculated. These scales were originally developed to identify people likely to have certain diagnoses. The MMPI-2 retained the original names of the scales despite newer diagnostic labels introduced since the scale was developed. Each clinical scale with a short description and an abbreviated item is in Table 4.4.

Scores from the MMPI-2 can suggest diagnoses, but they also indicate various problematic behaviors and personality styles. How does a mental health professional interpret MMPI-2 pro�les? Think about Professor Smith, who agreed to consult with a clinical psychologist after struggling with panic attacks and depression for many months. The clinical psychologist

TABLE 4.4

MMPI-2 Clinical Scales and Abbreviated Items

1. Hypochondriasis (Hs) High scores indicate excessive concern with bodily functions (“Upset stomach”).

2. Depression (D) High scores indicate pessimism, hopelessness, and slowing of action and thought (“Work atmosphere tense”).

3. Hysteria (Hy) High scores indicate tendency to use physical and mental problems to avoid con�icts or responsibility (“Feel band around head”).

4. Psychopathic deviate (Pd)

High scores indicate a disregard for social custom, shallow emotions, and inability to pro�t from experience (“Haven’t led a good life”).

5. Masculinity- femininity (Mf)

Items on this scale differentiate traditional gender roles (“Likes mechanic magazines”). High scores indicate a tendency to endorse a nontraditional gender role.

6. Paranoia (Pa) High scores indicate unusual suspiciousness and possible delusions of grandeur or persecution (“Insulting, vulgar things are said about me”).

7. Psychasthenia (Pt) High scores indicate obsessions, compulsiveness, fears, guilt, and indecisiveness (“Have strange thoughts”).

8. Schizophrenia (Sc) High scores indicate bizarre or unusual thoughts or behavior, withdrawal, hallucinations, and delusions (“Unusual experiences”).

9. Hypomania (Ma) High scores indicate emotional overexcitement, �ight of ideas, and overactivity (“Sometimes thoughts race”).

10. Social introversion (Si) High scores indicate shyness, disinterest in others, and insecurity (“Easily defeated in argument”).

Source: MMPI®-2 (Minnesota Multiphasic Personality Inventory®-2) Manual for Administration, Scoring, and Interpretation, Revised Edition. Copyright © 2001 by the Regents of the University of Minnesota. Used by permission of the University of Minnesota Press. All rights reserved. “MMPI®” and “Minnesota Multiphasic Personality Inventory®” are trademarks owned by the Regents of the University of Minnesota. MMPI®-2 Booklet of Abbreviated Items. Copyright © 2005 by the Regents of the University of Minnesota. All rights reserved. Used by permissions of the University of Minnesota Press. “MMPI®” and “Minnesota Multiphasic Personality Inventory®” are trademarks owned by the Regents of the University of Minnesota.

asked Professor Smith to complete the MMPI-2 before their �rst session, and this information was used with a clinical inter- view. The following excerpt is from a report based on Professor Smith’s MMPI-2 pro�le (see Figure 4.2):

Professor Smith approached testing in a frank manner, and his re- sponses suggest a valid MMPI-2 pro�le. His scores indicate concern about his present mental state and a willingness to receive help to

overcome his problems. The MMPI-2 clinical pro�le highlights sev- eral problems and symptoms Professor Smith experienced during ini- tial treatment. His responses suggest he is anxious, nervous, tense, and high-strung. He worries excessively and expects more problems to occur in the future. Professor Smith also has concerns about his health and body. He may complain of feeling fatigued, exhausted, and pained. Professor Smith appears depressed, pessimistic, and discour- aged about his current situation and may feel lonely and insecure. He

10 10

15 20

35 45

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105

110

120

115

100

105

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Profile for Basic Scales Minnesota Multiphasic Personality Inventory-2 Copyright © by THE REGENTS OF THE UNIVERSITY OF MINNESOTA 1942, 1943 (renewed 1970), 1989. This Profile Form 1989. All rights reserved. Distributed exclusively by NATIONAL COMPUTER SYSTEMS, INC.All rights reserved. Distributed exclusively by NATIONAL COMPUTER SYSTEMS, INC. under license from The University of Minnesota.

“MMPI-2” and “Minnesota Multiphasic Personality Inventory-2” are trademarks owned“MMPI-2” and “Minnesota Multiphasic Personality Inventory-2” are trademarks owned by The University of Minnesota. Printed in the United States of America

Minnesota MultiphasicMinnesota Multiphasic Personality Inventory-2™rsonality Inventory-2™

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FIGURE 4.2 PROFESSOR SMITH’S PRETREATMENT MMPI-2 CLINICAL PROFILE. Reproduced by permission of the University of Minnesota Press. All rights reserved. “MMPI®” and “Minnesota Multiphasic Personality Inventory®” are trademarks owned by the University of Minnesota.

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders84

has great dif�culty concentrating on his work and is likely to be indeci- sive. Professor Smith may blame himself for his current problems and feel guilty or disappointing to others. His responses also indicate little zest for life and preoccupation with inability to accomplish personal goals.

You can see that MMPI-2 interpretation does not rely on a single score but rather a pro�le of a client based on all scores. Pro�les like Professor Smith’s can then be interpreted using certain guidelines. These guidelines, or “cookbooks” as they are sometimes called, outline frequently obtained pro�les and descriptions of typical symptoms, complaints, and characteris- tics of those who produce these pro�les. These guidelines help mental health professionals standardize the interpretation of the MMPI-2.

Projective Personality Measures Not all personality tests emphasize standardized administra- tion, scoring, and interpretation as the MMPI-2 does. Some tests require mental health professionals to use their skill and judg- ment to interpret an individual’s responses. Projective tests are based on the assumption that people faced with an ambigu- ous stimulus such as an inkblot will “project” their own needs, personality, and con�icts. One person looking at a particular inkblot might see a monster’s face, but another person might see two children playing near a stream. Projective techniques differ drastically from objective questionnaires like the MMPI-2 because (1) responses are not linked to certain scales and (2) responses are interpreted as individual characteristics, such as one’s unconscious processes. Projective tests include sentence completion tasks, in which people complete a series of un�n- ished sentences, and drawing tests, in which people are asked to draw a �gure such as a house or their family. We brie�y discuss two other popular projective tests next: the Rorschach and the Thematic Apperception Test.

Rorschach. Hermann Rorschach was a Swiss psychiatrist who experimented with inkblots as a way to diagnose psy- chological problems. The Rorschach test consists of 10 inkblot cards that are symmetrical from right to left. Five cards are black and white (with shades of gray) and �ve are colored. A simulated Rorschach card is shown in Figure 4.3.

The Rorschach can be administered in different ways, but many clinicians give a client the �rst card and say, “Tell me what you see—what it looks like to you.” All cards are shown to a client in order, and the clinician writes down every word the client says. The clinician then moves to an inquiry phase: She reminds the client of each previous response and asks what prompted each response. The client also indicates the exact location of various responses for each card and may elaborate or clarify responses. Many clinicians focus on these major aspects of responses:

• Location refers to area of the card to which the client responded; examples include the whole blot, a large detail, a small detail, or white space.

• Content refers to nature of the object seen, such as an aniContent refers to nature of the object seen, such as an aniContent - mal, person, rock, or fog.

• Determinants refer to aspects of the card that prompted a client’s response, such as the inkblot’s form, color, texture, apparent movement, and shading.

Scoring the Rorschach involves computing the ratio of cer- tain responses, such as responses to colored parts of the ink- blots, to total number of responses. Clinicians may also compute the ratio of one set of responses to another, such as number of responses describing human movement to number of color responses. Many mental health professionals do not formally score the Rorschach but rely instead on their clinical impres- sions of a client’s responses.

The utility of the Rorschach is hotly debated. Research- oriented psychologists often question the reliability and validity of Rorschach scores. Some Rorschach proponents argue that interrater and test–retest reliability are excellent, but oth- ers remain unconvinced (Lilienfeld, Ammirati, & David, 2012; Viglione et al., 2015). Evidence exists to support the predictive validity of some Rorschach scores with respect to thought dis- turbance, psychotherapy prognosis, and dependency (Mihura, Meyer, Dumitrascu, & Bombel, 2013).

Thematic Apperception Test. Another popular projective test to assess motivations and interpersonal style is the Thematic Apperception Test (TAT). The TAT is a series of pictures like Apperception Test (TAT). The TAT is a series of pictures like Apperception Test

FIGURE 4.3 INKBLOT SIMILAR TO RORSCHACH INKBLOTS. From Timothy Trull, Clinical Psychology (7th ed.), Fig. 8.2. Copyright © 2005 Wadsworth, a part of Cengage Learning. Reproduced with permission. www.cengage. com/permissions

the ones in Figure 4.4. Most TAT cards depict people in vari- ous situations, but some cards contain only objects. Clinicians typically select 6 to 12 cards to give to a client. Clients are asked to say what is happening in the picture now and in the future. Instructions vary from clinician to clinician, but many say something such as, “I want you to make up a story about each of these pictures. Tell me who the people are, what they are doing, what they are thinking or feeling, what led up to the scene, and how it will turn out.” The client’s stories are then transcribed word-for-word by the clinician.

A mental health professional can learn about a client’s personality from these stories. One person might say a pic- ture in Figure 4.4 shows a mother worried about her daugh- ter who is leaving home, but another might say a woman is constantly �ghting with her mother and now refuses to talk to her. These different stories help us understand how a client relates to others. The TAT is not generally used to de- rive speci�c diagnoses but rather to make judgments about personality themes such as hostility, defensiveness, jealousy, and rebelliousness. The reliability and validity of this test may be enhanced by using certain coding and rating techniques (Stein et al., 2015).

Behavioral Assessment The purpose of behavioral assessment is to measure overt behaviors or responses shown by a person (McCahill, Healy, Lydon, & Ramey, 2014). Instead of relying only on Profes- sor Smith’s report of how fearful and anxious he is when lecturing in class, a behavioral assessor might also observe Professor Smith in this situation. Behavioral assessment pro- vides a snapshot of an actual problem behavior. Traditional assessments such as intelligence or personality tests rely on responses as indirect indicators of underlying traits or char- acteristics. Behavioral assessment relies on as little interpre- tation or inference as possible—the behavior observed is the main interest.

Behavioral assessment often involves a functional analysis of behavior. This involves understanding antecedents, or what precedes a behavior, and consequences, or what follows a behavior. A functional analysis for Professor Smith might reveal that certain student questions (antecedents) led to stress and panic attacks and that letting class out early (consequences) helped ease these anxious feelings, which is reinforcing. Conse- quences are often reinforcers of problematic behavior.

Careful and precise description of antecedents, behavior, and consequences is crucial to functional analysis. Important antecedents that you could easily measure and observe include student questions, time spent lecturing, and class attendance. You would also have to specify behaviors of interest, such as frequency and length of Professor Smith’s chest pains. Impor- tant consequences that you could easily measure and observe include the number of minutes Professor Smith let class out early and the number of times he excused himself from class. You would also have to obtain similar level of detail for other situations in which Professor Smith had a panic attack because antecedents and consequences of behavior often differ from situation to situation.

Behavioral therapists often broaden functional analysis to include organismic variables. Organismic variables include a person’s physiological or cognitive characteristics that may help the therapist understand a problem and determine treatment. A major organismic variable for Professor Smith is worry about future panic attacks and fear that certain physical sensations indicate an impending attack. Organismic variables such as wor- ries and cognitions are also sometimes assessed via self-report questionnaires.

Naturalistic Observation Behavioral assessors often use observation to conduct a func- tional analysis. One form is naturalistic observation, in which a client is directly observed in his or her natural environment. A naturalistic observation might involve observing Professor Smith in his of�ce, classroom, and home for a week. You can see, though, that naturalistic observation can be impractical, dif�cult, time-intensive, and expensive. Observers also cannot know for sure the problem behavior will even occur, so they sometimes must be present for long periods to capture a certain behavior.

FIGURE 4.4 THEMATIC APPERCEPTION TEST (TAT) CARDS.

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CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders86

Controlled Observation Controlled observation is a more practical and less expensive form of observation and involves analogue tests; these tests in- volve tasks that approximate situations people face in real life and that may elicit a certain problem behavior (Miltenberger, 2012). A person anxious about public speaking could be asked to give a short presentation before others in a psychologist’s of�ce. Or a troubled married couple might be asked to solve a hypothetical problem. A person’s responses are observed and analyzed in each case. This information helps us understand precise mistakes the person makes when speaking before others or the couple makes when solving a problem. These observations can then lead to a treatment plan that might include relaxation and interpersonal skills training for the anxious public speaker and problem-solving and communication skills training for the troubled couple.

Self-Monitoring Controlled observations are more practical than naturalistic observations but can be dif�cult to arrange. Many behavior assessors thus rely on self-monitoring, where a person ob- serves and records his own emotions, thoughts, and behav- iors. Professor Smith could be asked to complete a daily diary to record the frequency, intensity, and duration of his panic attacks, related thoughts and emotions, and antecedents and consequences of his panic attacks. Self-monitoring can be in- formal or more structured like a dysfunctional thought record (see Figure 4.5). Dysfunctional thought records help identify and monitor situations, thoughts, responses, and outcomes as- sociated with problems such as depression. A therapist and client can thus better understand what precedes and follows these problems. Technological advances also mean clients can

Directions: When you notice your mood getting worse, ask yourself, “What’s going thDirections: When you notice your mood getting worse, ask yourself, “What’s going through my mind right now?” and as soon asugh my mind right now?” and as soon as possible jot down the thought or mental image in the Automatic Thought(s) column.possible jot down the thought or mental image in the Automatic Thought(s) column.

Date/time Situationte/time Situation

1. What actual event or stream of thoughts, or daydreams or recollection led to the unpleasant emotion?

2. What (if any) distressing physical sensations did you have?

Automatic thought(s)

1. What thought(s) and/or image(s) went through your mind?

2. How much did you believe each one at the time?

Emotion(s)

1. What emotion(s) (sad/anxious/ angry/etc.) did you feel at the time?

2. How intense (0–100%) was the emotion?

Adaptive response

1. (optional) What cognitive distortion did you make?

2. Use questions at bottom to compose an adaptive response to the automatic thought(s).

3. How much do you believe each response?

Outcome

1. How much do you now believe each automatic thought?

2. What emotion(s) do you feel now? How intense (0–100%) is the emotion?

3. What will you do (or did you do)?

Questions to help compose an adaptive response: (1) What is the evidence that the automatic thought is true? Not true? (2) IsQuestions to help compose an adaptive response: (1) What is the evidence that the automatic thought is true? Not true? (2) IsQuestions to help compose an adaptive response: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) What’s the worst that could happen? Could I live ththere an alternative explanation? (3) What’s the worst that could happen? Could I live through it? What’s the best that could happen?ugh it? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the effect of myWhat’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the effect of myWhat’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the effect of my changing my thinking? (5) What should I do about it? (6) If [friend’s name] was in the situation and had this thought, whatchanging my thinking? (5) What should I do about it? (6) If [friend’s name] was in the situation and had this thought, whatchanging my thinking? (5) What should I do about it? (6) If [friend’s name] was in the situation and had this thought, whatchanging my thinking? (5) What should I do about it? (6) If [friend’s name] was in the situation and had this thought, what would I tell him/her?

Friday 2/232/232/ 10 A.M.

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Talking on the phone with Donna.

Studying for my exam.

Thinking about my economics class tomorrow.ow.ow

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She must not like me anymore. 90%

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A little bit/Less sad (50%)/I will ask Donna if she is upset with me.

Sad 95% Maybe I can’t n’t n’ learn all of this, is, is but I can learn some of this. 50%

Somewhat/More motivated (60%)/I will study as hard as I can and ask someone to help me.

Anxious 80% Dos 80% Doing my best is all I can do. 70%

To some extent/Ant/Ant little better (70%)/I’er (70%)/I’er ll just give the best answer I swer I swer can.

Anxious 80% I’m s 80% I’m just nervous; I’m not having a heart art ar attack. 90%

Less so/More calm (80%)/ Relax and steady my breathing.

FIGURE 4.5 AN EXAMPLE OF A DYSFUNCTIONAL THOUGHT RECORD. The dysfunctional thought record is a type of self-monitoring diary or log used to identify what may prompt and what may follow negative emotions. Source: Adapted from J.S. Beck, Cognitive Therapy: Basics and Beyond, New York: Guilford, 1995.

record their emotions, thoughts, and behaviors during their everyday lives. Handheld computers, smartphones, and lap- top computers have been used to collect self-monitoring data (Faurholt-Jepsen et al., 2015).

Biological Assessment Recall from Chapter 2 that mental disorders often involve ab- normalities in brain structure or function. Many medical tests are available for examining general central nervous system dysfunction, such as from a stroke, but technological advances have led to amazing assessment techniques that can measure very speci�c central nervous system changes. Brain imaging techniques now provide detailed and precise evaluations of brain structure and function. We next provide an overview of neuroimaging and other biological tests used to assess psycho- pathology, although these tests are typically used in research settings or in cases involving clear brain dysfunction from prob- lems such as stroke.

Neuroimaging Brain images can be derived in several ways. Computerized axial tomography (CT scan) assesses structural abnormalities of the brain. A CT scan can detect brain tumors and other struc- tural abnormalities such as enlarged ventricles or hollow spaces in the brain sometimes seen in people with schizophrenia or other mental disorders. The CT scan is essentially an X-ray of a cross-section of the brain. X-ray dye (iodine) is injected into the person, and the CT scan assesses brain tissue density by detecting the amount of radioactivity from a moving beam of X-rays that penetrates the tissue. A computer then interprets this information to provide a two-dimensional picture of that cross- section of the brain.

Magnetic resonance imaging (MRI) produces higher- quality brain images without radiation. MRI is costly but is bet- ter than CT scans in detecting brain tumors, blood clots, and other structural abnormalities. A person lies in a large cylindri- cal magnet, and radio waves are beamed through the magnetic �eld. Sensors read the signals, and a computer integrates the information to produce a high-resolution brain image. Func- tional MRI (fMRI) goes a step further in that pictures are taken rapidly to assess metabolic changes in the brain; fMRI thus assesses how the brain is working. This can have im- portant implications for understanding risk factors of mental disorder. If fMRI results reveal a person’s frontal lobes to be poorly activated during a decision-making task, then frontal lobe dysfunction may be associated with a learning or thought disorder.

Positron emission tomography (PET scan) is an invasive procedure to evaluate brain structure and function. Radioactive molecules are injected into the bloodstream and emit a particle called a positron. Positrons collide with electrons, and light par- ticles emit from the skull and are detected by the PET scan- ner. A computer uses this information to construct a picture of how the brain is functioning. PET scans can identify seizure activity and even brain sites activated by psychoactive drugs (see Figure 4.6).

Neurochemical Assessment Neurochemical assessment is a biological assessment of dysfunctions in speci�c neurotransmitter systems. Recall neurotransmitter systems. Recall neurotransmitter from Chapter 2 that neurotransmitters are brain chemicals that can activate or inhibit neurons and are often part of several main systems such as: serotonin, norepinephrine, gamma-aminobutyric acid (GABA), and dopamine. Many symptoms of mental disorder are in�uenced by dysfunction of one or more of these neurotransmitter systems in certain regions of the brain.

No technology allows us to directly assess how much neu- rotransmitter is in a speci�c brain region, but we can indirectly assess this by focusing on neurotransmitter metabolites. Metab- olites are by-products of neurotransmitters that can be detected in urine, blood, and cerebral spinal �uid. Low levels of a me- tabolite suggest a low level of the associated neurotransmitter and vice versa. We will see later in this textbook how scientists

Cell phones and laptop and tablet computers can be used to monitor emotions, thoughts, and behaviors as they occur.

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CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders88

FIGURE 4.6 EXAMPLES OF BRAIN IMAGING TECHNIQUES. Several brain imaging techniques are used in biological assessment. Here are some examples: (top left) A CT scan; (top right) an MRI scan; (bottom left) an fMRI scan; and (bottom right) a PET scan.

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have used this methodology to evaluate neurochemical theories of depression (low levels of serotonin) and schizophrenia (high levels of dopamine).

Psychophysiological Assessment Psychophysiological assessment involves evaluating bodily changes possibly associated with certain mental conditions. We experience certain bodily changes when we are highly anxious, such as increased heart rate or sweating (yes, measures exist for sweating!). These kinds of bodily changes could be examined in someone like Professor Smith who is seeking treatment for an anxiety disorder.

A common type of psychophysiological assessment is an elec- trocardiogram, which measures heart rate. Electrodes are placed on a person’s chest, and the electrical impulse produced by the heartbeat and detected by each electrode is fed to an instrument that measures and integrates this information. Heart rate has been used to assess various emotional states and risk factors. Those with anxiety disorders (Chapter 5), for example, are at greater risk of cardiovascular disease (Chalmers, Quintana, Abbott, & Kemp, 2014). We might also expect Professor Smith’s heart rate to be elevated, even when he is not experiencing a panic attack, because his fear of future attacks makes him anxious most of the time.

Galvanic skin conductance is another index of emotional state. Some emotional states increase sweat gland activity and thus electrical conductance of the skin (electricity moves faster

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motor skills. Two general approaches are used for neuropsycho- logical testing. One approach is to employ commonly used neuro- psychological batteries such as the Halstead-Reitan Battery. These batteries involve various subtests that tap many cognitive and behavioral functions. The following descriptions of two Halstead- Reitan subtests provide good examples:

• Tactual performance test: The examinee is blindfolded and asked to place 10 variously shaped blocks into proper slots on a board using touch only. This is done once for each hand (dominant and nondominant) and once with both hands. The blindfold is then removed, and the examinee draws the board and located blocks from memory. This sub- test assesses damage to the brain’s right parietal lobe and tactile and spatial memory.

• Seashore rhythm test: The examinee hears 30 pairs of rhyth- mic acoustic patterns and states whether the patterns are the same or different. This subtest assesses damage to the brain’s anterior temporal lobes and nonverbal auditory perception.

A second approach to neuropsychological testing is to ad- minister one or more standardized tests to evaluate a speci�c area of brain functioning. This is known as focal testing. Sup- pose a neuropsychologist is primarily concerned with a person’s memory functioning. The neuropsychologist might administer the Benton Visual Retention Test, which measures memory for designs (Figure 4.7). Ten cards are presented for 10 seconds through skin when a person sweats). This is especially true for

people with anxiety. Some people, however, may display lower levels of skin conductance. This is true for some people with antisocial personality disorder who manipulate and harm others without guilt (Chapter 10; Pemment, 2013). People with antiso- cial personality disorder often have lower anxiety and fear about negative consequences to their behavior. They may thus be more likely than the rest of us to commit illegal or harmful acts.

The electroencephalogram (EEG) is a measure of brain activity. Electrodes are placed at various locations on the scalp so electrical activity in various brain areas can be assessed. Abnor- mal activity may indicate a lesion or tumor in that area or even sei- zure activity or epilepsy. Observation of possible abnormal brain wave activity might be followed by additional testing such as MRI.

Neuropsychological Assessment Methods of biological assessment are direct measures of brain direct measures of brain direct and physical function. Methods of neuropsychological assess- ment, however, are indirect measures of brain and physical funcindirect measures of brain and physical funcindirect - tion. Neuropsychological assessment is a noninvasive method of evaluating brain functioning via one’s performance on standard- ized tests and tasks that indicate brain–behavior relationships (Lezak, Howieson, Bigler, & Tranel, 2012). Many mental disorders involve some cognitive impairment, so neuropsychological tests can help identify or rule out physical problems. Biological assess- ment methods are invasive and expensive, so neuropsychological tests are often used as �rst-line screening measures. If problems are noted from these tests, then biological assessment may follow.

Neuropsychological tests typically assess abstract reasoning, memory, visual-perceptual processing, language functioning, and

One form of psychophysiological assessment is the electroencephalogram (EEG).

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FIGURE 4.7 EXAMPLES FROM THE BENTON VISUAL RETENTION TE EXAMPLES FROM THE BENTON VISUAL RETENTION TEST.ST.ST. Two Two cards from the Benton Visual Retention Test that assesses memory for designs. Adapted from M.D. Lezak, D.B. Howieson, E.D., Bigler, D. Tranel. (2012). Neuropsychological Assessment (5th ed.), New York: Oxford University Press.

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders90

each. After each presentation, the examinee draws the design from memory, and the examiner looks at number and type of errors in the drawings. A related test is the Bender Visual-Motor Gestalt Test (Bender-Gestalt II), which contains 14 stimulus Gestalt Test (Bender-Gestalt II), which contains 14 stimulus Gestalt Test cards and may be used for anyone aged 4 years or older (South & Palilla, 2013). These tests assess immediate memory, spatial perception, and perceptual-motor coordination.

➲ Interim Summary •

• DSM-5DSM-5DSM-5

•

• -

•

➲ Review Questions 1.

2. -

3. -

5. -

Culture and Clinical Assessment

Recall from Chapter 2 the sociocultural perspective of mental disorder, which focuses on in�uences that social institutions and other people have on one’s mental health. We next address the important topic of cultural considerations when assessing mental disorder, beginning with how culture might in�uence the development of psychological problems.

Culture and the Development of Mental Disorders As we discussed in Chapter 2, culture refers to unique behaviors and lifestyles that distinguish groups of people. Culture repre- sents a unique worldview and is re�ected in customs, laws, art, and music. Culture can also in�uence the development of men- tal disorders in several ways (Tseng, 2015).

1. Culture may cause stress and psychological problems. Cul- turally shared beliefs or ideas may lead to extreme stress and symptoms of mental disorders. A form of mental dis- order may be unique to a culture because of speci�c ideas or beliefs that are part of that culture. Ataque de nervios is a syndrome common to Latinos (APA, 2013). A person with this syndrome may sense losing control, shout uncon- trollably, experience attacks of crying and trembling, and faint or feel suicidal. These symptoms typically result from a stressful family event. Latino culture emphasizes family well-being and stability, so a family crisis can be extremely stressful and produce ataque de nervios.

2. Culture may in�uence a person’s reaction to stress. Certain cultures may disapprove of certain reactions to stressful events, such as becoming depressed. Some people may thus be expected to react to stress in only limited ways. A Japanese businessman’s �nancial failure might lead to suicide because the disgrace and shame of publicly acknowledging bankruptcy would be too painful.

3. Culture may in�uence which symptoms of a disorder are ex- pressed and the content of the symptoms. Symptoms of de- pression differ among people of various cultures. Societies or cultures that do not emphasize the concept of “guilt,” as in Indonesia, are less likely to have depressed clients who

feel guilty. The content of phobias or delusions can also depend on culture. People from poorly developed countries may be less likely to fear airplanes or believe their mind is controlled by satellites.

4. Culture may reinforce certain forms of mental disorder. The prevalence of certain mental disorders varies as a function of culture. General lifestyle patterns and attitudes, as well as acceptance of a disorder by the culture, likely in�uence prev- alence. Anorexia nervosa is more prevalent in societies such as ours that emphasize and reward thinness (Chapter 8).

Culture and Clinical Assessment Culture clearly in�uences the development and presentation of mental disorders, so culture must in�uence clinical assessment as well. This is important not only for assessing people from other countries but also for assessing diverse groups within the United States. This presents unique challenges to many clini- cians, however. Four main areas should be considered during assessment (Tseng, 2015).

1. Clinicians must overcome a language barrier if one exists. An interpreter with a background in mental health should be used if necessary. This is not the best option because people may feel uncomfortable disclosing certain informa- tion to more than one person. The translator could also mis- interpret or mistranslate information.

2. Clinicians must obtain information about the cultural back- ground of a client. This might involve reading clinical books on diversity or consulting with cultural experts. A mental health professional must also distinguish behavior collec- tively shared by a culture and a client’s responses or behav- iors. A helpful question to a client or family members thus might be, “How do your friends and other members of your community typically react in similar situations?”

3. Clinicians must be culturally sensitive. Mental health pro- fessionals must be aware that culture in�uences emotions, thoughts, and behavior. Psychological problems should also be understood and interpreted from a cultural perspective. Many people from East Asian cultures are more reserved, soft-spoken, and passive than people from the West. A men- tal health professional must be careful not to misinterpret this style as evidence of an interpersonal problem or depression.

4. Clinicians must be knowledgeable about cultural variations in psychological problems. Mental health professionals must �nd assessment and other materials that consider cultural variations in mental disorder. The DSM-5 presents general categories of information relevant to cultural considerations. First, for many mental disorders, a description of culture-re- lated diagnostic issues is included: how cultural background may in�uence the cause or presentation of symptoms, pre- ferred terms for distress, and/or prevalence of the disorder. Second, cultural syndromes are discussed; these are covered throughout this textbook. Third, an outline is presented for cultural formulation of presenting problems (see Table 4.5).

Culture can in�uence the development of psychological problems, and mental health professionals and medical doctors must consider cultural in�uences when conducting a clinical assessment or physical examination.

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TABLE 4.5 DSM-5

Cultural Formulation The DSM-5 (APA, 2013) suggests that a mental health professional DSM-5 (APA, 2013) suggests that a mental health professional DSM-5 supplement traditional diagnostic formulations with a cultural formula- tion of presenting symptoms of clients whose cultural background differs from the treating mental health professional. Information is obtained to address the following topics:

• Cultural identity of the client: Note the client’s ethnic or cultural reference groups as well as language abilities and preferences.

• Cultural ideas of distress: Note how the identi�ed cultural group might explain the present symptoms and how these symptoms com- pare with those experienced by those in the cultural reference group.

• Cultural factors related to the social environment: Note how the cultural reference group might interpret the social stresses, as well as availability of social supports and other resources that may aid treatment.

• Cultural in�uences on the relationship between the client and the mental health professional: Indicate differences in cultural and social status between the client and mental health professional that might in�uence diagnosis and treatment.

• Overall cultural assessment: Summarize how cultural factors and considerations are likely to in�uence the assessment and treatment of the client.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders92

If we develop a testable and refutable hypothesis regarding treatment for depression, then we must specify how we de�ne depression and exactly what comprises treatments A and B. We might de�ne depression as scores on a questionnaire or number of hours a person sleeps during the day. We might de�ne treat- ment A as a speci�c drug such as Prozac given at 60 milligrams (mg)/day and de�ne treatment B as Prozac given at 20 mg/day. Our hypothesis is now testable: We can measure or observe depression and provide speci�c doses of a medication. Our hy- pothesis is also refutable: Other people can clearly understand what we did, and they can try to replicate these results. We may also �nd no differences between our two groups, which refutes or contradicts our hypothesis.

Research Design The next step in the scienti�c experimental method is to develop a research design that allows us to test the hypothesis, or in this case, tell us whether treatment A is indeed more effective than treatment B. Research designs comprise dependent and inde- pendent variables. Dependent variables are those that measure a certain outcome the researcher is trying to explain or predict. Dependent variables in our experiment might include scores on a depression questionnaire or number of hours a person sleeps during the day. An independent variable is a manipulated vari- able that researchers hypothesize to be the cause of the out- come. The independent variable in our experiment is treatment: Some people will receive treatment A, and some people will receive treatment B.

Once we develop a testable and refutable hypothesis with dependent and independent variables, we must then test the hypothesis. We can do so by choosing people with depression from the general population and randomly assigning them to an experimental group and a control group. Randomization means assigning people to groups so each person has the same chance of being assigned to any group. The goal of randomization is to make sure our groups represent the general population with respect to age, gender, cultural background, income level, or other variables that could in�uence the dependent variable. If we examined only Hispanic males in our study, then our results would probably not be too useful to everyone.

The experimental group is one that receives the active independent variable, in this case medication at two levels. We actually need two experimental groups for our study: one receiv- ing medication at 60 mg/day and one receiving medication at 20 mg/day. The control group is one that does not receive the active independent variable. We may thus include people who are on a wait list for medication and monitor them over time to see if changes occur. They will receive no medication for a cer- tain period of time, so we will see if changes in the experimen- tal group are signi�cantly different than changes in the control group. If our hypothesis is correct, then manipulation of the independent variable in the experimental group will lead to less depression, but this change will not occur in the control group.

We will assign 50 people (participants) with depression to treatment A (experimental group 1; 60 mg/day), 50 people with depression to treatment B (experimental group 2; 20 mg/day),

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Studying Abnormal Behavior and Mental Disorder

We have so far discussed classi�cation, assessment, and cultural considerations regarding mental disorder. Mental health professionals also rely on the scienti�c method to study, describe, explain, predict, and treat disorders. The scienti�c method has three basic steps: generating a hypothesis, develop- ing a research design, and analyzing and interpreting data to test the hypothesis. We present �rst the most powerful scienti�c method: the experiment.

Experiment An experiment is a research design that allows us to draw cause-and-effect conclusions about particular variables or events. Researchers generally follow a speci�c path to draw such conclusions, beginning with a hypothesis.

Hypothesis A hypothesis is a statement about the cause of an event or about the relationship between two events. We might hypothesize that treatment A is more effective than treatment B for depression. Hypotheses are educated guesses based on previous studies but must be testable and refutable. This means hypotheses must contain constructs that can be measured or observed so others can try to replicate the study. Recall from Chapter 2 that one crit- icism of the psychodynamic perspective was that its constructs could not be measured or observed. Constructs such as id and unconscious cannot be directly or accurately measured, and so a cause–effect relationship between these constructs and behavior cannot be established.

and 50 people with depression to the control group (0 mg/day) for our experiment. Some control groups in an experiment such as this one receive a placebo or a substance or treatment that has no actual therapeutic effect. In this example, control group participants could receive a pill with no active treatment ingredient. Experimenters use placebos to control for bias or the possibility that a person receiving a medication will show im- proved symptoms simply because he expects to improve. Some experiments also use double-blind designs, meaning that nei- ther the experimenter nor the participants know who received a placebo or an active treatment. In this case, perhaps only an independent pharmacist knows who received a placebo or active treatment. Triple-blind designs are experiments in which participants, experimenters, independent raters of outcome, and even data managers are unaware of who received a placebo or active treatment. Blinded designs are meant to control for as much bias from different people as possible.

In our experiment, we will then monitor our participants over several weeks by examining their scores on a depression measure and tracking the number of hours they sleep during the day. We may �nd after 3 months that people in experimental group 1 experienced a substantial drop in depression, people in experimental group 2 experienced a slight drop in depression, and people in the control group experienced no change in depres- sion. This is done by analyzing and interpreting data, the third step in the scienti�c method. We could then conclude our hy- pothesis was correct: treatment A (60 mg/day) was indeed more effective than treatment B (20 mg/day). We could also conclude treatment is better than no treatment under these conditions.

Results such as these are a powerful testament to the causal role of treatment for reducing symptoms of depression. The groups were similar at the beginning of the experiment with re- spect to depression. The only difference between the groups was level of medication given. Differences in depression at the con- clusion of the experiment can thus be attributed con�dently to

the manipulation differences between the groups—those receiv- ing higher amounts of antidepressant medication experienced greater improvement.

Results such as these can be contaminated by variables other than the independent variable, however. If differences existed between the experimental and control groups, then we would have trouble concluding our treatment was effective. Imagine if the experimental group was mostly male African Americans and the control group was mostly female European Americans. How con�dent could we be in our results? Factors such as this affect the external validity of a study, or the extent to which results can be generalized to the whole population.

If the experimental group experienced something other than the manipulation, or treatment, then our conclusions would also be affected. Imagine if some members of the experimen- tal group were attending therapy sessions in addition to their medication but members of the control group were not. How con�dent could we then be that medication was the major cause of improved symptoms? Factors such as this can decrease the internal validity of an experiment, or the extent to which a researcher can be con�dent that changes in the dependent vari- able (depression symptoms) truly resulted from manipulation of the independent variable (medication).

The experiment remains the best strategy for testing hypotheses about mental disorder. Unfortunately, researchers are not able to use this strategy as much as they would like. Experiments are costly in time and resources and require many people to study. Experiments are sometimes criticized for being unethical as well. Making people wait in the control group for medication that could help their depression sooner might raise some questions. If we wanted to study the effects of alcohol use on women and their unborn children, we would not want to de- liberately introduce alcohol consumption to their diets. Because experiments can be costly and dif�cult to conduct, researchers often use correlational studies.

problems. Diverse ethnic groups are also subject to different types and degrees of environmental stressors, and these differences may in�uence mental health as well. Conclusions about psychological problems and their treatment in male European Americans may not be valid for women or people of color.

These concerns have heightened clinical psychologists’ awareness of these issues, and more formal requirements for studies supported by the U.S. government are now in place. The National Institutes of Health (NIH) has a policy about including women and members of minority groups in studies of human participants. These groups must be repre- sented in NIH-supported projects unless some clear and compelling ra- tionale exists for not doing so. Researchers must also provide a detailed and speci�c plan for the outreach and recruitment of women and minor- ity subjects in their study. Researchers can thus address whether general conclusions for men or European Americans also hold for women and diverse groups.

Focus On

Much concern has been expressed over the relative lack of women and diverse participants in mental health research. Some feel that many stud- ies use samples composed predominantly of male European Americans. This is a problem because results about causes and treatment of mental disorders in male European Americans may not generalize to others. Im- portant biological differences exist between men and women (like hor- mones) that may affect the development and expression of psychological

Law and Ethics Who Should Be Studied in Mental Health Research?

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CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders94

Correlational Studies A correlation is an association or relationship between two vari- ables. Correlational studies allow researchers to make state- ments about the association or relationship between variables based on the extent to which they change together in a predict- able way. A dependent variable and an independent variable may be related to each other such that high scores on one are associated with high scores on the other and vice versa. You would expect number of hours spent studying for an abnormal psychology test to be associated with higher grades. Height and weight in people are also closely associated. These examples indicate positive correlations where two variables are highly related to one another—as one goes up, the other does as well.

Dependent and independent variables may also be re- lated to each other such that low scores on one are associated with high scores on the other and vice versa. You might expect greater dosage of medication to be related to lower scores on a depression measure. This would indicate a negative correlation in which two variables are also highly related to one another— as one goes up, the other goes down.

Correlations or associations between two variables are rep- resented by a correlation coef�cient, which is a number from �1.00 to �1.00. The sign of the coef�cient, � or �, refers to type of association between variables. A positive sign indicates a positive correlation, and a negative sign indicates a negative cor- relation. The absolute value of the correlation coef�cient, how absolute value of the correlation coef�cient, how absolute value high the number is regardless of its sign, refers to the strength of the association between the two variables.

The closer a correlation is to �1.00 or �1.00, the stron- ger the association. A correlation coef�cient of exactly �1.00 or �1.00 means two variables are perfectly related: As one vari- able changes, the other variable always changes as well. Know- ing someone’s score on the independent variable thus allows us to predict a person’s score on the dependent variable with 100 percent accuracy. A correlation coef�cient of 0.00 means no re- lationship exists between the two variables: Knowing someone’s score on the independent variable allows no prediction about a score on the dependent variable.

Correlations of �1.00 or �1.00 are rare. Correlation coef- �cients of �0.50 to �0.99 or �0.50 to �0.99 re�ect strong asso- ciation between two variables. Correlation coef�cients of �0.30 to �0.49 or –0.30 to –0.49 re�ect moderate association between two variables. Correlation coef�cients of �0.01 to �0.29 or �0.01 to �0.29 re�ect weak association between two variables. Examples of correlation coef�cients are in Figure 4.8.

A correlation between two variables does not mean one variable causes another. Correlation does not imply causation. A problem with correlational methods is that we cannot rule out other explanations for the relationship between two variables because correlation does not control for the in�uence of third variables. This is the third variable problem. One of your authors lives in Las Vegas and has seen a strong correlation between number of churches built and number of violent crimes. The more churches built in Las Vegas, the more crime such as mur- der, rape, and robbery! Can we conclude church-building caused

more violent crime? Of course not. A third variable explains this third variable explains this third variable effect: massive population growth. More people are moving to Las Vegas, so more churches and greater prevalence of crime are to be expected.

Another problem with correlation methods is directional- ity. We know a correlation exists between marital �ghting and adolescent delinquency. This effect might at �rst seem easy to explain—parents who �ght a lot increase family stress, model violence as a way to solve problems, and fail to supervise their children. But the opposite direction is also possible: Some chil- dren get into trouble in their teenage years and cause their par- ents to �ght about how best to handle this situation. We may have a strong correlation, but we cannot know for sure which variable is the cause and which is the effect. We would have to conduct an experiment to know for sure.

Quasi-Experimental Methods An alternative approach to experiments and correlations is quasi-experimental methods or mixed designs. Mixed designs do not randomly assign people to experimental and control groups like a true experiment does. An experimenter instead examines groups that already exist. People already diagnosed with depression might be compared with people without depres- sion. We could compare these groups along different variables such as family history of depression and stressful life events. We could even examine subgroups within the depressed group to see what medications they are taking and whether any effects can be seen. We could also calculate correlations between level of depression and many other variables such as age, income level, and family size.

Quasi-experiments involve no randomization, so research- ers who use quasi-experiments must minimize confounds in their investigation. Confounds are factors that may account for group differences on a dependent variable. If we examine people with and without depression regarding stressful life events, then we should beware of these other factors. People with depression may have more stressful life events than people without depres- sion, but people with depression may simply be more likely to remember stressful life events than people without depression. remember stressful life events than people without depression. remember Confounds such as this impact the internal validity of results.

Researchers often try to match people in their groups on many variables to guard against these kinds of problems. They may try to ensure their groups are similar with respect to gender, age, race, income level, and symptoms of a speci�c disorder such as depression. Unfortunately, researchers cannot identify every variable necessary to match groups and protect internal validity. Experimental and control groups may still differ along important dimensions even after matching.

Other Alternative Experimental Designs Other designs also serve as alternatives to a large-scale true experiment. A natural experiment is an observational study in which nature itself helps assign groups. Recall John Snow from Chapter 3 who found that some residents getting sick

from tainted drinking water were accessing a particular pump, whereas other residents not getting sick were accessing a dif- ferent pump. The “natural” independent variable in this case was the source of drinking water. Natural experiments also com- monly occur following disasters such as tsunamis or hurricanes. One group of researchers studied different communities affected by the Gulf of Mexico Deepwater Horizon Oil Spill. One com- munity was indirectly affected, whereas another community was directly exposed to coastal oil. The researchers found that people with spill-related income loss had signi�cantly greater anxiety and depression than those with more stable incomes (Morris, Grattan, Mayer, & Blackburn, 2013). Such a study could not be “created” without the tragedy that took place.

Another alternative experimental design is an analogue experiment that involves simulating a real-life situation under

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FIGURE 4.8 SCATTERPLOTS SHOWING DIFFERENT STRENGTHS AND SIGNS OF CORRELATIONS. (Top left) Perfect positive correlation; (top right) moderate negative correlation; (bottom) no correlation. From Timothy Trull, Clinical Psychology (7th ed.), Fig. 4.2, p. 94. Copyright © 2005 Wadsworth, a part of Cengage Learning. Reproduced with permission. www.cengage.com/permissions

controlled conditions. Often this simulation is done because re- creating certain events or conditions is not ethical. Morina and colleagues (2013) were interested in examining trauma-related imagery and memories, but obviously subjecting their research participants to an actual trauma was out of the question. In- stead, the researchers conducted an analogue experiment in which participants watched a distressing video and then were monitored afterward. The study provided valuable information about different kinds of coping strategies that might be relevant to posttraumatic stress disorder (Chapter 5).

Researchers also use single-subject experimental designs that involve one person or a small group of persons who are examined under certain conditions. Single-subject designs still have experimental and control conditions to observe and measure behavior but do so in innovative ways. One type of

CHAPTER 4 Diagnosis, Assessment, and Study of Mental Disorders96

single-subject experimental design is an ABAB or reversal design. In this case, “A” may represent a control condition, and “B” may represent a treatment condition. If a research participant consis- tently bene�ts from the “B” condition but not the “A” condition, then we have some evidence that a treatment is working. Such a design is sometimes used for unusual behaviors where obtaining large groups would be dif�cult. Reversal designs are commonly used to examine treatments of such behaviors in persons with severe developmental disorders (Wine, Freeman, & King, 2015).

Developmental Designs Researchers also use developmental designs to examine new par- ticipants or already-existing groups to see how a certain problem or mental disorder unfolds over time. Developmental designs consist of longitudinal, cross-sectional, and sequential stud- ies. Longitudinal studies involve examining the same group of people over a long period of time. Researchers sometimes fol- low youth whose parents had schizophrenia during childhood and adolescence to see what risk factors eventually lead to the mental disorder.

Longitudinal studies are important for examining behavior change and development, but you can see that a major draw- back is the time needed to complete the study. Some longitudi- nal studies last 20 years or more. Longitudinal studies also run the risk of attrition, which means some participants will drop out of the study over time or can no longer be contacted by the researcher. If 100 children begin a study but only 15 are left at the end of adolescence, how useful would the results be?

An alternative approach to longitudinal studies is a cross- sectional study, which involves examining different groups of people at one point in time. If a researcher were interested in ex- amining children of parents of schizophrenia, then she might �nd children at different ages—say, 2, 7, 12, and 17 years—and study them right now. Cross-sectional studies are highly useful but suf- fer from cohort effects. This means children at different ages are being raised in different eras, which may affect their functioning. Think about the fast-paced changes in technology that occur in our society today. A 2-year-old child will likely have access to different kinds of experiences than a 17-year-old did. These dif- ferences will be re�ected in their behavior to some extent.

Some researchers thus blend aspects of longitudinal and cross-sectional studies into a sequential design. A sequential design begins as a cross-sectional study, but the groups are ex- amined over a short time frame. From the example above, 2-, 7-, 12-, and 17-year-old children whose parents had schizophrenia may be examined now and over a 5-year period. Cross-sectional and longitudinal changes can thus be examined.

Case Study The research designs discussed so far are useful but not always practical. A researcher using the case study method makes careful observations of one person over time. The researcher may describe in great detail types of symptoms, assessment, and treatment relevant to that case. Substantial data are made available about one person, but no experimental manipulation

occurs and no internal validity is present. We also cannot gen- eralize results from one person to the overall population, so no external validity is present.

Case studies are useful for several reasons, especially for describing rare phenomena. People with multiple personalities, for example, are too few to allow for a large experiment. Or a person may have an unusual presentation of symptoms and family background. Case studies are also useful for testing new treatments on a few people to judge their effect and safety. Data from these “pilot studies” can then be used to justify further studies with more people.

You can see researchers use many methods to study mental disorders and that each method has its advantages and limita- tions. Information derived from each of these methods is pre- sented throughout this textbook. We thus encourage you to keep in mind each method’s strengths and weaknesses.

Consuming the Media’s Research You can see that many types of research can be conducted, and some types (e.g., experiments) allow for stronger con- clusions than others (e.g., case studies). This is important to remember when reading a media report about a research �nding regarding a mental disorder. Media outlets often focus on sensa- tional aspects of a research study, especially differences found between men and women. When you read these reports, pay close attention to the study that is cited and whether the study is an experiment or something less rigorous. Take the extra step of reading the original research paper to get a sense of what the researchers truly found and what drawbacks exist for the study. Don’t just fall for the headline—be a wise consumer of media reports on psychological research.

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Final Comments You can see that mental health professionals take seriously the precise de�nition, classi�cation, assess- ment, and study of psychological problems. This is done to better understand, treat, and prevent mental disorders. If we have a well-de�ned mental disorder that can be more easily assessed, we can actively work to identify risk factors for the disorder that allow for early detection and prevention of symp- toms. We have now reached the point in the book where we begin to describe major mental disorders at length. Each of the following chapters cover important information about features, epidemiology (including diversity), stigma, risk factors, prevention, assessment, and treatment of these disorders. Keep in mind that the behaviors we describe can be seen along a continuum or spectrum. We all have many aspects of these problems to some extent at some point in our lives. We begin by discussing some of the most common forms of mental disorder, the anxiety, obsessive-compulsive, and trauma-related disorders.

Key Terms dimensions 74 categories 74 diagnosis 75 mental disorder 75 syndrome 75 classi�cation 76 clinical assessment 76 reliability 77 test–retest reliability 77 interrater reliability 78 internal consistency reliability 78 validity 78 content validity 78 predictive validity 78 concurrent validity 78 construct validity 79 standardization 79 unstructured interviews 80 structured interviews 80 intelligence tests 80 personality assessment 81 objective personality measures 81 MMPI-2 validity scales 82 MMPI-2 clinical scales 82

projective tests 84 behavioral assessment 85 functional analysis 85 antecedents 85 consequences 85 organismic variables 85 naturalistic observation 85 controlled observation 86 self-monitoring 86 computerized axial tomography

(CT scan) 87 magnetic resonance imaging (MRI) 87 functional MRI (fMRI) 87 positron emission tomography

(PET scan) 87 neurochemical assessment 87 metabolites 87 psychophysiological assessment 88 electrocardiogram 88 galvanic skin conductance 88 electroencephalogram 89 neuropsychological assessment 89 scienti�c method 92 experiment 92

hypothesis 92 dependent variables 92 independent variable 92 randomization 92 experimental group 92 control group 92 placebo 93 double-blind design 93 triple-blind design 93 external validity 93 internal validity 93 correlational studies 94 positive correlations 94 negative correlation 94 quasi-experimental methods 94 confounds 94 natural experiment 94 analogue experiment 95 single-subject experimental design 95 longitudinal studies 96 cross-sectional study 96 sequential design 96 case study method 96

Special Features

CONTINUUM FIGURE 5.1 Worry, Anxiety, and Fear Along a Continuum 102

CONTINUUM FIGURE 5.2 Continuum of Emotions, Cognitions, and Behaviors Regarding Anxiety-Related Disorders 102

• 5.1 FOCUS ON COLLEGE STUDENTS: Trauma and PTSD 116

• 5.2 FOCUS ON GENDER: Are There True Gender Differences in Anxiety-Related Disorders? 116

• 5.3 FOCUS ON DIVERSITY: Anxiety-Related Disorders and Sociocultural Factors 117

V THE CONTINUUM VIDEO PROJECT Darwin / PTSD 125

Personal Narrative 5.1 Anonymous 128–129

• 5.4 FOCUS ON LAW AND ETHICS: The Ethics of Encouragement in Exposure-Based Practices 138

C Angelina / What Do You Think?

Worry, Anxiety, Fear, and Anxiety; Obsessive-Compulsive; and Trauma-Related Disorders: What Are They?

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology

C Jonathan

C Marcus

Stigma Associated with Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Anxiety, Obsessive-Compulsive, and Trauma-Trauma-T Related Disorders 5

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders100

C / A/ A/ ngelina

Angelina was 25 years old when she was referred to a specialized outpatient clinic for people with anxiety-related disorders. She came to the clinic after a scary episode in which she nearly had a car accident. Angelina said she was driving across a high bridge when she suddenly felt her heart start to race, her breath become short, and her vision become blurry. These feelings were so intense she thought she might wreck the car and hurt herself or others. She was able to pull the car off to the shoulder of the bridge as she strug- gled with her symptoms. The symptoms seemed to ease a bit after a few minutes. Angelina then waited another 20 minutes, still shaken from the experience, before driving straight home to where she felt safe.

The therapist who spoke to Angelina asked if such an episode had happened before. Angelina said the experience had occurred several times, usually when she was driving or surrounded by many people. Angelina gener- ally felt she could handle her symptoms during these episodes. This last episode, though, and two more that followed, were much more intense than what she had felt before. She recently saw an emergency room doctor and a car- diologist to determine any potential medical causes for her symptoms, but none were found. Angelina was then referred for outpatient psy- chological treatment.

The therapist asked more about Angelina’s history with these symptoms. Angelina said she had always been “the nervous and worried type” and that her anxiety worsened as she attended college. She had particular trouble driving to school and walking into class where other people were sitting and possibly looking at her. Angelina usually sat in the back of the class in case she had to exit quickly to calm her- self. The therapist asked Angelina if she worried

something bad might happen. Angelina said she was most concerned about the professor look- ing at her or being asked a question for which she did not have an answer. She was also con- cerned other people would notice her physical symptoms of anxiety.

Angelina’s nervousness escalated a year earlier when she began to experience speci�c episodes of intense anxiety. Angelina said her �rst “anxiety attack” happened as she walked into class to take a midterm examination. Her heart began racing, and she was short of breath. When the professor handed her the test, she was shaking and having much trouble concentrating. Angelina said she felt she “wasn’t even there” and that “everything was moving in slow motion.” Worse, she felt she could not concentrate well enough to take the test. She did complete the test, however, and received a “B-minus” (she was normally an “A/B” student). Other “anxiety attacks” after that point tended to occur when she was going to school or about to enter a classroom. These attacks happened about once a week but not typically on weekends or when she was not in school.

Over the past few months, Angelina’s “attacks” became more frequent and affected other, similar situations. Angelina would some- times have trouble driving to a local mall and shopping among hundreds of people. She

was also reluctant to date because she might “seize up” and look foolish. Her greater con- cern, however, was that she might have to drop out of college even though she was near graduation. This belief arose from the fact that on her way to her �rst day of class, Angelina had driven across the bridge that led to her worst anxiety attack. The two other attacks that followed also caused her to miss so many classes, she felt she had to drop all of them. Angelina was thus sad and tearful, feeling she would not be able to return to college and �nish her degree.

Angelina now spent her days at home, and her mother had driven her to the therapist’s of�ce. She had trouble going to the supermar- ket or restaurants and preferred to avoid them altogether. Even speaking to the therapist now led Angelina to report an anxiety rating of 8 on a 0 to 10 scale. The therapist asked her what she would like to see different in her life, and Angelina said she wanted to be like her old self—someone who went to school, saw her friends, dated, and enjoyed life. The therapist asked her if she could commit to a full-scale assessment and treatment program, and Angelina agreed to do so.

What Do You Think? 1. Which of Angelina’s symptoms seem

typical of someone in college, and which seem very different?

2. What external events and internal factors might be responsible for Angelina’s feelings?

3. What are you curious about regarding Angelina?

4. Does Angelina remind you in any way of yourself or someone you know? How so?

5. How might Angelina’s anxiety affect her life in the future?

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Worry, Anxiety, Fear, and Anxiety; Obsessive-Compulsive; and Trauma-Related Disorders: What Are They? 101

Worry, Anxiety, Fear, and Anxiety; Obsessive-Compulsive; and Trauma- Related Disorders: What Are They?

Have you ever been concerned that something bad will hap-pen? Have you ever been nervous about an upcoming event? Have you ever been afraid of something, like Angelina was? Some people worry a lot about what could happen in the future. Other people become nervous or anxious at the thought of going on a date, speaking in public, or taking a test. For oth- ers, the sight of a snake or an airplane causes intense and im- mediate fear. For people like Angelina, worry, anxiety, and fear can spiral into an uncontrollable state that makes them want to avoid many things such as school. But what are worry, anxiety, and fear, and what are the differences among them?

Worry is a largely cognitive or “thinking” concept that re- fers to concerns about possible future threat. People who worry tend to think about the future and about what painful things might happen. A person might worry about failing to pay bills on time or a future terrorist attack. Worry is not necessarily a bad thing because it helps people prepare for future events and solve problems (Deschênes, Dugas, & Gouin, 2016). If you have a test next week and have not prepared for it, you may feel a

sense of dread and develop a study schedule to prevent failure. Worry is thus normal and even adaptive. Worry is often a grad- ual process that starts slowly for a distant event (oh, yeah, that test is coming) but becomes more intense as the event draws closer (uh-oh, better get studying). If the event draws closer and seems even more threatening, as when a test draws nearer and one is still not prepared, then anxiety may occur.

Anxiety is an emotional state that occurs as a threaten- ing event draws close. Worry is more cognitive in nature, but anxiety has three key parts: physical feelings, thoughts, and be- haviors. Physical feelings may include heart racing, sweating, dry mouth, shaking, dizziness, and other unpleasant symptoms. Thoughts may include beliefs that one will be harmed or will lose control of a situation. Behaviors may include avoiding cer- tain situations or constantly asking others if everything will be OK (Davies, Niles, Pittig, Arch, & Craske, 2015; Sharp, Miller, & Heller, 2015). If you have a test tomorrow, and have not studied, then you may feel muscle tension (physical feeling), believe you will not do well (thought), and skip the test (behavior). Anxiety, like worry, is a normal human emotion that tells us something is wrong or needs to change.

The three parts of anxiety often occur in a sequence. Think about a blind date. You might feel physically nervous as you are about to meet the other person for the �rst time—perhaps you will sweat, tremble a bit, or feel your heart race. You may then start to think the other person will notice your symptoms and that you will look foolish and be judged negatively. You may also be apprehensive about awkward pauses in the conversa- tion or what the other person will say or look like. You may even decide to shorten the date or cancel it because of these feelings and beliefs. Many people with anxiety have a combina- tion of troublesome physical feelings, thoughts, and behaviors. Think about Angelina—what were her major physical feelings, thoughts, and behaviors?

Fear is an intense emotional state that occurs as a threat is imminent or actually occurring. Fear is a speci�c reaction that speci�c reaction that speci�c is clear and immediate: fright, increased arousal, and an over- whelming urge to get away (Beckers, Krypotos, Boddez, Effting, & Kindt, 2013). A fear reaction is usually toward something well de�ned. If you take a quiz you have not studied for, you may experience se- vere physical arousal and dread and leave the situation quickly. Many people are afraid of snakes. If some- one places a cobra nearby, you may immediately become frightful and physically aroused, and run away as quickly as possible. Fear is an ancient human feeling that tells us we are in danger and that we may have to �ght whatever

Anxiety involves a sense of apprehension that something bad might happen.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders102

is before us or �ee the situation as quickly as possible (�ght or �ight). Fear is thus normal and protects us from potential harm, like when we jump away from a snake. Fear that is intense and severe is panic.

Differences among worry, anxiety, and fear can be illus- trated along a continuum or dimension (see Figure 5.1). Worry occurs in reaction to potential threat, anxiety occurs in reaction to approaching threat, and fear occurs in reaction to approaching threat, and fear occurs in reaction to approaching imminent threat. Worry is a largely cognitive concept that involves fewer physical feelings and less avoidance than anxiety or fear. A per- son may experience more physical feelings (arousal) and greater desire to avoid or escape, however, as a threatening event such

as a test comes closer in time and distance. Worry also tends to be a general and slow reaction that is cautionary, whereas moderate anxiety or apprehensiveness is more speci�c and often spurs a person into action (start studying!). Fear involves an im- mediate and focused reaction so a person can confront or �ee a certain situation.

Worry, anxiety, and fear can also be viewed along a dimen- sion of severity. Worry, anxiety, and fear are normal human emotions, so all of us experience them to some extent. We worry about the safety of our children, become anxious when about to perform or interview before others, and are frightened when airplanes experience severe turbulence. These experiences are a common part of life, and many people learn to cope with them successfully. Many people go on blind dates even when ner- vous, and they eventually relax and have a good time. Worry, anxiety, or fear may become more intense, however, to the point where a person �nds it dif�cult to concentrate, �nish a task, or relax (see Figure 5.2).

Worry, anxiety, and fear may even become severe and cresevere and cresevere - ate enormous trouble for a person—this could be an anxiety, obsessive-compulsive, or trauma-related disorder (we sometimes obsessive-compulsive, or trauma-related disorder (we sometimes obsessive-compulsive, or trauma-related disorder refer to these collectively as anxiety-related disorders in this chapter). People like Angelina with these kind of disorders have persistent episodes of severe worry, anxiety, or fear that keep them from doing things they would normally like to do, such as shop, drive, attend school, or get a new job (Figure 5.2). An anxiety-related disorder can be less severe, as when a person worries so much about getting into a car accident that driving is dif�cult. Or an anxiety-related disorder can be more severe, as when a person is so fearful of germs that she never leaves the house. People with anxiety-related disorders generally experi- ence worry, anxiety, or fear that is severe, that lasts for long pe- riods of time, and that interferes with daily living. We next cover

5.1 Worry, Anxiety, and Fear Along a Continuum

WORRY ANXIETY FEAR

Potential threat Approaching threat Imminent threat Potential threat Approaching threat Imminent threat Potential threat Approaching threat Imminent threat

Little arousal (physical feelings) (physical feelings)

Moderate arousal Severe arousal Moderate arousal Severe arousal Moderate arousal Severe arousal Moderate arousal Severe arousal

Heavily cognitive Moderately cognitive Scarcely cognitive Heavily cognitive Moderately cognitive Scarcely cognitive Heavily cognitive Moderately cognitive Scarcely cognitive

Little avoidance Moderate avoidance Severe avoidance Little avoidance Moderate avoidance Severe avoidance Little avoidance Moderate avoidance Severe avoidance Little avoidance Moderate avoidance Severe avoidance

General and slow reaction (caution)

More focused and quicker reaction (apprehensiveness)

Very focused and fast Very focused and fast reaction (�ght or �ight)

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5.2 Continuum of Emotions, Cognitions, and Behaviors Regarding Anxiety-Related Disorders

NORMAL MILD

Emotions Slight physical arousal but good alertness. Mild physical arousal, perhaps feeling a bit tingly, but with Mild physical arousal, perhaps feeling a bit tingly, but with good alertness.

Cognitions “I’m going on a job interview today. I hope they like me. I’m “I’m going on a job interview today. I hope they like me. I’m going to show them what I’ve got!”

“I’m going on a job interview today. I wonder if they will think “I’m going on a job interview today. I wonder if they will think badly of me. I hope my voice doesn’t shake.” badly of me. I hope my voice doesn’t shake.”

Behaviors Going to the job interview and performing well. Going to the job interview and performing well. Going to the job interview but �dgeting a bit. Going to the job interview but �dgeting a bit.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

CONTINUUM FIGURE

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 103

the major anxiety-related disorders that cause many people like Angelina so much distress.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology

The following sections summarize the major features and characteristics of the most commonly diagnosed anxiety- related disorders. Many of the disorders in this chapter have anxiety as a key component and were historically studied as one diagnostic group. In the �fth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the disorders were separated into smaller diagnostic groups labeled anxiety, obsessive-compulsive, and trauma- and stressor-related disorders (we shorten this latter label in this chapter). We �rst discuss the concept of a panic attack, which serves as a key part of several anxiety-related disorders.

Panic Attack Have you ever felt scared for no reason? Perhaps you were just sitting or standing and suddenly felt intense fear out of the blue. If so, you may have experienced a panic attack similar to the ones Angelina reported. A panic attack involves a period of time, usually several minutes, in which a person experiences intense feelings of fear, apprehension that something terrible will happen, and physical symptoms. A panic attack is not a diagnosis but an event that commonly occurs in people with anxiety disorders. Features of a panic attack are listed in Table 5.1 (APA, 2013).

MODERATE

ANXIETY-RELATED DISORDER—LESS ANXIETY-RELATED DISORDER—LESS

SEVERE

ANXIETY-RELATED DISORDER—MORE ANXIETY-RELATED DISORDER—MORE

SEVERE

Moderate physical arousal, including shaking Moderate physical arousal, including shaking and trembling, with a little more dif�culty and trembling, with a little more dif�culty concentrating.

Intense physical arousal, including shaking, Intense physical arousal, including shaking, dizziness, and restlessness, with trouble dizziness, and restlessness, with trouble concentrating.

Extreme physical arousal with dizziness, heart Extreme physical arousal with dizziness, heart palpitations, shaking, and sweating with great palpitations, shaking, and sweating with great trouble concentrating.trouble concentrating.

“Wow, I feel so nervous about “Wow, I feel so nervous about the interview today. I bet I the interview today. I bet I don’t get the job. I wonder if I should just forget about it?”

“Oh, no that interview is today. I feel sick. I just don’t “Oh, no that interview is today. I feel sick. I just don’t think I can do this. They will think I’m an idiot!”think I can do this. They will think I’m an idiot!”

“No way can I do this. I‘m a total loser. I can’t get “No way can I do this. I‘m a total loser. I can’t get that job. Why even bother? I don’t want to look that job. Why even bother? I don’t want to look foolish!”foolish!”

Drafting two e-mails to cancel the interview but not sending them. Going to the interview but appearing physically nervous.

Postponing the interview twice before �nally going. Postponing the interview twice before �nally going. Appearing quite agitated during the interview and Appearing quite agitated during the interview and unable to maintain eye contact.unable to maintain eye contact.

Canceling the interview and staying home all day. Canceling the interview and staying home all day.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders104

Common physical symptoms include accelerated heart rate, shortness of breath, chest pain or discomfort, dizziness, and feel- ings of choking. People having a panic attack also often worry about dying, going “crazy,” or losing control and doing some- thing terrible. Angelina’s panic attack in her car led her to think she might crash. Panic attacks may also involve feelings that sur- rounding events are not real (derealization) or that a person is watching himself go through the situation (depersonalization). Recall Angelina’s feeling of detachment when taking her test.

Panic attacks that occur out of the blue, or without warning or predictability, are unexpected panic attacks. This can make panic attacks pretty scary. Some people even have panic attacks during sleep (Boland & Ross, 2015). Over time, a person with panic attacks may be able to predict when these attacks are more likely to occur. Angelina said her panic attacks tended to occur when she was driving or among crowds. An expected panic at- tack has a speci�c trigger; for example, a person may experience severe panic symptoms when speaking in public. Panic attacks

thus involve many troubling physical symptoms and thoughts, two components of anxiety described earlier.

Panic Disorder People who regularly experience unexpected panic attacks have panic disorder, a diagnosis involving the DSM-5 criteria in Table 5.2 (APA, 2013). At least one of these attacks must be followed by a month or more of concern about having an- other attack, worry about what the panic attack might mean, or a change in behavior. Angelina did indeed worry about hav- ing more attacks and wondered if she might have to drop out of school because of her attacks. Her driving behavior also changed drastically. Panic attacks and panic disorder must not be a result of substance use or a medical condition. Panic disorder is different from other anxiety disorders (see following sections) in which panic attacks are more closely linked to spe- ci�c (or expected) situations such as public speaking.

TABLE 5.2 DSM-5

Panic Disorder A. Recurrent unexpected panic attacks. A panic attack is an abrupt

surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings or choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization

(being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying.

Note: Culture-speci�c symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences.

2. A signi�cant maladaptive change in behavior related to the attacks.

C. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

D. The disturbance is not better explained by another mental disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 5.1 DSM-5

Panic Attack Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, post- traumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identi�ed, it should be noted as a speci�er (e.g., “posttraumatic stress disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a speci�er.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being

detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying.

Note: Culture speci�c symptoms should not count as one of the four required symptoms.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 105

Panic disorder is a frightening condition for several reasons. First, a person often has little idea when a panic attack might happen. Panic attacks can occur frequently during the day or be spaced out across several days. Imagine going places and always wondering if a panic attack might strike. Second, panic attacks are not harmful, but many people with panic disorder become terri�ed of their own internal sensations of dizziness, heart pal- pitations, or other panic attack symptoms. Some people with panic disorder may believe their symptoms indicate something serious such as a terminal heart condition or illness. People with panic disorder thus fear the onset of more panic attacks.

People with panic disorder, like Angelina or Professor Smith from Chapter 4, might avoid situations in which they may have panic symptoms. Some people with panic disorder may thus be diagnosed with agoraphobia. Agoraphobia refers to anxiety about being in places where panic symptoms may occur, espe- cially places where escape might be dif�cult. Agoraphobia also refers to avoiding those places or enduring them with great anxiavoiding those places or enduring them with great anxiavoiding - ety or dread (see Table 5.3; APA, 2013). About half of those with panic disorder develop agoraphobia, though agoraphobia appears more common among people with severe or chronic panic disor- der (Greene & Eaton, 2016; Nay, Brown, & Roberson-Nay, 2013).

Recall that behavioral avoidance is a main component of anxiety. Angelina did not want to go to a restaurant because she might have a panic attack and look foolish. Many people with panic disorder stay close to exits or avoid potentially embarrass- ing situations. Some also develop agoraphobia so severe they cannot leave home. This can obviously lead to severe marital, occupational, academic, and other problems. Angelina was cer- tainly on that path.

Social Phobia Do you feel nervous when doing something in front of others? Do you cringe when asked to speak in public or meet someone for the �rst time? Many people feel nervous in these situations, which is normal. We are concerned about what other people think of us and what the consequences might be if they respond negatively to us. Most of us, however, can control or disregard our anxiety in these situations and function well. For other peo- ple, social anxiety is a crippling phenomenon that makes casual conversations or other interactions extremely dif�cult.

Social phobia, also called social anxiety disorder, is marked by intense and ongoing fear of potentially embarrassing social or performance situations. A diagnosis of social phobia involves the DSM-5 criteria in Table 5.4 (APA, 2013). Social situations include interactions with others, such as dating, having con- versations, or attending parties. Performance situations include some evaluation from others, such as taking a test, giving an oral presentation, or playing a musical instrument at a recital. People with social phobia are extremely fearful they will act in a way that causes great personal embarrassment or humiliation in these situations.

People with social phobia may have expected panic attacks in social and performance settings and avoid these settings. Or they endure the settings with great anxiety or dread. Angelina

had trouble dating, answering questions in class, and shopping and eating in front of others. These are all situations where she could be negatively evaluated. Social avoidance can obviously interfere with one’s ability to live a normal life. People with social phobia �nd it dif�cult to attend school, take high-pro�le jobs, and make and keep friends.

Many people with social phobia believe they will do some- thing “dumb” or “crazy” to make them appear foolish before others. They may fear stuttering, fainting, freezing, or shaking around other people. They know their fear is excessive and un- reasonable, but they still have trouble doing what they must, such as chatting during a job interview (Morrison & Heimberg, 2013).

TABLE 5.3 DSM-5

Agoraphobia A. Marked fear or anxiety about two (or more) of the following �ve

situations:

1. Using public transportation. 2. Being in open spaces. 3. Being in enclosed places. 4. Standing in line or being in a crowd. 5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might be dif�cult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the pres- ence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition is present, the fear, anxiety, or avoid- ance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symp- toms of another mental disorder—for example, the symptoms are not con�ned to speci�c phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclu- sively to obsessions (as in obsessive-compulsive disorder), perceived defects or �aws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear or separation (as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders106

People with social phobia may even have trouble with simple things like using a debit card in a store, using a public restroom, or getting together with friends at a mall. If someone with social phobia fears only speaking or performing in public, then the dis- order is speci�ed as performance only.

Speci�c Phobia We mentioned that most people are leery of snakes, so this kind of fear is normal. For other people, though, fear is so strong and pervasive that it interferes with daily functioning. Think about a fear of snakes so strong a person cannot walk in his yard or go to the park. Such is the case for some people with speci�c phobia.

A speci�c phobia is an excessive, unreasonable fear of a particular object or situation. A diagnosis of speci�c phobia involves the DSM-5 criteria in Table 5.5 (APA, 2013). People with speci�c phobia may have expected panic attacks when they

encounter a dog, airplane, clown, or whatever they fear. Speci�c phobias are arranged into �ve types:

• Animal phobias involve fears of—you guessed it, animals— especially dogs, rodents, insects, and snakes or other reptiles.

• Natural environment phobias involve fears of surrounding phenomena such as heights, water, and weather events such as thunderstorms.

• Blood-injection-injury phobias involve fears of needles, medical procedures, and harm to self.

• Situational phobias involve fears of speci�c areas such as enclosed spaces in airplanes and elevators.

• Other phobias involve any other intense fear of a specif- ic object. Examples include more common ones such as iophobia (fear of poison) but also unusual ones such as iophobia (fear of poison) but also unusual ones such as iophobia levophobia (fear of things to one’s left), levophobia (fear of things to one’s left), levophobia arachibutyrophobia (fear of peanut butter sticking to the roof of the mouth), and hippopotomonstrosesquippedaliophobia (you guessed hippopotomonstrosesquippedaliophobia (you guessed hippopotomonstrosesquippedaliophobia it—fear of long words).

Generalized Anxiety Disorder Do you ever get concerned about many things, large and small? If you do, welcome to the human race, especially if you are a student. Many people worry about what could happen, espe- cially in this day and age with threats everywhere. We seem to read every day about terrible events such as terrorist attacks and devastating weather. Knowing about these things and wonder- ing if they might happen to us naturally makes us uptight and worried. Such worry is normal.

TABLE 5.4 DSM-5

Social Anxiety Disorder (Social Phobia)

TABLE 5.5 DSM-5

Speci�c Phobia A. Marked fear or anxiety about one or more social situations in which

the individual is exposed to possible scrutiny by others.

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symp- toms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition is present, the fear, anxiety, or avoid- ance is clearly unrelated or is excessive.

A. Marked fear or anxiety about a speci�c object or situation.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the speci�c object or situation and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety, or avoidance causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 107

We mentioned that worry is an adaptive phenomenon that helps us prepare for and solve problems. Worry is also some- thing most of us can control and put aside when we have to concentrate. Many people can put aside their worries about the upcoming weekend as they prepare a Wednesday dinner. Worry is thus usually normal and controllable. For other people, though, worry is so strong and persistent it interferes with their ability to work, make decisions, and relax.

Generalized anxiety disorder involves extreme levels of Generalized anxiety disorder involves extreme levels of Generalized anxiety disorder worry about various events or activities. A diagnosis of gener- alized anxiety disorder involves the DSM-5 criteria in DSM-5 criteria in DSM-5 Table 5.6 (APA, 2013). People with generalized anxiety disorder have trou- ble controlling their worry and thus often have trouble concentrat- ing, sleeping, or resting. Those with generalized anxiety disorder often worry excessively about minor things such as paying bills or picking up their children on time. Such worry is not in proportion to actual risk or problems. Many people worry about paying bills when their homes are near foreclosure, but people with gener- alized anxiety disorder might worry about paying bills when no �nancial problems exist. Other common worries of those with generalized anxiety disorder include health issues, chores, being on time, work-related tasks, and competence in different activities.

You may have noticed from Table 5.6 that people with generalized anxiety disorder do not usually experience panic attacks but rather have muscle tension or trouble sleeping and

concentrating. Generalized anxiety disorder and worry are largely cognitive concepts, so physical and behavioral symp- toms are less prominent than what is seen in panic disorder and social and speci�c phobias. People with generalized anxi- ety disorder do not focus on internal symptoms of panic but more on potential external threats (Chen et al., 2013). They also believe these threats to be dangerous or full of dire con- sequences. One might worry excessively that not paying a bill 15 days early will result in a damaged credit rating and inability to buy a new car.

The key aspect of generalized anxiety disorder, worry, is re- ported by many people to be a lifelong problem. Generalized anxiety disorder is often the �rst of several anxiety and other mental disorders a person may have (Newman, Llera, Erickson, Przeworski, & Castonguay, 2013). Recall Angelina said she was always the “nervous and worried type.” Generalized anxiety dis- order that develops early in life is not associated with a speci�c life event, or trigger, but later-onset generalized anxiety disor- der often is related to a particular stressor such as bankruptcy. Generalized anxiety disorder is perhaps the least reliably diag- nosed of the major anxiety disorders. Uncontrollable and exces- sive worry, muscle tension, and scanning the environment for threats, however, are key symptoms that separate generalized anxiety disorder from other anxiety disorders (Prater, Hosanagar, Klumpp, Angstadt, & Phan, 2013; Rutter & Brown, 2015).

TABLE 5.6 DSM-5

Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occur-

ring more days than not for at least 6 months, about a number of events or activities.

B. The individual �nds it dif�cult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Dif�culty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance.

D. The anxiety, worry, or physical symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.Many people are afraid of spiders, but a phobia of spiders, known as

arachnophobia, involves a more intense and irrational fear.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders108

Obsessive-Compulsive Disorder Many of us have little rituals or habits, or compulsions, we do every day to keep order or check on things, but not to the ex- tent Jonathan does. Keeping things in place has its advantages in a competitive workplace or if you want to �nd something at home. Checking the windows and doors at night before go- ing to bed can also protect against disaster. For other people, rituals or compulsions are associated with painful thoughts, or obsessions, and become overly time-consuming, distressing, and destructive. Obsessions can also come in the form of con- stant ideas, impulses, or even images.

Obsessive-compulsive disorder involves (1) obsessions, or troublesome thoughts, impulses, or images, and/or (2) compul- sions, or ritualistic acts done repeatedly to reduce anxiety from the obsessions. A diagnosis of obsessive-compulsive disorder in- volves the DSM-5 criteria in Table 5.7 (APA, 2013). Obsessions occur spontaneously, frequently, and intrusively, meaning they are unwanted by the person but uncontrollable. Obsessions may also be quite strange—one might have images or thoughts of massive bacteria on doorknobs or coins. This is a contamina- tion obsession. Other common obsessions include the following:

• Doubt, such as concern about leaving the front door open • Need for order, such as need to have shoes organized by size

and type or food organized by expiration date

• Impulses toward aggression, such as intolerable thoughts about harming an infant

• Sexual imagery, such as recurrent mental pictures of pornography Compulsions are motor behaviors or mental acts performed

in response to an obsession. Someone who obsesses about the front door being open will keep checking the door to make sure it is closed and locked. This may continue so many times in

a row that the person misses school or work that day. Com- pulsions other than checking include hand washing, ordering, counting, silently repeating words or phrases, and seeking reas- surance from others. Hand washing usually occurs in response to a contamination obsession—a person may obsess about mas- sive bacteria on her hand and then wash vigorously and often to compensate. Obsessions and compulsions occur nearly every day and interfere with a person’s ability to concentrate or work.

Compulsions may take place at least 1 hour per day, but often last much longer. Counting your change when you get home from school might be normal, but counting the change so many times you take hours doing so might indicate obsessive-compulsive dis- order. Many people with little rituals are not disturbed by their be- havior, but people with obsessive-compulsive disorder �nd their obsessions and compulsions to be extremely distressing.

Obsessive-Compulsive-Related Disorders DSM-5 includes disorders that are related to obsessive-compulsive disorder. Hoarding disorder refers to people who have persistent Hoarding disorder refers to people who have persistent Hoarding disorder

case Jonathan was a 33-year-old man in therapy for behaviors that recently cost him his job and that were threatening his marriage. Jonathan said he had overwhelming urges to check things to see if they were in place and to order things if they were not. Jonathan said he would go to work and spend the �rst 3 hours organizing his desk, of�ce, e-mail messages, and computer �les. He would also check other of�ces to see if things were grossly out of place, such as plants, wastebaskets, and keyboards. He did this so often his coworkers complained that Jonathan spent more time with them than in his own of�ce. Jonathan did get some work done, but he usually could not concentrate for more than 3 hours per day. He was �red for his lack of productivity.

Jonathan said he often had troubling thoughts about things being out of order. He told his therapist he worried that disorganization would lead him to forget important pieces of information such as what bills needed to be paid and what reports were due. He spent so much time organizing items at work and home, however, that he could accomplish little else. His wife recently threatened to leave if Jonathan did not seek professional help. Jonathan also said he felt depressed and wished he “could think like a normal person.”

C / Jonathan TABLE 5.7 DSM-5

Obsessive-Compulsive Disorder A. Presence of obsessions, compulsions, or both:

Obsessions are de�ned by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are de�ned by (1) and (2):

1. Repetitive behaviors (e.g., hand washing) or mental acts (e.g., repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming or cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 109

dif�culty parting with possessions, who feel they need to save items, and who experience cluttered living areas. Other related disorders include people who continually pull out their own hair (trichotillomania) or pick their skin (excoriation disorder).excoriation disorder).excoriation disorder

Another disorder in this section, body dysmorphic dis- order, was once grouped with somatic symptom disorders (Chapter 6) but is now thought to be more closely related to obsessive-compulsive behavior. A diagnosis of body dysmorphic disorder involves the DSM-5 criteria in Table 5.8 (APA, 2013). People with body dysmorphic disorder are preoccupied with an imaginary or slight “defect” in their appearance. Many people with this disorder worry excessively about minor alterations in facial features, hair, wrinkles, skin spots, and size of body parts like noses or ears. Many of us are concerned with our appearance, but people with body dysmorphic disorder are so preoccupied they may spend hours per day checking and grooming themselves or they may visit cosmetic surgeons and undergo several surgeries to correct imagined or minor �aws (Phillips, 2015). People with body dysmorphic disorder may be unable to date or work because of deep embarrassment about some perceived body �aw.

Body dysmorphic disorder has some similarities to koro, a syndrome among people in West Africa and Southeast Asia who fear that external genitalia and body parts such as nipples or

breasts will shrink into one’s body and cause death (Promodu, Nair, & Pushparajan, 2012). The disorder may also be similar to shubo-kyofu, a phobia among some Japanese who fear a deformed face or body (Hofmann & Hinton, 2014).

Posttraumatic Stress Disorder and Acute Stress Disorder The disorders discussed so far are often linked to regularly occur- ring events like public speaking. Other disorders—posttraumatic stress and acute stress disorder—follow a speci�c traumatic event. DSM-5 lists these as trauma- and stressor-related disorders.

TABLE 5.8 DSM-5

Body Dysmorphic Disorder A. Preoccupation with one or more perceived defects or �aws in physi-

cal appearance that are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

C. The preoccupation causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Many people with obsessive-compulsive disorder will perform certain rituals more often than usual, such as this woman, who trims her grass with a pair of scissors several hours every day.

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case Marcus was a 27-year-old man in therapy for symptoms following a trau- matic event. Marcus was about to enter a shopping mall at night two months ago when two men threatened him with a gun and demanded his wallet. Marcus was initially shocked the event was occurring and thus hesitated, which prompted one of the men to strike him in the face. Marcus then gave his wallet to the men, who �ed. A shaken Marcus called police to report the incident and was taken to the hospital for treatment. The two assailants had not yet been caught at the time of Marcus’s therapy.

Marcus said he had been having trouble sleeping at home and concentrat- ing at work. The latter was especially problematic because he was an accoun- tant. He also felt he was living his life in a “slow motion fog” and that people seemed very distant from him. He increasingly spent time at home and avoided major shopping areas and large parking lots, especially at night. Marcus also feared the gunmen would �nd and rob him again because they had his driv- er’s license. Most distressing, however, were Marcus’s recurring images of the event; he said, “I just can’t get the whole scene out of my mind.” He thus tried to block thoughts about the trauma as much as possible, with little success.

C / Marcus

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders110

Have you ever been in a situation where you felt terri�ed, helpless, or extremely vulnerable? Some people experience traumatic events in their life, events so disturbing they produce changes in behavior and personality. Think about people victim- ized by the 9/11 terrorist attacks, Hurricane Katrina, the tsunami in Japan, recent earthquakes, or soldiers who faced constant danger in Iraq or Afghanistan. Some people can eventually deal with these stressors as they fade in memory over time. Other people like Marcus, however, �nd recovery from trauma to be a long and painful process.

Posttraumatic stress disorder is marked by frequent re- experiencing of a traumatic event through images, memories, nightmares, �ashbacks, or other ways. A diagnosis of post- traumatic stress disorder (PTSD) involves the DSM-5 criteria in Table 5.9 (APA, 2013). Marcus’s images of his trauma con- stantly entered his mind. He also became upset at reminders of the trauma, such as walking through a large parking lot at

People react in the aftermath of the Paris attacks. Trauma from events such as terrorism can cause posttraumatic stress disorder in some people.

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TABLE 5.9 DSM-5

Posttraumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family

member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., �rst responders collecting human remains;

police of�cers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., �ashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-speci�c reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing

memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 111

TABLE 5.9 DSM-5

Posttraumatic Stress Disorder—cont’d 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,”

“The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or

others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in signi�cant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., dif�culty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:Specify whether:Specify

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental Depersonalization: processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization:Derealization:D Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, erealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, erealization: dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic events(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.

Note: Witnessing does not include events that are witnesses only in electronic media, television, movies, or pictures.

3. Learning that the traumatic event(s) occurred to a parent or caregiving �gure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

3. Dissociative reactions (e.g., �ashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-speci�c reenactment may occur in play.

continued

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders112

TABLE 5.9 DSM-5

Posttraumatic Stress Disorder—cont’d C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s), or negative altera-

tions in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 4. Markedly diminished interest or participation in signi�cant activities, including constriction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).

2. Hypervigilance. 3. Exaggerated startle response. 4. Problems with concentration. 5. Sleep disturbance (e.g., dif�culty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically signi�cant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

Specify whether:Specify whether:Specify

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences per- sistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental Depersonalization: processes or body (e.g., feeling as though one were in dream; feeling a sense of unreality of self or body or of time moving slowly).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects or a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

night, and avoided many discussions of the event. People with posttraumatic stress disorder may also feel detached from oth- ers, have fewer positive emotional responses than before the event, and expect additional harm or negative consequences. A person may believe others will not want to socialize with her because of the trauma. The person may also experience substantial physical arousal and have problems sleeping, con- centrating, or completing everyday tasks.

Symptoms of posttraumatic stress disorder must last at least 1 month for a diagnosis to be made. Some symptoms of posttrau- matic stress disorder are delayed more than 6 months from time of trauma, and this refers to delayed expression. Most symptoms

of posttraumatic stress disorder, however, develop within 3 to 6 months of the trauma (Santiago et al., 2013). DSM-5 also lists separate criteria for PTSD in children younger than age 7 years (Table 5.9). Young children with PTSD may display reexperienc- ing symptoms through play, for example.

What about people with problems immediately after the trauma? Acute stress disorder refers to distressing memories and dreams, negative mood, dissociation (feelings of detach- ment from reality or disconnectedness from others), avoid- ance, and arousal that last between 3 days and 1 month after the trauma. A diagnosis of acute stress disorder involves the DSM-5 criteria in Table 5.10 (APA, 2013). People with acute

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 113

TABLE 5.10 DSM-5

Acute Stress Disorder A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) or the following ways:

1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the event(s) occurred to a close family member or close friend. Note: In case of actual or threatened death of a family member

or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., �rst responders collecting human remains,

police of�cers repeatedly exposed to details of child abuse).

Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of nine (or more) of the following symptoms from any of the �ve categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.

4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood

5. Persistent inability to experience positive emotions.

Dissociative Symptoms

6. An altered sense of the reality of one’s surroundings or oneself. 7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as

head injury, alcohol, or drugs).

Avoidance Symptoms

8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts,

or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

10. Sleep disturbance. 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or

objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

D. The disturbance causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by brief psychotic disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders114

Many children thus have trouble going to school for rea- sons other than separation anxiety. Many teenagers occasion- ally “skip” classes to have fun, but they eventually graduate. Ongoing or chronic absences, however, can lead to long-term problems such as delinquency, school dropout, and occupa- tional and marital problems in adulthood (Kearney, 2016). Youth who refuse school for a combination of the reasons listed above may also be at particular risk for school failure or dropout.

Epidemiology of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders Anxiety-related disorders are commonly found in the general population, affecting 28.8 percent of Americans at some point in their lives and 18.1 percent in the past 12 months. Lifetime and 12-month prevalence rates for the major anxiety-related dis- orders are outlined in Figure 5.3. Social phobia and speci�c phobia are especially common, affecting about 1 in 8 people.

stress disorder may eventually be diagnosed with posttraumatic stress disorder if symptoms continue longer than 1 month. Acute stress disorder is a good predictor of posttraumatic stress disorder (Bryant et al., 2015).

What traumas might lead to acute stress disorder or post- traumatic stress disorder? Key traumas include assault, rape, war, severe physical or sexual maltreatment, natural disasters such as tornados or �oods, robbery, home invasion, or wit- nessing horrifying events. More common events such as a car accident, learning of a trauma to a close friend or relative, or experiences of �rst responders (e.g., police, �re personnel) can also result in either disorder. Not everyone who experiences a traumatic event necessarily develops acute stress disorder or posttraumatic stress disorder, however (Lawrence-Wood, Van Hooff, Baur, & McFarlane, 2016).

Separation Anxiety Disorder and School Refusal Behavior Some anxiety-related disorders are more common in youth. Many young children experience anxiety that is normal for their age. One of the author’s children, when she was 2 years old, commonly got upset when Dad dropped her off at preschool in the morning—that’s normal. Some toddlers also need their parents close to them when it is time for sleep at night. Some children, however, fear separation so much they refuse to attend school or sleep over at a friend’s house. This behavior can be quite disruptive for some families, especially if parents are late for work, con�ict occurs, or no one can sleep.

Separation anxiety disorder is marked by substantial dis- tress when separation from a major attachment �gure occurs or is expected to occur. This distress must last at least 4 weeks in children, so initial distress about going to school is excluded. The separation anxiety must also be developmentally inappropriate. This means a child is at an age, perhaps in elementary school, where separation should not be a problem but is. A diagnosis of separation anxiety disorder involves the DSM-5 criteria in Table 5.11 (APA, 2013). A child with separation anxiety disorder will often have trouble going to school or sleeping alone, throw a tantrum when a parent wants to go someplace without him, and have physical complaints such as a stomachache when away from a parent.

One symptom of separation anxiety disorder is “persistent reluctance to go to school,” but school refusal behavior can also be due to other reasons. Kearney (2016) outlined four major reasons why children refuse school:

• To avoid something related to school that causes great distress, such as a teacher, bus, bully, or going from class to class

• To escape uncomfortable social and/or performance situa- tions such as conversations, performances, or tests

• To spend time with, or get attention from, parents • To get tangible rewards outside of school, such as time with

friends, television, or sleeping late

TABLE 5.11 DSM-5

Separation Anxiety Disorder A. Developmentally inappropriate and excessive fear or anxiety

concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment �gures.

2. Persistent and excessive worry about losing major attachment �gures or about possible harm to them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost) that causes separation from a major attachment �gure.

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major attachment �gures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment �gure.

7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms when separation

from major attachment �gures occurs or is anticipated.

B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

C. The disturbance causes clinically signi�cant distress or impairment in social, academic, occupational, or other important areas of functioning.

D. The disturbance is not better explained by another mental disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Features and Epidemiology 115

adulthood, however, as these disorders become more common, females show greater prevalence than males. Anxiety-related disorders generally begin at age 19 to 31 years, although some- what earlier for social phobia (median age of onset, 13 years) and separation anxiety disorder (median age of onset, 7 years; Kessler, Berglund, et al., 2005; Silove et al., 2015).

Few racial differences have been found with respect to anxiety-related disorders within the United States. One study, however, indicated a slightly greater risk for anxiety-related dis- orders among European Americans than African Americans or Hispanics (Kessler, Berglund, et al., 2005). In addition, African Americans may have a higher rate of PTSD than other ethnic groups (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011).

Anxiety-related disorders are generally more common in Euro/Anglo cultures (10.4 percent) than in African cultures (5.3 percent; Baxter, Scott, Vos, & Whiteford, 2013). People of one culture, however, may fear certain stimuli more so than peo- ple of another culture because of environmental experiences. A person living in a dense forest, for example, may be more afraid of animals than a person living in a large urban setting (see also

Anxiety is even more problematic when you consider other facts. First, many people experience symptoms of anxiety- related disorders that do not necessarily rise to the level of a formal diagnosis. Many people also have persistent and debili- tating worry that may not rise to the level of generalized anxiety disorder (Kanuri, Taylor, Cohen, & Newman, 2015). In addition, many people, including college students, experience a traumatic life event and may display various symptoms as a result (see Box 5.1). Second, many people delay seeking treatment for an anxiety-related disorder. Most people with panic disorder expe- rience full-blown symptoms in their early to mid-20s, as Ange- lina did, but they may delay psychological treatment because they visit medical doctors �rst to rule out physical conditions (Lessard et al., 2012). Many people with social or performance anxiety are also generally shy and may not believe their condi- tion to be serious (Henderson, Gilbert, & Zimbardo, 2014).

Strong fears of speci�c items are common in the gen- eral population, especially fears of snakes and other animals, heights, �ying in airplanes, enclosed spaces, illness or injury, blood, water, death, bad weather, medical procedures, and be- ing alone (Shearer, Harmon, Younger, & Brown, 2013). Recall that Angelina was afraid around crowds. Many people say they have had such fears all their life, but most do not seek treatment until the fear keeps them from doing something important like going to work (Iza et al., 2013).

Anxiety-related disorders in general tend to be more com- mon among females than males (Stein & Vythilingum, 2015). Several reasons that may account for this difference are outlined in Box 5.2. Anxiety-related disorders tend to be fairly equal among young boys and girls. During adolescence and early

Many children have separation anxiety when they are younger, but some continue to have the problem even during school-age years.

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FIGURE 5.3 LIFETIME AND 12-MONTH PREVALENCE RATES FOR THE ANXIETY-RELATED DISORDERS. Adapted from Kessler, Chiu, Demler, & Walters (2005) and Kessler, Berglund, et al. (2005).

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6.8 3.5

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1.6 1.0

1.4 0.8

Panic disorderPanic disorder

AgoraphobiaAgoraphobia without panicwithout panic

Social anxietySocial anxiety disorderdisorder

Specific phobiaSpecific phobia

GeneralizedGeneralized anxietyanxiety

disorderdisorder Obsessive-Obsessive- compulsivecompulsive

disorderdisorder

PosttraumaticPosttraumatic stress disorderstress disorder

SeparationSeparation anxietyanxiety

disorderdisorder

0 50 5 10 15 20 25 3010 15 20 25 30

Lifetime prevalence rate

12-month prevalence rate

Prevalence rate

Note: These numbers reflect the fact that some people have moNote: These numbers reflect the fact that some people have moNote: re than one anxiety-related disorder. ©

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders116

• Dhat: anxiety about loss of semen (India, Sri Lanka, China) • Pa-leng: intense fear of cold that may lead to wearing layers

of clothes even in hot weather (Asia)

• Ataques de nervios: a panic-like condition of uncontrol- lable episodes of shouting, crying, and trembling as well as feelings of heat rising to the head and aggression (Puerto Rico)

• Latah: an exaggerated startle response mixed with shouting obscenities (Malaysia)

the later section on cultural factors). The nature of how anxiety- related disorders are expressed can also differ from culture to culture. The following are examples of anxiety-related disorders across the globe (see also Box 5.3):

• Koro: intense fear of one’s penis or nipples retracting into the body or shrinking in size (South and East Asia)

• Taijin kyofusho: intense fear of offending other people, per- haps through one’s own body odor, inept conversation, or physical abnormality (Japan)

of a loved one (34 percent), accident/natural disaster (26 percent), physical violence (24 percent), sexual assault (7 percent), and combat (1 percent). Traumas were more common for female students and, to a lesser extent, members of ethnic minorities. Such traumas can lead to substantial risk for excessive alcohol and other drug use, depression, and withdrawal from college, among other problems.

Read and colleagues (2012) stated that because many incoming fresh- man experience psychological problems related to trauma, university out- reach efforts should involve several components. First, incoming students should be educated about the substantial prevalence of existing traumas and the concept of PTSD. Second, campus resources that are available to assist students with these problems should be widely publicized. Third, information about trauma types and number of traumas experienced should be collected anonymously by university counseling centers, in part to help identify stu- dents who may be at most risk for PTSD. Finally, treatments for trauma and PTSD among college students should be developed with an eye toward the special academic and other challenges that many of these students face.

Focus On

Trauma and trauma-related disorders may be particularly common among Trauma and trauma-related disorders may be particularly common among college students. Read and colleagues (2011) asked incoming college students to complete items from a widely used trauma questionnaire to assess how many had experienced trauma and how many were currently experiencing symptoms related to posttraumatic stress disorder (PTSD). Two-thirds (66 percent) reported a traumatic life event, and 25 percent reported three or more events; 9 percent met criteria for PTSD. Most com- mon traumas were life-threatening illness (35 percent), sudden death

5.1

College Students Trauma and PTSD

two-thirds of women suffer physical or sexual violence in their lifetime (Breiding, 2014). Women are more likely to be raped or sexually assaulted and may thus be predisposed to develop acute or posttraumatic stress, agoraphobia, or other anxiety-related disorders.

Women also tend to ruminate in a brooding and worrisome way more than men, but men are more likely to engage in anger rumination more than women (Johnson & Whisman, 2013; Nolen-Hoeksema, 2012). Women report more social and work-related fears than men, but men report more fears of dating than women (Xu et al., 2012). Women also have more cleaning and contamination obsessions, but men have more sexual and symmetry-related obsessions (Hallion, Sockol, & Wilhelm, 2015). Therapist bias may also be a contributing factor. Therapists may be more likely to assign an anxiety-related diagnosis to a female based on misguided expec- tations or assumptions about that gender (Ali, Caplan, & Fagnant, 2010). Controversy about a true gender difference in anxiety-related disorder is not likely to end anytime soon because many plausible explanations are supported by research.

Focus On

Females have more anxiety-related disorders than males. This is often re- ported, but is it actually true, and why? Are women just more nervous than men? Or are women more likely to report anxiety and more willing to seek therapy than men, who may prefer to keep their anxiety private or self- medicate their anxiety using alcohol or other drugs? These are common explanations for the gender difference in anxiety-related disorders.

A closer look at this gender difference reveals more intricate explana- tions. Women experience more physical and sexual trauma than men; almost

Gender Are There True Gender Differences

in Anxiety-Related Disorders?

5.2

Stigma Associated with Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders 117

Stigma Associated with Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Recall from Chapter 1 that an important aspect of this text-book is addressing stigma, which refers to characterizing others with disgrace or reproach based on an individual char- acteristic. People with anxiety-related disorders may feel stigma or negative judgment when nervously speaking before others or when having trouble boarding an airplane. Researchers have also found that people sometimes have negative attitudes to- ward those with generalized anxiety disorder. One survey re- vealed that a substantial percentage of people felt that those with generalized anxiety disorder were unstable (16.7 percent), that generalized anxiety disorder was not a real mental disor- der (13.0 percent), that people with an anxiety-related disorder were not suitable employees (7.8 percent) or were self-centered (6.4 percent), and that anxiety-related disorder was a sign of personal weakness (6.0 percent). Others endorsed the belief that people with an anxiety-related disorder were lazy, shame- ful, dangerous, or to blame for their problems (Grif�ths, Batterham, Barney, & Parsons, 2011). Teenagers of parents with obsessive-compulsive disorder also worry about what others might think of their parent’s condition and feel stigmatized as a result (Grif�ths, Norris, Stallard, & Matthews, 2011).

People with an anxiety-related disorder who feel stigma- tized may be less likely to admit a problem or to seek treatment. This may be especially evident in military personnel who have returned from Iraq and Afghanistan and who often have PTSD and related disorders. Unfortunately, military personnel often avoid treatment for PTSD because of self-stigma (Mittal et al.,

Anxiety-related disorders are highly comorbid, or associ- ated with, other mental disorders. People with one anxiety- related disorder often have another anxiety-related disorder. Recall that generalized anxiety disorder often leads to other anxiety-related disorders and is commonly associated with social phobia (Newman et al., 2013). Anxiety-related disor- ders and depression are also commonly seen in the same in- dividual because the disorders share many features such as irritability, restlessness, and withdrawal. Combined anxiety and depression is sometimes referred to as negative affectivity (Cummings, Caporino, & Kendall, 2014). People with anxiety- related disorders are also at particular risk for suicide (Bentley et al., 2016).

Anxiety-related disorders and substance use disorder may be comorbid as well because some people who are anxious self- medicate or ease their symptoms by using alcohol or other drugs (Grant et al., 2015). Anxiety-related disorders and substance use may also share common genetic and other causal factors, however, and a direct relationship between the two problems is likely in�uenced by factors such as gender or depression (Lai, Cleary, Sitharthan, & Hunt, 2015).

Anxiety-related disorders are also associated with eating disorders and avoidant, obsessive-compulsive, and dependent personality disorders (Chapters 8 and 10; Friborg, Martinussen, Kaiser, Overgard, & Rosenvinge, 2013; Swinbourne et al., 2012). As mentioned, obsessive-compulsive disorder is sometimes as- sociated with hoarding and with trichotillomania, or a compul- sion to pull out one’s hair, eyelashes, eyebrows, and other body hair (Abramowitz & Jacoby, 2015). Separation anxiety disorder can be associated with other conditions such as panic, gener- alized anxiety, and obsessive-compulsive disorders (Bogels, Knappe, & Clark, 2013).

Recall that koro represents an intense fear of one’s penis or nipples koro represents an intense fear of one’s penis or nipples koro shrinking into one’s body. One sociocultural factor that may in�uence this phenomenon is strong religious or Taoist beliefs about the need for sexual restraint and the harm that frequent semen ejaculation can bring. Because semen is seen as a source of energy or strength, any perceived threat to this, such as genital shrinkage, may provoke anxiety. Such beliefs may also affect dhat, or fear of loss of semen (Aneja et al., 2015).

Taijin kyofusho represents a fear of offending others, which is a bit differTaijin kyofusho represents a fear of offending others, which is a bit differTaijin kyofusho - ent from the Western form of social anxiety in which a person fears looking foolish before others. Taijin kyofusho may be heavily in�uenced by Japanese Taijin kyofusho may be heavily in�uenced by Japanese Taijin kyofusho emphases on the importance of appropriately presenting oneself to others and concern for others’ well-being (Vriends, P�altz, Novianti, & Hadiyono, 2013). Many cultures, including Hispanic ones, also place great emphasis on physical symptoms to express distress or anxiety. Such a phenomenon may help to explain the concept of ataques de nervios, a panic-like state that partially involves anguish and loss of sensation (Felix, You, & Canino, 2015).

Focus On

The anxiety-related disorders described in this chapter are those listed in the DSM, a manual written largely by American psychiatrists. Anxiety- related disorders are experienced differently across cultures, however, and sociocultural factors certainly in�uence why some people experience different kinds of anxiety symptoms. Some examples are described here. One thing that does not change across cultures, though, is the amount of distress these problems bring to people’s lives.

Diversity Anxiety-Related Disorders and Sociocultural Factors

5.3

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders118

2. Identify different kinds of panic attacks and the main fea- tures of panic disorder.

3. Describe anxiety-related disorders that involve severe social anxiety, fear of a speci�c object, worry, bizarre ideas and behaviors, and symptoms following a trauma.

4. Which anxiety-related disorder applies mostly to children, and what troublesome behavior is sometimes associated with it?

5. Describe the epidemiology of anxiety-related disorders, including issues of gender and culture.

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention

We have now covered the major features and epidemiology of anxiety-related disorders, so we turn our attention next to factors that cause the disorders. We also discuss how know- ing about these factors might help us prevent anxiety-related disorders.

Biological Risk Factors for Anxiety, Obsessive- Compulsive, and Trauma-Related Disorders Why do people have such intense physical feelings, strange thoughts, and urges to avoid situations? Recall from Chapter 3 that mental disorders are often viewed from a diathesis-stress model, which attributes causes to a combination of biologi- cal and environmental variables. Many people are born with a genetic or biological predisposition toward certain personality characteristics and mental conditions. These biological predis- positions are sometimes strong and sometimes weak, but they are almost always in�uenced or triggered to some degree by life events. So when talking about risk factors that may lead to anxiety-related disorders, we must consider biological predis- positions and environmental events. Biological predispositions in people with anxiety-related disorders may include genetics, brain features, neurochemical features, behavioral inhibition, and evolutionary in�uences.

Genetics Genetic researchers often rely on family studies, in which a cer- tain disorder is examined in people and their close relatives. If many more close, or �rst-degree, relatives have the disorder com- pared with the general population, the disorder is said to “run in the family” and perhaps have a genetic basis. First-degree relatives include parents, siblings, and children. Researchers also conduct twin studies, in which identical twins and noniden- tical, or fraternal, twins are compared. Identical (monozygotic) twins share much more genetic material with each other than fraternal/nonidentical (dizygotic) twins. Family and twin stud- ies are often used to determine heritability rates (Chapter 2).

Anxiety-related disorders do have some moderate genetic basis. First-degree relatives of people with panic disorder are panic disorder are panic disorder

2013). Greden and colleagues (2010) tried to address this issue by training “soldier peers” who encourage military personnel to enter treatment and then monitor adherence to treatment. A key aspect of this program is to convey the idea that seeking treatment is a sign of strength and to remove military cultural barriers such as stigma that prevent seeking treatment.

➲ Interim Summary • Anxiety is composed of three parts: physical feelings,

thoughts, and behaviors.

• Anxiety-related disorders often involve excessive worry, anxiety, or fear.

• Panic attacks involve (1) intense physical feelings such as heart racing, sweating, and dizziness and (2) thoughts that one will lose control, go crazy, or die. Panic attacks may be expected or unexpected.

• Panic disorder refers to regular unexpected panic attacks and worry about the consequences of these attacks.

• People with panic disorder may also have agoraphobia, or avoidance of situations in which a panic attack might occur.

• Social phobia refers to intense and ongoing fear of po- tentially embarrassing situations in the form of expected panic attacks.

• Speci�c phobia refers to excessive, unreasonable fear of an object or situation.

• Generalized anxiety disorder refers to extreme levels of persistent, uncontrollable worry.

• Obsessive-compulsive disorder refers to the presence of obsessions, or troublesome and recurring thoughts, and compulsions, or physical or mental acts performed in response to an obsession to lessen distress.

• Posttraumatic stress disorder refers to constant reexperi- encing of a traumatic event through images, memories, nightmares, �ashbacks, or other ways.

• Acute stress disorder refers to short-term anxiety and dissociative symptoms following a trauma.

• Separation anxiety disorder refers to children with exces- sive worry about being away from home or from close family members. The disorder may be associated with school refusal behavior.

• Anxiety-related disorders are common to the general population and especially females. Many anxiety-related disorders develop in later adolescence and early adulthood. Anxiety-related disorders are often associated with other anxiety-related disorders, depression, and substance use.

• People with anxiety-related disorders may feel stigma from others and thus may be less likely to seek treatment.

➲ Review Questions 1. How do Angelina’s symptoms differ from normal worry, anxi-

ety, or fear?

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention 119

other major mental disorders such as schizophrenia, however (Chapter 12). No single gene or set of genes leads directly to an anxiety-related disorder. Genetics may instead help produce brain or neurochemical features or temperaments that help lead to an anxiety-related disorder or otherwise interact with envi- ronmental events to predispose the person to development of an anxiety-related disorder. We next discuss some potential brain features that are associated with anxiety-related disorders.

Brain Features Recall from Chapter 2 that several areas of the brain are impor- tant for certain kinds of normal and abnormal behavior. Particu- larly important brain areas for increased physical arousal and anxiety-related disorders include the amygdala and the septal- hippocampal system (Desmedt, Marighetto, Richter-Levin, & Calandreau, 2015; see Figure 5.4). The amygdala is a brain area amygdala is a brain area amygdala long associated with fearful responses. The amygdala can be activated by a scary face or an imminent threat such as a nearby

3 to 17 times more likely than control participants to have panic disorder (Perez, Otowa, Roberson-Nay, & Hettema, 2013). The heritability of panic disorder has been reported to be 0.55 (Kendler et al., 2011). Studies also reveal social phobia to be more common in close family relatives compared with controls (Shimada-Sugimoto, Otowa, & Hettema, 2015). The heritability of social phobia has been reported to be 0.57 (Kendler et al., 2011). Generalized anxiety disorder also seems to run in fami- lies, especially for those with comorbid depression (Newman et al., 2013). The heritability of generalized anxiety disorder has been reported to be 0.51 (Kendler et al., 2011).

Speci�c phobia also seems to run in families: 31 percent of �rst-degree relatives of people with phobia report having a pho- bia themselves, compared with 9 percent of control participants (Perez et al., 2013). The heritability of speci�c phobia has been reported to be 0.55 (Kendler et al., 2011). Family members often share the same type of phobia as well. A family member with an animal or blood-injection-injury phobia may be more likely than controls to have relatives with that phobia type (Van Houtem et al., 2013). Family data indicate obsessive- compulsive disorder to be more com- mon among �rst-degree relatives of people with the disorder (8.2 percent) compared with control participants (2.0 percent). Children with obses- sive-compulsive disorder are also more likely than control participants to have parents with the disorder (Lebowitz, Scharfstein, & Jones, 2014; Perez et al., 2013). Twin data also in- dicate moderately higher concordance for obsessive-compulsive disorder among identical than fraternal twins. The heritability of obsessive-com- pulsive symptoms has been reported to be 0.52 (Mataix-Cols et al., 2013). Genetic in�uences for symptoms of posttraumatic stress disorder appear to be modest but higher for people like Marcus exposed to assault or com- bat compared with people exposed to nonassault trauma such as car acci- dents or natural disasters. The herita- bility of posttraumatic stress disorder has been reported to be 0.46 (Sartor et al., 2012; Wolf, Mitchell, Koenen, & Miller, 2014).

What can thus be said about these different genetic studies? Anxiety- related disorders do tend to run in families, and some people appear to be more genetically predisposed toward certain anxiety-related disorders. The contribution of genetics to the cause of anxiety-related disorders is less than

Prefrontal cortex

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Bed nucleusBed nucleus of stria

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Locus coeruleus

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders120

nucleus, anterior cingulate, and thalamus (Ahmari & Simpson, 2013). People with this disorder may experience increased or decreased volume (size) or activity in these areas. Such changes may result in intrusive thoughts, repetitive motor behaviors, de- pression, and disruptions in information processing (Piras et al., 2015). Panic attacks and disorder have been speci�cally linked to changes in the locus coeruleus, which is a main norepineph- rine center in the brain (see next section; Geiger, Neufang, Stein, & Domschke, 2014). These brain areas interact with various neu- rotransmitters, which are discussed next.

Neurochemical Features Recall from Chapter 2 that neurotransmitters affect a person’s mood and behavior, so it may come as little surprise that people with anxiety-related disorders have signi�cant neurochemical changes. Neurotransmitters most closely linked to anxiety-related disorders include serotonin, norepinephrine, and gamma-aminobutyric acid (GABA; Gelfuso et al., 2013). Changes in these neurotransmitter and related systems, as with the brain features just discussed, may be partly the result of genetic in�uences.

Serotonin is closely related to mood and motor behav- ior. Changes in serotonin have been found in people with many anxiety-related disorders, especially panic, obsessive- compulsive, and generalized anxiety disorders (see Figure 5.6). Serotonin receptors may be particularly sensitive in people with these disorders, creating hyperactivity in different parts of the brain. Medications effective for people with anxiety-related dis- orders often help normalize serotonin activity in the brain to produce calm (Baldinger et al., 2015). Serotonin is also related to depression (Chapter 7), so changes in this neurotransmitter may help explain the high comorbidity between anxiety and depression.

snake, and helps produce physical symptoms such as fast heart rate and sweating and emotional states of anxious apprehension and fear (see Figure 5.5; Gar�nkel et al., 2014). This helps a person cope with threat.

Key changes in the amygdala might be related to overarousal and excessive startle responses in people with different anxiety- related disorders (Rajbhandari, Baldo, & Bakshi, 2015). Such changes may thus be closely associated with speci�c or social phobia. People with obsessive-compulsive disorder or posttrau- matic stress disorder also show signi�cant activity in the amyg- dala when exposed to reminders of their trauma or other anxiety- provoking stimuli (Brunetti et al., 2015; Ducharme, Dougherty, & Drevets, 2016). Changes in the amygdala may be in�uenced by certain genes but more research in this area is needed.

Connections from the amygdala to other key areas of the brain seem even more pertinent to anxiety-related disorders. One such area is the septal-hippocampal system, which may help a person respond to threats and remember and learn about highly anxiety-provoking situations (Grupe & Nitschke, 2013). Unfortunately, this area may remain activated even when no threat exists, so a person with an anxiety-related disorder could be worried or anxious or fearful of something not threatening or, as with Marcus, could continue to vividly remember aspects of trauma. This area may be particularly affected by antianxiety drugs (John, Kiss, Lever, & Erdi, 2014). The amygdala and the septal-hippocampal system connect as well to the prefrontal cor-prefrontal cor-prefrontal cor tex and bed nucleus of the stria terminalis, brain structures also heavily involved in behavioral and emotional aspects of anxiety (Krüger, Shiozawa, Kreifelts, Schef�er, & Ethofer, 2015).

Other brain features seem very speci�c to certain disorders. People with obsessive-compulsive disorder can have altered functioning of the orbitofrontal cortex, basal ganglia, caudate

FIGURE 5.5 FEAR CAN BE EXPRESSED AS A FACIAL IMAGE (LEFT) AND AS A BRAIN IMAGE (RIGHT). IN THIS FUNCTIONAL MAGNETIC RESONANCE IMAGE (FMRI; RIGHT) OF A PERSON EXPERIENCING FEAR, THE AMYGDALA IS ACTIVE. Im

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Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention 121

Behavioral Inhibition Have you ever known someone who did not like new things or preferred to be near only familiar people and situations? Genetic contributions or brain features could predispose some- one for certain personality patterns, or temperaments, that have an impact on anxiety-related disorders. One such pattern is behavioral inhibition, or withdrawal from unfamiliar or new stimuli (Fox, Snidman, Haas, Degnan, & Kagan, 2015). Perhaps 10 to 15 percent of people are born with behavioral inhibition, which comes in the form of irritability, shyness, fearfulness, overcautiousness, and physical feelings of anxiety. Toddlers and children with behavioral inhibition are subdued and react fear- fully to new people or situations, often preferring to be close to their parents. Such behavior is normal for many young chil- dren, who eventually outgrow early shyness or fearfulness of new things, but behavioral inhibition in some youth is relatively stable across the life span (Henderson, Pine, & Fox, 2015).

People with behavioral inhibition seem to be at risk for developing anxiety-related disorders, which makes sense be- cause many people with these disorders avoid new situations, stay close to home (like Angelina), or become nervous or worry about unfamiliar circumstances. Long-term studies reveal chil- dren with behavioral inhibition to be more likely than control participants to develop anxiety-related disorders, especially social phobia (Perez-Edgar et al., 2014). Adults with anxiety disorders also commonly report aspects of behavioral inhibi- tion currently and during childhood (Frenkel, Fox, Pine, Walker, Degnan, & Chronis‐Tuscano, 2015).

Many children with behavioral inhibition later develop an anxiety-related disorder, but most children with such in- hibition do not. Not all people with anxiety-related disorders show behavioral inhibition either. Factors such as a support- ive family and social network likely protect some people from developing an anxiety-related disorder (Reinelt et al., 2014).

Norepinephrine is related to excessive physical symptoms Norepinephrine is related to excessive physical symptoms Norepinephrine of anxiety, partly because the locus coeruleus is heavily con- centrated with norepinephrine receptors. This is especially per- tinent to people with panic, phobic, and posttraumatic stress disorders. Some people with anxiety-related disorders may have poor regulation of norepinephrine, which can lead to sporadic bursts of activity and related physical symptoms, as in panic attacks. GABA helps inhibit nerve cells related to anxiety. This neurotransmitter may be de�cient in people with anxiety-related disorders and thus contribute to excessive worry and panic symptoms (Lipov & Ritchie, 2015; Nuss, 2015).

Another important neurochemical change in people with anx- iety-related disorders involves the hypothalamic-pituitary-adrenal (HPA) system and a substance called cortisol (Staufenbiel, Pencortisol (Staufenbiel, Pencortisol - ninx, Spijker, Elzinga, & van Rossum, 2013). The HPA system is responsible for helping a person respond to stressful situations by releasing substances allowing the body to confront or �ee a threat- ening stimulus (�ght or �ight). One such substance is cortisol, levels of which elevate when a person is faced with threat but that diminish over time as the threat fades. You may see your professor administering a pop quiz and become quite physically aroused as your cortisol level increases. Your cortisol level drops, however, as you calm down and focus.

In some people with excess arousal and anxiety-related dis- orders, cortisol levels remain high even when threat subsides. They may thus be agitated, watchful of threat, or physically anxious for little reason (Laurent, Gilliam, Wright, & Fisher, 2015). This is not always the case, however; some people with posttraumatic stress disorder have suppressed levels of cortisol (Nijdam, van Amsterdam, Gersons, & Olff, 2015). Therefore, more work must be done to see exactly what role cortisol plays with respect to the cause of these disorders.

Some children are naturally hesitant or even fearful in new situations, such as getting one’s �rst haircut.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders122

bad will happen or has happened despite lack of evidence to support this assumption. A person may wrongly assume that speaking before a small group will result in a poor performance. Similarly, someone may assume terrible but incorrect conse- quences will result from an event—this is catastrophizing. A person who makes mistakes in a speech may thus wrongly assume he will lose his job. A person may also assume her physical feelings re�ect how things truly are—this is emotional reasoning. People who are nervous speaking before others, and who have strong physical feelings of anxiety, may wrongly as- sume everyone can tell how nervous they are.

People with anxiety-related disorders also make errors in judgment about their skill. Many underestimate their level of social skill, believing they are less competent than others even when it is not true. People with anxiety-related disorders also tend to view social events negatively, believe their anxiety symptoms to be highly visible to others, and pay close atten- tion to their own errors when interacting with others. A person at a party may feel he is being judged harshly by others, that others can easily see his nervousness or trembling, and that he is constantly making minor slips of the tongue. Most people dismiss minor errors when speaking to others, but people with anxiety-related disorders can see these errors as serious and self- defeating (Buckner, Heimberg, Ecker, & Vinci, 2013; Morrison & Heimberg, 2013; Siddaway, Taylor, Wood, & Schulz, 2015).

Many people with anxiety-related disorders think nega- tively and then avoid anxious situations. They subsequently feel better after avoiding these situations because their physical arousal goes away. This rewards their negative way of thinking and avoidance. People with generalized anxiety disorder may believe worrying helps prevent bad things from happening. Anx- iety-related disorders are thus maintained over time. Angelina assumed terrible things would happen if she had a panic attack, avoided situations where a panic attack might occur, and felt relieved when those terrible things did not happen. Patterns like this keep many people from seeking treatment, and they kept Angelina from shopping, dating, and attending school.

People with obsessive-compulsive disorder have cata- strophic beliefs about their own thoughts. Jonathan and others with obsessive-compulsive disorder are greatly troubled by their intrusive and spontaneous thoughts, feeling guilty or blaming themselves for having them. This may be tied to thought– action fusion, in which one believes thinking about something, such as hurting a baby, means he is a terrible person or that the terrible thing is more likely to happen (Bailey, Wu, Valentiner, & McGrath, 2014). Many people with obsessive-compulsive dis- order also view their thoughts as dangerous, and this increases physical arousal and triggers even more obsessions. People with the disorder also try to suppress their thoughts, but this only leads to more obsessions (Allen, Krompinger, Mathes, Crosby, & Elias, 2016). Try not to think about “blue dogs” for the next not to think about “blue dogs” for the next not minute. What happens?

Cognitive theories of anxiety-related disorders also focus on emotional processing, or a person’s ability to think about a past anxiety-provoking event without signi�cant anxiety (Jazaieri, Morrison, Goldin, & Gross, 2015). Think about a person once

Other personality characteristics may also interact with behav- ioral inhibition to contribute to anxiety-related disorders, such as neuroticism or general distress, desire to avoid harm, and anxiety sensitivity (see anxiety sensitivity section later in the chapter; Doty, Japee, Ingvar, & Underleider, 2013).

Evolutionary In�uences Evolutionary in�uences may also contribute to anxiety-related disorders. Preparedness is the idea that humans are biologically prepared to fear certain stimuli more than others. People of all cultures seem particularly afraid of snakes and spiders but rarely of trees and �owers. We may have realized as we evolved that snakes and spiders represent true threats to be avoided but that trees and �owers are rarely threatening. People today are thus more likely, or prepared, to develop a phobia of snakes or spiders than a phobia of trees or �owers (Van Strien, Eijlers, Franken, & Huijding, 2014).

Evolutionary theories have also been proposed for other anxiety-related disorders. Social anxiety may help preserve so- cial order by inducing people to conform to social standards, form clear hierarchies, and avoid con�ict (Gilbert, 2014). Com- pulsive behaviors such as checking, hoarding, or washing may have been historically adaptive when hunting and gathering food (Aunger & Curtis, 2013). Fainting after a skin injury such as a needle injection may be an adaptive response to inescapable threat (Kozlowska, Walker, McLean, & Carrive, 2015).

Environmental Risk Factors for Anxiety, Obsessive- Compulsive, and Trauma-Related Disorders We have covered some of the biological or early-life risk fac- tors for anxiety-related disorders, so we turn our attention next to environmental risk factors that may develop over a person’s lifetime. These include cognitive risk factors, anxiety sensitivity, family factors, learning experiences, and cultural factors.

Cognitive Risk Factors An environmental risk factor closely related to anxiety-related disorders is negative thought patterns, or cognitive distor- tions. People with anxiety-related disorders often have ongoing thoughts about potential or actual threat from external events. We mentioned that people with generalized anxiety disorder of- ten scan their environment looking for threats or things to worry about. They generally see events in a negative light or look �rst negative light or look �rst negative light at how they might be harmed (Newman et al., 2013). Angelina’s concern that her professor might look at her was based on an assumption she would be called on, not know the answer to a question, and look foolish. She did not consider other possibili- ties like the fact she was a good student who probably did know the answer. Others with anxiety disorders experience intolerance of uncertainty, that is, fear of the unknown and a belief that uncertainty is threatening (Bomyea et al., 2015).

Common cognitive distortions in people with anxiety- related disorders include jumping to conclusions, catastrophizing, and emotional reasoning (Beck & Haigh, 2014; Gellatly & Beck, 2016). Someone who jumps to conclusions assumes something

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention 123

don’t have to go to that birthday party”). Such parents also tend to avoid or withdraw from various situations themselves (Drake & Ginsburg, 2012; Rapee, 2012).

Parents of anxious children also overemphasize opinions of, and negative evaluations from, others. Families of anxious children tend to be isolated or unstable and avoid many social situations. Parents may also serve as a model for their child’s anxiety (Ollendick & Benoit, 2012). A parent with panic disor- der may avoid anxious situations, appear physically nervous, attend closely to internal sensations, or withdraw from chores after having an attack. Some children may view these behaviors as ways of coping with anxious situations and do the same. Another important family variable involves insecure or anxious/ resistant attachment patterns, which commonly occur in chil- dren with anxiety-related disorders (Kerns & Brumariu, 2014). Childhood maltreatment is another key risk factor for anxiety- related disorders and especially for posttraumatic stress disorder (Choi & Sikkema, 2015).

How might these parent/family experiences interact to pro- duce an anxiety-related disorder? Parental practices, modeling, and insecure attachment could lead to reduced opportunities for a child to practice anxiety management skills in different social and evaluative situations. A child’s demands for close physical proximity to a parent may be frequently rewarded, and a child and parent may have an overdependent relationship that pre- vents effective separation. Many children refuse school because of anxiety about social and evaluative situations and about be- ing away from parents or home. Some parents also feel anxious about this separation and encourage a child to stay home. Fac- tors such as maltreatment can cause physical brain changes that lead to anxiety-related disorder as well.

Learning Experiences Excessive fear can also be a learned response. Modeling parent behavior is one learned pathway, but children can also become fearful through direct learning or information transfer (Milosevic information transfer (Milosevic information transfer & McCabe, 2015). Direct learning may involve classical con- ditioning and ditioning and ditioning operant conditioning. Classical conditioning is derived from Ivan Pavlov’s famous experiment in which he saw dogs instinctively salivate at the sight and smell of food (see Figure 5.7). Food is an unconditioned stimulus, and salivation is an unconditioned response because no learning unconditioned response because no learning unconditioned response occurs—the salivation is automatic. Pavlov then associated

trapped in an elevator and intensely fearful. Good emotional processing means the person can later talk about the story, lis- ten to others’ accounts of being trapped in an elevator, or even ride elevators without anxiety. People with anxiety-related dis- orders, however, often have trouble processing dif�cult events. Poor emotional processing helps explain why many forms of anxiety are maintained for long periods of time even when no threat is present. This is especially relevant to people like Mar- cus with posttraumatic stress disorder. Marcus continued to ex- perience reminders of the event in the form of nightmares and intrusive thoughts. He had not yet reached the point where he had fully processed or absorbed what had happened and was therefore still unable to function well on a daily basis.

Anxiety Sensitivity Related to cognitive distortions is the erroneous belief that inter- nal physical sensations are dangerous. Many of us are naturally concerned about our health, but some people become extremely worried about even minor physical changes. Anxiety sensitiv- ity is a fear of the potential dangerousness of internal sensations (Sandin, Sanchez-Arribas, Chorot, & Valiente, 2015). A person may experience a minor change in heart rate and excessively worry he is having a heart attack. Recall that Angelina went to an emergency room doctor and a cardiologist because she felt her symptoms were dangerous. Symptoms of panic are not actu- ally dangerous, but many people wrongly think the symptoms mean a serious medical condition, insanity, loss of control, or imminent death.

Children and adults with anxiety symptoms and anxiety- related disorders, especially those with panic attacks and panic disorder, often show high levels of anxiety sensitivity (Poletti et al., 2015). This makes sense when you consider that people with panic attacks often fear another panic attack and thus more negative physical symptoms and consequences. Anxiety sensi- tivity may be a characteristic learned over time, or it might be a type of temperament that is present early in life and related to certain biological predispositions.

Family Factors Family-based contributions to anxiety-related disorders are also important. Parents of anxious children may be overcontrolling, affectionless, overprotective, rejecting, and demanding. Reject- ing parents could trigger a child’s worry about being left alone or anxiety about handling threats from others without help. Overprotective or con- trolling parents may restrict a child’s access to friends or other social situations or pre- maturely rescue a child from an anxious situation, thus rewarding anxiety. Parents of anxious children may also encourage avoidance in their children and discourage pro- social behaviors (“OK, you FIGURE 5.7 CLASSICAL CONDITIONING MODEL OF FEAR.

Unconditioned stimulus 1. Food 2. Dog bite

Conditioned stimulus 1. Food with bell 2. Dog with pain/fear

Unconditioned response 1. Salivation 2. Pain and fear

Conditioned response 1. Salivation to bell 2. Fear of dog

When these are associated

over time

Automatically produces

Eventually produces

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders124

experienced a severe threat to his safety and later felt a sense of unpredictability regarding future threats.

Cultural Factors We mentioned that many anxiety-related disorders are present worldwide and often come in different forms across cultures. Still, ethnic groups may be more susceptible to certain kinds of anxiety-related disorders because of where they live and because of dif�cult conditions they experience. African Ameri- cans, for example, tend to have higher rates of posttraumatic stress disorder than other groups, which may be related to neg- ative life events (Alegria et al., 2013; Lewis, Byrd, & Ollendick, 2012). In addition, Hispanic college students who experience racial/ethnic discrimination are at risk for developing posttrau- matic stress symptoms and maladaptive alcohol use (Cheng & Mallinckrodt, 2015).

Posttraumatic stress and other anxiety-related disorders in people around the world have also been linked to mass trauma through natural disasters and war zones, terrorism, and torture. People exposed to Hurricane Sandy were prone to symptoms of posttraumatic stress disorder (Caramanica, Brackbill, Stellman, & Farfel, 2015). People exposed to earthquakes, volcanic erup- tions, typhoons, and other natural disasters also commonly de- velop symptoms of posttraumatic stress and depression (Boden, Fergusson, Horwood, & Mulder, 2015; Warsini, Buettner, Mills, West, & Usher, 2015). Other examples include U.S. soldiers in Afghanistan, Palestinians and Israelis, refugees from the Mid- dle East, and torture survivors from Eritrea (Amawi, Mollica, Lavelle, Osman, & Nasir, 2014; Ayer et al., 2015; Hoge et al., 2014; Song, Kaplan, Tol, Subica, & de Jong, 2015). Many people with anxiety-related disorders in various cultures also show dif- ferent kinds of anxiety symptoms, often in the form of physical symptoms. Cambodian refugees have common panic-like symp- toms that include feelings of paralysis during and after sleep and images of a being approaching them in the night (Hofmann & Hinton, 2014). Certain ethnic groups may thus be at particular risk for anxiety-related disorder because of the circumstances in which they live. These studies also indicate that clinicians must be sensitive to these issues when conducting assessment and treatment.

Causes of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders Now that you understand the many risk factors for anxiety- related disorders, let us explore how these factors might interact to produce an anxiety-related disorder. Researchers emphasize integrative, diathesis-stress models or pathways to help explain the cause of different anxiety-related disorders (Vasey, Bosmans, & Ollendick, 2014). These theorists believe certain people are born with biological vulnerabilities to experience high anxiety. Some people have genetic predispositions or various brain or neurochemical features that cause them to feel highly physically aroused and upset when negative life events occur. Others may have certain temperaments, such as behavioral inhibition, that predispose them to anxiety-related disorders as well.

the food/unconditioned stimulus with a ringing bell and con- ditioned his dogs to eventually salivate to the bell. The food/ unconditioned stimulus became associated with the bell, a con- ditioned (or learned) stimulus. Repeated pairings or associations of the food and bell then produced a situation where the condi- tioned stimulus (bell) produced a conditioned response, in this case salivation.

Such a process can also occur for the development of fears. Think about someone who walks through a park and is bit- ten by a vicious dog. The bite is an unconditioned stimulus be- cause it immediately causes pain and fear or an unconditioned response—no learning is necessary. If negative experiences with a dog happened repeatedly, then any exposure to a dog (now a conditioned stimulus) would result in fear of that dog (now a conditioned response). This fear may then become generalized, as when a person becomes afraid of many dogs, even those that have not bitten her. Such a model is often used to explain pho- bias, but many intense panic attacks also occur following stress- ful life events (Wood, Salguero, Cano-Vindel, & Galea, 2013).

Direct learning of fears may also involve operant condi- tioning, or subsequent rewards for fearful behavior. Parents of- ten reinforce certain apprehensions in their children, such as wariness around strangers. Too much reinforcement in this area could lead to a situation in which a child rarely interacts with other peers or adults and then does not develop good social or communication skills. Social anxiety may thus result when the child later tries to interact with others but does so in an awkward way that leads to social rejection and further social anxiety (Hoff et al., 2015).

Fears are also reinforced by avoidance. If you are nervous about an upcoming dental appointment, then you might can- cel it. The feeling of relief you then experience is quite reward- ing and may motivate you to cancel more appointments in the future. Some fears develop from classical and operant condi- tioning. A person bitten by a dog may associate dogs with pain and fear and then avoid dogs for the rest of her life. The fear thus remains even though no additional trauma is taking place (Cameron, Roche, Schlund, & Dymond, 2016).

Another factor in fear development is information transfer. A child may hear stories from other children or adults about the dangerousness of certain stimuli such as spiders and thus develop a fear of them. Many people also seem predisposed to fear certain things such as spiders, snakes, strangers, separation from loved ones, heights, and water. We may have developed an innate sense of fear about certain things that could harm us as we evolved. This is sometimes called a nonassociative theory of fear because no trauma is needed for someone to show the fear fear because no trauma is needed for someone to show the fear fear (Milosevic & McCabe, 2015).

Learning experiences may also lead a person to develop a sense of lack of control over, or sense of unpredictability about, life events (Havranek et al., 2016). Dif�culties at school and sub- sequent avoidance of evaluative situations there could lead a person to excessively worry about her competence and place in the surrounding world. Children maltreated by their parents have dif�culty knowing who they can trust and may develop a sense of lack of control about their environment. Marcus

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention 125

subject to social isolation from nervous parents. Parents may be unwilling to expose the child to birthday parties, play dates, or preschool.

If a toddler remains socially isolated and if his social inter- actions with parents are problematic, this could set the stage for later dif�culties. The child may imitate the parents’ behaviors of avoiding or withdrawing from different situations; this leaves the child with few opportunities to build social skills and re- ceive appropriate feedback from others. The child will also fail to control social anxiety or develop good coping skills in differ- ent situations. Children not in preschool or surrounded by peers, or those neglected or otherwise maltreated, might be more at risk for such outcomes.

As these children age and enter elementary and middle school, many academic, athletic, and social demands are placed on them. Youth are expected to cooperate with others on school projects, play on teams, and develop friendships. Unfortunately, children already predisposed to social anxiety and who have had early isolation and poor skill development may experience rejection from others. Such rejection could lead to other con- sequences such as increased anxiety in social and evaluative situations, thoughts that interactions with others and anxiety symptoms are dangerous, increased avoidance of others, ar- rested social skill development, and worry about future social and evaluative situations. As these youth enter high school, their patterns of social anxiety and avoidance may become in- grained, and they may meet diagnostic criteria for social phobia.

Other anxiety-related disorders also likely involve a blend of biological and psychological vulnerabilities. Some people with panic disorder are naturally high in physical arousal and eas- ily get upset or worried about stressful life events like starting school (biological vulnerability). This stress may lead to an un- expected panic attack, as it did for Angelina. Most people who have a panic attack dismiss the event as merely unpleasant but some, like Angelina, feel the panic attack is uncontrollable and will cause terrible things like a car accident (psychological vul- nerability). They then fear another panic attack and avoid situ- ations in which attacks may occur. A person might also monitor her internal sensations such as heart rate to see if a panic attack is about to happen. Of course, doing so will increase physical arousal, likely trigger another panic attack, and increase worry that even more will occur. The person is thus always worrying

People also develop a psychological vulnerability toward anxiety-related disorders. Some people continue to have anxiety- provoking thoughts, family experiences that reinforce anxious behavior, and anxiety-related learning experiences. Some people may also feel they lack control over many situations in their lives. Still others could experience anxiety-provoking trauma in the form of maltreatment, surrounding threats, or exposure to terrorism or natural disasters.

One possible developmental pathway to social phobia in youth is illustrated in Figure 5.8. Some youth are clearly born with predispositions toward overarousal and behavioral inhibi- tion, demonstrating fear and excitability, particularly in new situations. These predispositions may be the result of genetics and key brain and neurochemical features. These infants may be raised by parents who are themselves predisposed toward anxious and avoidant behavior. The early infant–parent relation- ship could thus be marked by poor attachment and problem- atic social interactions. As these infants grow into toddlerhood, they may isolate themselves from others by playing alone or be

FIGURE 5.8 SAMPLE DEVELOPMENTAL PATHWAY OF SOCIAL ANXIETY DISORDER.

Possible social anxiety disorderPossible social anxiety disorder

Biological vulnerabilities/early predispositions

Genetic contributions, brain and neurochemical changes, behavioral inhibition

Early problematic interactions with anxious parents

Poor attachment, social and play isolation, parental withdrawal of child from social activities

Difficulties in elementary school

Modeling of avoidance, poor development of social and coping skills, failure to master social and evaluative anxiety/sense of lack of control

Difficulties in middle and high school

Trouble making friendships or cooperating in team projects, social rejection, increased anxiety in social and evaluative situations, increased social avoidance and isolation, excessive worry about future social and

evaluative situations

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Darwin / PTSD

“I led men into combat. And sometimes when I made decisions, people died.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders126

self-statements, coping with troublesome situations, reward- ing themselves for approach behavior and not avoidant behav- ior, and practicing these steps in real-life situations. FRIENDS stands for:

• Feeling worried • Relax and feel good • Inner thoughts • Explore plans • Nice work so reward yourself • Don’t forget to practice • Stay cool

A child is encouraged to recognize when she is feel- ing anxious, work to control physical feelings of anxiety, and think more realistically (see later treatment sections). She would also be expected to practice situations, such as social and performance situations, to reduce anxiety in those situations. The FRIENDS program does reduce the prev- alence of anxiety symptoms in children (Barrett, Cooper, & Guajardo, 2014).

Anxiety prevention strategies also apply to adults. Efforts to change problematic feelings, thoughts, and behaviors re- lated to anxiety have been conducted for anxious college students, physical and sexual assault victims, those with pub- lic-speaking anxiety, and people with agoraphobia or stressful lifestyles (Gloster et al., 2015; Pull, 2012; Ratanasiripong, Sver- duk, Prince, & Hayashino, 2012; Regehr, Alaggia, Dennis, Pitts, & Saini, 2013). These programs help individuals relax, change problematic thoughts, develop social skills, and reduce avoid- ance and other behavior symptoms by confronting whatever provokes anxiety.

Other adult prevention programs are more government- based and focus on the general population. These programs have come in the form of media-based education and screening for anxiety-related disorders. Media-based education involves

about having a panic attack or actually having a panic attack. having a panic attack. having Such was the case for Angelina.

Other anxiety-related disorders involve more speci�c causal factors. People with speci�c phobias may have had a direct trau- matic experience, such as a dog bite, that caused intense fear. People with posttraumatic stress disorder must, by de�nition, have experienced a traumatic event for the disorder to occur. The presence of trauma and later recollections of the trauma likely converge with one’s belief that these events are uncon- trollable. The person may continue to experience high levels of physical arousal (just like during the trauma) and scan the en- vironment looking for threats or reminders of the trauma. Un- wanted thoughts about the trauma can also continue.

People with generalized anxiety disorder, a largely cogni- tive condition, may believe negative life events will happen frequently, suddenly, and uncontrollably. A person may even look for threats when they are not there. Worry about minor life events may be reinforced because it lowers physical arousal and keeps someone from thinking about more serious emotional or fearful issues. A person with obsessive-compulsive disorder may also believe his thoughts are dangerous. All anxiety-related disorders, however, involve an intricate combination of different biological and psychological vulnerabilities.

Prevention of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders Given what we know about risk factors and cause of anxiety- related disorders, what could be done to prevent them? Many fears and anxiety-related disorders begin in adolescence or early adulthood, so thinking of prevention during childhood and adolescence makes sense. Researchers have identi�ed sev- eral goals that might be important for prevention. These goals center on building a child’s ability to control situations that might lead to anxiety.

Children could be taught the difference between dangerous and nondangerous situations and learn which situations should de�nitely be avoided, such as being in the middle of the street. Children could also be taught strategies to address potentially threatening situations such as bullies, busy roads, and swim- ming pools. Rules about safety, talking to a teacher, and being with friends could be covered. Children could also be taught social and coping skills necessary when unfortunate events do occur. Youth may be taught how to cope with being turned down for a date, failing a test, or being cut from a team. The general idea is to teach children to successfully handle stress- ful situations and not resort to avoidance or feelings of loss of control. Other aspects of prevention that might be important include changing negative thoughts, having parents model good ways of handling stress, improving parent attitudes toward their children, reducing parent anxiety, reducing actual harmful situ- ations, and identifying and providing therapy for children with anxious parents (Corrieri et al., 2014).

An anxiety prevention program for children—the FRIENDS workbook—concentrates on educating children about anxiety, teaching them to relax, challenging and changing negative

Children have to be taught the difference between dangerous and nondangerous situations. This mother is showing her children how to safely cross a street.

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Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 127

changing negative thoughts, coping better with stress, and practicing skills in real-life situations.

➲ Review Questions 1. Describe data that support a genetic contribution to anxiety-

related disorders. 2. What key brain and neurochemical features may be related

to anxiety-related disorders? What temperamental charac- teristic occurs early in life and may predict anxiety-related disorders? How so?

3. What are some cognitive distortions associated with anxiety- related disorders, and what is anxiety sensitivity?

4. How might family factors, learning experiences, and cultural backgrounds help cause anxiety-related disorders?

5. Describe an overall causal model for anxiety-related disorders.

6. What factors might be important for a program to prevent anxiety-related disorders?

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment

We have covered risk factors for anxiety-related disorders and will next cover assessment and treatment methods most relevant to people with these disorders. We discuss as- sessment and treatment methods in general because most of these strategies apply to each anxiety-related disorder. How- ever, we also provide tables that contain treatment information speci�c to each major anxiety-related disorder. The assessment and treatment methods we discuss next are extremely important for people who are plagued by crippling fears and obsessions (see Personal Narrative 5.1), as well as other problems we discuss in this textbook.

Assessment of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders We mentioned in Chapter 4 that mental health profession- als use various methods to examine people. The primary methods to evaluate or assess people with anxiety-related disorders include interviews, self-report questionnaires, self- monitoring and observations from others, and psychophysi- ological assessment.

Interviews What would you be curious to know about Angelina, Jonathan, and Marcus? Mental health professionals who treat people with anxiety-related disorders are often curious about thoughts and physical feelings, daily activities and avoidance, targets of anxi- ety and fear, and long-term goals. This information is impor- tant for knowing how to treat someone with an anxiety-related

teaching the public about symptoms of anxiety and that these symptoms can be successfully treated before they get worse. Examples include telephone information lines, websites, public service announcements, printed material, and cooperation with local mental health agencies. May 1 of each year is set aside as National Anxiety Disorders Screening Day, which helps provide quick assessment for those struggling with panic or other anxi- ety symptoms. Those identi�ed with problematic anxiety can then be referred for professional treatment.

➲ Interim Summary • A moderate genetic basis has been found for many

anxiety-related disorders.

• Several brain areas have been implicated in anxiety- related disorders, especially the amygdala and septal- hippocampal regions, which are associated with physical arousal, emotion, and memories surrounding fearful and anxiety-provoking stimuli. Other brain areas are speci�c to certain anxiety-related disorders, such as the anterior cingulate in obsessive-compulsive disorder and the locus coeruleus in panic disorder.

• Neurotransmitters most implicated in anxiety-related disorders include serotonin, norepinephrine, and gamma- aminobutyric acid (GABA).

• People with behavioral inhibition—a temperamental pat- tern of irritability, shyness, fearfulness, overcautiousness, and physical feelings of anxiety—seem predisposed to disorders such as social phobia.

• Anxiety may be in�uenced by evolutionary processes in that some avoidance behaviors seem adaptive in certain contexts.

• Cognitive risk factors include distorted thinking about the dangerousness of various stimuli, assumptions that something bad will happen, assumptions of terrible con- sequences, and assumptions that others can easily notice one’s anxiety.

• Anxiety sensitivity refers to fear of the potential danger- ousness of one’s own internal sensations such as dizziness and increased heart rate.

• Family factors may contribute to anxiety-related disorders, especially overcontrolling, affectionless, overprotective, rejecting, and demanding parents.

• People can learn aspects of fear and anxiety through direct experience, information transfer, or reinforcement for fear of strangers or other stimuli.

• Cultural factors in�uence the development of anxiety- related disorders, particularly in people more commonly exposed to traumas.

• Biological and environmental risk factors can make a person vulnerable to anxiety-related disorder.

• Preventing an anxiety-related disorder involves building ability to control situations that might lead to anxiety, education about dangerous and nondangerous situations,

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders128

Self-Report Questionnaires Anxiety-related disorders consist of many internal symptoms such as increased heart rate or negative thoughts, so clients are often asked to rate symptoms on questionnaires. The Anxiety Sensitivity Index—3 evaluates fear of the dangerousness of one’s internal sensations, a key aspect of panic disorder. Selected items from this scale are in Table 5.12 (Ebesutani, McLeish, Luberto, Young, & Maack, 2014; Taylor et al., 2007). Other com- monly used questionnaires for people with anxiety-related dis- orders are in Table 5.13.

Self-Monitoring and Observations from Others People with anxiety-related disorders are often asked to moni- tor and keep a record of their symptoms on a daily basis (Cohen, Edmunds, Brodman, Benjamin, & Kendall, 2013). This serves several purposes. First, monitoring symptoms every day cuts down on having to remember what happened the previous week, such as what happened during a certain episode of worry, and helps provide material for discussion in a therapy session. Second, monitoring increases a person’s self- awareness of the frequency, intensity, and change in anxiety symptoms over time, such as panic attacks. Third, monitoring helps keep a person focused on a task such as exposure to anxiety instead of distracting or avoiding. Others who know the client well may also keep records of her more obvious anxi- ety symptoms, such as avoidance. This applies especially to children and adolescents.

disorder because speci�c client characteristics can be identi�ed and addressed. Angelina’s therapist was able to uncover some interesting information about what exactly happens during her panic attack while driving:

Therapist: What kinds of thoughts do you have when driving?

Angelina: I think I’m going to crash the car because it keeps swerving in the lane.

Therapist: What do you usually think and do next? Angelina: I focus a lot on my symptoms, like my heart

racing or dizziness, and try to look around fast to see where I can pull the car over . . . I think I’m going to smash into someone because I’m not being too careful.

Therapist: Are you able to get the car over to the shoulder? Angelina: Yes, I’ve never had an accident, but you never

know, the next time could be the time I really hurt someone!

Many therapists prefer unstructured interviews, but struc- tured interviews usually rely on diagnostic criteria and contain a list of questions a therapist asks each client with a possible mental disorder. A common interview for people with anxiety- related disorders is the Anxiety Disorders Interview Schedule (ADIS-5; Brown & Barlow, 2013). This interview is primarily useful for evaluating anxiety disorders, but other disorders can be assessed as well.

From as far back as I can remember, my life had

been plagued by mental disorder. As a child and

through adolescence, obsessions and compul-

sions wreaked havoc on my brain and my life.

I used to have irrational fears of catching fatal

illnesses or getting abducted by aliens.

The obsessions could be best described as

chaos occurring in my head. Any thought I had

was accompanied with that current obsession.

There was no complete joy in any activity, be-

cause at no point was my day free from anxiety.

I became a prisoner of my own brain. Further-

more, I would complete certain rituals, such as

adding numbers in my head, or placing items in

my pockets in the exact same order every day;

if I didn’t do this, I feared something bad would

happen.

As time went on, these obsessions and

compulsions occurred periodically in my life,

lasting for a few weeks or a few months at a

time. During my last few years of high school

and freshmen year of college, the obsessions

subsided and were at worst mild and short-

lived. However, they reared their ugly head

my sophomore year in college, and it was at

this point that I knew I had a mental disor-

der; I realized a normal brain wouldn’t func-

tion this way. I knew these fears and thoughts

were completely irrational, but I couldn’t help

them.

I began to seek help during the summer;

by that time the obsessions had ceased, but

a horrible feeling came over me as I drove to

school for that fall semester. That feeling I felt,

which progressively got worse throughout the

semester, was depression. It’s a feeling that

sucks the life out of you.

I �nally saw a psychiatrist in the fall, and he

prescribed me psychotropic medication. The

depression began to ease for a while, but when

the winter came, depression reclaimed my en-

tire body. I spent months trapped in the dark

cloud of depression. I couldn’t sleep, couldn’t

eat and after a while, questioned how I could

live like this much longer. I saw my doctor more

frequently during this time period, and after a

while, we were able to work out the proper medi-

cations that were able to completely alleviate my

symptoms.

From that moment on, every day has

been a gift to be alive. Now to say that every

5.1 / A / A / nonymous

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 129

day from then on has been the best day of my life would be a lie. However, I was al- most dead; I now have a new lease on life and I appreciate all things in life to a greater degree.

Besides my new lease on life, this ex- perience also had another powerful effect on me. From then on I decided to be an advocate for mental health. I had formed a chapter of the National Alliance on Mental Illness (NAMI) at my school. In overcom- ing this past experience, I felt as if I had been to the gates of hell and back, and now it was time to use my experience to make sure no one goes to those gates, at least not alone.

In my eyes I’ve always viewed it as an ob- ligation to speak about my disorder and help

perceived notion of being embarrassed, or fear of the unknown. This hurts the econo- my, the health care system, education, and, most importantly, people’s individual lives. To eliminate this stigma, those in the men- tal health field must work tirelessly against this prejudice. Those with a mental disor- der should not be ashamed of their disor- der; some of the smartest and most creative people in the world had a mental disorder. As more people step out of the seclusion caused by stigma, the stigma itself will dis- appear. People will realize how common- place mental disorder is in this society, how real of a medical condition it is, and how to treat it effectively.

others. God blessed me with numerous gifts to help me become a successful student and person. I knew that if I told others I dealt with depression and anxiety, they would be com- pletely shocked. I was also pretty certain that the people who knew me wouldn’t view me any differently. Therefore, I felt that I wouldn’t face much stigma. It still wasn’t the easiest step to take, but I decided at that point to carry this cross of mental disorder everywhere I go. I want to assure people they can be suc- cessful and break down the stigma every chance I get, and most importantly making sure no one feels as I did on those desolate earlier days.

The stigma of mental disorder causes problems in many aspects of society. People don’t want to receive treatment due to the

personal narrative

• It is important to me not to appear nervous.

very little a little some much very much

• When I tremble in the presence of others, I fear what people might think of me.

very little a little some much very much

• I think it would be horrible for me to faint in public.

very little a little some much very much

• When my stomach is upset, I worry that I might be seriously ill.

very little a little some much very much

• I worry that other people will notice my anxiety.

very little a little some much very much

• When I feel pain in my chest, I worry that I’m going to have a heart attack.

very little a little some much very much

• When my throat feels tight, I worry that I could choke to death.

very little a little some much very much

• When I have trouble thinking clearly, I worry that there is something wrong with me.

very little a little some much very much

• It scares me when my heart beats rapidly.

very little a little some much very much

• It scares me when I blush in front of other people.

very little a little some much very much

TABLE 5.12

Sample Items from the Anxiety Sensitivity Index—3

Anxious clients are usually asked to record episodes of panic attacks and/or speci�c physical symptoms, thoughts, and behav- iors (Gee, Grif�ths, & Gulliver, 2016). Angelina’s therapist asked her to track her panic attacks, list her thoughts during and after each attack, and rate her symptoms of accelerated heart rate and

trouble breathing. Behavioral avoidance tests may also be done to see how close someone with an anxiety-related disorder can get to a feared situation or object (Davis et al., 2013). Marcus’s therapist accompanied him as he drove near the spot he was at- tacked, but Marcus did not get very far before stopping.

Used with permission.

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders130

2014). Psychophysiological assessment may reveal rich informa- tion about a client, but it is costly and time-intensive. This kind of assessment is most often seen in research or medical settings.

Biological Treatment of Anxiety, Obsessive- Compulsive, and Trauma-Related Disorders How do you think the various people discussed in this chap- ter might be treated for their anxiety-related disorders? Recall that anxiety consists of three components: physical feelings, thoughts, and behaviors. Treating anxiety-related disorders may thus involve biological interventions, or medications, to quell physical feelings and enhance approach behaviors.

Antianxiety medication has become a leading method of treating people with anxiety-related disorders. Some of the most common antianxiety medications are listed in Table 5.14. One particular class of antianxiety drug is the benzodiazepines, or drugs that produce a sedating effect. Recall that one risk factor for anxiety-related disorder seems to be excess neurochemical activity

Psychophysiological Assessment Psychophysiological assessment is sometimes done to measure severity of physical symptoms in people with anxiety-related disorders. Common measures include heart rate, blood pres- sure, and respiration, but more sophisticated measures may be used in research settings. These include skin conductance and resistance, electromyogram (for muscle tension), and measures of vasomotor activity. In skin conductance, electrodes are placed on a person’s �ngertip and wrist and a small, nonpainful elec- trical current is introduced to one electrode. A computer mea- sures the time the current takes to travel from one electrode to another. An anxious person may have more active sweat glands and thus conduct the electricity faster than a nonanxious person (Klucken, Kruse, Schweckendiek, & Stark, 2015). Some research- ers also use biological challenge procedures during assessment. These procedures may involve inducing panic-like symptoms (e.g., increased heart rate) using a certain agent such as car- bon dioxide to safely assess how a person typically responds to anxious symptoms (Gorlin, Beadel, Roberson-Nay, & Teachman,

Questionnaire What does it assess?

Beck Anxiety Inventory General symptoms of anxiety

Children’s Manifest Anxiety Scale Worry, oversensitivity, concentration problems, and physical feelings of anxiety

Fear Questionnaire Avoidance due to agoraphobia, blood injury phobia, or social phobia

Fear Survey Schedule for Children—Revised Fears of failure and criticism, the unknown, injury and small animals, danger and death, and medical procedures

Impact of Event Scale Hyperarousal, reexperiencing, and avoidance/numbing symptoms of posttraumatic stress disorder

Maudsley Obsessional-Compulsive Inventory Checking, washing, doubting, and slowness/repetition

Mobility Inventory Agoraphobia-related avoidance behavior

Multidimensional Anxiety Scale for Children—2 Harm avoidance and physical, separation, and social anxiety

Panic and Agoraphobia Scale Severity, frequency, and duration of panic attacks and avoidance

Penn State Worry Questionnaire Intensity and excessiveness of worry

School Refusal Assessment Scale–Revised Why a child refuses to attend school

Social Anxiety Scale for Children—Revised Fear of negative evaluation, social avoidance and distress, and generalized social distress

Social Interaction Anxiety Scale Anxiety about interpersonal interactions

Social Phobia and Anxiety Inventory Physical, cognitive, and behavioral components to social anxiety

State-Trait Anxiety Inventory Anxiety symptoms at this moment and anxiety symptoms felt much of the time

Symptom Checklist 90-R Crime-Related PTSD Scale

Symptoms of posttraumatic stress disorder

TABLE 5.13

Common Questionnaires for Assessing Anxiety-Related Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 131

can lead to unpleasant physical symptoms. People who use ben- zodiazepines, however, can become dependent on the drugs (Sabioni, Bertram, & Le Foll, 2015).

Psychological Treatments of Anxiety, Obsessive- Compulsive, and Trauma-Related Disorders Psychological interventions have also been designed to ad- dress each of the three anxiety components—physical feelings, thoughts, and behaviors. You will see in this textbook that many of these interventions are similar to those described for other dis- orders. Transdiagnostic treatments are those that can be used for people with various problems, especially those related to anxiety and depression (Chapter 7; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). In addition, many of these interventions are now being conducted not just in person but via the Internet as well (Arnberg, Linton, Hultcrantz, Heintz, & Jonsson, 2014).

Psychoeducation and Somatic Control Exercises Many anxiety-related disorders involve uncomfortable levels of physical arousal. Such arousal can come in the form of in- creased heart rate, dizziness, short breath, hot �ashes, and other symptoms. People with generalized anxiety disorder can also have severe muscle tension. Physical feelings of anxiety can trigger unpleasant thoughts and then avoidance, so an im- portant �rst step of treatment is to educate a person about the three components of anxiety and how these components relate to her. This process is psychoeducation. Examples are listed in Table 5.15.

Angelina’s therapist knew her client often had unpleasant and intense physical symptoms during her panic attacks. These symptoms then led to worries about harm from a panic attack and avoidance of places where an attack could occur. Teaching people with anxiety-related disorders about their symptoms and about how their physical feelings, thoughts, and behaviors in�u- ence each other is important to develop a good treatment plan, to ease concerns about the disorder, to emphasize that many people have these symptoms, and to convey that the symptoms can be successfully treated. Clients are sometimes taught so- matic control exercises to address physical feelings of anxiety. Somatic control exercises help clients manage physical arousal so it is less strong and threatening. Common somatic control ex- ercises include relaxation training and breathing retraining (see Table 5.15 for examples for each anxiety-related disorder).

In relaxation training, a person is taught to tense and re- lease different muscle groups to diffuse tension (Hayes-Skelton, Roemer, Orsillo, & Borkevec, 2013). The therapist may ask a per- son to sit in a comfortable chair, close his eyes, make a �st, and hold tightly for 10 seconds. The person then releases the �st quickly and repeats the process (try it). This is done for other muscle groups as well, such as those in the shoulders, face, stomach, and legs. The therapist encourages the client to attend to the difference between a tense muscle and a relaxed one. Many people with anxiety-related disorders have trouble even knowing they are tense. The procedure is often audiotaped and the person practices at home.

in different areas of the brain. Benzodiazepines help modify this excess activity to make a person feel more calm. These drugs may also enhance the GABA system of the brain to produce a more in- hibiting effect on anxiety. Benzodiazepines are often used to treat people with panic disorder (Guaiana et al., 2015).

Another major class of drugs for anxiety-related disorders is the antidepressants (see also Chapter 7), speci�cally, drugs that moderate serotonin levels in the brain. Recall that serotonin lev- els are not always well regulated in people with anxiety-related disorders, so antidepressants sometimes help provide this regu- lation. Antidepressant drugs are often used to treat people with social and generalized anxiety and obsessive-compulsive and posttraumatic stress disorders (Guaiana et al., 2015; Of�dani, Guidi, Tomba, & Fava, 2013).

Drug treatment is effective for 60 to 80 percent of adults with anxiety-related disorders but less so for people with severe, long-term anxiety comorbid with other mental disorders. Re- lapse rates can also be high when a person stops taking the drug (Kimmel, Roy-Byrne, & Cowley, 2015). Medication side effects can be unpleasant as well. Possible side effects of benzodiaz- epines include motor and memory problems, fatigue, depression, and irritability and hostility. Possible side effects of antidepres- sants include nausea, drowsiness, dizziness, and sexual dysfunc- tion (Huffman, Beach, & Stern, 2016). Antidepressants have not been found to be addictive, but their sudden discontinuation

TABLE 5.14

Common Medications for People with Anxiety-Related Disorders

Benzodiazepines

• Alprazolam (Xanax)

• Lorazepam (Ativan)

• Clonazepam (Klonopin)

• Diazepam (Valium)

• Chlordiazepoxide (Librium)

• Temazepam (Restoril)

• Oxazepam (Serax)

Antidepressants

• Fluoxetine (Prozac)

• Paroxetine (Paxil)

• Sertraline (Zoloft)

• Fluvoxamine (Luvox)

• Citalopram (Celexa)

• Escitalopram oxalate (Lexapro)

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders132

�rst step in cognitive therapy is to educate the person about her cognitive distortions and have her keep track of them during the week (Gregory et al., 2015). Angelina was asked to keep a daily log of panic attacks as well as thoughts that accompanied the attacks. She was also shown how many of her thoughts led to her avoidant behaviors.

Clients are encouraged to dispute negative thoughts by ex- amining the evidence for and against a certain thought (Gkika & amining the evidence for and against a certain thought (Gkika & amining the evidence Wells, 2015). A person is encouraged to look realistically at what is happening instead of assuming the negative in a situation. Angelina was convinced panic would lead to a car accident. She was asked if she had ever had a car accident before from a panic attack, and she said no. She was also asked what she did when she did panic while driving, and she said she usually went to the side of the road. The therapist helped her examine evidence about the situation:

Therapist: You said earlier you think you will crash the car when having a panic attack. What evidence do you have this will happen?

Angelina: I’m swerving a bit and feel I have to pull over because of my symptoms.

Therapist: But earlier you said you’ve never been in a car accident, right? So what is the evidence against the idea you might crash?

Angelina: Well, I am a very careful driver, and especially when I feel these symptoms coming on. I drive slower and usually stay in the right lane so I can get over to

Another procedure to reduce physical feelings of anxiety is breathing retraining (Nishith, Mueser, & Morse, 2015). This procedure involves having a person change her breathing during anxious times to include long, deep breaths in through the nose and out through the mouth. The person is encouraged to feel the breaths in the diaphragm (diaphragmatic breathing) by holding her �ngers below her stomach. Breaths should be slow, deep, and regular (try it a few times). One advantage of this strategy is that a person can use it in public situations without drawing much attention.

Cognitive Therapy Recall that another aspect of anxiety-related disorder is negative thoughts. Angelina was concerned a panic attack might cause extensive harm to her or others. Therapists often use cognitive therapy to change these negative thought patterns. Cognitive therapy involves examining negative statements a person may be making and encouraging the person to challenge the thought (Gregory, Peters, Abbott, Gaston, & Rapee, 2015). Cognitive therapy helps people change their way of reasoning about the environment, think more realistically, and see the positive side of things as well as the negative. Examples of cognitive therapy for different anxiety-related disorders are listed in Table 5.16.

Recall that many people with anxiety-related disorders engage in cognitive distortions such as catastrophizing, or incor- rectly assuming terrible things will happen from a certain event. Angelina catastrophized by assuming she would lose control, go crazy, or harm herself or others during a panic attack. A

Disorder Psychoeducation example Somatic control exercise example

Panic disorder Education about typical panic attack symptoms and a person’s sequence of physical feelings to thoughts to behaviors

Correct breathing and muscle relaxation during a panic attack

Social phobia Education about common worries and avoidance as- sociated with social and evaluative anxiety

Muscle relaxation during a public speaking assignment

Speci�c phobia Education about the irrational and excessive nature of fear and how avoidance interferes with quality of life

Correct breathing and muscle relaxation during exposure to a feared stimulus such as a dog

Generalized anxiety disorder Education about excessive, uncontrollable worry and dif�culty sleeping and other physical consequences

Muscle relaxation before bedtime to ease transition to sleep

Obsessive-compulsive disorder Education about the nature and content of key thoughts (obsessions) and how they can lead to speci�c behav- iors (compulsions)

Muscle relaxation following getting one’s hand dirty

Posttraumatic stress disorder Education about how one’s trauma has led to symptoms of reexperiencing, physical arousal, and avoidance of certain places

Correct breathing during a trip near where the trauma occurred

Separation anxiety disorder Education to parents and children about worries regard- ing harm befalling a parent or the child

Muscle relaxation upon having to enter school without parents

TABLE 5.15

Psychoeducation and Somatic Control Exercise Examples for People with Anxiety-Related Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 133

Clients are also encouraged to decatastrophize by thinking decatastrophize by thinking decatastrophize about the worst that could happen in a situation and thinking about whether this is really so bad (Newman, 2015). Angelina was terri�ed of shopping at the mall for fear of a panic attack. The therapist calmly asked her, “What is the worst thing that could happen if you had a panic attack at the mall?” Angelina said she would feel her physical symptoms. Again the therapist asked, “So? What’s the worst thing about that?” Angelina was surprised at the therapist’s calm and said she would feel embar- rassed. The therapist challenged this again by saying, “OK. Have you ever felt embarrassed before?” Angelina had, of course, and saw that being embarrassed was an uncomfortable but control- lable and temporary state of mind. She came to see over time that, even if she had a panic attack, the consequences were not severe and she could handle them.

A key goal of cognitive therapy is to increase a person’s ability to challenge negative thoughts and develop a sense of control over anxious situations. Cognitive therapy can be used to help people control fears of symptoms, negative consequences, threat, obses- sions, and reexperiencing images or thoughts (Table 5.16). Many studies have shown cognitive therapy to be a useful component for treating people with anxiety-related disorders (Hanrahan, Field, Jones, & Davey, 2013; Newman, 2015). Cognitive therapy is often combined with exposure-based practices, which we turn to next.

the shoulder. Plus, I’ve never gotten a ticket for my driving.

Therapist: That sounds like a lot of evidence against crashing.

Angelina: Yes, I guess that’s true, maybe I can handle the symptoms while driving better than I thought.

The therapist pointed out to Angelina, using several driving examples, that not only was there no evidence she would get no evidence she would get no evidence into a car accident while having a panic attack, but that even if she did have a panic attack while driving, she had the ability to protect herself by pulling over. Angelina was encouraged during future panic attacks to examine evidence that something harm- ful was going to happen. Little evidence was available to suggest this in almost all cases.

Clients may also engage in hypothesis testing to see what the actual chances are that something bad will happen (Friedberg & McClure, 2015). Angelina was asked to rate the probability she would “go crazy” and be institutionalized for a panic attack in the upcoming week. Angelina regularly replied that the odds of this happening were 60 to 80 percent, although the therapist would give estimates closer to 1 percent. Angelina came to see over time that the therapist’s hypotheses were more accurate than hers, and her estimates of disaster decreased.

Disorder Cognitive therapy example

Panic disorder Examine evidence whether heart palpitations truly indicate a heart attack. Discuss worst-case scenario of having a panic attack in a department store and how the person could control panic symptoms without avoidance.

Social phobia Test a client’s hypothesis that if she calls a coworker for information that the coworker will become ir- ritated and hang up on her. Have the client guess the probability of this happening and then make the call to see if her prediction is accurate.

Speci�c phobia Examine the worst-case scenario for what could happen if the client were exposed to something he feared, such as a snake. Explore the realistic probabilities of unlikely scenarios such as being attacked by the snake.

Generalized anxiety disorder Examine a client’s belief that worry itself has successfully stopped disaster from happening. Instead, help the client understand that worrying about some disaster does not make the disaster less likely to happen.

Obsessive-compulsive disorder Consider a client’s concern that taking risks will lead to disaster. A client may be persuaded to delib- erately make mistakes and realize that disaster will not result. Or a therapist may convey that compul- sions such as checking and handwashing do not necessarily guarantee safety or total cleanliness.

Posttraumatic stress disorder Investigate a client’s belief that all thoughts about the trauma must be suppressed. Teach the client that thoughts about the trauma are not harmful and that a full processing of these thoughts is necessary for recovery.

Separation anxiety disorder An older child or adolescent may be encouraged to consider alternative explanations for a parent being late to pick her up from school. Examples include traf�c congestion and unexpected errands and not necessarily a car accident, which is a low-probability occurrence.

TABLE 5.16

Cognitive Therapy Examples for People with Anxiety-Related Disorders

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders134

Angelina’s therapist accompanied her on various driving trips, excursions to the mall and restaurants, and classes at school (items in Figure 5.9). Angelina was also given homework assignments to practice these and other exposures on her own, including calling friends, going on dates, and driving across a high bridge. She was encouraged during these times to change her thoughts and note her control over her anxiety symptoms:

Therapist: OK, we’re in the car driving on the freeway, what are you feeling and thinking?

Angelina: I feel a little shaky, and my heart is pounding. My lungs feel tight. I’m afraid of having a panic attack and crashing and killing my therapist.

Therapist: What are the odds of that? Angelina: Pretty low. It’s not likely to happen. I’ve never

crashed the car before even when having a panic attack. Therapist: And what about your physical feelings? Angelina: I can control my breathing and stay steady. I

know I can do this! Therapist: Great! I know you can too. Let’s keep driving.

Real-life exposures are in vivo exposures, but other expo- sures can be imaginal. The latter may involve describing dif- �cult or grotesque stories to a person to have her think about negative events. We obviously do not want to re-create a trauma for someone with posttraumatic stress disorder. Many with

Exposure-Based Practices Face your fears. Have you heard that phrase before? This is one of the most important aspects of treatment for people with anx- iety-related disorders. Exposure-based practices are typically used to draw a person closer to whatever he is anxious or fear- ful about (Schneider, Arch, & Wolitsky-Taylor, 2015). A person’s fear tends to increase as he approaches a feared object or situa- tion. As the person continues to stay in the situation, however, he becomes more used to it, and fear tends to fade. The problem many people with anxiety-related disorders have is they avoid a situation or escape it as fear becomes severe. A person engaged in exposure-based practices is asked to stay in the situation, such as a mall, to experience high levels of fear and learn (1) the fear will eventually decrease over time and/or (2) the person can control the fear. Examples of exposure-based practices for different anxiety-related disorders are listed in Table 5.17.

Exposure can be gradual or fast-paced. Gradual exposure may occur during systematic desensitization, in which a person slowly approaches a feared situation while practicing relaxation training and/or cognitive therapy (Triscari, Faraci, Catalisano, D’Angelo, & Urso, 2015). An anxiety hierarchy is formed (see an example in Figure 5.9) that lists items ranging from easy to hard. The person is then exposed to the easiest (bottom) item until his anxiety level is low. He is then exposed to each subsequent step on the hierarchy until he reaches the �nal goal.

Disorder Exposure-based therapy example

Panic disorder Ride in a car with a client who fears panic attacks while driving. This may consist of sitting in a car, then driving in a parking lot, then driving on an empty road, then driving on a busier road, and then driving on a freeway.

Social phobia Gradually increase the number of minutes a person is expected to stay at a social function. Have the client practice social- and performance-based tasks such as introducing oneself, maintaining a conversation, or speaking in public.

Speci�c phobia Gradually approach a feared stimulus such as a dog. This may begin with watching �lms of dogs, then visiting a pet store, then visiting an animal shelter, then visiting a park, and then slowly approaching a friendly dog.

Generalized anxiety disorder Ask a client to expose herself to worry instead of suppressing it but to consider alternative explana- tions for events. Also, practice refraining from checking, cleaning, or other “worry behaviors.”

Obsessive-compulsive disorder Ask a client to plunge his hands into a pile of dirt and not wash. Or ask him to park near a Dumpster but breathe normally, throw shoes haphazardly into a closet and refrain from ordering them, or drive to work after checking the oven just once.

Posttraumatic stress disorder Gradually approach a setting where a trauma took place or visit a key gravesite. Engage in discussions about the traumatic event instead of suppressing reminders about the event.

Separation anxiety disorder Require a child to attend school without her parents initially for 1 hour per day. On subsequent days, add an extra 15 to 30 minutes until full-time school attendance is achieved.

TABLE 5.17

Exposure-Based Therapy Examples for People with Anxiety-Related Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 135

Exposure can also be made to internal sensations as well as external items. This refers to interoceptive exposure and is most useful for those with panic attacks (Boettcher, Brake, & Barlow, 2016). A per- son undergoing interoceptive exposure is exposed to her most terrifying physical feel- ing and asked to endure it or engage in relaxation training. A person afraid of increased heart rate might be asked to run up and down a �ight of stairs for 1 minute and then calm down and realize the symptom is not dangerous nor does it have to be avoided.

Exposure-based thera- pies are useful for all anxiety- related disorders. This is true even for obsessive-compulsive disorder, for which exposure and response (or ritual) pre-

vention are often used (Zandberg et al., 2015). A person may be exposed to her obsession and not allowed to engage in the compulsion. A person with a contamination obsession might be asked to plunge his hands into dirt and then refrain from wash- ing. His anxiety will initially be high, but over time he will learn that anxiety decreases without having to wash and that the thought is not harmful. Response prevention for someone with body dysmorphic disorder might involve limiting the number of times she can check some perceived �aw or groom herself.

A similar procedure is used for people with generalized anxiety disorder. A person is asked during worry exposure to concentrate on her anxious thought and then think of as many alternatives to the event as possible (McIntosh & Crino, 2013). A father worried about his teenager getting into a car accident be- cause she is late coming home would think about this scenario and then give more believable alternatives—perhaps the teen- ager was caught in traf�c or dropped off a friend. People with generalized anxiety disorder are also encouraged to stop their “worry behaviors” such as avoiding tasks, checking on loved ones, or cleaning their house (Newman et al., 2013). Managing time and prioritizing tasks (those to be done today, tomorrow, the next day) is also important.

Exposure-based practices are often integrated with other be- havioral procedures such as modeling and modeling and modeling biofeedback. A client during modeling watches someone else engage in an approach behavior and then practices it himself. Someone afraid of dogs could gradually approach a dog as her therapist pets the dog to model lack of fear. Clients during biofeedback are attached to a device that gives them visual feedback about heart rate, respira- tion rate, or brain wave activity. Clients are taught to relax and control their arousal by seeing how relaxation lowers heart and

posttraumatic stress disorder continue to try to avoid thinking about the event, which of course triggers more memories and �ashbacks. A person doing imaginal exposure thinks �rst about minor aspects of the trauma and later thinks about more de- tailed descriptions of the entire event. Anxiety tends to fade as a person thinks more about the event and talks about it.

Exposure for posttraumatic stress disorder can be supple- mented as well with a technique known as eye movement de- sensitization and reprocessing (EMDR). EMDR involves inducsensitization and reprocessing (EMDR). EMDR involves inducsensitization and reprocessing - ing back-and-forth eye movements in people as they recall and process traumatic memories. This process is similar to rapid eye movement during sleep and may help reduce the strength of traumatic memories in the hippocampus, as well as anxiety trig- gered by the amygdala (Shapiro, 2014). EMDR remains some- what controversial, however, and requires additional research (van den Berg et al., 2015).

Another type of exposure that simulates in vivo experiences is virtual reality therapy, which involves asking a client to wear a headset and watch computer-generated images. These images can be related to stimuli people fear, such as being on an air- plane, sitting in an enclosed space, or standing in a high place. A virtual environment can also be set up for people with public speaking anxiety. Virtual reality therapy is effective for people with phobias and is particularly useful for people with unusual or dif�cult-to-treat phobias (Diemer, Alpers, Peperkorn, Shiban, & Muhlberger, 2015).

Exposure can also be fast-paced and intensive, as in �ood- ing (Schumacher et al., 2015). Flooding involves exposing a person to fear with little preparation. A person afraid of dogs could be placed in a room with a dog (in a safe situation, of course) until intense fear subsides and he can approach the dog.

Item Anxiety rating (0-10) Avoidance rating (0-10)

Driving across a high bridge

Going on a date

Attending class

Shopping in a large department store

Eating in a restaurant

Driving along a flat road

Walking along campus

Going to a supermarket

Riding in the car with someone driving

Attending a therapy session

FIGURE 5.9 SAMPLE ANXIETY HIERARCHY FOR ANGELINA.

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CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders136

they can still function socially and occupationally. Mindfulness approaches continue to gain prominence as a key treatment for anxiety-related disorders (Orsillo, Danitz, & Roemer, 2015).

What If I Have Anxiety or an Anxiety-Related Disorder? People are often screened for anxiety-related disorders, and the answers to some basic questions may indicate whether further assessment or even treatment is warranted. Some of these ques- tions are listed in Table 5.18. If you �nd yourself answering “yes” to most of these questions, then you may wish to consult a clinical psychologist, psychiatrist, or other mental health profes- sional (see also Chapter 15). Cognitive-behavioral therapy and/ or medication for your anxiety may be best.

If you feel you have unpleasant anxiety but not necessar- ily an anxiety-related disorder, then teaching yourself to relax, changing your thoughts, and facing your fears may be best. Talk about your feelings with your family and friends or attend

respiration rates. This process is sometimes tied to exposures. A client may be asked to perform a stressful task such as count- ing backward by sevens and then relax and note how heart and respiration rates decline (Lydon, Healy, O’Callaghan, Mulhern, & Holloway, 2015; Schoenberg & David, 2014).

Mindfulness Traditional cognitive-behavioral therapies work well for many people with anxiety-related disorders, but not all, particularly those with severe or complicated symptoms. Clinical research- ers have thus designed a relatively new set of therapies to help people understand and accept their anxiety symptoms but still live a normal life. The therapist helps a client develop mind- fulness, or greater daily awareness and acceptance of his symptoms and how the symptoms can be experienced without severe avoidance or other impairment (Gu, Strauss, Bond, & Cavanagh, 2015).

A therapist might ask Jonathan, who had severe obsessions and compulsions, how he could accept his thoughts and be- havioral urges but still get work done at his job. Someone with social phobia at a party could be asked to accept the fact she is anxious but still consider what she needs to say and do to inter- act with others. Therapists using mindfulness help people recog- nize they are anxious but focus on how the anxiety can be “set aside” or how to allow thoughts to “pass through their body” so

Exposure therapy for people with phobias often means actual physical contact with the feared stimulus.

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Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 137

seem more ingrained and severe. Marcus’s prognosis may depend on how well he can face and address the trauma he experienced.

Researchers have also looked at the long-term function- ing of children with anxiety and anxiety-related disorders. Many fears and worries in childhood are temporary, such as a 4-year-old’s fear of monsters in the closet. Some traits related to anxiety, however, are more stable over time. These include behavioral inhibition and shyness. Disorders that stem from these characteristics, like social phobia or generalized anxiety disorder, may be fairly chronic over time (Copeland, Angold, Shanahan, & Costello, 2014). We also mentioned that childhood problems such as separation anxiety disorder and school re- fusal behavior can lead to long-term problems if left untreated. Obsessive-compulsive disorder is fairly stable for children and adolescents in severe cases as well (Mancebo et al., 2014). The best approach for addressing anxiety-related disorders at any age is early and complete treatment.

➲ Interim Summary • Interviews, self-report questionnaires, and observations

are used to collect information about people with anxiety-related disorders because of the internal nature of the symptoms.

• Psychophysiological assessment of anxiety-related disorders can involve heart rate, muscle tension, sweat gland activity, and other symptoms.

• Effective treatment for anxiety-related disorders addresses unpleasant physical feelings, negative thoughts, and avoidant behaviors. Biological treatment for anxiety-related disorders includes medications such as benzodiazepines and antidepressants.

• Psychological treatments for people with anxiety-related disorders often begin with psychoeducation and somatic control exercises like relaxation training or breathing retraining.

• Cognitive therapy can involve techniques such as examining the evidence, hypothesis testing, and decatastrophizing.

• Exposure-based practices are important to help a person reduce anxious avoidance.

• Exposure may be done quickly through �ooding or more gradually through systematic desensitization.

• Long-term outcome for people with anxiety-related disor- ders is best when they receive early and longer treatment and have less severe symptoms.

➲ Review Questions 1. Outline the major assessment techniques for anxiety-related

disorders, including interviews, self-report questionnaires, observations, and psychophysiological measurement.

2. What different methods may be used to control physical symptoms of anxiety?

an anxiety screening. Further information about screening and treatment for anxiety disorders can be found at the websites of the Anxiety Disorders Association of America (www.adaa. org) and the Association for Behavioral and Cognitive Thera- pies (www.abct.org). Anxiety and anxiety-related disorders can be quite painful; if they are for you, do not wait to seek more information.

Long-Term Outcome for People with Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders What is the long-term picture, or prognosis, for people with anxiety-related disorders? Factors that predict better treatment outcome include treatment compliance and completion, longer treatment (especially exposure), better social skills and social support, less depression and other comorbid disorders, less se- vere trauma and anxiety symptoms, fewer negative thinking patterns, and fewer stressful life events (Francis, Moitra, Dyck, & Keller, 2012; Goodwin, Beesdo-Baum, Knappe, & Stein, 2014; Hoffart, Hedley, Svanoe, & Sexton, 2014; Jakubovski et al., 2013; Nugent, Brown, Stratton, & Amstadter, 2014).

Angelina’s long-term prognosis was probably good be- cause she sought treatment soon after her most severe panic attacks, was motivated and did complete treatment success- fully, had supportive friends and family, and did not have other major disorders such as depression or substance use. Jonathan’s prognosis might be poorer because his symptoms

TABLE 5.18

Screening Questions for Anxiety-Related Disorder

Do you �nd that many of the anxiety symptoms described in this chapter apply to you?

Are there many things you would like to do but can’t because you feel too anxious?

Are you greatly troubled by your anxiety symptoms?

Do other people notice your anxiety or encourage you to seek help?

Does your anxiety last much of the time, even when nothing stressful is happening?

Has your work or social life or sleep suffered a lot because of anxiety or worry?

Do you get extremely upset over even little things most of the time?

Have you experienced a traumatic event that you just can’t seem to put behind you?

Do you feel sad, irritable, tense, and pessimistic much of the time?

If you could improve your life, would it include feeling less anxious?

CHAPTER 5 Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders138

5. What is the prognosis or long-term outcome for people with anxiety-related disorders?

3. What techniques might be used to help an anxious person change negative thoughts?

4. What strategies could a mental health professional use to help someone with anxiety eliminate avoidance?

How much prodding is too far? Don’t people have a right to live their lives the way they want to, even if it means avoiding some places? On the other hand, don’t therapists have an obligation to their client to end their distress, even if it means short-term fear? The ethical guidelines of the American Psychological Association stipulate that psychologists are expected to “make reasonable efforts to answer patients’ questions and to avoid apparent misunderstandings about therapy.” The client should thus know ahead of time what will occur in therapy, including dif�cult real-life exposures, and agree to it. This also involves informed consent, which means people entering therapy should be fully informed about all potential risks and bene�ts of therapy.

Angelina expressed a lot of hesitation about the exposure process, but the therapist made sure she was fully educated about what to expect—such as a possible panic attack—as well as what bene�ts suc- cessful therapy might bring, such as ability to return to school. In this way, no surprises awaited Angelina, and she was more accepting of the therapy process.

Focus On

Imagine you are the therapist treating Angelina for her panic attacks and ago- raphobia. Imagine also that one of your treatment sessions involves accom- panying Angelina to a local mall she has not visited for several months. She greatly fears having a panic attack, but your job is to expose her to the setting so she can realize her intense anxiety will subside and she can control her panic symptoms. People with panic disorder and agoraphobia are often able to successfully complete their anxiety hierarchy. In other cases, though, fear is so intense it takes a lot of encouragement, even prodding, by the therapist.

Law and Ethics The Ethics of Encouragement in Exposure-Based Practices

5.4

Final Comments People with anxiety and anxiety-related disorders suffer substantial distress from scary physical feelings, negative thoughts, and avoidance of things they normally like to do. This is important to remember the next time someone you know does something like speak in front of others or �y nervously in an airplane. Fear and anxiety are normal, but there can be situations in which the emotions get out of control. If they do, talking to someone about it or contacting a quali�ed mental health professional is a good idea.

Thought Questions 1. Think about television shows or �lms you have seen that have anxious characters in them. Do you

think these characters display realistic or unrealistic symptoms of anxiety? How so?

2. What situations make you most anxious? How do you feel physically, what do you think in those situations, and what do you do? Would you change anything after having read this chapter?

3. What would you now say to a friend who might be very anxious?

4. What separates “normal” anxiety from “abnormal” anxiety? Do you think anxiety has more to do with personal, family, or other factors? Why?

5. What do you think could be done socially to reduce anxiety in people?

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment 139

Key Terms worry 101 anxiety 101 fear 101 anxiety-related disorder 102 panic attack 103 panic disorder 104 agoraphobia 105 social phobia 105 speci�c phobia 106 generalized anxiety disorder 107 compulsions 108 obsessions 108 obsessive-compulsive disorder 108

body dysmorphic disorder 109 posttraumatic stress disorder 110 acute stress disorder 112 separation anxiety disorder 114 school refusal behavior 114 behavioral inhibition 121 cognitive distortions 122 catastrophizing 122 emotional reasoning 122 thought–action fusion 122 emotional processing 122 anxiety sensitivity 123 behavioral avoidance tests 129

psychoeducation 131 somatic control exercises 131 relaxation training 131 breathing retraining 132 cognitive therapy 132 exposure-based practices 134 systematic desensitization 134 �ooding 135 interoceptive exposure 135 response (or ritual) prevention 135 worry exposure 135 mindfulness 136 informed consent 138

141

Special Features

CONTINUUM FIGURE 6.1 Continuum of Somatization and Somatic Symptom Disorders 144–145

CONTINUUM FIGURE 6.4 Continuum of Dissociation and Dissociative Disorders 158

Personal Narrative 6.1 Heather Pate 160

• 6.1 FOCUS ON COLLEGE STUDENTS: Somatization 148

• 6.2 FOCUS ON VIOLENCE: Terrorism and Medically Unexplained Symptoms 152

• 6.3 FOCUS ON COLLEGE STUDENTS: Dissociation 161

• 6.4 FOCUS ON LAW AND ETHICS: Recovered Memories and Suggestibility 162

• 6.5 FOCUS ON DIVERSITY: Dissociation and Culture 162

• 6.6 FOCUS ON VIOLENCE: Dissociative Experiences and Violence Toward Others 166

V THE CONTINUUM VIDEO PROJECT Lani and Jan / Dissociative Identity Disorder 169

Somatic Symptom and Dissociative Disorders: A Historical Introduction

Somatization and Somatic Symptom Disorders: What Are They?

C Gisela / What Do You Think?

Somatic Symptom Disorders: Features and Epidemiology

Stigma Associated with Somatic Symptom Disorders

Somatic Symptom Disorders: Causes and Prevention

Somatic Symptom Disorders: Assessment and Treatment

Dissociative Disorders

C Erica / What Do You Think?

Normal Dissociation and Dissociative Disorders: What Are They?

Dissociative Disorders: Features and Epidemiology

Stigma Associated with Dissociative Disorders

Dissociative Disorders: Causes and Prevention

Dissociative Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Somatic Symptom and Dissociative Disorders 6

CHAPTER 6 Somatic Symptom and Dissociative Disorders142

or identity were differentiated. Researchers now study somatic symptom and dissociative disorders as largely distinct entities, so we describe the disorders separately here. We begin our dis- cussion with somatic symptom disorders.

Somatization and Somatic Symptom Disorders: What Are They?

We get more aches and pains as we age (trust us). Many additional aches and pains result from normal wear in joints, muscles, and tendons. We also take longer to heal as we age and often cannot do what we could when we were 20 years old (trust us again). We thus spend more time in doctors’ of�ces as we age. All of this is normal. Many of us also visit health pro- fessionals for regular checkups and preventive care.

Many people also engage in somatization, or a tendency to communicate distress through physical symptoms and to pursue medical help for these symptoms (Garcia-Albea, Garcia-Parajua, & Navas, 2015). The pre�x soma means “body”; therefore, anysoma means “body”; therefore, anysoma - thing “somatic” refers to the physical body. Many of us become concerned with strange symptoms that compel us to visit a phy- sician. We may be told nothing is wrong or that the problem is minor and not to be dwelled on. We then experience relief and usually let the matter rest. Other times physicians prescribe a general remedy for a vague problem like moderate back pain, which typically addresses the problem to our satisfaction. All of these are normal occurrences.

Somatic Symptom and Dissociative Disorders: A Historical Introduction

This chapter is actually like two mini-chapters: one on so-matic symptom disorders and one on dissociative disorders. Somatic symptom and dissociative disorders were once seen as related but are now considered distinct disorders. Somatic symp- tom disorders generally involve physical symptoms with great distress and impairment. Dissociative disorders often involve a disturbance of consciousness, memory, or identity (American Psychiatric Association [APA], 2013).

In the past, people believed that both somatic symptom dis- orders and dissociative disorders were the result of psychologi- cal factors such as trauma. Psychodynamic theorists believed strange or “hysterical” behaviors resulted from unconscious con�icts related to personal trauma. An adult severely neglected as a child may relate to others with dif�culty, seek attention through constant physical complaints, or channel distress into bizarre and medically unexplained sensory-motor symptoms. These symptoms may include glove anesthesia (numbness in the hand only), paralysis, and sudden blindness or deafness (Brown, 2013). Or a person may develop amnesia about trau- matic events in childhood that allows him to detach or dissoci- ate from those events.

As perspectives other than the psychodynamic one gained traction within clinical psychology, disorders related to physi- cal symptoms and disorders related to consciousness, memory,

C / G/ G/ isela

Gisela was referred to psychological treatment by her physician. Gisela was 29 years old and had a 5-year history of physical complaints that medical tests could not explain. She often complained of general abdominal and back pain but no speci�c physical trauma. Gisela visited the physician several times a year, typically with some variation of the same complaint, and asked for waivers and doctors’ notes to help her miss work. The physician conducted a wide array of tests multiple times over several years but concluded that Gisela’s constant complaints were due to stress, child rearing, marital issues, or another psychologi- cal variable.

Following two cancellations, Gisela met with a clinical psychologist who often ac- cepted referrals from physicians. Gisela was

emotional during her initial interview and said she had difficulty caring for her two small chil- dren and her husband while working full time. She said she often felt pain in her “lower gut,” as well as different places in her back. Gisela could not specify an area of pain, instead saying, “It just hurts all over.” The therapist asked Gisela about when or how often pain occurred, but she gave vague answers such as “all the time,” “when I am at work or work- ing at home,” and “I don’t know exactly.” Gisela added she sometimes felt numbness in her feet, a symptom her doctors could not explain. She also had occasional nausea and vomiting.

The psychologist asked how long Gisela had been in pain, and she replied, “It feels like I’ve had it all my life.” She also could

not connect her symptoms to any physical trauma. She had not been, for example, in a car accident or the victim of a crime. The psychologist then suggested that Gisela’s back pain might be due to the psychological and physical stress of caring for two small chil- dren. Gisela dismissed this notion, however, saying the pain could not be explained by sim- ply lifting children because the pain was often sharp, severe, and debilitating. She thus felt unable to complete chores, go to work, or drive when her pain �ared.

The psychologist also explored other concerns Gisela had, such as her fear that “something is really wrong with me.”

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Somatization and Somatic Symptom Disorders: What Are They? 143

Other people like Gisela make frequent doctor visits for physical symptoms with no clear biological cause. Physicians are struck by the number of visits these patients request or num- ber of surgeries they want. These patients are not relieved by constant reassurances from their physicians that no real prob- lem exists. Hostility is thus common between physicians and these patients, and many of the patients visit multiple doctors and hospitals for relief or to understand what is wrong with them. Many resist suggestions their physical symptoms have some psychological basis. Gisela dismissed the psychologist’s suggestion that stress or family issues caused her symptoms.

People with extreme somatization may have a somatic symptom disorder (see Figure 6.1). A person with a somatic symptom disorder experiences physical symptoms that may or may not have a discoverable physical cause. These symptoms may resemble minor complaints such as general achiness or pain in different areas of the body. Complaints that are more moder- ate may include loss of sexual desire, nausea and vomiting, and bloating. The person is highly distressed by the symptoms.

Other disorders are related to somatic symptom disorder, although the term somatic symptom disorders is used in this chapter to collectively refer to all of these disorders (APA, 2013). For example, some people are excessively preoccupied with the consequences of various physical symptoms. These people may be less concerned with general symptoms, but they fear they have some serious disease. In addition, other people have symp- toms that are quite severe and include sudden blindness, deaf- ness, or paralysis. These physical symptoms may be linked to

Gisela worried she had a serious condition such as Epstein-Barr virus, lupus, or Lyme disease. She also became de�ant when the psychologist mentioned her doctor tested for these disorders multiple times with negative results. Gisela said she did not trust her doctor to care adequately for her. She also revealed she had seen other doctors in the past but complained they seemed overwhelmed by their numbers of patients and did not have time to consider all possibilities for her symptoms.

The psychologist received permission from Gisela to speak to her husband, physi- cian, and boss. Each said Gisela was a sweet, decent person who truly loved her children and husband. Each commented, however, about Gisela’s great need for attention, continual symptom complaints, and desire for reassur-

ance. Her husband and boss described Gisela as a manipulative person who would bend the truth to get something she wanted. Her hus- band said Gisela sometimes embellished dif- �culties to avoid obligations or gain attention and volunteered that she was no longer inter- ested in sex.

Gisela also revealed that she often evaluated herself for physical problems. She often noted her pulse rate and blood pressure, kept a diary of times when her pain �ared, and concentrated on minor changes in her physical condition. These factors seemed related to a somatic symptom disorder. Gisela’s psychologist suggested a treat- ment approach that would include physical and psychological components, although Gisela re- mained more interested in alleviating her physi- cal symptoms than any psychological problem.

What Do You Think? 1. Which of Gisela’s symptoms seem typical

or normal for someone with family and job demands, and which seem very different?

2. What external events and internal factors might be responsible for Gisela’s dramatic presentation of physical symptoms?

3. What are you curious about regarding Gisela?

4. Does Gisela remind you in any way of yourself or someone you know? How so?

5. How might Gisela’s physical complaints affect her life in the future?

case

Many people naturally worry about various health concerns as they age, but excessive worry can become a problem.

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CHAPTER 6 Somatic Symptom and Dissociative Disorders144

anxiety and depression. Finally, other people deliberately induce symptoms in themselves.

A psychological component likely contributes to somatic symptom disorders. Such components often involve stress, con- �ict, isolation, or trauma. You may have heard the term psycho- somatic to describe people with physical symptoms that seem somatic to describe people with physical symptoms that seem somatic “all in their head.” A person may be constantly complaining about real physical symptoms or diseases, but the complaints seem a little exaggerated or far-fetched. Psychosomatic and so- matic symptom disorders are not exactly the same, but our body and mind are closely connected, so disturbances in one area can lead to problems in the other. We next describe the most com- monly diagnosed somatic symptom disorders.

Somatic Symptom Disorders: Features and Epidemiology

Major somatic symptom disorders in the �fth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include somatic symptom disorder, illness anxiety dis- order, conversion disorder, and factitious disorder.

Somatic Symptom Disorder Do you ever have strange, unexplained feelings in your body? Many people do, such as a sudden pain in the head or a twinge in the abdomen. Most of us pay little attention to these changes because they are not severe and do not last long. Other people like Gisela pay much attention to these physical symptoms and complain about them for many years. A diagnosis of somatic symptom disorder may thus apply.

Somatic symptom disorder involves at least one physical symptom that causes a person great distress as well as impair- ment in daily functioning. A key part of the disorder, however, is that the person has recurrent thoughts that the symptom is serious or has great anxiety about the symptom or one’s health. The per- son may also devote substantial time and energy to the symptom,

such as visiting doctors. Gisela’s symptoms caused her to experi- ence distress, miss work, and fail to complete obligations at home. Keep in mind the symptoms the person feels are real—they are not “faked”—and the symptoms may or may not have a medical expla- nation. Somatic symptom disorder in the �fth edition of the DSMDSM (DSM-5(DSM-5( ) is related to somatization disorder and pain disorder in the fourth edition of the DSM (DSM (DSM DSM-IV (DSM-IV ( ), and many of those with the older diagnoses are expected to meet criteria for somatic symptom disorder (APA, 2013). Much of the research literature thus concerns somatization and pain disorders and is presented in this chapter.

A diagnosis of somatic symptom disorder involves the DSM-5 criteria in Table 6.1 (APA, 2013). Some people with

6.1 Continuum of Somatization and Somatic Symptom DisordersCONTINUUM FIGURE

NORMAL MILD

Emotions Optimism regarding health. Mild physical arousal and feeling of uncertainty Mild physical arousal and feeling of uncertainty about certain physical symptoms.

Cognitions No concerns about health. Some worry about health, perhaps after Some worry about health, perhaps after reading a certain magazine article.

Behaviors Attending regular, preventive checkups with a physician. Checking physical body a bit more Attending regular, preventive checkups with a physician. Checking physical body a bit more or scheduling one unnecessary physician visit.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

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TABLE 6.1 DSM-5

Somatic Symptom Disorder A. One or more somatic symptoms that are distressing or result in

signi�cant disruption of daily life.

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

2. Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy devoted to these symptoms or health

concerns.

C. Although any one somatic symptom may not be continuously pres- ent, the state of being symptomatic is persistent (typically more than 6 months). Specify if symptoms primarily involve pain, if symptoms have a persistent course, and if severity is mild (one criterion B symptom), moderate (two criterion B symptoms), or severe (2–3 criterion B symptoms with multiple somatic complaints or one very severe somatic symptom).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Somatic Symptom Disorders: Features and Epidemiology 145

somatic symptom disorder experience signi�cant pain. Gisela reported pain in several areas of her body. People with somatic symptom disorder may complain of pain in areas of the body dif�cult to assess for pain. Common examples include the back, neck, face, chest, pelvic area, abdomen, sciatic nerve, urinary system, and muscles. Some people initially experience pain from a physically traumatic event but continue to report pain even when fully healed. A burn victim may continue to report pain even when grafts and dressings are �nished and when no medi- cal explanation for pain exists. Other people undergo limb am- putation and still report pain in that limb, a condition known as phantom pain that may have psychological and physical causes (Johnson, Mulvey, & Bagnall, 2015).

Other common complaints include fatigue, shortness of breath, dizziness, and heart palpitations (Vishal, Brahmbhatt, & Vankar, 2014). People with somatic symptom disorder may also have certain personality traits or patterns—they may be atten- tion seeking, seductive, manipulative, dependent, and/or hostile toward family, friends, and clinicians. They may show aspects of personality disorders marked by dramatic or unstable behavior (Chapter 10; Laugharne & Flynn, 2013).

Somatization problems may be “functional” or “present- ing.” Functional somatization refers to what we just described— medically unexplained symptoms not part of another mental disorder. Presenting somatization refers to somatic symptoms usually presented as part of another mental disorder, especially anxiety or depression (Murray, Toussaint, Althaus, & Lowe, 2016). Someone with depression may feel fatigued or have low sexual drive, but these physical symptoms are because of the de- pression. Overlap may occur between functional and presenting somatization. Mental conditions such as depression and stress are good predictors of whether someone with chronic physical symptoms will seek help (Caplan & Buyske, 2015).

Illness Anxiety Disorder Other people are less concerned with symptoms than of some overall disease. People with illness anxiety disorder are

preoccupied with having some serious disease that may explain general bodily changes. Someone with illness anxiety disor- der may worry about having hepatitis or AIDS based on mi- nor changes in pulse rate, perspiration, or energy level. Recall that Gisela worried about illnesses such as Lyme disease. Illness anxiety disorder in DSM-5 is related to hypochondriasis in DSM- IV, and many of those with the older diagnosis are expected to meet criteria for illness anxiety disorder (APA, 2013). Much of the research literature thus concerns hypochondriasis and is presented in this chapter.

A diagnosis of illness anxiety disorder involves the DSM-5 criteria in Table 6.2 (APA, 2013). People with illness anxiety

MODERATE

SOMATIC SYMPTOM DISORDER—LESS SOMATIC SYMPTOM DISORDER—LESS

SEVERE

SOMATIC SYMPTOM DISORDER—MORE SOMATIC SYMPTOM DISORDER—MORE

SEVERE

Moderate physical arousal and greater Moderate physical arousal and greater uncertainty about one‘s health.uncertainty about one‘s health.

Intense physical arousal misinterpreted as a sign or Intense physical arousal misinterpreted as a sign or symptom of some terrible physical disorder.symptom of some terrible physical disorder.

Extreme physical arousal with great trouble Extreme physical arousal with great trouble concentrating on anything other than physical state.concentrating on anything other than physical state.

Strong worry about aches, pains, Strong worry about aches, pains, possible disease, or appearance. possible disease, or appearance. Fleeting thoughts about death or dying.Fleeting thoughts about death or dying.Fleeting thoughts about death or dying.

Intense worry about physical state or appearance. Intense Intense worry about physical state or appearance. Intense fear that one has a serious disease. Common thoughts fear that one has a serious disease. Common thoughts about death and dying.about death and dying.

Extreme worry about physical state. Extreme fear of Extreme worry about physical state. Extreme fear of having a serious potential disease. Frequent thoughts having a serious potential disease. Frequent thoughts about death and dying.about death and dying.about death and dying.

Scheduling more doctor visits but generally feeling relieved after each one.

Regular doctor shopping and requests for extensive and Regular doctor shopping and requests for extensive and repetitive medical tests with little or no relief. Checking repetitive medical tests with little or no relief. Checking body constantly for symptoms.

Avoidance of many social and work activities. Scheduling regular surgeries, attending specialized clinics, or searching for exotic diseases.

Back pain is one of the most common complaints reported by people with somatic symptom disorder.

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CHAPTER 6 Somatic Symptom and Dissociative Disorders146

disorder may worry about having a particular disease even after medical tests prove otherwise. A person may receive a negative HIV test but still worry about having AIDS. Such a preoccupa- tion must last at least 6 months and cause substantial distress or impairment in daily functioning. A diagnosis of illness anxiety disorder can also involve frequent medical care such as testing, or avoidance of doctors and hospitals.

People with illness anxiety disorder may have other unique characteristics. Thoughts about having an illness are constant and may resemble those of obsessive-compulsive disorder (Chapter 5). People with illness anxiety disorder may also have signi�cant fears of contamination and of taking prescribed med- ication. They are intensely aware of bodily functions, and many complain about their symptoms in detail (unlike those with so- matic symptom disorder). This may be because they want to help their physician �nd a “diagnosis” and a “cure” even though an actual disease may not exist. Many people with illness anxi- ety disorder fascinate themselves with medical information and have autosuggestibility, meaning that reading or hearing about an illness can lead to fear of having that disease (Bailer et al., 2015). This may be particularly problematic in the age of the Internet with its many websites that offer self-diagnostic tools.

Conversion Disorder People with conversion disorder experience motor or sensory problems that suggest a neurological or medical disorder, even suggest a neurological or medical disorder, even suggest though one has not been found. Examples include sudden blind- ness or deafness, paralysis of one or more areas of the body, loss of feeling or ability to experience pain in a body area, feeling

of a large lump in the throat (globus hystericus), and pseudo- seizures, or seizure-like activity such as twitching or loss of consciousness without electrical disruptions in the brain.

A diagnosis of conversion disorder involves the DSM-5 cri- teria in Table 6.3 (APA, 2013). Symptoms related to the disorder are real—again, they are not “faked”—but have no medical ex- planation. The symptoms are also not part of a behavior or ex- perience that is part of one’s culture. Many religious and healing rituals in different cultures involve peculiar changes such as loss of consciousness, but this is not conversion disorder.

Psychological, not physical, stressors generally trigger symptoms of conversion disorder. Examples include trauma, con�ict, and stress. A soldier may suddenly become paralyzed in a highly stressful wartime experience. A psychodynamic theo- rist might say the terror of trauma is too dif�cult to bear, and so distress is “converted” into a sensorimotor disability that is easier to tolerate. You might guess that these symptoms cause substantial distress and signi�cantly interfere with daily func- tioning. However, many people with conversion disorder also experience la belle indifference, meaning they are relatively un- concerned about their symptoms. This seems odd because most of us, if we suddenly developed a severely disabling condition, would be distraught. A lack of concern, however, may indicate other psychological factors are at play, perhaps including dra- matic or attention-seeking behavior (Fadem, 2013).

Factitious Disorder and Malingering Factitious disorder disorder refers to deliberately falsifying or producing physical or psychological symptoms (see Table 6.4; APA, 2013). A person with factitious disorder may fabricate physical complaints such as stomachaches or psychological

TABLE 6.2 DSM-5

Illness Anxiety Disorder A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate.

C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

D. The individual performs excessive health-related behaviors or exhibits maladaptive avoidance.

E. Illness preoccupation has been present for at least 6 months, but the speci�c illness that is feared may change over that period of time.

F. The illness-related preoccupation is not better explained by another mental disorder. Specify whether medical care is frequently used (care-seeking type) or medical care is rarely used (care-avoidant type).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 6.3 DSM-5

Conversion Disorder (Functional Neurological Symptom Disorder) A. One or more symptoms of altered voluntary motor or sensory

function.

B. Clinical �ndings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

C. The symptom or de�cit is not better explained by another medical or mental disorder.

D. The symptom or de�cit causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type, if symptoms are acute (less than 6 months) or persistent (6 months or more), and if symptoms occur with or without a psychological stressor.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Somatic Symptom Disorders: Features and Epidemiology 147

complaints such as sadness to assume the sick role. People with factitious disorder may purposely make themselves sick by tak- ing medications or inducing fevers. Factitious disorder is thus different from somatic symptom and illness anxiety disorders in which a person does not deliberately cause his symptoms.

Munchausen syndrome is a factitious disorder in which a person causes symptoms and claims he has a physical or mental disorder. This could involve mimicking seizures or injecting fe- cal bacteria into oneself. The disorder may be somewhat more common among women visiting obstetricians and gynecolo- gists, including women who deliberately induce vaginal bleed- ing. Some people with Munchausen syndrome may experience stressful life events or depression or have aspects of borderline or antisocial personality disorder (Bass, Acosta, Adshead, & Byrne, 2014). The prevalence of factitious disorder is 0.5 to 2 percent; Munchausen syndrome is rare. Treatments for factitious disorder are not well developed (Bass & Halligan, 2014).

Munchausen syndrome by proxy (or factitious disorder im- posed on another) refers to adults who deliberately induce illness posed on another) refers to adults who deliberately induce illness posed on another or pain into a child and then present the child for medical care (Table 6.4). The parent is usually the perpetrator and often de- nies knowing the origin of the child’s problem (Burton, Warren,

Lapid, & Bostwick, 2015). The child generally improves once separated from the parent. Most child victims of Munchausen syndrome by proxy are younger than age 4 years, and most per- petrators are mothers. A main motive for these terrible acts is at- tention and sympathy the parent receives from others (Ozdemir et al., 2015).

External incentives are absent in factitious disorder, but ma- lingering refers to deliberate production of physical or psycho- logical symptoms with some external motivation. Malingering is not a formal DSM-5 diagnosis like factitious disorder but rather an additional condition that may be a focus of clinical atten- tion. A person may complain of back pain or claim he hears voices to avoid work or military service, obtain �nancial com- pensation or drugs, or dodge criminal prosecution (APA, 2013). Symptom exaggeration may occur, especially in cases involving disability or workers compensation (30 percent), personal injury (29 percent), criminality (19 percent), and medical or psychiat- ric issues (8 percent; Bass & Halligan, 2014).

Physicians are often encouraged to note when reported symptoms do not match �ndings from medical tests (Zubera, Raza, Holaday, & Aggarwal, 2015). Mental health profession- als may use neuropsychological testing or tests such as the Minnesota Multiphasic Personality Inventory—2 (MMPI-2; Chapter 4) to identify someone with malingering (Fazio, Sand- ers, & Denney, 2015). People who malinger sometimes deliber- ately do worse on certain tests that even grossly impaired people can do. Mental health professionals generally avoid promises of external commitments such as �nancial bene�ts and gently confront a malingering client to keep him focused on immediate and veri�able problems (Bass & Halligan, 2014).

Epidemiology of Somatic Symptom Disorders DSM-5 diagnostic labels are used in the following sections for continuity purposes, but keep in mind that the research base is largely from parallel DSM-IV diagnoses of somatization and DSM-IV diagnoses of somatization and DSM-IV pain disorders (akin to somatic symptom disorder) and hypo- chondriasis (akin to illness anxiety disorder). Many people with somatic symptom disorders remain in the medical system and not the mental health system, and many have vague symptoms, so data regarding epidemiology remain sparse. Complicating matters is that several known medical conditions include vague, unde�ned symptoms that make it dif�cult to tell whether a per- son has a true physical disorder. Examples of these conditions include �bromyalgia (widespread pain in muscles and soft tis- sue), chronic fatigue syndrome, lupus (an autoimmune disor- der causing organ damage), and irritable bowel syndrome (see Appendix; Fadem, 2013).

Many people display moderate somatization and not a for- mal somatic symptom disorder. Medically unexplained symp- toms occur in about 40.2 to 49.0 percent of patients presenting to primary care doctors. Formal somatic symptom disorders are less common, however (Table 6.5). The prevalence of somatic symptom disorder (somatization disorder) is 0.8 to 4.7 percent. The prevalence of DSM-IV pain disorder, now part of somatic DSM-IV pain disorder, now part of somatic DSM-IV symptom disorder, is 1.9 percent. The mean prevalence rate of

TABLE 6.4 DSM-5

Factitious Disorder Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

B. The individual presents himself or herself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)

A. Falsi�cation of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identi�ed deception.

B. The individual presents another individual (victim) to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, receives this diagnosis.

Specify if there is a single episode or recurrent episodes of falsi�- cation of illness and/or induction of injury.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 6 Somatic Symptom and Dissociative Disorders148

illness anxiety disorder (hypochondriasis) in the general popula- tion is reportedly about 0.25 to 1.0 percent, although this may rise to 2 percent in medical settings. Conversion disorder has been less studied epidemiologically and is probably more rare. Conversion disorder may be present in only 0.3 percent of the general population, but this rate likely differs across cultures (Dobbelstein, 2015; Haller, Cramer, Lauche, & Dobos, 2015). Fac- tors associated with high total somatic symptoms include less education, nonmarried status, history of child maltreatment, presence of other medical illnesses, anxiety, and depression (Creed et al., 2012). Somatic symptoms are also common among college students (see Box 6.1).

The most common medically unexplained symptoms across cultures are gastrointestinal problems and strange skin sensations such as feelings of burning, crawling, and numbness. These symp- toms are reported more often among people in Africa and southern Asia than in Europe and North America. Conversely, Europeans and North Americans tend to be more preoccupied with symp- toms related to heart disease and cancer compared with other re- gions of the world (Bouman, 2015). In addition, many people of non-Western nations express distress (depression and anxiety) in more somatic than cognitive forms. Certain cultures may socially reinforce somatic expressions of distress (Zhou et al., 2015).

Somatic symptom disorders are closely related to depres- sion and anxiety, as well as greater general impairment and health care use (Toussaint et al., 2016). Somatic symptom and illness anxiety disorders have features similar to panic, gener- alized anxiety, and obsessive-compulsive disorders. Somatic

symptom and illness anxiety disorders also present together in 20 percent of cases (Lee, Creed, Ma, & Leung, 2015). Overlap be- tween somatic symptoms and personality disorders, especially personality disorders involving dramatic or erratic behavior, has also been noted (Silberschmidt, Lee, Zanarini, & Schulz, 2014).

Stigma Associated with Somatic Symptom Disorders

People of different cultures may report various types of psy-chological symptoms depending on local norms and whether stigma is present. For example, those from Asian cultures tend to use somatic complaints to express depression because doing so is less stigmatizing than admitting emotional sadness (Zhou et al., 2015). In addition, fear of stigma may delay treatment among some people with depression and somatization (Wang, Peng, Li, & Peng, 2015). Indeed, family members, friends, and even physicians may view a person with a somatic symptom disorder as more of a nui- sance than someone who needs psychological help (Noyes, 2014).

Stigma can affect illness behaviors as well. People with unexplained medical symptoms, such as those with chronic fatigue syndrome, often face blame or dismissal from others who attribute their symptoms to emotional problems. This may affect their decision to seek treatment. People with somatiza- tion concerned about stigma will also continue to emphasize somatic and not psychological explanations for their symptoms (Rohlof, Knipscheer, & Kleber, 2014). Such stigma concerns even affect people with severe medical conditions, such as epilepsy (England, Austin, Beck, Escoffery, & Hesdorffer, 2014).

➲ Interim Summary • Somatic symptom and dissociative disorders were once

thought to be linked, but they are now seen as largely separate entities.

• Somatization is a tendency to communicate distress through physical symptoms and to pursue medical help for these symptoms.

TABLE 6.5

Prevalence Rates of Major Somatic Symptom Disorders

Somatic symptom disorder 0.8–4.7 percent

Illness anxiety disorder 0.25–1.0 percent

Conversion disorder 0.3 percent

the day of the exam. Somatic symptoms that increased most included headache, back pain, nausea, stomach discomfort or churning, loss of ap- petite, and excessive tiredness. Other symptoms that increased somewhat included abdominal and joint pain, frequent diarrhea, and sexual indif- ference. Much of the increased somatization was due to neuroticism, or a general personality trait characterized by anxiety, worry, and moodiness (Zunhammer, Eberle, Eichhammer, & Busch, 2013). Others have found college student somatization to relate to perfectionism, depression, loneli- ness, and symptoms of eating disorder (Chapter 8; Klibert et al., 2014; Soares, Lucas, Oliveira, Roque, & Cadima, 2012; Tseng, Gau, Tseng, Hwu, & Lee, 2014). Stress in college thus appears to exacerbate many anxiety- and mood-related problems that perhaps previously existed.

Focus On

Stress is obviously a big part of the college experience (see Appendix), and Stress is obviously a big part of the college experience (see Appendix), and somatic symptoms can accompany exam stress in many cases. College stusomatic symptoms can accompany exam stress in many cases. College stu- dents in one study reported a variety of somatization problems that dra- matically increased during an examination period, which was de�ned as

6.1

College Students Somatization

Somatic Symptom Disorders: Causes and Prevention 149

• Somatic symptom disorder refers to medically explained or unexplained pain or other physical symptoms that cause distress and impairment.

• Illness anxiety disorder refers to excessive concern that one has a serious disease.

• Conversion disorder refers to medically unexplained pseu- doneurological symptoms.

• Factitious disorder refers to deliberately inducing symp- toms in oneself or others, whereas malingering refers to doing so for some external motivation.

• Somatization is common among medical patients, but formal somatic symptom disorders are less prevalent. Somatic symptom disorder and illness anxiety disorder are more common than conversion disorder.

• Medically unexplained symptoms differ across cultures and are closely related to depression and anxiety and personality disorders.

• Fear of stigma could delay treatment among some people with somatic symptom disorders.

➲ Review Questions 1. What is the difference between somatization and a somatic

symptom disorder? 2. De�ne and contrast different somatic symptom disorders. 3. How does functional somatization differ from presenting

somatization? 4. How common are different somatic symptom disorders? 5. How might stigma affect somatic symptom disorders?

Somatic Symptom Disorders: Causes and Prevention

Data regarding the cause of somatic symptom disorders have emerged slowly. Key factors related to the development of these disorders may include genetics, brain changes, illness be- havior, and cognitive, cultural, evolutionary, and other factors.

Biological Risk Factors for Somatic Symptom Disorders Genetics Somatic symptom disorder may have a moderate genetic basis, with a heritability estimate of 0.44 (Kendler et al., 2011). Ill- ness anxiety disorder may also have a moderate genetic basis, with a reported heritability estimate of 0.54 to 0.69 (Taylor & Asmundson, 2012). Somatic symptom disorders often cluster among family members, particularly female relatives and be- tween parents and children (Schulte & Petermann, 2011). Sev- eral aspects of somatic symptom disorders have a genetic basis as well, especially anxiety, anxiety sensitivity (Chapter 5), de- pression (Chapter 7), and alexithymia (dif�culty understanding one’s emotions; Cairncross, Veselka, Schermer, & Vernon, 2013).

Brain Features Another biological risk factor for somatic symptom disorders may be brain changes, especially in areas relevant to emotion, percep- tion, and physical feeling. Key aspects of the brain thus include the amygdala and limbic system, hypothalamus, and cingulate, prefrontal, and somatosensory cortices (see Figure 6.2; Fayed et al., 2012; Su et al., 2014). These areas may be overactive in some people with somatic symptom disorders (Perez, Barsky, Vago, Baslet, & Silbersweig, 2015). Some people may thus perceive or “feel” bodily changes and experiences that are not actually oc- curring. Recall from Chapter 5 that the amygdala is associated with fearful emotional responses and physical symptoms such as increased heart rate and sweating. An overactive amygdala may thus explain why people with somatic symptom disorders experi- ence many physical changes and concern about the changes.

Others propose that changes in these brain areas interfere with inhibitory behavior and promote hypervigilance about symptoms, as well as increased central nervous system activity and stressful responses (Matthias & Pollatos, 2014). Some dis- ruption is occurring in communications between the brain and body. Some people with somatic symptom disorders may thus feel they must constantly check physical status indicators such as heart rate, blood pressure, and respiration (Klaus et al., 2015).

Recall from our earlier discussion that some people report feeling pain in a recently amputated limb. People with phantom limb pain appear to have changes in the brain’s motor and so- matosensory cortices. The brain initially seems to have trouble adjusting to the missing limb because motor and somatosensory cortices must undergo a neuronal reorganization to account for the missing limb (Flor, Diers, & Andoh, 2013). Other research- ers have also noted substantial somatization among people with medical illnesses such as coronary heart disease, multiple scle- rosis, diabetes, chronic obstructive pulmonary disease, cancer, or arthritis (Wiborg & Lowe, 2015).

Other biological evidence also suggests that people with somatic symptom disorders have brain changes that lead to dis- tractibility, dif�culty growing accustomed to continuous stimuli such as physical sensations, and limited cognitive functioning. These brain changes may include dysfunction in the frontal lobe and right hemisphere (Labate et al., 2012). Changes in the right hemisphere may help explain why many somatic complaints tend to be on the left side of the body.

Neuroimaging evidence also reveals possible changes in blood �ow to key brain areas. Researchers have found changes in different areas of the cortex among people with conversion disorder (Burke, Ghaffar, Staines, Downar, & Feinstein, 2014). Decreased blood �ow may occur in areas of the prefrontal cortex and other aspects of the brain related to loss of sensory and mo- tor function as seen in conversion disorder (Schrag et al., 2013; see Figure 6.3).

Environmental Risk Factors for Somatic Symptom Disorders Environmental risk factors are also likely for people with somatic symptom disorders, especially those preoccupied with disease.

CHAPTER 6 Somatic Symptom and Dissociative Disorders150

We also generally accept sickness as a socially appropriate means of withdraw- ing from obligations, so negative rein- forcement can be powerful as well. For people with somatic symptom disorders, like Gisela, social reinforcement for con- stant complaints or doctor visits may help explain why these disorders persist for long periods. Such demands for at- tention may intersect as well with some- one’s dramatic personality structure or disorder.

Another form of comfort relevant to this population is reassurance. Many of us feel reassured by medical tests and doctor reports that give us a “clean bill of health,” but people with somatic symptom disorders may not. Reassur- ance is also an effective anxiety-reducer in the short term but not the long term. People like Gisela may thus pursue on- going, repetitive, and lengthy medical tests and visits. Some believe children model parents’ use of reassurance seek- ing as they age (Alberts & Hadjistav- ropoulos, 2014). Children may copy parents’ frequent complaints about physical symptoms or calls to friends for sympathy.

Secondary gain sometimes refers to receiving social reinforcement for so- matic complaints. Psychodynamic theo- rists view primary gain as unconscious use of physical symptoms to reduce psychological distress. People who pay close attention to minor physical symp- toms thus reduce attention toward some internal or external stressor (Pellicciari, Superbo, Gigante, Livrea, & Defazio, 2014). Some people may �nd it easier to concentrate on minor bodily changes than major life stressors such as marital con�ict, �nancial troubles, or academic failure.

Cognitive Factors Related to illness behaviors are illness beliefs or somatic attribu- tions, or perceived causes of physical symptoms. People may believe a virus, a psychological condition such as depression, or an external problem such as working too much causes their illness or physical sensation (Douzenis & Seretis, 2013). People with somatic symptom disorders tend to adopt biological or ill- ness explanations for their symptoms compared with people with other disorders, who adopt psychological explanations. A person coming home from a long and dif�cult day at work may adopt a physical explanation for his fatigue (I am sick),

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These factors include illness behavior and reinforcement, as well as cognitive, cultural, evolutionary, and other factors.

Illness Behavior and Reinforcement Illness behavior is a key concept of somatic symptom disorIllness behavior is a key concept of somatic symptom disorIllness behavior - ders and refers to behaviors one does when sick (Sirri, Fava, & Sonino, 2013). Examples include resting in bed, seeing a physician, and taking medication. Partners, family members, and friends may reinforce these behaviors by giving sympathy, attention, and comfort. This may help explain the phenome- non of la belle indifference in people with conversion disorder.

Somatic Symptom Disorders: Causes and Prevention 151

whereas many of us would adopt a psychological explanation (I am stressed out).

Those with somatic symptom disorders also see themselves as particularly vulnerable to illness and thus engage in more ill- ness behaviors (Sirri, Fava, & Sonino, 2013; Toussaint et al., 2016). The presence of anxiety and depression, problems also related to cognitive distortions, seem closely linked to increased health anxiety and internal illness beliefs as well (Olatunji et al., 2014).

Another cognitive factor in somatic symptom disorders is somatosensory awareness, or a tendency to notice and amplify physical sensations (Perez et al., 2015). This is a condition also seen in those with panic disorder and refers to people who attend closely to minor bodily changes. The changes thus become ampli�ed and seem more severe than they are. Indeed, overlap exists between illness anxiety disorder and panic disorder (Torres et al., 2014). Try it. Concentrate in- tensely on your heart rate for a few minutes and see if you notice any changes or a feeling your heart is “pounding” more so than before.

Cultural Factors We mentioned that people of non-Western nations tend to express feelings of depression and anxiety as physical symp- toms more than people of Western nations do. Psychological conditions are highly stigmatizing in non-Western countries, so a greater emphasis on physical symptoms may be more acceptable. Many cultures have “cultural idioms of distress” to make various experiences seem more normal (Hinton, Reis, & de Jong, 2015). Consider the Vietnamese notion of phong tap, which refers to general aches and pains and distress attribut- able to fatigue and cold. Attributing one’s mental distress to external factors beyond one’s control is acceptable practice. This may �t into the notion we mentioned earlier that social

reinforcement in a culture is important for how peo- ple express their distress.

Evolutionary and Other Factors Evolutionary theories of somatic symptom disorders are sparse, but symptoms of conversion disorder may have developed as an adaptive way of coping with inescapable threats to life. People faced with warfare or massacre may show debilitating symptoms such as blindness as a signal to others that one is not a dan- ger; this may help ward off harm. Displaying somatic complaints relates to social closeness and adaptive coping among people faced with loss of a close rela- tive (Thege, Pilling, Cserhati, & Kopp, 2012). This may help increase support or care from others.

Other general factors may also apply to somatic symptom disorders. Examples include poor medical attention and care, stressful life events, and general emotional arousal (Rief & Martin, 2014). Poor medical attention and care may include insuf�cient feedback by a general physician to someone worried about a particular disease as well as unnecessary treatment.

Stressful life events relate closely to severity of conversion disor- der symptoms (Aybek et al., 2014). These general factors seemed evident for Gisela. Her life was clearly stressful because she had two small children and a full-time job, and she became over- excited quickly. Her point that her doctors seemed overwhelmed by their numbers of patients may also have been valid. Some also point to large-scale events such as terrorism as potentially related to medically unexplained symptoms (see Box 6.2).

Causes of Somatic Symptom Disorders Different factors likely cause somatic symptom disorders, but much controversy remains about exactly how these problems originate. Some believe the best way to view somatic symp- tom disorders is as changes in perception, control, and atten- tion (Rachman, 2012). Some people misinterpret or misperceive sensory experiences as real and dangerous symptoms of some serious medical problem. One might think of general gastroin- testinal discomfort as stomach cancer. Someone with somatic symptom disorder may also view internal sensory experiences as uncontrollable, meaning the symptoms are beyond her ability to in�uence or treat. This makes the experiences more frightening.

The way people with somatic symptom disorders misperceive internal sensations is similar to the way some people with anx- iety-related disorders, especially panic disorder, do (Chapter 5). Recall that somatic symptom and anxiety-related disorders are closely linked. One possibility for this link is that physical symp- toms of anxiety, such as heart palpitations or dizziness, become part of a powerful memory later used to explain minor physical discomfort (Woud, Zhang, Becker, McNally, & Margraf, 2014). An anxious person might have chest pain and worry (wrongly) she is having a heart attack. This person may later have slightly blurred vision and worry (wrongly) she has a brain tumor.

FIGURE 6.3 BRAIN IMAGING OF DECREASED BLOOD FLOW IN PEOPLE WITH CONVERSION DISORDER. From Black, D.N., Seritan, A.L., Taber, K.H., & Hurley, R.A. (2004). Conversion Hysteria: Lessons from Functional Imaging. Journal of Neuropsychiatry and Clinical Neuroscience, 16, 245-251.

CHAPTER 6 Somatic Symptom and Dissociative Disorders152

Many people with somatic symptom disorders also over-over-over attend to even minor changes in their body (Wagner & Brown, 2012). If you constantly and intensively concentrate on your heart or respiration rate, you may notice some changes over time. These are normal, of course. For some people with so- matic symptom disorders, however, overattention ampli�es the intensity of their symptoms and contributes to worries about their meaning. They may come to believe they have some seri- ous disease. Not surprisingly, such overattention exists in peo- ple with anxiety-related and depressive disorders (Chapters 5 and 7). All of these processes—sensory misperception, feelings of uncontrollability, and overattention—can then lead to ill- ness behaviors, social reinforcement for playing the “sick role,” avoidance of daily activities, and a somatic symptom disorder (Bouman, 2015).

Prevention of Somatic Symptom Disorders Data are scarce regarding the prevention of somatic symp- tom disorders, but information about the disorders in chil- dren and adolescents may be instructive. Youths with so- matization are often female, and their parents are often of lower socioeconomic status and educational level. Stressful life events, traumatic experiences such as maltreatment, history of physical disease, unnecessary medical interven- tions, and the presence of other mental disorders such as anxiety and depression also relate to somatization in youths (Basch, Chow, Logan, Schechter, & Simons, 2015; Kailish, Mehta, & Sagar, 2015). Others have stated as well that some youths receive substantial attention from parents for somatic complaints, and this serves as a reinforcer (Wilson, Moss, Palermo, & Fales, 2014).

Given this information, strategies to prevent the develop- ment of somatic symptom disorders may include several compo- nents. Examples include educating children and parents about

dangerous and nondangerous physical symptoms, attending to serious but not common bodily changes, helping youths cope with traumatic events and related mental disorders, ensuring ad- equate and competent health care, and practicing anxiety man- agement (Chapter 5). Given that somatic symptom disorders may endure over time, addressing risk factors for the problems as early as possible is important.

➲ Interim Summary • Biological risk factors for somatic symptom disorders

may include genetic predispositions, as well as key brain changes in the amygdala, hypothalamus, limbic system, and cingulate, prefrontal, and somatosensory cortices.

• Environmental risk factors for somatic symptom disor- ders include illness behaviors, which involve medically related behaviors potentially reinforced by signi�cant others.

• Cognitive factors are likely powerful in�uences in somatic symptom disorders because many people with these disorders use somatic explanations for even minor bodily changes.

• Cultural and other factors may in�uence somatic symp- tom disorders as well. Poor medical attention and care, stressful life events, and emotional arousal may be risk factors.

• A causal model of somatic symptom disorders focuses on misperception of symptoms, feelings of uncontrollabil- ity about symptoms, and overattention to minor bodily changes.

• Risk factors in children and adolescents may inform strat- egies for preventing somatic symptom disorders. Examples include stressful life events, traumatic experiences, and comorbid anxiety and depression.

such as terrorism may have a causal role. For example, somatization and conversion disorders were commonly found in one emergency room following the Boston Marathon bombings (Guerriero et al., 2014). Somatization has also been noted in people following the Mumbai ter- rorist attacks in India and the Utoya terrorist attack in Norway (Con- tractor et al., 2014; Stene & Dyb, 2015). Stress related to fear of at- tack at an unknown moment can create intense physiological changes in some people. Indeed, Holman and Silver (2011) examined 2,592 adults who completed a health survey before 9/11 and an assessment of acute stress responses after the attacks. Reports of physical ail- ments increased 18 percent over 3 years following 9/11. Many people across the country were thus traumatized by the terrorist attacks and had medical symptoms as a result.

Focus On

Do terrorist attacks and suicide bombings create physical changes in people exposed to these events? Somatization and somatic symptom disorders are certainly related to various psychological factors and per- sonal trauma, but some have claimed that even large-scale traumas

Violence Terrorism and Medically Unexplained Symptoms

6.2

Somatic Symptom Disorders: Assessment and Treatment 153

➲ Review Questions 1. Describe how certain brain changes may be associated with

somatic symptom disorders. 2. What forms of social reinforcement relate to somatic symp-

tom disorders? 3. What cognitive factors relate to somatic symptom disorders? 4. Describe an overall causal theory to explain Gisela’s somatic

symptom disorder. 5. Outline a prevention strategy for a youth at risk for medically

unexplained symptoms.

Somatic Symptom Disorders: Assessment and Treatment

We turn next to strategies for assessing and treating somatic symptom disorders. Keep in mind the psychological as- sessment of someone with a possible somatic symptom disorder should be done in conjunction with a comprehensive medical evaluation.

Assessment of Somatic Symptom Disorders Assessing someone like Gisela with a somatic symptom disor- der usually involves interviews, questionnaires, and personality assessment. We discuss each method next.

Interviews Interviews to gather information about people with somatic symptom disorders include structured, research-based ones such as the Structured Clinical Interview for DSM-5, Composite Inter-Structured Clinical Interview for DSM-5, Composite Inter-Structured Clinical Interview for DSM-5, Composite Inter national Diagnostic Interview, Somatoform Disorders Schedule, and International Diagnostic Checklists (First, Williams, Karg, & Spitzer, 2015; Kessler et al., 2013). These interviews cover diag- nostic criteria for various somatic symptom disorders.

Questions given to someone like Gisela with a possible somatic symptom disorder should involve a detailed history of physical and psychological problems. Somatic symptom disorders can be complex and long-standing, and we know these disorders often begin in childhood and adolescence, so questions about one’s history should extend far into the past. Pertinent topics include early and recent life experiences and stressors, medica- tion and substance use history, others’ reactions to somatic com- plaints, cognitive distortions, interference in daily functioning, and motivation for seeking and pursuing psychological treatment for what the client may believe is mostly a medical problem.

Gisela hesitated about using psychological treatment to ad- dress what she thought were simply medical problems. Inter- viewing a person with a somatic symptom disorder thus requires a therapist to develop good rapport with her client. Guidelines for communicating with a person with a somatic symptom dis- order are in Table 6.6.

Questionnaires Screening instruments also exist for possible somatic symptom dis- orders. Common ones include the Screening for Somatoform Dis- orders (SOMS) and SOMS-7, which cover diagnostic criteria and measure a person’s medically unexplained physical symptoms (Zijlema et al., 2013). Psychological factors are often a part of so- matic symptom disorders, so some questionnaires assess these constructs. The Somatic Symptoms Experiences Questionnaire, for example, assesses health worries, illness experience, dif�culties in interaction with doctors, and impact of illness (Herzog et al., 2014).

Other questionnaires speci�c to hypochondriasis include the Whiteley Index, Illness Behaviour Questionnaire, Illness Atti- tude Scales, and Somatosensory Ampli�cation Scale (SAS). These Somatosensory Ampli�cation Scale (SAS). These Somatosensory Ampli�cation Scale scales measure diagnostic symptoms, perceptions of illness, and awareness of internal sensations (Fava, Sonino, & Wise, 2012). Sample SAS items are in Table 6.7.

Personality Assessment Recall that somatic symptom disorders and unrealistic health con- cerns sometimes relate to certain personality traits or disorders. Assessment for this population may thus include personality in- ventories. The Minnesota Multiphasic Personality Inventory—2 (MMPI-2) includes clinical subscales for hypochondriasis, so- matic complaints, and health concerns (Friedman, Bolinskey, Levak, & Nichols, 2015). Several MMPI-2 scales have been used to discriminate people with malingering and somatoform pa- tient conditions from control participants (Sellbom, Wygant, & Bagby, 2012). Others have found the scales useful for assessing coping strategies, emotional dysfunction, somatic complaints, low positive emotions, and cynicism in this population (Myers, Fleming, Lancman, Perrine, & Lancman, 2013).

TABLE 6.6

Guidelines for a Therapist Communicating with a Person with Possible Somatic Symptom Disorder

Acknowledge that the symptoms are real and distressing to the client.

Accept the need to address somatic complaints.

Avoid attempts to convince the client of a psychological cause for symptoms.

Continue to gently refer to the role of tension and stress.

Discuss various topics, not just symptoms.

Schedule regular visits not predicated on complaints.

Develop goals in conjunction with the client.

Discuss how symptoms limit a client’s functioning instead of what might be physically wrong.

Maintain empathy with a client but set limits on behavior.

From Maynard (2003).

CHAPTER 6 Somatic Symptom and Dissociative Disorders154

Biological Treatment of Somatic Symptom Disorders People with somatic symptom disorders often experience co- morbid anxiety and depression, so a key treatment approach has been medication to address these conditions. The most common medications for this population have been selective serotonergic reuptake inhibitors (Chapters 5 and 7) such as esci- talopram (Lexapro), �uoxetine (Prozac), �uvoxamine (Luvox), and paroxetine (Paxil). Use of these drugs for somatic symptom and illness anxiety disorders helps improve anxiety and depres- sion, as well as fears of disease, symptom preoccupation, and overall functioning (Kleinstauber et al., 2014). Antidepressant medication may help reduce the severity of pain as well (Jaracz, Gattner, Moczko, & Hauser, 2015). Much work remains regard- ing these medications with respect to dosing, treatment duration and individualized assignment, and long-term outcome, how- ever (Somashekar, Jainer, & Wuntakal, 2013).

Psychological Treatments of Somatic Symptom Disorders Somatic symptom disorders are associated with problematic ill- ness behaviors and signi�cant cognitive factors, so the use of psychological treatments for these disorders has begun to garner more research attention. You might not be surprised that psy- chological treatments for somatic symptom disorders resemble the treatments for anxiety-related disorders (Chapter 5). Keep in mind, however, that many people with somatic symptom dis- order resist the idea of treatment from a mental health profes- sional. Clients like Gisela might have to �rst recognize that their symptoms may have some psychological basis, but this is often not easy for them to do.

Cognitive Therapy Cognitive therapy for anxiety-related disorders involves exam- ining inaccurate statements a person may be making and en- couraging the person to challenge the thought and think more realistically. This therapy works the same way for treatment of people with somatic symptom disorders. People with somatic symptom disorders should �rst understand the connection be- tween their problematic thoughts and their physical symptoms. Someone who constantly worries about having a disease and who checks her body constantly for changes may amplify those changes and misperceive them as dangerous. Cognitive therapy helps a person examine evidence to challenge this thought pro- cess. A person may come to realize that minor physical sensa- tions and changes are not dangerous because all humans have them and because the symptoms are often temporary and con- trollable.

A client with a somatic symptom disorder may also bene�t from logically examining her thoughts about the consequences of physical symptoms. Someone like Gisela may constantly worry her physical symptoms will devastate her life. A therapist might help Gisela understand she can effectively cope with or control physical symptoms and additional stressors in her life. Biofeedback, in which a person learns to consciously control bodily functions such as heart rate, can be useful in this regard (Mora, Weber, Neff, & Rief, 2013).

The various somatic symptom disorders involve problem- atic thought processes that can be treated with cognitive ther- apy. People with illness anxiety disorder fear their symptoms in- dicate a serious disease. A cognitive therapist may help a client with illness anxiety disorder discuss evidence for and against a disease belief, assess realistic probabilities for a certain physical symptom, and understand that a 100 percent certainty of know- ing one is not ill is never possible. A person with abdominal dis- tress should list all possible reasons and probabilities for such distress, including cancer but also gas, indigestion, and other common but harmless conditions (Keefer & Mandal, 2015). Mindfulness-based cognitive therapy with meditation may be helpful as well (van Ravesteijn, Lucassen, Bor, van Weel, & Speckens, 2013).

Behavior Therapy Behavior therapy for somatic symptom disorder helps a person reduce excess behaviors such as checking symptoms and visiting doctors. Behavior therapy aims to reduce the excess attention-seeking and reassurance-seeking behaviors that many people with somatic symptom disorders engage in; these behaviors cause others to reinforce their symptoms. Contingency management involves educating family mem- bers and friends about a person’s somatic symptom disorder and encouraging them to reinforce “well” behaviors such as going to work, finishing chores, and staying active. This seems especially important for treating conversion disorder, in which an emphasis is placed on removing medical and social attention for abnormal sensory-motor conditions, ad- ministering physical therapy to restore normal movement,

TABLE 6.7

Sample Items from the Somatosensory Ampli�cation Scale

I am often aware of various things happening within my body.

When I bruise myself, it stays noticeable for a long time.

I can sometimes feel the blood �owing in my body.

I can sometimes hear my pulse or my heartbeat throbbing in my ear.

I am quick to sense the hunger contractions in my stomach.

Even something minor, like an insect bite or a splinter, really both- ers me.

I have a low tolerance for pain.

Note: Items are scored on a scale from 1 to 5 re�ecting how much each item characterizes a person (5 equals more so). Barsky, A.J., Wyshak, G., & Klerman, G.L. (1990). The Somatosensory Ampli�cation Scale and its relationship to hypochondriasis. Journal of Psychiatric Research, 24, 323- 334. Reprinted by permission of Elsevier.

Somatic Symptom Disorders: Assessment and Treatment 155

and helping clients cope with stress and trauma (Hopp & LaFrance, 2012).

The primary behavioral treatment components for so- matic symptom disorders are relaxation training, exposure, re- sponse prevention, and social skills and assertiveness training (Ricciardi & Edwards, 2014). You may notice these treatments are similar to those mentioned in Chapter 5 for anxiety-related disorders, especially obsessive-compulsive disorder. Somatic symptom disorders often have an anxious component, so treat- ments aimed at anxiety may work well for this population. Relaxation training and exposure are often conducted together to help ease muscle tension, which aggravates physical symp- toms, and reduce anxiety when a person confronts anxiety- provoking stimuli. Such stimuli usually include avoided situ- ations such as social interactions, dating, and work. Gisela’s therapist worked with her to establish a regular pattern of work attendance. Response prevention involves limiting the number of times a person can monitor physical symptoms or engage in some other excess behavior. Many therapists use behavioral procedures with cognitive therapy to treat people with somatic symptom disorders.

Cognitive plus behavioral therapy for people with somatic symptom disorders is quite helpful in many cases (van der Feltz-Cornelis, Hoedeman, Keuter, & Swinkels, 2012). Exposure, response prevention, and cognitive therapy in one study pro- duced signi�cant improvements in illness attitudes and behav- iors as well as somatoform symptoms (Weck, Gropalis, Hiller, & Bleichhardt, 2015). Success rates for people with somatic symptom disorders are generally less positive, however, than for people with anxiety disorders or depression. This is because people with somatic symptom disorders often show multiple symptoms over long periods (Koelen et al., 2014). The most use- ful approach for this population will likely include medication and comprehensive psychological treatment within medical and mental health settings.

What If I or Someone I Know Has a Somatic Symptom Disorder? If you suspect you or someone you know might have features of a somatic symptom disorder, then seeking a full medical and psychological examination is important. You may also want to think about related problems of stress, anxiety, or depres- sion that aggravate physical symptoms or worries about having some disease (Chapters 5 and 7). Somatic symptom disorders can be distressing and often greatly interfere with one’s ability to accomplish even simple tasks. Encouraging someone who may have features of a somatic symptom disorder to continue to stay active and “work through” his symptoms is a good idea as well.

Long-Term Outcome for People with Somatic Symptom Disorders Longitudinal studies indicate that many people (50–75 percent) with medically unexplained symptoms or somatic symptom

disorder show improvement over time but that about 10 to 30 percent deteriorate. People with illness anxiety disorder often have a more chronic course, with 50 to 70 percent maintaining their symptoms over time. Predictors of more chronic course of somatic symptom disorder include greater severity of symptoms such as degree of pain or illness behavior as well as poor physi- cal functioning. Other possible predictors include female gender, comorbid mood problems, and unrealistic fears of illness (olde Hartmann et al., 2013).

How do people with somatic symptom disorders fare after treatment? People do respond to treatment for these problems, although researchers have found certain charac- teristics related to better long-term outcome. These charac- teristics include longer treatment as well as less anxiety and fewer pretreatment symptoms, comorbid conditions, cogni- tive distortions about bodily functioning, and hospital stays (Nakao, Shinozaki, Ahern, & Barsky, 2011; Olatunji et al., 2014). As we mention throughout this textbook, the more severe one’s symptoms, the more difficult successful treat- ment will be.

➲ Interim Summary • Therapists use interviews and questionnaires to assess

people with somatic symptom disorders. These measures concentrate on diagnostic criteria, history of symptoms, illness behaviors and beliefs, personality patterns, and other relevant topics.

• Biological treatments for people with somatic symptom disorders include antidepressant medication to ease comorbid depression, fears of disease, and symptom preoccupation.

• Psychological treatments for people with somatic symp- tom disorders involve cognitive-behavioral strategies to reduce illness behaviors and avoidance, improve physical functioning, address trauma, and limit checking and other excessive behaviors.

• The long-term outcome of people with somatic symptom disorders is variable but may be somewhat worse for people with illness anxiety disorder. Severity of symptoms and degree of comorbid conditions are good predictors of outcome.

➲ Review Questions 1. Describe various methods of assessing people with somatic

symptom disorders. 2. What medications might be best for people with somatic

symptom disorders? 3. What issues might arise when trying to get family members in-

volved in treating someone with a somatic symptom disorder? 4. Describe psychological treatments for people with somatic

symptom disorders. 5. Outline the long-term outcome for people with somatic

symptom disorders.

CHAPTER 6 Somatic Symptom and Dissociative Disorders156

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Erica was attending outpatient therapy for depression and “strange experiences.” The 25-year-old was attending therapy sessions for about 3 months after a breakup with her boyfriend. Her romantic relationship lasted only a few months but was con�ictive and oc- casionally violent. Erica said her interactions with her boyfriend were “intense” because they engaged in frequent sexual contact but also constant �ghting about time spent to- gether, progression of the relationship, and failure to communicate verbally. Erica said her boyfriend hit her on more than one occasion, although hospitalization or the police were never involved. Erica and her boyfriend mutu- ally agreed to part after a serious decline in the quality of their relationship.

Erica said she was depressed and tearful about the breakup and especially about being alone. She said she was having trouble eating and sleeping and missed several days of work to stay in bed. Erica’s therapist was able, however, to help her client gradually gain control of her life and improve her mood. Erica became more active in seeing her family members and friends, resumed work on a regular basis, thought about new dating opportunities, and engaged in cogni- tive therapy to reduce self-blame about her past relationship.

Therapy progressed in these areas but remained stagnant in other areas. Erica often had trouble remembering things from the past week or even the day before, seemed dis- tracted in therapy sessions, and even missed some sessions. The therapist sometimes asked Erica if anything was wrong, but Erica would only say she was having some recent memory dif�culties and felt “strange.” When asked

for details, Erica said she would sometimes come home to �nd her apartment a mess even though she was a very neat person. She also received two speeding tickets in the mail but did not remember a police of�cer stopping her. Erica also said she sometimes forgot what day of the week it was.

Erica’s therapist tried to go into detail about these experiences, but with little success. The therapist also thought it strange that Erica was generally unwilling or unable to talk about past relationships or even her childhood. When asked about these periods in her life, Erica became ashen and said she could not “really remember my birthdays or anything speci�c” about childhood. Following several unfruitful sessions, Erica’s therapist decided a more in- depth discussion of Erica’s past would help her fully understand her current depression and re- lationship problems.

The therapist called Erica one night at home to ask if she could delve into Erica’s past in more detail. This might involve con- versations with Erica’s parents and others who had known her for a long time. Erica answered the telephone and listened to the therapist before excusing herself. The thera- pist waited about 4 minutes before a young voice came on the telephone. The therapist was confused because Erica lived alone and had no children. The young voice on the line told the therapist, “I can’t let you talk to her about those things.” The therapist, startled and alarmed, asked the voice to explain. The voice said, “We can’t talk about those bad things,” paused, and said, “We just can’t.” The therapist asked the voice to identify it- self but the voice only said, “It’s me,” before

hanging up. The therapist called back, but no one answered.

Erica came to her therapy session the next day as if nothing had happened. The therapist told her about the telephone conversation but Erica was perplexed and did not know how to respond. The therapist then asked Erica about recent days and times that she could not remember, and the previous night was one of those times. The therapist delicately explained to Erica that she may be experi- encing episodes of dissociation whenever stressful events occurred and that Erica may have a separate personality structure. Erica was confused but listened intently because the description of dissociation fit her history. Erica did say, somewhat out of the blue, that the young voice her therapist heard was likely 7 years old. She did not know why she thought this to be the case. Erica’s therapist believed her client was likely having symptoms of a dissociative disorder and perhaps even had multiple personalities.

What Do You Think? 1. Which of Erica’s symptoms seem normal,

and which seem odd for someone with intense, recent life stressors such as hers?

2. What external events and internal factors might be responsible for Erica’s odd symptoms?

3. What are you curious about regarding Erica?

4. Does Erica remind you in any way of yourself or someone you know? How so?

5. How might Erica’s odd symptoms affect her life in the future?

case

Dissociative Disorders

Dissociative Disorders: Features and Epidemiology 157

Normal Dissociation and Dissociative Disorders: What Are They?

Have you ever been in a stressful situation where you felt “out of it”? Perhaps you were taking a test or talking before a group of people and suddenly felt as if you were watching your- self do the task or �oating above yourself? These experiences, though somewhat odd, are normal and represent dissociation. Dissociation refers to some separation of emotions, thoughts, memories, or other inner experiences from oneself. In other words, we feel as if we have split from ourselves.

Such separation is often mild and temporary and can include things like daydreaming, being absorbed by a �lm, “spacing out,” or highway hypnosis, in which a person drives for a distance but cannot recall how he arrived at his destination (Barabasz & Barabasz, 2015). In other cases, separation is moderate, mean- ing a person may feel temporarily outside of her body or walk through hallways as if in a fog. Or a person may feel he cannot recall all details of a certain event (see Figure 6.4).

These episodes of dissociation are normal because they are temporary and do not interfere with daily life. A person may take an important test and feel dissociated for the �rst few minutes. She may feel as if she is watching herself take the test and have trouble concentrating on the questions. Usually, however, this feeling dissipates quickly, and the ability to concentrate returns. We may feel we are “coming back to the test” and see it more clearly than before. Another person may see a terrible accident and feel as if events are progressing in dreamlike slow motion. Everything might then suddenly snap back to “real time.” Minor dissociation may help us temporarily handle stress by keeping it at arm’s length. The dissociation usually dissipates as we adjust to the stressful situation, calm ourselves, and do what we need to do.

In some cases, however, separation can be severe and lead to dissociative disorders. Dissociative disorders often involve disturbance in consciousness, memory, or identity (APA, 2013). A person may experience some form of dissociation for lengthy periods of time or in some extremely odd way. Erica may have

coped with recent or past stress by forgetting information that reminded her of trauma. She may have even developed a sepa- rate personality at age 7 years that “kept” traumatic memories of that time hidden so she would not have to think about them. Such extreme dissociation may be reinforced over time because it works so well—in other words, the person does not have to address a particular trauma. Unfortunately, as with Erica, long- term dissociation can cause signi�cant problems in social rela- tionships and even legal status.

Dissociative Disorders: Features and Epidemiology

Dissociative disorders include dissociative amnesia, dissocia-tive identity disorder, and depersonalization/derealization disorder. We next discuss features of these challenging disorders.

Dissociative Amnesia Do you ever forget things for no reason? Of course you do! We all forget things from time to time, and forgetfulness increases with age (Chapter 14). Normal forgetfulness is nothing much to worry about because the items we forget are minor and can easily be remembered with a cue. For some people like Erica, however, forgotten items are highly personal—examples include childhood experiences, family members, and even identifying information like one’s name. A diagnosis of dissociative amne- sia may thus apply (see Table 6.8; APA, 2013).

Dissociative amnesia involves forgetting highly personal infor- mation, typically after some traumatic event. A person may have trouble remembering his name after a car accident or assault. To be de�ned as dissociative amnesia, such forgetfulness is not caused by substance use or neurological or other medical disorder. The memory loss can, however, cause distress and impair one’s ability to function on a daily basis. Imagine being unable to remember who you are—this would cause enormous stress and would obvi- ously prevent you from working and even taking care of yourself.

Brief episodes of dissociation, such as depersonalization, are common and normal.

Jason Bourne, Matt Damon’s character in The Bourne Identity, has dissociative amnesia and spends much of the �lm attempting to discover his true identity.

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CHAPTER 6 Somatic Symptom and Dissociative Disorders158

Dissociative amnesia can come in several forms. People with dissociative amnesia may have only one severe episode of forgetfulness or several smaller or equally severe episodes. This may depend on the degree of trauma in their life. Recol- lection of important personal information may return suddenly for some but more gradually in others. Oddly, a person may forget personal information but remember historical events or how to drive a car. Such semantic or procedural memory can be lost in some cases, however (Staniloiu & Markowitsch, 2014a). Dissociative amnesia seems common among television

characters, but loss of widespread personal information is ac- tually quite rare.

Dissociative amnesia can also include dissociative fugue. Some people develop amnesia about personal events and sud- denly move to another part of the country or world. People with dissociative fugue cannot recall their past, and sometimes their identity, and end up living and working far away from family and friends. The person often assumes a new identity or is greatly confused about personal identity. Dissociative fugue most often occurs after a traumatic event. A man about to be publicly embarrassed in a scandal may suddenly move to another part of the country and assume a new name and job. Fugue states are characterized by dissociation, so in this case the person did not consciously plan to move. Instead, he likely had little recollection of what happened to him in the past. Fugue states can eventually disappear and a person may resume his old life, although memories of the original trauma may still be poor (Raval, Upadhyaya, & Panchal, 2015).

Dissociative Identity Disorder Other people with dissociative disorder experience identity problems that involve formation of different personalities. Those with dissociative identity disorder actually have two or more distinct personalities within themselves (this disorder was once called multiple personality disorder). These personmultiple personality disorder). These personmultiple personality disorder - alities may wrest control of a person’s consciousness and for a time become the dominant personality (see Table 6.9; APA, 2013). When this happens, as it did for Erica, a person may feel as if strange events are happening around her. The per- son may have trouble recalling personal information and have memory gaps about childhood or recent events. To be de�ned as dissociative identity disorder, the development of multiple personalities must not result from substance use or a medi- cal condition. Identity “splitting” is often due to a traumatic

6.4 Continuum of Dissociation and Dissociative Disorders

NORMAL MILD

Emotions Feeling good connection with others and environment. Mild physical arousal, especially when forgetting something.Feeling good connection with others and environment. Mild physical arousal, especially when forgetting something.Feeling good connection with others and environment. Mild physical arousal, especially when forgetting something.

Cognitions No concerns about forgetfulness. Slight worry about lack of concentration on an examination Slight worry about lack of concentration on an examination or about increasing forgetfulness as one ages.or about increasing forgetfulness as one ages.or about increasing forgetfulness as one ages.or about increasing forgetfulness as one ages.

Behaviors Occasional forgetfulness but little problem remembering Occasional forgetfulness but little problem remembering with a cue.with a cue.

Daydreaming during class, minor “spacing out” during a Daydreaming during class, minor “spacing out” during a boring abnormal psychology lecture, mild forgetfulness.boring abnormal psychology lecture, mild forgetfulness.

Emotions

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Behaviors

Emotions

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TABLE 6.8 DSM-5

Dissociative Amnesia A. An inability to recall important autobiographical information,

usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

Note: Dissociative amnesia most often consists of localized or selective amnesia for a speci�c event or events; or generalized amnesia for identity and life history.

B. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

C. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition.

D. The disturbance is not better explained by dissociative identity dis- order, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder. Specify if with dissociative fugue, or travel or wandering associated with amnesia for identity or other autobiographical information.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CONTINUUM FIGURE

Dissociative Disorders: Features and Epidemiology 159

event or set of events such as child maltreatment (Dorahy et al., 2015).

What is remarkable about dissociative identity disorder is that true differences supposedly exist among the personalities. true differences supposedly exist among the personalities. true Each personality may have its own distinctive traits, memories, posture, clothing preferences, and even physical health (Rolls, 2015)! Keep in mind a person with dissociative identity disor- der is not pretending to be someone different, such as when not pretending to be someone different, such as when not pretending an adult acts and talks like a child. Instead, true differences exist in behavior and other characteristics that make someone unique. Some researchers, however, question the existence of multiple personalities and see only differences in representa- tions of different emotional states or sociocultural expectations

(Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der Kloet, 2012). Others maintain that dissociative identity disorder is a valid diagnosis but one that should involve a clearer de�nition of symptoms (Biswas, Chu, Perez, & Gutheil, 2013).

Many people with dissociative identity disorder have a host personality and subpersonalities, or alters. A host personality is the one most people see and is likely present most of the time.

MODERATE DISSOCIATIVE DISORDER—LESS SEVERE DISSOCIATIVE DISORDER—MORE SEVEREDISSOCIATIVE DISORDER—LESS SEVERE DISSOCIATIVE DISORDER—MORE SEVEREDISSOCIATIVE DISORDER—LESS SEVERE DISSOCIATIVE DISORDER—MORE SEVERE

Greater dif�culty concentrating, feeling Greater dif�culty concentrating, feeling more alienated from others and one’s more alienated from others and one’s environment.

Intense dif�culty concentrating and feelings of Intense dif�culty concentrating and feelings of estrangement from others.

Feelings of complete alienation and separation from Feelings of complete alienation and separation from others or one’s environment.others or one’s environment.

Greater worry about minor Greater worry about minor dissociation, such as sitting in a dissociation, such as sitting in a dissociation, such as sitting in a car at the supermarket and wondering how one arrived there.wondering how one arrived there.

Intense worry about substantial dissociation or “gaps” in Intense worry about substantial dissociation or “gaps” in memory or little realization that something is wrong.memory or little realization that something is wrong.memory or little realization that something is wrong.

Potential lack of insight or thought about one’s personal Potential lack of insight or thought about one’s personal identity or changed living situation.identity or changed living situation.identity or changed living situation.identity or changed living situation.

Highway hypnosis, more frequent forgetfulness, or acting as if in a fog or a dream.

Infrequent episodes of depersonalization, intense forgetfulness, or missing appointments with others.

Severe and frequent episodes of dissociation, constant Severe and frequent episodes of dissociation, constant amnesia or fugue, presence of multiple personalities.amnesia or fugue, presence of multiple personalities.

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Jeffrey Ingram (pictured with his wife) woke up on a sidewalk in downtown Denver with no memory of who he was. Doctors believed he was in a dissociative fugue state.

TABLE 6.9 DSM-5

Dissociative Identity Disorder A. Disruption of identity characterized by two or more distinct personal-

ity states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinu- ity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symp- toms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

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CHAPTER 6 Somatic Symptom and Dissociative Disorders160

A host personality is like your general personality that changes from time to time but is not dramatically different. Subpersonali- ties, however, are additional, distinct personalities within a per- son that occasionally supplant the host personality and interact with others. This may help explain memory gaps. A different personality may have temporarily dominated Erica’s conscious- ness, trashed her apartment, and sped recklessly while driving. This would help explain some of Erica’s odd experiences and her dif�culty remembering recent events. Subpersonalities also have their own set of memories, such as the 7-year-old Erica who may have been hiding memories of severe maltreatment from the host personality.

The relationships between subpersonalities and between subpersonalities and the host personality can be complex. Dif- ferent relationship possibilities exist for the various personalities of the person with dissociative identity disorder, including the following:

• A two-way amnesiac relationship means the personalities two-way amnesiac relationship means the personalities two-way amnesiac are not aware of the existence of one other.

• A one-way amnesiac relationship means some personalities one-way amnesiac relationship means some personalities one-way amnesiac are aware of other personalities, but this awareness is not always reciprocated.

• A mutually aware relationship means the personalities are mutually aware relationship means the personalities are mutually aware aware of all other personalities and may even communicate with one another (Howell, 2011; Ringrose, 2012).

Erica was clearly unaware of at least one subpersonality, but the subpersonality was aware of Erica, who was the host personality. This is common to many people with dissociative identity disorder, especially at the beginning of therapy.

Depersonalization/Derealization Disorder Another dissociative disorder is depersonalization/derealiza- tion disorder, which involves persistent experiences of detach- ment from one’s body as if in a dream state (see Table 6.10; APA, 2013). People with this disorder maintain a sense of reality but may feel they are �oating above themselves, watching them- selves go through the motions of an event, or feel as if they are in a movie or like a robot. Depersonalization often exists with derealization, or a sense that surrounding events are not real (Schulz et al., 2015). Think about suddenly waking up to an odd noise—you perhaps feel disoriented or feel the surrounding environment is a bit surreal.

Depersonalization or derealization episodes can be short or long, but a person may have trouble feeling sensations or emotions. These episodes cause great distress and signi�cantly interfere with daily functioning. The depersonalization or dere- alization episodes should not occur because of another mental disorder such as panic disorder, or substance use or a medical condition. However, people with panic and other anxiety-related disorders commonly report depersonalization and derealization.

Heather Pate has dissociative identity disorder (DID). Her therapist diagnosed Pate with this rare mental disorder in 2002. “She said it’s what was called multiple personality disorder,” Pate remembers. “And my immediate response was, ‘No I’m not Sybil.’” Pate refers to Sybil, a book and subsequent movie about a young woman coming to grips with the dissociative identity disorder—which was then called multiple per- sonality disorder. Experts believe it develops from overwhelming childhood trauma. To cope, the patient’s personality splits, or develops additional personalities.

Pate estimates she has more than 30 per- sonalities. “When I think I’ve gotten to where I think they’re all there, somebody pops up,” she explains. Besides Heather, who she is most of the time, there’s also a teenager called ‘A’ and a pair of 8-year-old twins Little One and Tommy.

DID is stig- m a t i z e d — even within the mental health com- munity. And, it’s a rare men- tal disorder. Ex- perts estimate that only one percent of all people are affected by it. Unfortunately for Pate, she knows no one else in Central Vir- ginia with dissociative identity disorder. “Even with the voices, the personalities internally, you would think you wouldn’t be alone, but it does feel very alone.”

What’s helped Pate manage the disor- der and symptoms? She receives treatment to integrate her personalities, and she ad- justed her outward appearance and habits

by wearing cartoon t-shirts and keeping sugary drinks with her, to satisfy all the ages inside.

Pate has adapted to the disorder, and is considered “high-functioning.”

She was diagnosed in 2002, but worked full-time until 2007 and was married until

2014. Now, giving a face to the condition is her mission, and she hopes to become a peer counselor.

“There is a purpose and plan for my life,” she says. “To be able to come alongside oth- ers is that much more healing and encouraging and helpful and a part of the wellness in and of itself.”

Published April 13, 2016. http://wric. com/2016/04/13/faces-of-recovery-living-with- dissociative-identity-disorder-did/

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Dissociative Disorders: Features and Epidemiology 161

Brief episodes of depersonalization are common in the general population and are not a mental disorder (APA, 2013). Symp- toms of depersonalization and fugue are also sometimes dif�cult to tease apart.

Epidemiology of Dissociative Disorders You can understand how researchers have a dif�cult task when studying people with dissociative disorders. Symptoms of these disorders are often hidden, and many people with dissociative disorders do not seek therapy. Many people who attend therapy for some other disorder, however, also experience symptoms of dissociation. Erica’s original reason for attending therapy was symptoms of depression. Symptoms of dissociation are also

common in posttraumatic stress, panic, and obsessive-compul- sive disorders (Briere, & Runtz, 2015; Soffer-Dudek, 2014). Up to 25 percent of people with another mental disorder have a dis- sociative disorder (Sar, 2011). Symptoms of dissociation can also be prevalent among college students (see Box 6.3). The preva- lence of pathological dissociation ranges depending on the as- sessment method but may be up to 10 percent. Prevalence rates are less for depersonalization/derealization (1–2 percent) and dissociative identity (1 percent) disorders (Sar, 2011). The prev- alence of dissociative amnesia, however, is highly debatable. Some researchers claim this is a rare phenomenon, but others believe the disorder is more common than previously thought. The discrepancy derives from controversy as to whether adults can suddenly recall long-forgotten events from childhood (see Box 6.4; Morgan, Southwick, Stef�an, Hazlett, & Loftus, 2013).

Pathological dissociation may be more common in younger people and is fairly equal across men and women. Men may be more likely to experience amnesia, however, and women may be more likely to experience dissociative

TABLE 6.10 DSM-5

Depersonalization/Derealization Disorder A. The presence of persistent or recurrent experiences of deperson-

alization, derealization, or both: 1. Depersonalization: Experiences of unreality, detachment, or

being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions.

2. Derealization: Experiences of unreality or detachment with respect to surroundings.

B. During the depersonalization or derealization experiences, reality testing remains intact.

C. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

E. The disturbance is not better explained by another mental disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

Judy Castelli and her art. Judy has been diagnosed with 44 personalities.

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had a desire to dissociate also tended to engage in more binge drinking, which was de�ned in men as having 6 or more drinks in one session and in women as having 4 or more drinks in one session (Chapter 9). The authors speculated that some college students want to dissociate but do not always have the ability to do so and thus turn to alcohol to enhance dissociation (Klanecky, McChargue, & Bruggeman, 2012). Dissociation has also been found to be higher among college students with a history of nonsuicidal self-injury, such as cutting oneself (Karpel & Jarram, 2015). Another study indicated that only about 38 percent of college students sought help for dis- sociative and other problems caused by a history of maltreatment (Sedlacek et al., 2015). If you �nd yourself struggling with the issues noted here, then seeking help at your student counseling center may be a good start.

Focus On

Have you ever “zoned out” during a lecture or while studying? Many students experience minor dissociation and fantasizing. Other instances of dissociaexperience minor dissociation and fantasizing. Other instances of dissocia- tion, however, can be more serious. One study indicated that college stu- dents who had a history of childhood or adolescent sexual maltreatment and

6.3

College Students Dissociation

CHAPTER 6 Somatic Symptom and Dissociative Disorders162

The validity of these recovered memories remains unclear, however. This takes on greater meaning when a prosecutor decides to indict someone based on recovered memories.

This controversy stems from the fact that children, adolescents, and even adults may be susceptible to leading questions about past events. This is suggestibility. In one study, maltreated children were asked misleading questions about a recent play activity in a hospital. An example is the ques- tion “There wasn’t a chair out there in the hallway, was there?” when in fact there was. Young children were more prone to “fall” for misleading questions than older children and adolescents (Chae, Goodman, Eisen, & Qin, 2011).

Some thus recommend strict ethical guidelines for assessing people with memories of maltreatment. These guidelines include warning clients about the possibility of recovering false memories, outlining limits to con�dentiality, obtaining special training for eliciting memories, making conclusions only with corroborating evidence, and always acting in the best interests of a cli- ent (Pope & Vasquez, 2011; Robbins, 2015).

Focus On

Reports have appeared in the media over the years about people accused of child maltreatment or domestic violence by other individuals who have suddenly recalled these events after many years. A heated controversy in this area, however, is the topic of recovered memories. Recall that Erica’s subpersonality seemed to have memories of severe maltreatment from childhood. In other people with dissociative disorders, memories of past maltreatment emerge as amnesia or fugue dissipates during treatment.

Law and Ethics Recovered Memories and

Suggestibility

6.4

identity disorder (Scholzman & Nonacs, 2016). Dissociative experiences may also be more common among certain cultural groups. Pibloktoq is an episode involving a type of dissocia- tive fugue in which people leave home and shed their clothes in the Arctic weather (Paniagua, 2013). Others speculate that African Americans use dissociation as a coping strategy for operating as a minority group or that this group is more sus- ceptible to dissociation (Anglin, Polanco-Roman, & Lui, 2015). Unfortunately, no clear reason has emerged for this difference (see Box 6.5).

Aspects of dissociative disorders seem highly comorbid with other mental disorders, especially those involving trauma. Up to 30 percent of people with posttraumatic stress disorder, for example, report high levels of dissociative symptoms (Daniels, Frewen, Theberge, & Lanius, 2016). Dissociative behavior is also quite common among homeless and runaway youths and adolescents who have experienced trauma (Bender, Thompson, Ferguson, Yoder, & Kern, 2014; Kaur & Kearney, 2015).

Stigma Associated with Dissociative Disorders

Stigma may be an important issue in dissociative disorders. One group of researchers surveyed people with dissociative and other disorders and found that nearly 60 percent believed that most people would not allow someone with a mental dis- order to take care of their children and that most young women would be reluctant to date a man who had a mental disorder. Most of the respondents also believed that potential employers would bypass applications of psychiatric patients. In addition, a majority of those surveyed believed that people in the gen- eral population saw psychiatric patients as less intelligent, trust- worthy, and valued with respect to their opinions (Freidl et al., 2007). Negative beliefs such as these could lead to reluctance to

rely on others for support or to seek treatment if psychological symptoms persisted or worsened.

➲ Interim Summary • Normal dissociation refers to separation of emotions,

thoughts, memories, or other inner experiences from one- self. Dissociation that occurs in a severe or very odd way may be a dissociative disorder.

• Dissociative amnesia refers to loss of memory for highly per- sonal information. This may be related to dissociative fugue, which involves sudden movement away from home or work with loss of memories for personal and other information.

• Dissociative identity disorder refers to two or more distinct personality states within a person. These states may include a host personality and subpersonalities that can differ in their awareness of each other.

• Depersonalization/derealization disorder refers to persis- tent experiences where a person feels detached from his body as if in a dream state.

• Dissociation is common in people with mental disorders, although the prevalence of formal dissociative disorders in the general population is less common. Dissociative disor- ders are often associated with trauma and trauma-related mental disorders.

• Many people with dissociative symptoms feel stigmatized by others.

➲ Review Questions 1. What is the difference between normal and abnormal

dissociation? 2. Discuss features of major dissociative disorders. 3. What is a host personality and subpersonalities?

Dissociative Disorders: Causes and Prevention 163

4. What types of relationships might subpersonalities have with one another?

5. How common are dissociative experiences?

Dissociative Disorders: Causes and Prevention

The cause of dissociative disorders remains unclear, but evi-dence is emerging that key brain changes and trauma are important risk factors. These factors likely work in tandem in diathesis-stress fashion to help produce dissociative disorders.

Biological Risk Factors for Dissociative Disorders Brain and memory changes are key risk factors of dissociative disorders. We discuss these risk factors next.

Brain Features A key aspect of dissociative disorders is disintegration of con- sciousness, memory, and identity. Brain areas responsible for integrating incoming information may thus be altered in some way. Key brain areas for integration include the amygdala, locus coeruleus, thalamus, hippocampus, anterior cingulate cortex, and frontal cortex (see Figure 6.5; Brand, Lanius, Vermetten, Lowenstein, & Spigel, 2012; Scaer, 2014). Some believe disintegra- tion or dissociation in times of stress creates an arousal threshold

in these brain areas. Reaching this threshold triggers increased alertness but also inhibition of strong emotional responses such as anxiety (Jay, Sierra, Van den Eynde, Rothwell, & David, 2014; Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012).

We may detach ourselves from a terrible event so we can control our responses and react adaptively. A person in a car accident may feel she is �oating above the crash scene but at the same time can rescue others, talk to police, and call family members. Her alertness is increased, but excesses in emotion and physical arousal are temporarily blunted. This person may later appreciate the full weight of what happened and experi- ence nightmares or �ashbacks of the trauma. People with acute stress or posttraumatic stress disorder commonly have dissocia- tion (Chapter 5; Armour & Hansen, 2015).

Dissociative disorders, especially depersonalization/dereal- ization and perhaps amnesia/fugue, may also be due to problems in connections between various brain areas, especially between sensory systems (eyesight, hearing) and the limbic system. A possible consequence of such disruption is that a person sees an event, especially a strongly negative event, but “detaches” herself and experiences little emotional response. Such disconnection can also lead to blunted pain experiences and a decrease in irrelevant thoughts. Evidence indicates that people undergoing depersonali- zation have blunted reactions to arousing stimuli (Owens, David, Low, Mathias, & Sierra-Siegert, 2015). Others have found that neu- rochemical changes in endorphin, endogenous opioid, and gluta- mate systems relate to depersonalization as well (Lanius, 2014).

“sense of self” in these countries tends to be highly individualistic and au- tonomous, and thus more susceptible to separation from one’s social con- text. Non-Western societies tend to emphasize a more collectivist orientation involving greater social integration and interdependence. People who adopt a collectivist sense of self may thus be less predisposed to depersonalization or other dissociative experiences.

Focus On

Dissociation is evident across many cultures, although many other condi- tions seem related to the Western concept of dissociation. One such contions seem related to the Western concept of dissociation. One such contions seem related to the Western concept of dissociation. One such con- dition is possession disorder, in which a person believes he is possessed by some type of entity (van Duijl, Kleijn, & de Jong, 2013). In Japan, animal and other spirits are commonly thought to in�uence people’s be- havior. In Thailand, phii bob refers to the belief that the spirit of another phii bob refers to the belief that the spirit of another phii bob living person can enter a person’s body and cause behavioral changes. One particular Islamic belief is that of jinn, or genies, that can cause harm to humans sometimes through possession (Lim, Hoek, & Blom, 2015). These phenomena underscore the importance of considering a person’s cultural background when addressing a possible case of dis- sociative disorder.

Certain cultures may be more predisposed to dissociative experiences like depersonalization. Depersonalization experiences might be more com- mon to people of Western countries (Kerr, 2014). This is because a person’s

Diversity Dissociation and Culture

6.5

People in a trance-like state may show behaviors that resemble a dissociative disorder.

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CHAPTER 6 Somatic Symptom and Dissociative Disorders164

Memory Changes Work in the area of memory changes and dissociative disorder remains in development, but some suggest that intense negative emotions lead to compartmentalization and dif�culty retrieving information (Huntjens & Dorahy, 2015). Exposure to a negative event and intense negative emotions may instigate a segrega- tion or “compartmentalization” of one part of the mind from other areas. This appeared to happen with Erica—her thera- pist later discovered that her client’s 7-year-old alter personal- ity held memories of childhood trauma. Compartmentalization may help explain why certain memories or personalities are not “known” by the host personality.

Compartmentalization may not be complete, however. When one personality learns new information, interference in learning in another personality can occur. One personality may also retrieve information learned by another personality (Huntjens, Verschuere, & McNally, 2012). This provides support for the existence of mutually aware or one-way amnesiac

relationships among personalities. Trans- fer of information across different per- sonalities may depend, however, on emotional and personal content of the information. Dif�culty retrieving infor- mation is also common in people with dissociative identity disorder and disso- ciative amnesia. People with these dis- orders may have trouble distinguishing true and false memories, especially of childhood. People with these disorders often have de�cits in short-term mem- ory and working memory, which is the ability to hold information while com- pleting another task. Problems in these areas of memory, which may result from increased emotional arousal, may relate to irrelevant thoughts and disso- ciative experiences (Huntjens, Wessel, Hermans, & van Minnen, 2014; Olsen & Beck, 2012).

Think about trying to remember someone’s telephone number as you are driving a car (working memory). If you are extremely upset about something at this time, you may temporarily forget the telephone number because you are thinking about other things and “spac- ing out” a bit. People with dissociative disorders may have such problems on a grander scale. What causes these memory changes to begin with, how- ever, remains unclear. One possibility is that people with dissociative amne- sia and identity disorder have reduced blood �ow in the right frontotempo- ral cortex (see Figure 6.6; Staniloiu &

Markowitsch, 2012). Excessive stress and trauma may create these metabolic changes.

Environmental Risk Factors for Dissociative Disorders We next discuss important environmental risk factors for disso- ciative disorders such as trauma and cultural in�uences.

Trauma Traumatic experiences and posttraumatic stress disorder are closely linked to dissociative disorders. Adult dissociation of- ten follows a severe traumatic event such as child maltreatment (Dorahy et al., 2015). Consider a 4-year-old child experiencing severe physical maltreatment from a parent. The options avail- able to this child are few: He is unlikely to run away, kill the parent, or commit suicide. An alternative coping strategy is to dissociate or detach from the trauma in a psychological way.

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Dissociative Disorders: Causes and Prevention 165

Such dissociation may be mild in the form of thinking about something else or more severe in the form of developing am- nesia or even a different personality. Perhaps this occurred in Erica’s case.

Traumatic problems may follow dissociation in other cases. A good predictor of posttraumatic stress disorder is dissocia- tion during a traumatic event (De Soir et al., 2015). Someone during a traumatic event (De Soir et al., 2015). Someone during who dissociates during a traumatic event may not cognitively process all relevant stimuli in that situation. Such avoidance can help produce symptoms of posttraumatic stress disorder, and exposure to reminders of the trauma is a key part of treatment for posttraumatic stress disorder (Chapter 5). A person who is assaulted may dissociate somewhat and even describe her at- tacker to police. She may cognitively avoid other stimuli associ- ated with the event, however, such as the parking lot where the assault occurred. If she walks through that parking lot in the future, doing so may trigger posttraumatic stress.

Dissociation may thus be a way of temporarily coping with a terrible event. This is especially likely if the event involved intense fears of death, loss, or lack of control. Such fears are in addition to the terror of the trauma and increase the likelihood one will experience long-term emotional distress or posttrau- matic stress disorder (Solomon, Snir, Fingerhut, & Rosenberg, 2016). Other researchers, however, refute a causal relationship between dissociation and trauma because some third variable may explain the relationship. A third variable such as intense family con�ict could explain trauma and dissociation in an ad- olescent (so trauma or dissociation may not have caused the other). People with dissociative disorders also do not remember earlier traumatic events with great accuracy (Ozdemir, Ozdemir, Boysan, & Yilmaz, 2015).

Cultural Factors Cultural factors may also relate to dissociation because cases of dissociative identity disorder seemed to peak before 1920 and after 1970. In addition, 82 percent of cases of the disorder oc- cur in Western countries (Boysen & VanBergen, 2013). Some

speculate that changes in how the concept of “self” is de�ned from generation to generation may affect the prevalence of dis- sociative identity disorder (Kihlstrom, 2012). Some people may rely on “an alternate personality” explanation to avoid personal responsibility for certain acts, even violent ones. We sometimes refer to ourselves and others in terms of Dr. Jekyll and Mr. Hyde (see Box 6.6).

Little research is available about dissociative disorders in other countries. Researchers have recognized dissociative am- nesia and depersonalization in Uganda and found the disorders followed traumatic circumstances as they often do in Western cultures. Dissociative fugue and dissociative identity disorder, however, were usually confused with other, local concepts of dementia (Chapter 14) or possession trance disorder (van Duijl, possession trance disorder (van Duijl, possession trance disorder Kleijn, & de Jong, 2013). Possession trance disorder (or disso- ciative trance disorder) refers to a sense that a new identity at- tributable to a spirit or other entity replaces one’s identity and controls a person’s behavior and possibly his memory. This un- derscores the need to consider local contexts and beliefs before assigning a DSM-5 diagnosis.

Causes of Dissociative Disorders Some propose that neurodevelopmental approaches explain how disparate factors such as brain and memory changes interact with trauma to help cause dissociative disorders (Silberg, 2014). Consider what normally happens in a positive childhood. First, children grow to develop strong and positive attachments to family members and caregivers, emotional regulation, and adap- tive brain structure. Children learn to associate well with others, control excess emotions such as rage, and adapt to normal life changes.

Second, young children begin to coordinate different as- pects of thinking and emotions into a consolidated sense of self. A youngster gains information from different situations and learns that certain rules apply and that he has some control over what will happen. A sense of self develops as children realize who they are and how the world works.

Third, loving parents accelerate this process by setting rules, providing support, and helping a child gain control of emotions and behaviors. We teach our children to listen carefully, come to us when scared, and communicate and develop self-control— “Use your words!” We also encourage them to explore different aspects of life while protecting them from harm. Many parents also develop daily routines for their children so youngsters feel safe in knowing what comes next.

A maltreated child, however, may not develop a strong and uni�ed sense of self. The child is unsure about which rules ap- ply, who to trust, and what happens next. An integrated sense of self and control over different life situations is thus lacking. This could lead to overarousal and development of different person- alities or dissociative states. A lack of uni�ed self may relate to changes in the orbitofrontal cortex, an area of the brain largely responsible for memory and consciousness (Murray, Debbane, Fox, Bzdok, & Eickhoff, 2015). Empirical data to support these ideas remain necessary, however.

FIGURE 6.6 REDUCED BLOOD FLOW IN THE FRONTAL LOBE OF A PERSON WITH DISSOCIATIVE AMNESIA. From Plate 2 of Markowitsch, H.J. (1999). Functional neuroimaging correlates of functional amnesia. Memory, 7, 561-583.

CHAPTER 6 Somatic Symptom and Dissociative Disorders166

Prevention of Dissociative Disorders Data are lacking regarding prevention of dissociative disorders, but preventing traumatic events that might lead to dissociative disorders may be instructive. An important traumatic event is child maltreatment. No studies have shown that reducing child maltreatment necessarily prevents dissociative disorders, but this is certainly possible. Efforts to prevent child maltreatment generally focus on the following:

• Teaching children to resist maltreatment by reporting it to others.

• Educating children about unsafe situations. • Educating parents about normal child development and

high-risk situations that often lead to maltreatment, such as family transitions and stress.

• Teaching parents appropriate disciplinary practices. • Implementing home visitation programs staffed by nurses,

physicians, social workers, paraprofessionals, or others, especially following a child’s birth.

• Providing support groups for parents. • Encouraging pediatricians, psychologists, and other health

professionals to report suspected incidents of maltreatment.

Prevention programs involving these components have shown variable success. Getting children to report maltreatment is dif�cult to do. The long-term effectiveness of home visitation pro- grams is also unclear (Selph, Bougatsos, Blazina, & Nelson, 2013). Still, helping parents raise their children in a safe environment can only increase a family’s quality of life and perhaps prevent mal- treatment and even later dissociative experiences for a given child.

➲ Interim Summary • Biological risk factors for dissociative disorders may

include key brain changes in areas most responsible for memory and consciousness integration.

• Memory changes in people with dissociative disorders often involve compartmentalization of personal material and failure to retrieve information.

that men often commit violent acts when dissociated and end up in prison, whereas women with dissociation are more likely to be less aggressive and enter therapy. Prison inmates often report severe dissociative experiences (Garofalo, 2014).

Violence and dissociation may be linked in a couple of ways. First, a person may experience dissociative/traumatic �ashbacks, believe he is in danger, and lash out at others. Second, dissociation may occur during the commission of a violent crime of passion. A man who strangles another per- son during an intense argument may have trouble grasping the enormity of his act and experience a sense of depersonalization. These possibilities underscore the importance of closely monitoring a person’s dissociative symptoms in treatment (Daisy & Hien, 2014).

Focus On

Violence Dissociative Experiences and

Violence Toward Others

6.6

A key component of different dissociative disorders is that a person be- comes detached from reality at one time or another. An interesting ques- tion, however, is whether people in dissociative states are particularly violent toward other people. Occasionally we see people charged with a violent crime who claim no memory of their act or

that “a different part of themselves” was responsible.

One of the “Hillside Stranglers”— responsible for the rape and stran- gulation of several young women in

California in 1977 and 1978— later claimed to have alter personalities. Films such as Psycho reinforce the Psycho reinforce the Psycho

impression as well that dissociative experi- ences are associated with violence. Some have also speculated

“Hillside Strangler” Kenneth Bianchi at one point falsely claimed he had alter personalities responsible for his killings.

In the �lm Psycho, the character Norman Bates appeared to have different personalities; some were meek and some were violent.

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Dissociative Disorders: Assessment and Treatment 167

• Trauma and dissociation are linked but the causal rela- tionship between the two remains unclear.

• Neurodevelopmental models of dissociative disorder con- centrate on how young maltreated children fail to develop a uni�ed sense of self.

• Prevention of dissociative disorders has not received much research attention, but prevention of child maltreatment may be helpful in this regard.

➲ Review Questions 1. What brain changes may be associated with dissociative

disorders? 2. What memory changes seem central to dissociative disorders? 3. How are trauma and dissociation linked? 4. Describe a general causal theory of dissociation in early life. 5. Outline a strategy for preventing child maltreatment.

Dissociative Disorders: Assessment and Treatment

We have covered the major features and causes of dissocia-tive disorders, so we turn next to ways of assessing and treating these devastating problems. A full medical examination must �rst rule out biological conditions that may explain disso- ciative symptoms. Biological conditions with similar symptoms could include epilepsy, migraine headache, and brain injury or disease, among others (Lanius, Paulsen, & Corrigan, 2014).

Assessment of Dissociative Disorders Assessing someone like Erica with a possible dissociative disor- der may be accomplished using interviews and questionnaires. We describe these next.

Interviews Interviewing people with dissociative disorder can be a dif�cult task for several reasons. First, many people with these disorders, such as those with amnesia or fugue, do not seek therapy for disso- ciation. Second, recollection of memories from dissociative states is often poor. Third, accessing different personalities in someone with dissociative identity disorder can be quite challenging.

Still, interviews are available to assess for dissociative symptoms and disorders. Prominent ones include the Clinician- Administered Dissociative States Scale and Administered Dissociative States Scale and Administered Dissociative States Scale Structured Clinical Inter-Structured Clinical Inter-Structured Clinical Inter view for Dissociative Disorders—Revised (SCID-D-R; Pomeroy, 2015; view for Dissociative Disorders—Revised (SCID-D-R; Pomeroy, 2015; view for Dissociative Disorders—Revised Steinberg, 2000). The SCID-D-R is a semistructured interview for symptoms of amnesia, depersonalization, derealization, identity confusion, and identity alteration. The interview also covers sever- ity of these symptoms and degree to which they interfere with daily functioning. Sample SCID-D-R questions include the following:

• Have you ever felt as if there were large gaps in your mem- ory? (amnesia)

• Have you ever felt that you were watching yourself from a point outside of your body, as if you were seeing yourself from a distance (or watching a movie of yourself)? (deper- sonalization)

• Have you ever felt as if familiar surroundings or people you knew seemed unfamiliar or unreal? (derealization)

• Have you ever felt as if there was a struggle going on inside of you? (identity confusion)

• Have you ever acted as if you were a completely different person? (identity alteration)

An interview of someone with a possible dissociative disorder should include a detailed history of trauma and symptoms of acute stress or posttraumatic stress disorder. Recall that many people with dissociative disorder have experienced recent or past traumatic events. Erica’s therapist embarked on a long assessment process that included interviews of Erica and her 7-year-old personality, who named herself Erica-Bad. The thera- pist compiled a detailed history about severe maltreatment of Erica-Bad by her father, who was now deceased. The therapist also explored recent stressors such as Erica’s breakup with her boyfriend to know why the subpersonality suddenly appeared to the therapist. The con�ict and distress of Erica’s relationship and breakup seemed to have triggered intense, compartmental- ized memories of maltreatment in childhood.

Questionnaires Questionnaires are also available to assess dissociative symp- toms; one commonly used questionnaire is the Dissociative Experiences Scale—Revised (DES; Dalenberg & Carlson, 2010). The DES covers three main categories of dissociative symptoms: dissociative amnesia, absorption and imaginative involvement, and depersonalization/derealization. Absorption and imagina- tive involvement refer to engaging in fantasy to such an extent that reality and fantasy are blurred.

An adolescent version of this scale (A-DES) covers dissocia- tive amnesia, absorption and imaginative involvement, passive in�uence, and depersonalization and derealization (Armstrong, Putnam, Carlson, Libero, & Smith, 1997; Silberg, 2014). Passive in�uence refers to the experience of not having full control over one’s body and physical sensations. The DES and A-DES are use- ful for identifying people with pathological levels of dissociative symptoms. Sample A-DES items are in Table 6.11.

Other popular scales contain items or subscales relevant to dissociative symptoms. Examples include MMPI-2 items and the dissociation scale from the Trauma Symptom Checklist for Children (Briere, 2012). The use of multiple measures to as- sess dissociation is usually recommended because dissociative symptoms are often complex, hidden, and unpredictable.

Biological Treatment of Dissociative Disorders The biological treatment of dissociative disorders largely in- volves medication to ease comorbid symptoms of anxiety, posttraumatic stress, depression, and related conditions such as personality disorders. The most commonly used drugs are

CHAPTER 6 Somatic Symptom and Dissociative Disorders168

anxiolytics, antidepressants, and antipsychotic and anticonvul- sant medications. Much of the research in this area comes from case study material, and some people with dissociative disor- ders do improve in their symptoms when taking these medi- cations. Other researchers, however, report little effect (Brand et al., 2012; Gentile, Snyder, & Gillig, 2014).

One problem with using these drugs to treat dissociative disorders is that side effects of these medications, especially antipsychotic drugs, can include feelings of dissociation (Gentile et al., 2014). Another issue is that medications used for dissocia- tive symptoms were designed for other mental disorders, so little information is available about the biological treatment of disso- ciative disorders per se (Brand et al., 2012). Medication may be an adjunct to psychological treatment for dissociation.

Psychological Treatments of Dissociative Disorders Psychological treatments for dissociative disorders are often geared toward reducing comorbid problems of anxiety, posttrau- matic stress, and depression. Many of the cognitive-behavioral approaches we discussed in Chapter 5 also apply to people with dissociative disorders. The goals of these approaches are also the same: help people cope with trauma, develop skills to think rationally and realistically, and reduce avoidance of social and other activities. Cognitive-behavioral treatment of symptoms of posttraumatic stress disorder is usually essential for address- ing the problems of people with dissociative disorders (Brand et al., 2012). Additional approaches to treat the core symptoms of dissociation, especially with respect to dissociative identity disorder, are sometimes necessary as well. We discuss these approaches next.

Psychotherapy A key goal of psychological treatment for dissociative disor- ders is to help a person reintegrate memories, personalities, and other aspects of consciousness. For dissociative amnesia, the goal is to help a person recall previous aspects of certain

trauma or past events in a supportive and safe way and ease her transition back to a normal routine (Sharma, Guirguis, Nelson, & McMahon, 2015). For depersonalization/derealization disor- der, the goal is to help a person reinterpret symptoms as non- threatening, increase safety behaviors, and decrease avoidance (Gentile et al., 2014).

For dissociative identity disorder, treatment is often complex and can last months to years (Brand, Loewenstein, & Spiegel, 2014). Some clinicians use a psychodynamic stage approach for this population that may resemble the following (Brand et al., 2012; Kluft, 2012):

1. Create a safe, empathic environment in therapy to build a strong therapist-client relationship that also includes all subpersonalities.

2. Enhance a person’s ability to function on a daily basis, which includes communicating with and gaining coopera- tion from subpersonalities.

3. Gather detailed information about all subpersonalities, es- pecially their personal histories.

4. Discuss and process traumatic events associated with each subpersonality, sometimes using hypnosis. Processing means repeated and detailed discussions of these events.

5. Encourage cooperation, empathy, and communication among all subpersonalities as these traumatic events are processed.

6. Integrate subpersonalities into one another, perhaps be- ginning with those sharing similar histories or personal- ity traits. A single personality is sought, but a collection of fewer subpersonalities may be the �nal result.

7. Learn coping skills as an alternative to dissociation to ad- dress dif�cult daily events, especially in social relationships.

8. Engage in long-term follow-up to help prevent relapse to- ward dissociation.

Hypnosis Hypnosis refers to a relaxed and focused state of mind in which a person is highly suggestible. People with dissociative disor- ders may undergo hypnosis to increase continuity of memory and identity. A person may undergo hypnosis to try to retrieve forgotten memories, access hidden personalities, or integrate different dimensions of consciousness (Kihlstrom, 2014). Some use hypnosis as well to derive more information about traumatic experiences that led to dissociative states (Terhune & Cardena, 2015). Hypnosis may be useful but data to support this approach largely involve case reports. Hypnosis may also lead to distorted memories (Dasse, Elkins, & Weaver, 2015).

Other Psychological Approaches People with dissociative identity disorder may bene�t from sup- portive family therapy as they enter the reintegration process and address past traumas. These people may also bene�t from emo- tional expression through art, music, dance, and poetry (Kluft, 2012). Techniques are sometimes necessary to address suicidality

TABLE 6.11

Sample Items from the Adolescent Dissociative Experiences Scale

I get so wrapped up in watching TV, reading, or playing video games that I don’t have any idea what’s going on around me.

People tell me I do or say things that I don’t remember doing or saying.

I feel like I’m in a fog or spaced out and things around me seem unreal.

I don’t recognize myself in the mirror.

I �nd myself someplace and don’t remember how I got there.

Note: Items are scored on a 0-to-10 scale where 0 = never and 10 = always.

Dissociative Disorders: Assessment and Treatment 169

in subpersonalities as well (Chapter 7; Ringrose, 2012). Dissocia- tive experiences among youths may be associated with ongoing maltreatment, so eliminating maltreatment and providing a safe environment are obviously important (Deblinger, Mannarino, Cohen, Runyon, & He�in, 2015). The psychological treatment of dissociative disorders generally involves helping a person de- velop a uni�ed sense of self and daily cohesiveness with respect to emotions, thoughts, and behaviors.

Erica’s therapist devoted 2 years to detailed discussions of past trauma. Erica’s siblings participated in therapy to help con�rm previous aspects of maltreatment and provide sup- port. The therapist was able to establish a good working re- lationship with Erica-Bad, the 7-year-old subpersonality. The child personality gave important information about the past, including physical and sexual maltreatment from Erica’s fa- ther and uncle. This process was a long and painful journey that required antidepressant medication and interventions to address intermittent suicidal urges. Many people erroneously believe, perhaps based on the �lms The Three Faces of Eve or Sybil, that once a person remembers past trauma, all subper- sonalities disappear.

What If I or Someone I Know Has a Dissociative Disorder? Knowing if you or someone you know has a dissociative dis- order can be dif�cult because the symptoms of these disorders are often murky. Pay attention to ongoing forgetfulness, odd ex- periences, and detachment from others, among other sudden peculiarities. If you suspect someone you know might be expe- riencing symptoms of a dissociative disorder, then referring her for a full medical examination and even an emergency room consultation is important. The possible consequences of being in a state of dissociation can be devastating.

Long-Term Outcome for People with Dissociative Disorders The long-term outcome for people with dissociative disorders is variable because integration of consciousness is dif�cult and because the problems usually extend from childhood. Some

people with dissociative amnesia or fugue are able to recover and return to their past lifestyles. Others continue to have prob- lems with information recall and disruption in their lives. They may experience more episodes of severe memory loss as well (Staniloiu & Markowitsch, 2014b).

Many people with dissociative identity disorder do respond positively to biological and psychological treatment. Improve- ments occur with respect to dissociation, anxiety, depression, and pain as a person addresses traumas and integrates sub- personalities (Brand et al., 2013). A person’s initial degree of dissociation, other psychopathology, and trauma may be good predictors of whether full personality integration can be achieved (Brand & Stadnik, 2013; Myrick, Brand, & Putnam, 2013).

Erica did not achieve full integration of her host person- ality and subpersonality (Erica-Bad). Over time and with ex- tended treatment, however, appearances by Erica-Bad became fewer and Erica herself experienced less disruption in her daily life. She also felt less depressed, began to forge good relationships with her siblings, and considered new dating op- portunities.

➲ Interim Summary • Interviews to assess people with dissociative disorders

often cover recent and past stressors and the presence of amnesia, depersonalization, derealization, identity confu- sion, and identity alteration.

• Questionnaires screen for dissociative symptoms such as amnesia, absorption and imaginative involvement, deper- sonalization, and passive in�uence.

• The biological treatment of dissociative disorders usually includes medication for concurrent symptoms of anxiety, depression, and other problems.

• Psychotherapy for dissociation helps a person reintegrate consciousness, process traumatic events, and learn to cope with daily events without using dissociation.

• The long-term outcome of people with dissociative dis- orders is variable and likely depends on severity of past trauma and current degree of psychopathology.

➲ Review Questions 1. Describe various methods to assess people with dissociative

disorders, and devise an assessment strategy you think might be most helpful.

2. What medications might be best for people with dissociative disorders?

3. What aspects of psychotherapy might be best for people with dissociative disorders?

4. How might expressive and other psychological therapies help people with dissociation?

5. Describe the long-term outcome for people with dissociative disorders.

V THE CONTINUUM VIDEO PROJECT

Lani and Jan / Dissociative Identity Disorder

“It’s like living with 13 roommates . . . and your responsibility is to make sure everyone’s needs get met.”

Access the Continuum Video Project in MindTap at Tap at T www.cengagebrain.com.

CHAPTER 6 Somatic Symptom and Dissociative Disorders170

Final Comments Somatic symptom and dissociative disorders are among the strangest but most fascinating disorders we discuss in this textbook. Perhaps you noticed many of the similarities among these sets of disorders and the anxiety-related disorders in Chapter 5; related factors include apprehension, trauma, interpersonal dif�culties, cognitive distortions, and avoidance of social and other situations. Treatments for these prob- lems often overlap. In the next chapter, we discuss another set of disorders closely related to those we have discussed so far: the depressive and bipolar disorders.

Thought Questions 1. If you were a medical doctor, what would you say and do in response to a patient who presents

with somatic symptom or illness anxiety disorder?

2. Think about people in the news who have claimed that some dissociative experience has kept them from remembering a crime or other event. Do you believe them? Why or why not?

3. What would you say to a friend who told you that his relative seems to be “spacing out” a lot in his life?

4. What separates “normal aging” from somatization and “normal forgetfulness” from dissociation? At what point does one “cross the line” from regular changes in thinking, memory, and behavior to more serious problems?

5. How might we reduce the prevalence of somatic symptom and dissociative disorders in the general population?

Key Terms somatization 142 somatic symptom disorder 143 illness anxiety disorder 145 conversion disorder 146 pseudoseizures 146 factitious disorder 146

Munchausen syndrome 147 malingering 147 contingency management 154 dissociation 157 dissociative disorders 157 dissociative amnesia 157

dissociative fugue 158 dissociative identity disorder 158 depersonalization/derealization

disorder 160

173

Special Features

CONTINUUM FIGURE 7.1 Continuum of Sadness and Depression 176–177

CONTINUUM FIGURE 7.2 Continuum of Happiness, Euphoria, and Mania 176–177

Personal Narrative 7.1 Karen Gormandy 180–181

• 7.1 FOCUS ON GENDER: Forms of Depression Among Women 182–183

• 7.2 FOCUS ON COLLEGE STUDENTS: Depression 195

V THE CONTINUUM VIDEO PROJECT Emilie: / Bipolar Disorder 200

• 7.3 FOCUS ON LAW AND ETHICS: Ethical Dilemmas in Electroconvulsive Therapy 206

• 7.4 FOCUS ON DIVERSITY: Depression in the Elderly 208

C Katey / What Do You Think?

Normal Mood Changes and Depression and Mania: What Are They?

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology

Stigma Associated with Depressive and Bipolar Disorders

Depressive and Bipolar Disorders and Suicide: Causes and Prevention

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Depressive and Bipolar Disorders and Suicide 7

CHAPTER 7 Depressive and Bipolar Disorders and Suicide174

C / Katey

Katey was a 30-year-old woman referred for outpatient therapy after a stay in an inpatient psychiatric unit. Katey’s hospital visit came after police found her atop a tall building threatening to jump. Her behavior at the time was somewhat bizarre—the police said Katey was talking very fast and claiming she could �y. Katey was dif�- cult to converse with, but police of�cers eventu- ally convinced her to move away from the edge of the building and come with them to the psy- chiatric hospital.

At the hospital, Katey said she had been feeling strange over the past several weeks. She rarely slept and instead wanted to “meet new and interesting people.” She frequented dance clubs and bars and fearlessly walked down alleyways to meet people. These actions led to some potentially dangerous situations and interactions, especially given the provocative way Katey dressed, but fortunately no physi- cal harm had come to her. She also said she needed to talk fast because “so many thoughts �y through my head.” Katey had lost her job recently and much of her contact with family members. She was also in danger of losing her apartment because she had spent her savings on lavish clothes.

Katey’s therapist asked what happened the night the police found her. Katey said she had been drinking at a dance club and could not re- member how she arrived at the top of the build- ing. Her memory of that night was poor, although she did recall bits and pieces of conversations. Katey received medication at the hospital and

slept for most of 3 days, saying she felt much more “normal” and “with it” afterward.

Katey said she had always battled moodi- ness and substance use problems. She said her “mood swings” began in adolescence after her �rst breakup with a boyfriend and continued during her college and early career years. She often compensated for mood changes by drink- ing alcohol and working hard. Katey said she could occasionally go 2 or 3 days working with little sleep, and this intense activity seemed to alleviate some sadness. She remained haunted, however, by her often-changing mood.

Katey said she was married brie�y several years ago, but the marriage ended because both partners tired of the other’s “drama.” Since that time, Katey continued her work as a legal assistant and received substantial raises over the years. Her work during recent months, however, was sloppy and tardy, and she was often absent. Katey’s boss �red her 3 months ago after several warnings. Katey said her �ring triggered much anxiety for her and prompted her current string of strange behaviors.

Katey also said she occasionally thought about hurting herself. These thoughts usually

came when she felt unhappy but intensi�ed recently as her unusual behavior became more stressful. Katey reluctantly admitted she once tried halfheartedly to kill herself in college. Her attempt followed a night of drinking during which she became sad and found some pills (unknown kind) in her roommate’s bathroom. She took sev- eral pills but woke the next morning in a daze and with a severe headache. Katey said she had not attempted suicide from that point to the night when police found her atop the building.

Katey cried in session and felt her life was in disarray. She had no job, few friends, was barely hanging on to a place to live, and had not spoken with her family in months. Her recent emotional states seemed to propel her toward self-destruc- tion. Katey said she desperately wanted to regain control of her moods and her life in general. Her therapist assured her that Katey’s compliance with medication and therapy attendance would go a long way in helping her do so.

What Do You Think? 1. Which of Katey’s symptoms seem typical

of a young adult, and which seem very different?

2. What external events and internal factors might be responsible for Katey’s feelings?

3. What are you curious about regarding Katey?

4. Does Katey remind you in any way of yourself or someone you know? How so?

5. How might Katey’s mood changes affect her life in the future?

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Normal Mood Changes and Depression and Mania: What Are They?

Have you ever been very sad or “down in the dumps” like Katey? Have you ever reacted badly to a stressful life event like a breakup? Have you ever felt you could not control your behavior or ever had thoughts about hurting yourself? For most people, sadness is a natural reaction to unfortunate events that happen in their lives. Many of us become sad when we receive a poor grade, have an argument with a loved one, or discover a friend is sick. Such sadness is usually mild and temporary.

Other times our sadness can be more intense and last for a longer period. We are particularly sad when a family member dies, when lengthy separation from loved ones occurs, or when overwhelmed by life’s demands. This sadness generally lingers but eventually fades as we cope with the stressor more effec- tively. We often rely on our friends and family members to help us through life’s “rough patches.”

For people like Katey, however, sadness lingers for a long time, occurs for little reason, or is so intense that interacting with others is dif�cult. The sadness often prevents a person from functioning effectively at school or work. A person may have trouble eating, sleeping, or concentrating; feel responsible

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 175

(see Criteria A–C in Table 7.1; American Psychiatric Association [APA], 2013). A major depressive episode does not refer to tem- porary sadness that may last a day or two or for only part of a day. Instead, the problem refers to a lengthy period in which a person is depressed during different times of the day and almost every day of the week. The sadness is usually intense, to the point that the person has trouble functioning in her daily life. Such was true for Katey.

People experiencing a major depressive episode also lose pleasure doing things they used to enjoy. A person may have always enjoyed being with friends or family, pursuing a hobby, or working at his job. After a major depressive episode, how- ever, he may withdraw from these activities or no longer get much pleasure from them. Katey became increasingly with- drawn from her family. We have also seen in other chapters (on anxiety-related and somatic symptom/dissociative disorders) that people with mental disorders often avoid or withdraw from social contact. You will see throughout this textbook that many people with mental disorder often have problems interacting with others.

Major depressive episodes also may involve severe changes in appetite, weight, and sleep (Harshaw, 2015). People who are depressed often fail to eat or they overeat, perhaps to help com- pensate for sadness. People who are depressed also have trouble sleeping and may wake up very early each morning, lying in bed until it is time to rise for the day (early morning waken- ing). Conversely, though, many people with depression have a ing). Conversely, though, many people with depression have a ing heavy feeling of fatigue and loss of energy that leads to over- sleeping. Such hypersomnia may also be a way to escape painful hypersomnia may also be a way to escape painful hypersomnia life events or extreme feelings of sadness.

A key characteristic of a major depressive episode is a feel- ing of “slowness,” or trouble gathering much physical energy. A person may simply want to lie on the couch all day, pas- sively surf the Internet at work, or sleep a lot. People with very severe cases of depression, or melancholia, may be so slowed down they do not move any muscles for hours. Although depressive episodes can resemble anxiety-related disorders in many respects (Chapter 5), this melancholic feeling of slowness is much more characteristic of depression (MacKinnon, 2015).

for things beyond her control; and feel extremely fatigued. Sad- ness or a sense of hopelessness can become so intense that harming oneself or committing suicide seems like the only way to stop the pain. These symptoms refer to depression, which is at the far end of the sadness continuum (see Figure 7.1).

Sadness is an emotion or mood, and its natural opposite is happiness. Many events and people make us happy, and all of us strive to be happy when we can. Most of us �nd hap- piness in the little things of life, such as coming home and hugging one’s children, talking to close friends, and accom- plishing signi�cant goals at work. Sometimes we even get carried away with our happiness, such as laughing a little too loudly at a social event. Such behaviors might even cause us some embarrassment!

Other people sometimes experience an intense state of happiness called euphoria. Euphoria is a wonderful feeling many people sense immediately after hearing good news or after a joyous event like childbirth. Euphoria is usually a short-term feeling that fades as a person becomes accustomed to whatever experience they had—the joy of having a newborn quickly gives way to exhaustion! Euphoria is not generally harmful as long as it is temporary.

Euphoria can be lingering or ongoing for some people. Peo- ple with chronic euphoria often have constant feelings of being “on the go,” thoughts “racing” through their head, a sense of pressure to keep talking, and chronic loss of sleep. They are also distracted and make poor personal decisions, as Katey did. One may also have a sense of grandiosity, or a belief that he is espe- cially powerful or talented when this is not actually true. These symptoms can be so severe they lead to extreme irritability and self-destructive or even suicidal behavior. These symptoms refer to mania, which is at the far end of the happiness and euphoria continuum (see Figure 7.2).

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology

People whose depression or mania becomes so severe it interferes with daily functioning may have a depressive disorder or a bipolar disorder. Depressive and bipolar dis- orders are sometimes collectively referred to as mood disor- ders. Someone with only depression may have a unipolar (one pole) disorder, as in unipolar depression or depressive disorder. Depression and mania can occur in the same individual, how- ever, as they do in Katey’s case. This person may have a bipolar (two pole) disorder. We next cover major depressive and bipolar disorders that cause people like Katey so much distress. We also discuss suicide, which is often associated with depressive and bipolar disorders.

Major Depressive Episode A major depressive episode involves a period of time, typically at least 2 weeks but usually longer, in which a person experi- ences sad or empty moods most of the day, nearly every day People with depression are often sad and isolated from others.

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People experiencing a major depressive episode tend to feel worthless and guilty about many things, including life events beyond their control. They may blame themselves for not preventing a friend’s divorce. Trouble concentrating or making decisions is also common in this population and often leads to problems at work or school, as was true for Katey. The most serious symptom of a major depressive episode is thoughts or ideas about death or suicide, or an actual suicide attempt. Many people facing a major depressive episode, like Katey, have mor- bid thoughts and fantasies about dying, their own funeral, and cutting or otherwise hurting themselves. These thoughts some- times precede actual attempts to harm oneself. Tragically, these attempts are sometimes fatal.

Following is a conversation between a therapist and a client who is severely depressed:

Therapist: Can you tell me what you have planned for today?

Client: (after long pause) Well . . . not sure . . . might get up today.

Therapist: OK, you might get up—what do you think you could do next?

Client: Well . . . (very long pause) Therapist: Yes, keep going. Client: I don’t know, I can’t really think about it . . . I just

want to sleep.

7.1 Continuum of Sadness and Depression

NORMAL MILD

Emotions Good mood. Mild discomfort about the day, feeling a bit irritable or down.Mild discomfort about the day, feeling a bit irritable or down.Mild discomfort about the day, feeling a bit irritable or down.

Cognitions Thoughts about what one has to do that day. Thoughts Thoughts about what one has to do that day. Thoughts about how to plan and organize the day.about how to plan and organize the day.

Thoughts about the dif�culty of the day. Concern that Thoughts about the dif�culty of the day. Concern that Thoughts about the dif�culty of the day. Concern that something will go wrong.something will go wrong.

Behaviors Rising from bed, getting ready for the day, and going to school or work.

Taking a little longer than usual to rise from bed. Slightly less concentration at school or work.

7.2 Continuum of Happiness, Euphoria, and Mania

NORMAL MILD

Emotions Feeling good. Happiness about good events that day, such as an Happiness about good events that day, such as an unexpected check in the mail. Feeling a “bounce” in one’s unexpected check in the mail. Feeling a “bounce” in one’s step.

Cognitions Thoughts about the pleasant aspects of the day.Thoughts about the pleasant aspects of the day. Thoughts about the good things in life.Thoughts about the good things in life.

Behaviors Normal daily activity.Normal daily activity. Completing daily tasks with great vigor. Being quite social Completing daily tasks with great vigor. Being quite social and talkative.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

CONTINUUM FIGURE

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 177

which a person may experience multiple major depressive episodes (see Figure 7.3 and Table 7.1). A 2-month interval of normal mood must occur for episodes to be considered separate from one another (APA, 2013). Major depressive disorder can be diagnosed, however, in someone who has only a single or �rst episode of depression. Major depressive disorder may be mild, moderate, or severe and may occur with or without psychotic features such as bizarre ideas or hearing voices that are not real (we discuss psychotic features in more detail in Chapter 12). Depressive symptoms may also be peripartum or postpar- tum, occurring during pregnancy or after the birth of a child (see Box 7.1) (Nakamura, Iga, Matsumodo, & Ohmori, 2015; O’Hara & McCabe, 2013). In addition, depression in some people

A major depressive episode must interfere with daily func- tioning and not be directly caused by a medical condition or substance. People temporarily bereaved after the loss of a loved bereaved after the loss of a loved bereaved one may not necessarily receive a diagnosis of a major depressive episode because grief is a normal human reaction. Feelings of sad- ness in children are more dif�cult to identify, so irritable mood can replace obvious signs of unhappiness. Failure to gain weight may also be symptomatic of a major depressive episode in youths.

Major Depressive Disorder Major depressive disorder, sometimes called major depression or unipolar depression, usually involves a longer period during

MODERATEMODERATE DEPRESSION — LESS SEVEREDEPRESSION — LESS SEVERE DEPRESSION — MORE SEVEREDEPRESSION — MORE SEVERE

Feeling upset and sad, perhaps becoming a bit Feeling upset and sad, perhaps becoming a bit teary-eyed.

Intense sadness and frequent Intense sadness and frequent crying. Daily feelings of crying. Daily feelings of “heaviness” and “heaviness” and emptiness.emptiness.

Extreme sadness, very frequent crying, and Extreme sadness, very frequent crying, and feelings of emptiness and loss. Strong sense of feelings of emptiness and loss. Strong sense of hopelessness.

Dwelling on the negative aspects of the day, Dwelling on the negative aspects of the day, such as a couple of mistakes on a test or a such as a couple of mistakes on a test or a cold shoulder from a coworker.

Thoughts about one’s personal de�ciencies, strong Thoughts about one’s personal de�ciencies, strong Thoughts about one’s personal de�ciencies, strong pessimism about the future, and thoughts about pessimism about the future, and thoughts about pessimism about the future, and thoughts about harming oneself (with little intent to do so).harming oneself (with little intent to do so).

Thoughts about suicide, funerals, and instructions Thoughts about suicide, funerals, and instructions to others in case of one’s death. Strong intent to to others in case of one’s death. Strong intent to harm oneself.

Coming home to slump into bed without eating dinner. Tossing and turning in bed, unable to sleep. Some dif�culty concentrating.

Inability to rise from bed many days, skipping classes Inability to rise from bed many days, skipping classes at school, and withdrawing from contact with others.at school, and withdrawing from contact with others.

Complete inability to interact with others or even leave the house. Great changes in appetite and weight. Suicide attempt or completion.

MODERATE MANIA— LESS SEVEREMANIA— LESS SEVERE MANIA — MORE SEVEREMANIA — MORE SEVERE

Sense of temporary euphoria Sense of temporary euphoria about some grand life event about some grand life event such as a wedding or birth such as a wedding or birth of a newborn. Feeling on of a newborn. Feeling on “cloud nine.”

Intense euphoria for a longer period. Feelings of Intense euphoria for a longer period. Feelings of agitation and in�ated self-esteem.agitation and in�ated self-esteem.

Extreme euphoria for very long periods, such as Extreme euphoria for very long periods, such as months. Sense of grandiosity about oneself, such months. Sense of grandiosity about oneself, such as the belief that one is a great playwright.as the belief that one is a great playwright.

Thoughts racing a bit about all the changes to Thoughts racing a bit about all the changes to one’s life and how wonderful life is.one’s life and how wonderful life is.

Intense, racing thoughts that lead to distractibility and Intense, racing thoughts that lead to distractibility and dif�culty concentrating.

Racing thoughts almost nonstop that lead to complete inability to concentrate or speak to others coherently.

Some dif�culty sleeping due to sense of elation.Some dif�culty sleeping due to sense of elation. Less need for sleep, pressure to talk continuously, working for hours on end.

Engaging in pleasurable activities that lead to damage, such as racing a car down a residential street or spending all of one’s money.

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Persistent depressive disorder still involves an intense feel- ing of sadness most of every day, with relief from symptoms never longer than 2 months at a time (see Figure 7.4). Some people with dysthymia also have one or more major depressive episodes during the 2-year course of their disorder. The presence of dysthymia and a major depressive episode at the same time is double depression (Hellerstein & Eipper, 2013). Double depres- sion is dif�cult to spot unless a client has seen a therapist for some time and the therapist notices a sudden or gradual worsen- ing of the client’s symptoms.

Persistent depressive disorder must not be caused by a medical condition or substance, and the disorder must signi�cantly interfere with daily functioning. The disorder may be classi�ed as early or late onset depending on whether late onset depending on whether late onset symptoms developed before age 21 years or at age 21 years or older. Persistent depressive disorder may be diagnosed in

occurs more in fall or winter months, or seasonal depression. People with seasonal depression often experience reduced energy, poor motivation, and anxiety with depressed mood (Melrose, 2015).

Persistent Depressive Disorder (Dysthymia) Another mood disorder similar to major depression is persis- tent depressive disorder, commonly called dysthymia, which is a chronic feeling of depression for at least 2 years (see Table 7.3; APA, 2013). People with persistent depressive disorder may not have all the severe symptoms of major depression but instead have “low-grade” symptoms that persist for much of their life. A mixture of symptoms is often seen involving appetite and sleep changes, fatigue, low self-esteem, trouble concentrating or mak- ing decisions, and feeling hopeless (Rhebergen & Graham, 2014).

TABLE 7.1 DSM-5

Major Depressive Disorder A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning;

at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

3. Signi�cant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed

down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt

about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear or dying), recurrent suicidal ideation without a speci�c plan, or a suicide attempt or a speci�c plan

for committing suicide.

B. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: Criteria A–C represent a major depressive episode. Note: Responses to a signi�cant loss may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a signi�cant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of the distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other speci�ed and unspeci�ed schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physi- ological effects of another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 179

Manic and Hypomanic Episodes Have you ever felt euphoric or had seemingly boundless ela- tion? We hope you have! As we mentioned, euphoria for a short time is usually not harmful. Feelings of euphoria that continue uncontrollably for long periods, however, can lead to destructive behavior. A manic episode is a period during which a person feels highly euphoric or irritable (see Table 7.5; APA, 2013). The person has key symptoms that may lead to severe problems dur- ing this period of euphoria. She may have a sense of grandiosity, or a feeling she can do something unlikely or impossible (Nasci- mento et al., 2015). Katey felt she might be able to �y. A person may also pursue pleasurable activities to such an extent that the activities become self-destructive. A person in a manic episode may engage in a shopping or sexual spree, pour money into foolish investments, or joyride in a car at high speeds. Severe problems in functioning at school or work can also result from extreme distractibility many people have during a manic episode.

People experiencing a manic episode also tend to speak rapidly, as if their mind is generating so many thoughts they

children and adolescents after a 1-year period of depressed 1-year period of depressed 1-year or irritable mood.

Other Depressive Disorders Other formal depressive disorders were added to the Diag- nostic and Statistical Manual of Mental Disorders (DSM-5). Disruptive mood dysregulation disorder refers to youth aged Disruptive mood dysregulation disorder refers to youth aged Disruptive mood dysregulation disorder 6 to 18 years with recurrent temper outbursts that are severe and well out of proportion to a given situation (see Table 7.4; APA, 2013). The outbursts occur at least 3 times per week, and the child is often irritable or angry. Symptoms must be pres- ent for at least 1 year and be seen in multiple settings. Onset is before age 10 years. The disorder was meant to address the fact that many children with these symptoms may have been diagnosed and treated for bipolar disorder (discussed later in the chapter). More research is needed on this disor- der. Another new formal depressive disorder is premenstrual dysphoric disorder, which was once a condition for further study (see Box 7.1).

People with depression often sleep a lot or have trouble sleeping and do not take pleasure in many activities.

Manic

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FIGURE 7.3 CYCLE OF MAJOR DEPRESSIVE DISORDER. Major depressive disorder may involve one or more major depressive episodes.

FIGURE 7.4 CYCLE OF PERSISTENT DEPRESSIVE DISORDER. Persistent depressive disorder (or dysthymia) involves low-grade symptoms of depression for at least 2 years.

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CHAPTER 7 Depressive and Bipolar Disorders and Suicide180

cannot express them quickly enough. Such �ight of ideas was true for Katey at times. Following is part of a conversation be- tween a therapist and a client experiencing �ight of ideas with some grandiosity:

Therapist: Can you tell me what you have planned for today?

Client: Oh yeah! Lots of things, lots of things, lots of things!

Therapist: OK, can you . . . Client: (interrupting) Gonna drive, gonna �y, gonna bus,

gonna ride! Therapist: (speaking quickly to get a word in) Where do

you want to go? Client: Anywhere, anytime, Rome, Greece, wherever I go,

I can go!

Those in a manic state may be highly agitated and pursue a certain goal with great enthusiasm. They may “pour them- selves” into a project at work and seem to accomplish a lot, although closer examination reveals the project to be riddled with mistakes. Katey worked hard, but her sloppiness cost her job. Someone in a manic episode usually requires little sleep to feel fully rested. Manic episodes last at least 1 week but could be much longer, perhaps lasting weeks or months. The manic episode must interfere with daily functioning and not be caused by a medical condition or substance.

Other people experience what is known as a hypomanic episode. Have you ever suddenly had a huge burst of energy or inspiration and completely cleaned the house or �nished a project at work? Many of us have felt a “rush” like this, although the experience never lasts more than a few hours or a couple of days. A hypomanic episode, however, comprises the same

Falling into depression was slow and deceptively delicious. By all accounts, it should have never been. There were no signs or clues when I was very young. In fact, my childhood was a blast.

But by the time I was 12, I was someone else. Not the wild child who was dubbed the “Queen of Play” but a confused adolescent whose ac- tions, thoughts, and desires were motivated by a desire to disengage and become numb. I’m not sure what happened or how it started, but I remember beginning to feel the inward pull when I was 12 years old, when within months of arriving to New York from Trinidad my mother moved out. No one said anything for days. She was just not there. Days later, my father called me into his bedroom and told me she was gone and he didn’t know when she’d be back. I was 15 before it was full-blown, almost immobilizing depression.

I would get up, go to school, and simply sit—inattentive and spaced out in class—the teachers’ voices, when I did hear them, sound- ed like distorted noise and incomprehensible static. It wasn’t long before I wasn’t doing as- signments; pretty soon I was cutting classes. I would get all the way to school and stand in front of the building knowing full well I was not going to set foot in there; I would turn tail and head home.

I would take the sub- way as far as Lexington Avenue and without leaving the station, would catch a train back to Queens, stop off at the candy store, get a Twix bar for lunch and a monthly Harlequin, and share the last leg of my trip home on the bus with a smattering of MTA workers re- turning home from the graveyard shift.

Before I knew it, when my father �icked the light on for me to get me up for school, I would follow the sound of his footsteps down the car- peted stairs, listen for the front door to close and instead of getting up, I’d turn over and go back to sleep.

I don’t think anyone noticed that I spent my entire sophomore year of high school in my room. I left it only when everyone else was in bed to indulge my one pleasure—the late and then the late late show.

When my mother returned to the family, I was 17 and �rmly ensconced under sheets and blankets that had not been changed in weeks and surrounded by books that took me far away from anything that resembled my world. All she could think to do was sprinkle holy water

in my room and pray that what- ever force that was having its way with me would leave. I don’t remember how I came to get up and out and back to

school. It may have had some- thing to do with a threat from the

Board of Education. My second major depressive

episode didn’t last quite a year. I had started college on a high note, excited and expectant. But there was a part of me that was knotted up. My husband had taken a job out of state and my teenage son, Justin, was spending more and more time with his friends. I thought my going to school would give me something to replace my lost identity as wife and my dwindling presence as mother. Displacement was not so easy. School could not cover up or replace the shock of being left by my husband and not needed as much by my son.

I lasted a year, and then my resolve started to collapse. I had studied architecture in San Francisco and at the University of Colorado, and I continued on and enrolled as an archi- tecture major at Montana State University. After the second semester, my work was becoming more and more un-architectural and

7.1 / Karen Gormandy

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Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 181

symptoms as a manic episode but may not cause severe impair- ment in daily functioning. Unlike “bursts of energy” that many of us occasionally have, hypomanic episodes last at least 4 days (see Table 7.6; APA, 2013).

Bipolar I Disorder Bipolar I disorder refers to one or more manic episodes in a person. The disorder is sometimes called manic-depression because a person may alternate between episodes of major depression and mania or hypomania. Such was likely true for Katey. Bipolar I disorder may involve just a single manic epi- sode, however. People with bipolar I disorder often have a major depressive episode that lasts weeks or months, followed by an interval of normal mood before another manic or hypomanic

wilder. I drew curves and lines that had no order and created work outside the perim- eters of the assignments.

My son was also falling off the edge of adolescence. He started hanging out with pot- heads and the high school clique of marginal characters. He was edgy and moody and rebel- ling against something.

By the time winter came, I was ready to jump out of my own skin. I was agitated, grumpy, and unhappy. I would get up, see Justin off to school, go to class but not do the assignments. After a few weeks, I would go to one class and skip all my other classes, work frantically to catch up on the schoolwork, and when it became too hard to catch up, I stopped going. Justin moved out at 16, and I stopped getting up in the morning.

Days went by and aside from getting out of bed to go to the bathroom, or to watch TV—my attention span lasted an hour or so before I got drowsy and went back to bed—I stayed under a cocoon of covers. When Justin dropped in, I got out of bed and pretended to be a mother. I can’t remember where the time went; I hibernated and lost track of days and nights.

I started to cry. I cried a lot. I cried in front of the university bursar when he asked me why

TV series and watched them again and again. I laughed again.

My fall was slow and almost sensual. My journey up and out is a daily decision. The inclination not to give up and to shut down is like �ghting a powerful force of nature that is as strong and as unyielding as gravity. There are days when I am repelled by the sight of myself in the mirror and the surges of self-loathing are incapacitating.

I am in talk therapy. Therapy is a safe place to be raw and vulnerable, maybe it has something to do with just acknowledging the existence of my demons. For whatever reason, it’s what I need. My moods undulate not in an up/down, happy/sad way, but more in a hang- ing on, keeping it together, being distracted kind of way. At this writing it’s pretty horrible. The sadness seems ever present and I have to return to meds.

A place to be honest about my feelings, a few very good and empathetic friends and sup- portive community—such as NAMI (National Alliance on Mental Illness)—keeps me out of the hole. Sometimes I can even remember and smile at the wild child I used to be.

Used with permission.

I hadn’t paid the rent. Too much in shock to think of a polite answer, I just blurted out the truth: that I wasn’t sure if I was married, that I wasn’t sure what was happening with my son. He recommended a university therapist.

Jim Murphy was a compassionate, sen- sitive therapist. He had red hair and the old trick of wearing a full beard so that he wouldn’t be mistaken for a student. My moods were easy to read: invisible—when I stuffed my wild hair under a baseball cap and kept my eyes trained to the ground, or de�ant—I let my wooly mane loose and un- combed, glared at all the young, hopeful stu- dents (who I was furiously jealous of!) in the eye and de�ed them to stare back. I got brave enough to insist Justin see a doctor. The doc- tor said he tested positive for marijuana, but otherwise he was �ne.

After four sessions, I was on Zoloft and academic probation instead of being sus- pended. I could reapply for �nancial aid and get myself back into the university’s good graces.

With Jim’s help, I rethought my future and changed my major from architecture to �lm, enrolled in art classes to begin in summer, and spent the spring alone. I went for long walks and drives, and borrowed movies and

personal narrative

People in a state of mania often do things that may be self-destructive, such as indulging in a shopping spree that they cannot afford.

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CHAPTER 7 Depressive and Bipolar Disorders and Suicide182

Premenstrual dysphoric disorder is a controversial condition that refers to depressive or other symptoms during most menstrual cycles in the past year (Table 7.2; APA, 2013). These symptoms include depressed, anxious, or angry mood; mood swings; fatigue; trouble concentrating; eating and sleep- ing changes; feeling out of control; and physical symptoms such as bloating or joint pain. The symptoms mainly occur in the week prior to menses and must cause distress or interfere with a woman’s daily functioning. About 3 to 9 percent of women may have this condition, which may link to hormonal changes that alter serotonin levels. Treatment thus usually involves antide- pressant medication (Yonkers et al., 2015).

Peripartum depression or postpartum depression refers to symptoms of depression or a major depressive episode that occurs during pregnancy or in the weeks after childbirth (APA, 2013). Postpartum depression is not simply the “blues” that many women face after childbirth, which may be caused

Focus On

Women report more depression than men, and this difference may be due to genetic factors as well as stressful marital and other relationships. However, conditions speci�c to women may also help to explain this differ- ence. Examples include premenstrual dysphoric disorder and postpartum depression.

Gender Forms of Depression

Among Women

7.1

TABLE 7.2 DSM-5

Premenstrual Dysphoric Disorder A. In the majority of menstrual cycles, at least �ve symptoms must be present in the �nal week before the onset of menses, start to improveimprove improve

within a few days after the onset of menses, and become minimal or absent in the week postmenses.minimal or absent in the week postmenses.minimal

B. One (or more) of the following symptoms must be present: 1. Marked affective lability. 2. Marked irritability or anger or increased interpersonal con�icts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of �ve symptoms when combined with symptoms from �ve symptoms when combined with symptoms from �ve Criterion B above.

1. Decreased interest in usual activities. 2. Subjective dif�culty in concentration. 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked changes in appetite; overeating; or speci�c food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, sensation of “bloating,” or weight gain.

Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the preceding year.

D. The symptoms are associated with clinically signi�cant distress or interference with work, school, usual social activities, or relationships with others.

E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F. Criterion A should be con�rmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this conformation.)

G. The symptoms are not attributable to the physiological effects of a substance or another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 183

Focus On

Gender Forms of Depression Among

Women—cont’d

7.1

by hormonal changes or social isolation. Instead, postpartum depression is a severe condition that affects about 13 percent of women after they give birth. Postpartum depression is commonly associated with depression and anxiety during pregnancy (peripartum), stressful life events during pregnancy, lower social support, and previous history of depression (O’Hara & McCabe, 2013). Women with these risk factors should thus be monitored closely before and after childbirth in case suicidal ideation is present.

Brooke Shields has been an outspoken educator about postpartum depression in women since the birth of her child.

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TABLE 7.3 DSM-5

Persistent Depressive Disorder (Dysthymia) A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observations by others, for at least

2 years.

Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or dif�culty making decisions. 6. Feelings of hopelessness.

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other speci�ed or unspeci�ed schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning. Specify if in partial or full remission, early (before age 21 years) or late (after age 21 years), and mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 7 Depressive and Bipolar Disorders and Suicide184

TABLE 7.4 DSM-5

Disruptive Mood Dysregulation Disorder

TABLE 7.5 DSM-5

Manic Episode

A. Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others.

E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.

F. Criteria A and D are present in at least two of three settings and are severe in at least one of these.

G. The diagnosis should not be made for the �rst time before age 6 years or after age 18 years.

H. By history or observation, the age at onset of Criteria A–E is before 10 years.

I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypo- manic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder.

Note: This diagnosis cannot coexist with oppositional de�ant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-de�cit/hyperactivity disorder, conduct disorder, and substance use disorders. Indi- viduals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional de�ant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a signi�cant degree and represent a noticeable change from usual behavior: 1. In�ated self-esteem or grandiosity. 2. Decreased need for sleep. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility, as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences.

C. The mood disturbance is suf�ciently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is suf�cient evidence for a manic episode and, therefore, a bipolar I diagnosis.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 185

Bipolar II Disorder Bipolar II disorder comprises episodes of hypomania that alter- nate with episodes of major depression. Full-blown manic epi- sodes are not seen as they are in bipolar I disorder (see Table 7.8 and Figure 7.5b; APA, 2013). Hypomanic episodes could worsen and become manic episodes, however, so bipolar II may become bipolar I disorder. For a diagnosis of bipolar II disorder to be made, the condition must not be caused by a medical problem or substance. Hypomanic episodes by themselves may not cause sig- ni�cant impairment in functioning, but hypomanic episodes with major depressive episodes (bipolar II disorder) do signi�cantly interfere with daily functioning.

Cyclothymic Disorder Cyclothymic disorder, sometimes called cyclothymia, refers to symptoms of hypomania and depression that �uctuate over at least a 2-year period (see Table 7.9; APA, 2013). People with cyclothymic disorder do not have full-blown episodes of de- pression, mania, or hypomania. Instead, general symptoms of hypomania and depression cycle back and forth, perhaps with intermediate periods of normal mood (see Figure 7.5c). A diag- nosis of cyclothymic disorder requires that these symptoms not be absent for more than 2 months. Cyclothymic symptoms may last only 1 year in children and adolescents. Cyclothymic disor- der must not be caused by a medical condition or substance but must signi�cantly interfere with daily functioning.

episode (see Table 7.7 and Figure 7.5a; APA, 2013). Other peo- ple with bipolar I disorder have mixed features, which refers to mania with symptoms of depression that do not rise to the level of a major depressive episode.

Some people with bipolar I disorder experience rapid cycling, which means they frequently switch from depression to mania and back again with little or no period of normal mood. At least four cycles occur per year in these cases. Still others with the disorder, especially females and those with psychotic symptoms, experience ultra-rapid cycling or even ultra-rapid cycling or even ultra-rapid cycling continuous (ultradian) cycling in which sharp changes in mood toward (ultradian) cycling in which sharp changes in mood toward (ultradian) cycling depression or mania occur almost daily for a certain period (Valenti et al., 2015).

TABLE 7.6 DSM-5

Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or

energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a signi�cant degree: 1. In�ated self-esteem or grandiosity. 2. Decreased need for sleep. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility as reported or observed. 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences.

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by de�nition, manic.

F. The episode is not attributable to the physiological effects of a substance.

Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is suf�cient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as suf�cient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 7.7 DSM-5

Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A–D

under “Manic Episode”).

B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other speci�ed or unspeci�ed schizophrenia spectrum and other psychotic disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 7 Depressive and Bipolar Disorders and Suicide186

Suicide Suicide refers to killing oneself and is commonly associated with depressive and bipolar disorders. Suicide is not a mental disorder but is the most serious aspect of depressive and bipolar disor- ders. Suicide also occurs in people with other mental disorders

TABLE 7.8 DSM-5

Bipolar II Disorder A. Criteria have been met for at least one hypomanic episode

(Criteria A–F under “Hypomanic Episode”) and at least one major depressive episode (Criteria A–C under “Major Depressive Episode”).

B. There has never been a manic episode.

C. The occurrence of the hypomanic episode(s) and major depres- sive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other speci�ed or unspeci�ed schizophrenia spectrum and other psychotic disorder.

D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 7.9 DSM-5

Cyclothymic Disorder A. For at least 2 years (at least 1 year in children and adolescents)

there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

C. Criteria for a major depressive, manic, or hypomanic episode have never been met.

D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other speci�ed or unspeci�ed schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiological effects of a substance or another medical condition.

F. The symptoms cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Manic

Normal

Depressive

(a)

Bipolar I Disorder

Manic

Normal

Depressive

(b)

Bipolar II Disorder

Manic

Cyclothymic Disorder

Normal

Depressive

(c)

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FIGURE 7.5 COMPARISON OF CYCLES OF BIPOLAR I DISORDER, BIPOLAR II DISORDER, AND CYCLOTHYMIC DISORDER. (a) Bipolar I disorder may involve alternating manic and major depressive episodes. (b) Bipolar II disorder may involve alternating hypomanic and major depressive episodes. (c) Cyclothymic disorder may involve alternating symptoms of hypomania and depression.

Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 187

through death. Some people may feel condemned by fate, such as a woman who cannot have children—childlessness in women is indeed a risk factor for suicide attempt (Perry, 2016). Altruistic suicide refers to a situation in which a person commits suicide suicide refers to a situation in which a person commits suicide suicide to bene�t society or others around him. Think of a soldier who sacri�ces his life in Afghanistan to save comrades (Braswell & Kushner, 2012).

Epidemiology of Depressive and Bipolar Disorders General feelings of sadness are quite common: As many as 20 percent of adults and 50 percent of youths report recent symp- toms of depression (Kessler et al., 2014). Feelings of sadness can intensify and result in diagnoses of major depressive disorder or dysthymia. The lifetime prevalence of major depressive dis- order is 16.6 percent, and 6.7 percent of adults had the disorder in the previous year (see Figure 7.7). The lifetime prevalence of dysthymia is 2.5 percent, and 1.5 percent of adults had the disorder in the previous year (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler, & Walters, 2005). The prevalence of major

or no mental disorder. Different aspects of suicide include suicidal ideation, suicidal behavior, suicide attempt, and suicide completion (see Figure 7.6; Klonsky, May, & Saffer, 2016). Suicidal ideation refers to thoughts about death, killing oneself, funerals, or other morbid ideas related to one’s death. Thinking about suicide does not mean a person will commit suicide, but such thoughts can be a risk factor. Suicidal behavior, sometimes called parasuicidal behavior or parasuicidal behavior or parasuicidal behavior deliberate self-harm, refers to self-destructive behavior that may or may not indicate a wish to die. Examples include cutting or burning oneself.

Suicide attempt refers to severe self-destructive behavior in Suicide attempt refers to severe self-destructive behavior in Suicide attempt which a person is trying to kill herself. Common methods of suicide attempt include �rearms, hanging, alcohol/substance/ medication overdose, carbon monoxide poisoning, and jumping from a high place. A suicide attempt may or may not lead to sui- cide completion, which refers to people who do kill themselves. All aspects of suicide are commonly associated with people with depressive, bipolar, and other mental disorders.

Some theorists have proposed different types of suicide. One in�uential theorist was Emile Durkheim (1858–1917), a French sociologist who studied people and their relationship to society. Durkheim believed some people commit suicide for dif- ferent reasons related to social integration. Egoistic suicide refers Egoistic suicide refers Egoistic suicide to a situation in which a person’s social integration is weak, and so he believes committing suicide comes at little cost to others. Think of a teenager who believes no one cares for him— social alienation is indeed a risk factor for suicide (Barzilay et al., 2015). Anomic suicide refers to a situation in which a Anomic suicide refers to a situation in which a Anomic suicide person has great dif�culty adapting to disrupted social order created by events such as economic crises. A surge of suicide among elderly adults in China relates somewhat to massive economic changes there (Wang, Chan, & Yip, 2014).

Fatalistic suicide refers to a situation in which a person Fatalistic suicide refers to a situation in which a person Fatalistic suicide feels oppressed by society and that his only means of escape is

Common means of committing suicide include overdosing, cutting, hanging, jumping from a high place, or shooting.

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FIGURE 7.6 SUICIDALITY SPECTRUM. Suicidality can be viewed along a spectrum from thoughts of suicide to actual death.

Suicide attempt

Suicide completion

Planning suicidal acts

Suicidal ideation

Fleeting thoughts of death

Will to live

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FIGURE 7.7 LIFETIME AND 12-MONTH PREVALENCE RATES FOR THE MAJOR DEPRESSIVE AND BIPOLAR DISORDERS.

Any moodAny mood disorderdisorder

20.8 9.5

16.6 6.7

3.9 2.6

2.5 1.5

MajorMajor depressivedepressive

disorderdisorder

DysthymiaDysthymia

Bipolar I andBipolar I and II disordersII disorders

0 250 2200 20 2150 20 21050 2

D is

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Lifetime prevalence rate (%)

12-month prevalence rate (%)

Note: These numbers reflect the fact that some people have more than one mood disorder.

Percentage

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CHAPTER 7 Depressive and Bipolar Disorders and Suicide188

Severe depression and dysthymia usually begin in late ado- lescence or early adulthood (especially mid-20s), but they could occur at any age. Many people have the disorders for several years before seeking treatment, and most adults are diagnosed at age 29 to 43 years (Kessler et al., 2014). Many people with dys- thymia do not seek treatment until severe depression develops. Others do not seek treatment because they assume depressive symptoms are simply part of their shy or withdrawn personal- ity. Less than half of people with depressive or bipolar disorders sought treatment for the problem in the previous year.

depression and dysthymia in adolescents is 8.2 percent (Kessler et al., 2012).

Depression in females increases signi�cantly around the beginning of adolescence, and female adolescents and adults are generally depressed at twice the rate of males (Hankin et al., 2015). Women may be more willing to admit symptoms of depression than men, but several studies indicate women to be more likely to have a �rst episode of depression, longer episodes of depression, and more recurrent episodes of depression than men. This gender difference may relate to frequency of stress- ors and other events in the lives of women (Hammen, Hazel, Brennan, & Najman, 2012; Hilt & Nolen-Hoeksema, 2014; see Box 7.1). Women also become depressed during certain seasons such as winter and have anxious depression more so than men (Altemus, Sarvaiya, & Epperson, 2014).

Rates of depression differ around the world (see Figures 7.8 and 7.9). Rates of depression are relatively higher in higher income countries (14.6 percent) than lower income countries (11.1 percent; Kessler & Bromet, 2013). Among Americans, depression seems equally prevalent among European and African Americans but higher in Hispanics and lower in Asian Americans. These �ndings reveal signi�cant cross-cultural dif- ferences with respect to depression (see later section on cul- tural in�uences; Keeler, Siegel, & Alvaro, 2014; Kim, DeCoster, Huang, & Chiriboga, 2011).

Nineteen-year-old Army Pfc. Ross McGinnis died saving the lives of four comrades in Iraq by voluntarily jumping on a grenade tossed into their military vehicle. He received the Medal of Honor for what may have been an example of altruistic suicide.

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FIGURE 7.8 RATES OF MAJOR DEPRESSION AND DYSTHYMIA BY GENDER IN COMMUNITY SURVEYS. Gender differences in rates of major depression (a) and dysthymia (b) vary in different areas of the world. ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study.

Puerto RicoPuerto Rico

Seoul, KoreaSeoul, Korea

New ZealandNew Zealand

Edmonton, CanadaEdmonton, Canada

USA-ECAUSA-ECA

USA-NCSUSA-NCS

3.5 5.5

2.4 4.1

8.8 16.3

5.9 11.4

12.7 21.3

2.6 7.0

0 250 2200 20 2150 20 2100 2

Lifetime prevalence rates

0 250 2

Male FemaleMale FemaleMale Female

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(a)

Puerto RicoPuerto Rico

Seoul, KoreaSeoul, Korea

New ZealandNew Zealand

Edmonton, CanadaEdmonton, Canada

USA-ECAUSA-ECA

USA-NCSUSA-NCS

1.6 7.6

1.6 2.8

1.6 7.6

2.2 5.2

1 8

2.2 4.1

0 108640 18640 1

Lifetime prevalence rates

0 120 1

Male FemaleMale FemaleMale Female L

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(b)

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Depressive and Bipolar Disorders and Suicide: Features and Epidemiology 189

depression is especially harmful—many with the disorder expe- rience work and school dif�culties and problems with interper- sonal and marital relationships (Gadassi & Rafaeli, 2015; Sharabi, Delaney, & Knobloch, 2015). Does this remind you of Katey?

Bipolar disorders are somewhat less common. The lifetime prevalence of bipolar I and bipolar II disorders is 3.9 percent among American adults. In addition, 2.6 percent of American adults had the disorders in the previous year (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). Bipolar II disorder is different from bipolar I disorder because manic episodes are not seen, but one study indicated that 17.4 percent of people with bipolar II disorder eventually progressed to bipolar I disorder (Alloy et al., 2012). Bipolar I and II disorders are also present in 2.1 percent of adolescents (Kessler et al., 2012). Cyclothymic disorder occurs in 0.4 to 2.5 percent of the general population. About one-third to two-thirds of those with cyclothymic disorder eventually develop bipolar I or bipolar II disorder (Van Meter, Youngstrom, & Findling, 2012).

Bipolar I and cyclothymic disorders seem equally present in men and women and among people of different cultures (Fountoulakis, 2015). European Americans tend to be diagnosed more with bipolar disorder than African Americans, although this may be due to differences in access to care and symptom presentation (Haeri et al., 2011). Bipolar II disorder may be somewhat more common in women than men, perhaps because of the presence of major depressive episodes (Erol et al., 2015). The age of onset of bipolar I, bipolar II, and cyclothymic dis- orders seems to be adolescence and early adulthood, although many of these youths may be diagnosed instead with disruptive behavior (Chapter 13) or depressive disorders. The increasingly frequent diagnosis of bipolar disorder in youth remains some- what controversial because many youth are still learning how to regulate their emotions (Sparks et al., 2014). This is partly why disruptive mood regulation disorder was introduced as a formal diagnosis in DSM-5.

People with bipolar I, bipolar II, and cyclothymic disorders often have several comorbid mental disorders, especially sub- stance use, eating, anxiety-related, and personality disorders (Merikangas & Paksarian, 2015). Those with the disorders tend to have many recurrent depressive and manic episodes, and the disorders can lead to severe consequences with respect to daily functioning (Vieta et al., 2013).

Epidemiology of Suicide About 800,000 lives are lost due to suicide worldwide each year (Katz, Bolton, & Sareen, 2016). The Centers for Disease Control and Prevention reports that 42,773 Americans committed sui- cide in 2014, representing 1.6 percent of all deaths. Suicide is the tenth leading cause of death overall, third among young adults, and common among the elderly. About 1 to 12 percent of the population have attempted suicide, and 8.3 million Americans think about suicide each year—although only a fraction (0.3 percent) go on to commit suicide (Crosby, Han, Ortega, Parks, & Gfroerer, 2011). Approximately 6 percent of undergraduate and 4 percent of graduate students have seriously contemplated

Severe depression and dysthymia are highly comorbid with many other mental disorders, particularly anxiety-related and personality disorders and substance use problems (Green & Stuart, 2014; Kohling, Ehrenthal, Levy, Schauenburg, & Dinger, 2015; Mineka & Vrshek-Schallhorn, 2014). Even on its own,

FIGURE 7.9 TRANSCULTURLTURL AL VARIATIONATIONA IN THE PREVALENCE OF DEPRESSION. (a) Current depression rate in selected countries. (b) Lifetime prevalence rate of depression in selected countries.

Santiago, ChileSantiago, Chile

Rio de Janeiro, BrazilRio de Janeiro, Brazil

Paris, FranceParis, France

Manchester, UKManchester, UK

Groningen, The NetherlandsGroningen, The Netherlands

Mainz, GermanyMainz, Germany

Bangalore, IndiaBangalore, India

Athens, GreeceAthens, Greece

Berlin, GermanyBerlin, Germany

Ankara, Turkeyrkey

Seattle, WA, USASeattle, WA, USA

Verona, Italyrona, Italy

Nagasaki, JapanNagasaki, Japan

Shanghai, ChinaShanghai, China

Ibadan, NigeriaIbadan, Nigeria

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29.5

15.8

13.7

16.9

15.9

11.2

9.1

6.4

6.1

11.6

6.3

4.7

4.0

4.2

2.6

0 20 25 35 300 220151050 2Total Male Female

10.4% 6.8%

12.4% Current depression

(a)

9.6

4.34.3

16.4

9.2

12.4

19.0

1.5

2.9

11.6

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Canada (Edmonton)Canada (Edmonton)

Puerto RicoPuerto Rico

France (Paris)France (Paris)

West GermanyWest Germany

Italy (Florence)Italy (Florence)

Lebanon (Beirut)Lebanon (Beirut)

Taiwaniwan

KoreaKorea

New Zealand (Christchurch)New Zealand (Christchurch)

Lifetime prevalence rates(b)

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et al., 2014). Suicidality is also associated with family history of mental disorder, hopelessness, misuse of alcohol and other drugs, and several other mental disorders, such as anxiety and schizo- phrenia (Hawton, Comabella, Haw, & Saunders, 2013).

Stigma Associated with Depressive and Bipolar Disorders

People with depressive and bipolar disorders may experience substantial stigma given the debilitating nature of their symptoms. Lasalvia and colleagues (2013) surveyed hundreds of people worldwide with depression. Most (79 percent) reported some form of discrimi- nation in at least one domain. In addition, many said they had stopped themselves

from (1) starting a close personal relationship (37 percent), (2) applying for work (25 percent), or (3) applying for education or training opportunities (20 percent). Participants also generally stated that they concealed their depression or were unwilling to disclose their depression for fear of discrimination by others. High levels of stigma have also been found among people with bipolar disorder. Many reportedly believe that the public holds negative attitudes toward people with a mental disorder (Levy, Tsoy, Brodt, Petrosyan, & Malloy, 2015).

Grif�ths and colleagues (2014) have found that programs to combat stigma can be effective, especially for stigma related to depression. In one of their studies, the researchers asked people with depression to review two websites. One website included education about aspects of depression, such as symp- toms, causes, sources of help, prevention, and the need to seek treatment. The site also contained short biographies of famous people with depression. A second website was devoted to cog- nitive behavioral methods to help people think more realisti- cally, solve problems more effectively, and cope better with relationship dif�culties or events that could trigger depressive symptoms. Perceived stigma was reduced signi�cantly more for the website intervention group compared with control par- ticipants who did not review online materials. The study sup- ports our assertion in Chapter 1 that education is a powerful antidote to stigma.

➲ Interim Summary • Depressive and bipolar disorders refer to extreme emotional

states of sadness or euphoria.

• A major depressive episode is a lengthy period of sad or empty mood, eating and sleeping problems, concentration dif�culties, fatigue, sense of worthlessness, and suicidal

suicide within the past year (Brownson, Drum, Smith, & Denmark, 2011).

Most suicides come from �rearms, suffocation, and poison- ing, although many people deliberately kill themselves in cars and other “accidents” to save family members and friends from additional grief. Men are more likely than women to use par- ticularly lethal methods of suicide such as �rearms and hang- ing. Men thus actually complete suicide at four times the rate of females (Callanan & Davis, 2012). Suicide attempts, however, are much more common in women than men, perhaps because women try to commit suicide in ways that take longer and have a higher chance of rescue. Examples include drug overdose and carbon monoxide poisoning (Ardani, Naghibzadeh, Hosseini, Asadpour, & Khabazianzadeh, 2015).

Suicide rates are highest in Eastern Europe but considerably lower in the United States, Taiwan, Korea, Japan, China, and Canada and lowest among Latin American and Muslim coun- tries (see Figure 7.10; World Health Organization, 2014). Sui- cide is more common among European Americans, lower skilled workers, and sexual minorities and less common among mar- ried, socially integrated, and religiously af�liated people. Rates of adolescent suicide have increased substantially over the past several decades, and adolescent and adult Native Americans are at particular risk. African Americans, Hispanics, and Asian/ Paci�c Islanders tend to have the lowest rates of suicide (Brown & Johns, 2015; Milner, Spittal, Pirkis, & LaMontagne, 2013; Ploderl et al., 2013; Tsai, Lucas, Sania, Kim, & Kawachi, 2014).

Risk for suicide in people with bipolar disorder is 20 to 30 times greater than the general population (Pompili et al., 2013). In addition, about 15 to 20 percent of those with depression commit suicide (Miret, Ayuso-Mateos, Sanchez-Moreno, & Vieta, 2013). About half of those with depression have suicidal ideation, depending on the assessment method used (Vuorilehto

FIGURE 7.10 TRANSCULTURAL VARIATION IN SUICIDE RATES. Suicide rates vary widely across geographical areas and cultures of the world.

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Depressive and Bipolar Disorders and Suicide: Causes and Prevention 191

bipolar disorders. Family studies, in which researchers assess family members of a person with a mental disorder, indicate that depression does run in families. First-degree relatives of people with depression have depression themselves 2.8 times more than the general population (Levinson, 2013). Children of depressed parents are 2 to 4 times more likely to have a mood disorder than children of nondepressed parents (Gladstone, Forbes, Diehl, & Beardslee, 2015). Bipolar disorder also runs in families. Relative risk for bipolar disorder among �rst-degree relatives is about 7 to 10 times greater than in the general popu- lation (Sklar, 2013).

Twin studies also suggest that depressive and bipolar disor- ders have a genetic basis. Across several studies, identical twin males and females have been found concordant for depression 40.3 and 50.0 percent of the time, respectively, compared with nonidentical twin males and females (28.0 and 33.5 percent, respectively; Strakowski & Nelson, 2015). Studies of bipolar dis- order indicate that identical twins share the disorder about 40 to 70 percent of the time, a concordance rate much higher than that of fraternal twins (15–25 percent; Craddock & Sklar, 2013; Strakowski, 2014). Overall, genetics account for about 37 to 50 percent of depression symptoms, but heritability for bipolar disorder is about 79 to 93 percent (Sklar, 2013; Sullivan, Daly, & O’Donovan, 2012).

Several genes for depression have been implicated, espe- cially those on chromosomes 2, 3, 7, 12, and 15 (Levinson, 2013). Many researchers believe depression results from a polygenic transmission, in which a small set of genes work interactively to cause this complex mental disorder (Milanes- chi et al., 2015). Researchers of bipolar disorder have focused on genes on chromosomes 1, 5, 11, 12, 13, 17, 22, and X (Hart, Brock, & Jeltova, 2014). However, genes on different chromo- somes may also work in a polygenic fashion to help produce bipolar disorder (Kerner, 2015).

Some people seem genetically predisposed toward cer- tain depressive and bipolar disorders, although no one gene or set of genes likely leads directly to the disorders. Genetics may instead help produce brain, neurochemical, hormonal, or other changes that lead to a depressive or bipolar disorder or otherwise interact with environmental events to lead to these disorders. We discuss some of these potential biological differ- ences next.

Brain Features People with depressive and bipolar disorders may have differ- ences in brain areas affected by genetic predispositions. People with these disorders often display reduced activity and size changes in the prefrontal and other cortical areas of the brain (see Figure 7.11; Arnone, Mumuni, Jauhar, Condon, & Cavanagh, 2015). This reduced activity relates to decreased serotonin levels (see next section). People who have experienced strokes (Chapter 14) or other brain injuries that affect the prefrontal cor- tex often display depression afterward as well (Juengst, Kumar, Failla, Goyal, & Wagner, 2015).

Other brain areas implicated in mood disorders include the amygdala, hippocampus, caudate nucleus, and anterior cingulate

thoughts or attempts. Major depressive disorder may involve several major depressive episodes.

• Persistent depressive disorder (dysthymia) is a chronic feeling of depression for at least 2 years.

• Other formal depressive disorders include disruptive mood dysregulation disorder and premenstrual dysphoric disorder.

• A manic episode is a period of uncontrollable euphoria and potentially self-destructive behavior. Hypomanic epi- sodes are similar to manic episodes but with less impaired functioning.

• Bipolar I disorder involves one or more manic episodes. Bipolar II disorder refers to hypomanic episodes with major depressive episodes.

• Cyclothymic disorder refers to symptoms of hypomania and depression that �uctuate over a long time.

• Depressive and bipolar disorders are common in the general population and often occur with anxiety-related or other mental disorders.

• Suicide is commonly seen in people with depressive and bipolar disorders, especially among men.

• Many people with depressive and bipolar disorders feel stig- matized for their condition by family members and others.

➲ Review Questions 1. What are depressive and bipolar disorders, and how do these

differ from normal sadness or happiness? 2. What are characteristics of depression? 3. Describe differences between bipolar I, bipolar II, and

cyclothymic disorder. 4. Describe different dimensions of suicide. 5. How common are depressive and bipolar disorders and

suicide? What populations are most at risk?

Depressive and Bipolar Disorders and Suicide: Causes and Prevention

We turn our attention next to factors that cause major de-pressive and bipolar disorders and suicide. We also dis- cuss how knowing about these factors might help us prevent depressive and bipolar disorders and suicide.

Biological Risk Factors for Depressive and Bipolar Disorders and Suicide Biological risk factors in people with depressive and bipolar dis- orders include genetics, brain features, neurochemical and hor- monal features, and sleep de�ciencies.

Genetics Researchers rely on family and twin studies to evaluate genetic contributions to mental conditions such as depressive and

CHAPTER 7 Depressive and Bipolar Disorders and Suicide192

all of which can be problematic in people with depressive or bipolar disorders.

On the other hand, increased activity of these key brain areas may occur in people with bipolar disorder (see Figure 7.13). Heightened activity in the anterior cingulate and increased size of the putamen relate to mania (Bernstein et al., 2013; Cui et al., 2011). These areas work with other brain structures to in�uence motor activity, so hyperactivity in these areas may help explain constant restlessness, movement, and goal-directed activity in people with bipolar disorder. In addition, changes in areas such as the hippocampus that affect depression do not always seem evident in people with bipolar disorder (Foland-Ross et al., 2013). Instead, areas such as the amygdala and hippocampus seem intact.

Some evidence indicates that certain brain areas are re- duced in size in some people with bipolar disorder, and these changes may relate somewhat to changes seen in people with schizophrenia (Chapter 12). Indeed, the two disorders have some symptoms in common (see Figure 7.14). People with bipolar disorder and people with schizophrenia may have re- duced white and gray matter in the brain (Anderson et al., 2013). Such abnormalities may interfere with connections among im- portant brain areas, which could lead to disruptive thought pat- terns seen in people with bipolar disorder and schizophrenia.

Brain changes for depression generally seem to involve cortical-limbic circuits, whereas brain changes for bipolar dis- order generally seem to involve limbic-thalamic-cortical circuits, so some overlap is apparent (Kim et al., 2013; Price & Drevets, 2013). These changes may come from early effects such as genetics, maternal stress during pregnancy and altered hormonal levels, reduced blood �ow to the fetus, poor prenatal care, or pregnant mothers’ use of antidepressant medication, among other reasons (Sandman, Buss, Head, & Davis, 2015; Sarkar et al., 2014). Not everyone who experiences these early effects necessarily develops a mood disorder, however. Brain changes affecting depressive and bipolar disorders likely intersect with neurochemical and hormonal features, which we discuss next.

Neurochemical and Hormonal Features Recall from Chapter 3 that mental disorders such as depression involve certain neurotransmitters, especially serotonin, norepi- nephrine, and dopamine. These neurotransmitters closely link to limbic and other key brain systems that in�uence motivation level and emotional state. People with depression have lower than normal levels of these neurotransmitters, especially sero- tonin (see Figure 7.15; Mahar, Bambico, Mechawar, & Nobrega, 2014). Antidepressant medications are often effective in people with mood disorders because they boost serotonin levels in the brain (see later treatment section).

Neurochemical features of bipolar disorder are less clear, although elevations in dopamine may occur and may explain some overlap with schizophrenia (Whitton, Treadway, & Pizzagalli, 2015). Such elevations could help create in�amma- tion and cellular damage, especially in the prefrontal cortex (Andreazza & Young, 2014). Excess glutamate may relate as well to some manic symptoms (Ehrlich, Schubert, Pehrs, & Gallinat,

cortex, which may be smaller or damaged (see Figure 7.12; Fu, Steiner, & Costafreda, 2013). This is particularly so in people who have lived a long time or those with long histories of de- pression, which may help explain the prevalence of depression among the elderly (Sexton, Mackay, & Ebmeier, 2013). These brain areas are involved in goal-directed behavior and inhibi- tion of negative mood and troublesome thoughts. Someone with less activation of these areas (depression) may thus fail to pur- sue important work goals and have recurrent negative thoughts. Memory dif�culties among people with depression might also relate to these brain changes (Trivedi & Greer, 2014).

Subtle damage to certain brain areas may also contribute to mood disorders in general and depression in particular, especially damage to white matter, basal ganglia, and the pons (Sera�ni et al., 2015). These brain areas may be involved in regulation of attention, motor behavior, memory, and emotions,

FIGURE 7.11 IMAGES COMPARING THE BRAIN OF A CONTROL PARTICIPANT (TOP) WITH THE BRAIN OF A CLINICALLY DEPRESSED PERSON (BOTTOM). Note the lower activity (less yellow coloring) of the cortex and other areas in the brain of someone who is depressed.

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Depressive and Bipolar Disorders and Suicide: Causes and Prevention 193

2015). Excess glutamate also occurs in people with schizophrenia and can produce severe damage to neurons in the brain (Marsman et al., 2013). Medi- cations for bipolar disorder, such as lithium, help reduce levels of dopamine and glutamate (Malhi, Tanious, Das, Coulston, & Berk, 2013).

Key hormonal changes also occur in depressive and bipolar disorders. People with depression and cognitive de�cits such as memory problems often have increased cortisol levels (Staufenbiel, Penninx, Spijker, Elzinga, & van Rossum, 2013). This is especially true after experiencing a stressor. Recall from Chapter 5 that increased cortisol, as well as disruption of the hypothalamic- pituitary-adrenocortical axis, impacts the anxiety-related disorders. This may help explain why people with mood and anxiety-related disorders show similar symptoms such as agitation or restless- ness. Increased cortisol may mean a person has a more biologically based depression best treated with medication (Hinkelmann et al., 2012).

Other hormonal changes also re- late to depressive and bipolar disorders.

People with underactive thyroid conditions (and correspond- ingly low levels of thyroid hormones) often experience symp- toms of depression (Ittermann, Völzke, Baumeister, Appel, & Grabe, 2015). A key thyroid hormone, triiodothyronine, interacts

FIGURE 7.12 BRAIN AREAS MOST IMPLICATED IN THE DEPRESSIVE AND BIPOLAR DISORDERS.

FIGURE 7.13 THE BRAIN OF A PERSON WITH BIPOLAR DISORDER SHOWS INCREASED ACTIVITY COMPARED WITH THE BRAIN OF A PERSON WITH UNIPOLAR DEPRESSION. From Mayberg, H.S., Keightley, M., Mahurin, R.K., & Brannan, S.K. (2004). Neuropsychiatric aspects of mood and affective disorders. In S.C. Yudofsky & R.E. Hales (Eds.), Essentials of neuropsychiatry and clinical neurosciences (pp. 489-517). neuropsychiatry and clinical neurosciences (pp. 489-517). neuropsychiatry and clinical neurosciences Washington, DC: American Psychiatric Publishing.

Mania: Irritability Grandiosity Euphoria

Overlap: Aggression Agitation Anxiety Mood swings Psychotic thinking Anger Impulsivity Suicidal thoughts

Schizophrenia: Negative symptoms:

Affective flattening Apathy Positive symptoms: Delusions Hallucinations

FIGURE 7.14 SYMPTOM OVERLAP BETWEEN SCHIZOPHRENIA AND BIPOLAR DISORDER. From C. Daban et al. (2006). Speci�city of cognitive de�cits in bipolar disorder versus schizophrenia: A systematic review. Psychotherapy and Psychosomatics, 75, 72-84. Reprinted by permission of S. Karger AG, Basel.

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also seems related to intense but less stable REM sleep. These factors can disrupt sleep and cause fatigue. Sleep problems affect about 50 to 90 percent of people with depression and likely relate to genetic factors and changes in hormones and neurotransmit- ters such as serotonin (Rosenstrom et al., 2012). A disruption in circadian rhythms, or one’s internal sleep–wake clock, may also occur in people with early morning wakening or depression in winter months. The latter may occur because sunlight is less available to help regulate a person’s internal clock (McEwen & Karatsoreos, 2015).

People with bipolar disorder may also have disrupted REM and slow-wave sleep, and some sleep deprivation may trigger manic episodes and especially rapid cycling (Abrial et al., 2015). Changes in one’s social routine during the day—such as loss of a spouse or partner, travel across time zones, or birth of a new- born—may disrupt biological rhythms that surround sleep. This likely occurs more so for people predisposed to sensitive inter- nal biological clocks or those with poor coping skills. Disruption of circadian rhythms may spiral out of control and contribute to a manic state (Grierson et al., 2016). Such may have been true for Katey, whose late night attendance at clubs may have helped trigger a manic episode.

Environmental Risk Factors for Depressive and Bipolar Disorders and Suicide We turn our attention next to environmental risk factors that de- velop over time to create depressive or bipolar disorders. These include stressful life events and cognitive, interpersonal, and fam- ily factors. We also discuss cultural and evolutionary in�uences.

Stressful Life Events We all experience negative life events that cause us to struggle, but we often “bounce back” with the help of others. For people predisposed to depression, however, stressful life events seem more frequent, painful, and dif�cult to cope with (see Box 7.2). Stressful life events often precede depressive symptoms, though their relationship to ongoing depression is less clear. Stressful ongoing depression is less clear. Stressful ongoing life events may help trigger manic symptoms as well, as Katey’s job loss did (Koenders et al., 2014).

Why do some people develop depression after a stressful life event but others do not? The severity and meaning of the meaning of the meaning stressful life event are clearly important (Espejo, Hammen, & Brennan, 2012). People who become depressed tend to experi- ence major, uncontrollable, and undesirable events highly sig- ni�cant to them. Examples include death of a child or partner, job loss, marital in�delity, business failure, and serious illness. Social support and ability to cope with a negative event are also important. A person who recently lost a loved one may be less depressed if she has a supportive partner and maintains regular eating and sleeping patterns. Personality traits may be important as well, including dependency, rumination, conscientiousness, and self-criticism (Klein, Kotov, & Bufferd, 2011). The impact of stressful life events often interacts with a person’s cognitive misinterpretations of these events, and we discuss these risk factors next.

signi�cantly with serotonin and is sometimes used with anti- depressants to relieve depression (Chang, Sato, & Han, 2013). Rapid cycling in bipolar disorder relates to a less active thyroid as well, so treating the latter condition is often important (Carv- alho et al., 2014). People with depression also have suppressed levels of growth hormone and the hormones somatostatin and prolactin (Faron-Gorecka et al., 2013). These de�ciencies, along with increased cortisol, may help explain the sleep and mood changes seen in people and especially premenopausal women with depression. We describe these sleep de�ciencies next.

Sleep De�ciencies People with depressive and bipolar disorders often have disrup- tions in their normal sleep–wake cycle. Those with depression

often have insom- nia or hypersom- nia and usually feel tired during the day. On the other hand, peo- ple with bipolar disorder in a manic state usually sleep very little. What might explain these effects?

People with depression tend to enter rapid eye movement (REM) sleep more quickly and display less slow-wave, or deep, sleep than normal (Palagini, Baglioni, Ciapparelli, Gemi- gnani, & Riemann, 2013). Depression

FIGURE 7.15 POSITRON EMISSION TOMOGRAPHY (PET) SCAN OF LOWER SEROTONIN FUNCTION IN A PERSON WITH MAJOR DEPRESSION (RIGHT) COMPARED WITH A PERSON WITHOUT DEPRESSION (LEFT). Original source unknown.

Increased cortisol levels may help explain why some people with depression are so agitated.

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Depressive and Bipolar Disorders and Suicide: Causes and Prevention 195

the world around them, and their future. This is the negative cognitive triad. Some people view a certain event in a negative way and have catastrophic thoughts about the event (Beck & Dozois, 2014). These thoughts tend to be automatic thoughts, meaning they constantly repeat over the course of a day.

Consider Victor, who recently failed his math test, as an ex- ample of the negative cognitive triad. After receiving his grade, Victor believed he was not too bright (oneself), thought others would see him as a complete failure (world), and thought he would have to drop out of school (future). Victor gave a single negative event much more weight than should be the case. Many people with depression focus their thoughts on themes of loss and personal failure, inadequacy, and worthlessness (Jeon et al., 2014).

A similar cognitive theory of depression, hopelessness (or attribution) theory, focuses on attitudes or attributions people make about an event (Liu, Kleiman, Nestor, & Cheek, 2015). People with depression experience a negative life event, assume the event will last a long time (stable), and believe the event will affect most areas of their life (global). Victor assumed a single bad performance on a math test would doom the entire semes- ter and would affect other courses and even his interpersonal relationships.

Hopelessness may also result from internal attributions beinternal attributions beinternal - cause a person could excessively blame himself for a negative life event and develop low self-esteem. Hopelessness develops be- cause a person believes that, no matter what he does, his efforts will not lead to change. A person may believe increased studying will not lead to passing grades or college graduation. This sense of learned helplessness might relate to excessive dependency on others (McClintock, McCarrick, & Anderson, 2014).

The concept of learned helplessness comes from experi- ments with dogs exposed to inescapable shock. Once the dogs

Cognitive Factors An environmental risk factor closely related to depressive and bipolar disorders is negative thought patterns, or cognitive dis- tortions. You may recall we mentioned cognitive distortions in Chapter 5 because many people with anxiety-related disorders have unrealistic thoughts about potential or actual threat from internal sensations or external events. Examples of unrealistic thoughts include jumping to conclusions, catastrophizing, and emotional reasoning (see Figure 7.16).

Aaron Beck and others contend that some people with depres- sion develop overly distorted, pessimistic views of themselves,

Stressful life events often help predict depression symptoms in col- lege students and include relationship breakup, illness, and relocation to college (Reyes-Rodriguez, Rivera-Medina, Camara-Fuentes, Suarez- Torres, & Bernal, 2013). Interethnic dif�culties and con�icts as well as achievement stress also contribute to depression symptoms in Asian American, African American, and Latino/a American college students (Wei et al., 2010). College students with unaddressed mental health con- cerns and impulsivity are also at higher risk for suicide (Dvorak, Lamis, & Malone, 2013; Keyes et al., 2012).

Treatments for depression in college students are largely successful and primarily include cognitive behavior therapy, behavioral activation, and inter-primarily include cognitive behavior therapy, behavioral activation, and inter-primarily include cognitive behavior therapy, behavioral activation, and inter personal therapy. Treatment for depressed college students tends to be more effective if conducted individually rather than in a group format (Cuijpers et al., 2015). College students sometimes self-stigmatize regarding treat- ment and thus delay seeking needed help (Downs & Eisenberg, 2012). If you feel symptoms of depression or suicidality, however, then seeking help, perhaps at your school’s counseling center, is strongly encouraged.

Focus On

About 30.6 percent of college students experience depression, particu- larly among female students and students in their earlier years of study. In addition, many college students reportedly feel very sad (37.5 percent), very lonely (36.1 percent), or hopeless (25.9 percent). Most commonly reported symptoms of depression include trouble sleeping, fatigue, loss of energy, appetite changes, and self-criticism. Some college students (20 percent) report increased pessimism, guilt, and sense of failure, and many turn to excessive alcohol use to cope (Geisner, Mallett, & Kilmer, 2012; Ibrahim, Kelly, Adams, & Glazebrook, 2013).

7.2

College Students Depression

Negative view of world Victor: “Everyone will think I’m a failure.”

Negative view of self Victor: “I’m stupid.”

Negative view of future Victor: “I’ll have to drop out of school.”

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FIGURE 7.16 NEGATIVEATIVEA COGNITIVE TRIAD INVOLVINGLVINGL COGNITIVE DISTORTIONS ABOUT THE SELF, WLF, WLF ORLD, AND FUTURE.

CHAPTER 7 Depressive and Bipolar Disorders and Suicide196

as socially ineffective with others. Other people who observe a person with depression may also reject the person and rate him as having poor social skills. Social skill problems may involve poor eye contact, sad facial expression, head drooping, little smiling, or lack of motivation to communicate or to be expres- sive. Social skill de�cits do predict levels of depression (Hames, Hagen, & Joiner, 2013).

People with depression also have communication problems. They speak slowly and softly, have �at affect or little emotion when speaking, and pause a long time before responding to oth- ers (Segrin, 2011). People with depression also frequently seek reassurance and choose topics of conversation that surround sadness, negative self-evaluation (“I’m no good”), and personal �aws (“I’m clumsy around others”; Hames et al., 2013).

Depression also affects many romantic and marital rela- tionships, although such relationships can also serve as a pro- tective factor. Marital dissatisfaction, however, relates closely to depression, especially for partners with high neuroticism, anx- ious attachment, lower self-esteem, and a tendency to believe a spouse intentionally hurts them emotionally. Marital dissat- isfaction often leads to more con�ict and less communication, which can increase depression. Depression and marital prob- lems may co-occur because one spouse becomes withdrawn or angry, sexual relations suffer, or problems are not solved well. The relationship between marriage and depression is likely complex, however (Stroud, Feinstein, Bhatia, Hershenberg, & Davila, 2014).

Depression may relate to amount of social reinforcement one receives for certain behaviors (Hopko, Ryba, McIndoo, & File, 2016). Some people receive attention, reassurance, comfort, and sympathy from others when depressed. Friends and family members may call or visit more, offer to help with children and chores, and listen to problems. Conversely, prosocial behavior is ignored or taken for granted—a person may thus revert to de- pressive behavior to receive more attention. A social behavioral theory of depression may help explain why some depressive be- haviors continue over time.

“learned” they could not escape, they simply sat in a corner and passively accepted the shock. Learned helplessness contin- ued even in later situations in which the dogs could obviously escape. The dogs may have learned that nothing they did had any effect on their environment (Reivich, Gillham, Chaplin, & Seligman, 2013). Such beliefs may occur in people as well. Cognitive theories of depression generally relate to mild or moderate cases of depression or what is sometimes called non- biological, environmentally based, or exogenous depression.

Cognitive risk factors can also be important for bipolar dis- order. Cognitive distortions in this regard often refer to beliefs that one can do something she cannot actually do (recall Katey’s belief she might be able to �y) or beliefs that using medication will be harmful. These beliefs may lead people to stop using medication. People entering a manic or hypomanic episode will also adopt a more carefree attitude, underestimate risk, develop an overly optimistic outlook, emphasize immediate grati�cation, minimize problems, experience increased speed of thoughts, and have trouble concentrating and paying attention (Deckers- bach, Holzel, Eisner, Lazar, & Hierenberg, 2014).

Interpersonal Factors Depression also seems linked to interpersonal dif�culties such as social skill de�cits, communication problems, and relation- ship or marital con�ict. People with depression see themselves

Stressful life events such as caring for two young children while working full time can help trigger depressive or bipolar disorders.

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especially so if a parent has other mental disorders such as a substance use or personality disorder. Marital con�ict, poor parenting, and low parental warmth and family cohesion closely relate to childhood bipolar disorder (Nader et al., 2013). Poor parenting includes substantial criticism and other negative behaviors toward a child (Ellis et al., 2014). How such parent and family problems speci�cally lead to bipolar disorder re- mains unclear. One possibility is that unstable parent and family behaviors hinder a child’s ability to control her emotions.

Cultural Factors We mentioned that rates of depression vary across areas of the world and even among subgroups of a country like the United States. One possible explanation is that depression and other mental disorders are especially high among immigrant and migrant populations (we discuss a similar �nding for schizo- phrenia in Chapter 12). In the United States, the Hispanic popu- lation is one of the fastest growing subgroups. Many Latinos are Mexicans who immigrate to the United States for better working conditions but who have high rates of health problems, stress, and depression (Saint Onge, Cepeda, King, & Valdez, 2013). High rates of depression and other mental health problems also occur among migrant workers in Europe (Levecque & Van Rossem, 2015). However, some researchers also believe that more acculturated immigrants, or those who adopt more prac- tices of the mainstream culture such as music and food, tend to be more depressed than those less acculturated. Those who stay close to others who share a common cultural identity may experience some protection from depression (Meyer, Geller, He, Gonzalez, & Hinton, 2014).

Bipolar disorders are seen fairly equally across cultures, but researchers have found some interesting differences when examining speci�c aspects of these disorders. One group of re- searchers found that African American mothers had a higher prevalence of bipolar disorder (2.5 percent) than Caribbean

Family Factors Children of parents with a depressive or bipolar disorder have more of these disorders themselves compared with the gen- eral population. Genetics may play a role in this connection, but problems among family members are also likely a factor. One such problem involves attachment. Impaired attachment to parents at an early age, especially anxious or ambivalent or avoidant attachment, can lead to later depression that surrounds overdependency on others, loss, fear of abandonment, poor self-worth, self-criticism, and anger toward parents and oneself (Duchesne & Ratelle, 2014; Morley & Moran, 2011). Recall that Katey had little contact with her family members. Later in ther- apy, she also said her relationship with her parents had never been particularly close.

Depression in mothers can also be a strong risk factor for depression in children. Depressed mothers often display inade- quate parenting, tend to disengage from their children, and show many negative and few positive behaviors toward their children. Depressed mothers may withdraw from or ignore child-rearing situations that demand supervision and discipline, and focus on criticism and not affection toward their children. Depressed fathers also tend to be withdrawn, indecisive, cynical, and irritable (Koh, Chui, Tang, & Lee, 2014). Children may thus model depressive symptoms in their parents and develop overly negative views of themselves (Kamkar, Doyle, & Markiewicz, 2012). Families of children with depression are often marked by less available parents and little support and nurturance for the child. Some depressed parents engage in more irritability and overinvolvement, however. This means family members often �ght but remain deeply involved in the details of one anoth- er’s lives (Reising et al., 2013). Family stressors such as marital problems, maltreatment, and poverty also relate to child depres- sion (Yap, Pilkington, Ryan, & Jorm, 2014). Children may thus develop cognitive and attributional distortions and poor social skill with respect to communication, problem solving, and as- sertiveness. These problems relate to interpersonal dif�culties, social withdrawal, and depression (Garber & Rao, 2014).

Children whose parents have bipolar disorder are also at high risk for developing the disorder themselves. This is

Marital problems may be a key trigger for depression. Mothers with depression are at signi�cant risk for having children with depression.

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CHAPTER 7 Depressive and Bipolar Disorders and Suicide198

Causes of Depressive and Bipolar Disorders and Suicide Integrative models are often emphasized to explain how many risk factors can produce depressive and bipolar disorders (see Figure 7.17). Certain people are likely born with a biological vulnerability to experience different depressive or bipolar disor- ders. Some people clearly have a genetic predisposition toward depression or bipolar disorder. These genetic factors may inter- act with or predispose someone toward important neurochemi- cal, hormonal, and brain changes that affect ability to control mood and related behavior.

People also develop a psychological vulnerability toward depressive and bipolar disorders. Some people experience stressful and life-changing events such as loss of one’s mother in early childhood, come to believe they have little control over life events, and experience interpersonal and family problems that contribute to their disorder or deprive them of social support.

Think about depression. Some people are naturally pre- disposed, perhaps via genetics and/or low serotonin and nor- epinephrine levels or prefrontal brain changes, to experience depressed mood and lack of motivation or energy (biological vulnerability). As these people develop as children, sad mood and slow motor behavior may interact with various parental

black mothers (1.2 percent; Boyd, Joe, Michalopoulos, Davis, & Jackson, 2011). In addition, Subramaniam and colleagues (2013) found bipolar disorder to be more frequent among Indians than Chinese living in Singapore. These subtle differences may be due to various risk factors, but some populations may also be less likely to seek help earlier for their symptoms. Recent immi- grants, for example, tend to use fewer services than those who have lived in the United States longer (Sylvia et al., 2013). Some diverse individuals may hide symptoms or seek help only when symptoms are severe, and so clinicians must be sensitive to dif- ferences in culture and ways mental disorders are expressed.

Evolutionary In�uences Evolutionary theories also exist for depressive and bipolar disorders. Some believe depressed states evolved so certain people could withdraw from social interactions. Perhaps cer- tain people feel their value to others is low and their burden on others is high. A person may feel at risk for exclusion from the social group and thus minimize contact with the group. This might help explain depressive symptoms such as sen- sitivity to comments of others and low risk-seeking behav- ior (Zeigler-Hill, Welling, & Shackelford, 2015). In addition, depression may have evolved so people could ruminate over problems until a proper solution is found, because depres- sive behaviors signal to others the need for help, or that depression and withdrawal from dif�cult situations helps lower stress (Rottenberg, 2014).

Evolutionary theories of mania are sparser, although hypo- manic states may help improve physical �tness, level of prestige to enhance reproductive opportunities, and energy for invading or settling a new territory (Le Bas, Castle, Newton, & O’Loughlin, 2013). In addition, cyclothymic tendencies may increase creativ- ity and extravagance, which helps in sexual seduction and in- creases chances for leadership of a group (Fountoulakis, 2015; Vellante et al., 2011).

Migrant workers and immigrants have been shown to be especially susceptible to depression. FIGURE 7.17 SAMPLE DEVELOPMENTAL PATHWAY OF DEPRESSION.

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Biological vulnerabilities/early predispositions

Genetic contributions, neurochemical and hormonal changes, brain changes

Early family problems

Stressful life events

Cognitive-stress and behavioral vulnerabilities

Poor attachment, disengaged parents, expressed emotion, modeling of parental depression

Family conflict, alienation from others, academic and other challenges

Sense of learned helplessness and hopelessness, intense negative emotions and arousal, escape- oriented behavior, lack of social support

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Depressive and Bipolar Disorders and Suicide: Causes and Prevention 199

Prevention of Depressive and Bipolar Disorders and Suicide Depressive and bipolar disorders often begin in adolescence or early adulthood, so it makes sense to think of prevention during childhood and adolescence. Several target areas might be im- portant for prevention. These targets involve coping with stress- ful life events and addressing individual, cognitive, and family factors. Individual factors include social skill and interpersonal problems, medical illness, and academic dif�culties, among others. Cognitive factors include low self-esteem, attributional distortions, and hopelessness, among others. Family factors in- clude marital con�ict and disengaged or hostile parents, among others (Munoz, Beardslee, & Leykin, 2012).

Prevention programs for depressive disorders typically address (1) people without any symptoms of the disorders; (2) people at risk for developing the disorders, such as children of parents with depressive disorders; and (3) people who have a depressive disorder and wish to prevent relapse. For people without symptoms of depressive disorder, researchers have eval- uated large-scale primary or universal prevention programs. One such program was developed by Ian Shochet and colleagues; its two sections are the Resourceful Adolescent Program-Adolescents (RAP-A) and the Resourceful Adolescent Program-Family (RAP-F). The RAP-A program involves an 11-session group approach to teach adolescents to:

• Declare existing strengths, such as being a good student or son/daughter

• Manage stress in dif�cult situations • Modify negative and irrational thoughts to think more

realistically

• Solve problems effectively • Develop and use social support networks such as friends

and other social groups

• Develop strategies to reduce family and interpersonal con- �ict, such as negotiating solutions and repairing relationships

• Enhance social skill and recognize other people’s perspectives The RAP-F program, which focuses on parents, involves

stress management, education about normal teenager develop- ment, promotion of self-esteem, and strategies to reduce family con�ict. Symptoms of depression and hopelessness declined sig- ni�cantly for RAP-A and RAP-F groups compared with control participants. A nice advantage of this program is that it is based in schools where more adolescents might have access (Shochet, Montague, Smith, & Dadds, 2014).

For people at risk for developing depressive disorders, researchers have evaluated large-scale secondary or selected/ indicated prevention programs (Munoz et al., 2012). One group of researchers evaluated a program that focused on adolescents whose parents had a history of depression. Teenagers partici- pated in group and booster sessions to identify and challenge unrealistic thoughts, especially thoughts related to their de- pressed parents (“I will be just like my parents”). Parents also attended education sessions. At-risk adolescents who received

and family factors we mentioned earlier. These factors include poor attachment, disengaged parenting, family dysfunction, and modeling depressive behaviors. In turn, these factors can lead to a child’s problems controlling emotions, solving problems ratio- nally, and interacting with others.

During adolescence and young adulthood, more stress- ful life events are likely to occur. These events include family changes and con�ict, alienation from peers and others, illness, or academic challenges and problems. A cognitive vulnerabil- ity may develop in which one believes he has little control over these events and develops a sense of hopelessness about changing negative experiences (cognitive-stress psychological vulnerability). Some may try to escape depression by marrying or having a child early in life, but this strategy is not gener- ally effective. If a person also experiences poor social support and is overdependent on others, then depression may be even more likely.

Some people have a strong biological vulnerability to de- pression that requires few environmental triggers. People with biologically oriented, or endogenous, depression often develop sadness for little apparent reason. Other people have a weak biological predisposition toward depression but still become de- pressed when frequent, overwhelming, and negative life events occur. People with environmentally oriented, or exogenous, de- pression develop sadness primarily because they cope poorly with major life stressors. Exogenous or reactive depression often reactive depression often reactive follows some major event.

People with bipolar disorders likely have a strong bio- logical vulnerability toward recurrent manic or hypomanic episodes. Genetic predispositions and neurochemical changes are well documented in this population. Little environmen- tal in�uence may be needed to trigger the disorders. Some psychological factors relate to onset and duration of bipolar symptoms, including stressful life events, family hostility and con�ict, lack of social support, cognitive distortions, and per- sonality disturbances (Johnson, Cuellar, & Peckham, 2014). Katey’s therapist discovered that Katey’s mother also had symptoms of bipolar disorder and that Katey was alienated from her family.

What about suicide? Models of suicide also gravitate toward integrating various risk factors into an organized framework. Key biological variables may include tendencies to ruminate intensely about stressful life events and then to experience strong negative emotions after these events. These repetitive thinking processes and negative emotions aggravate one another over time and lead to an emotional cascade that is dif�cult for a person to tolerate and can lead to self-injury (Selby & Joiner, 2013).

These biological vulnerabilities can be aggravated by envi- ronmental factors, such as poor social support and inability to cope effectively with stress as well as symptoms of depression or bipolar disorder. A person who reaches the point of suicide feels unable to escape torment and feels such pain is intolerable and will last a long time. Severe hopelessness develops such that a person has trouble thinking about problem solutions other than suicide (Hagan, Podlogar, Chu, & Joiner, 2015).

CHAPTER 7 Depressive and Bipolar Disorders and Suicide200

physicians, clergy, pharmacists, and other “�rst responders” to help them recognize and treat suicidal tendencies in people who come for help. Screening programs to help identify early suicidal behaviors are an avenue to get people help via medication and psychotherapy. Follow-up care after a suicide attempt is critical as well to prevent a second attempt. These programs have also been moderately successful for lowering suicide rates in speci�c groups (Goldney, 2013).

➲ Interim Summary • Biological risk factors for depressive and bipolar disorders

include genetics, brain changes, neurochemical and hor- monal differences, and sleep de�ciencies.

• Environmental risk factors for depressive and bipolar disor- ders include stressful and uncontrollable life events, nega- tive thought processes and misattributions, problematic interpersonal relationships, and parent and family factors that help create an unstable living environment for a child. Cultural and evolutionary factors may also be in�uential.

• Biological and environmental risk factors can make a person vulnerable to a depressive or bipolar disorder. These risk factors inhibit one’s ability to control emotions, cope with stress, solve problems, and relate to others effectively.

• Depressive and bipolar disorders may result from a combi- nation of (1) early biological factors and (2) environmental factors related to ability to cope, think rationally, and regulate intense emotions.

• Preventing depressive and bipolar disorders involves building one’s ability to control situations that might lead to symptoms.

➲ Review Questions 1. Describe data that support a genetic contribution to depres-

sive and bipolar disorders. 2. What key brain, neurochemical, and hormonal brain changes

relate to depressive and bipolar disorders, and how might sleep de�ciencies contribute?

3. Describe two main cognitive theories of depression. 4. How might interpersonal and family factors help cause

depressive and bipolar disorders? 5. Describe an overall causal model for depressive and bipolar

disorders. 6. What factors might be important in designing a program to

prevent depressive and bipolar disorders as well as suicide?

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment

Primary methods to assess people with depressive and bipo-lar disorders include interviews, self-report questionnaires, self-monitoring, observations from others, and physiological measurement. A person suspected of having a depressive or

the prevention program displayed less onsets of depression over time than controls, even after 6 years (Brent et al., 2015). An advantage of this approach is that one key intervention ingre- dient—cognitive restructuring—was found so effective. Cog- nitive restructuring, or cognitive therapy, as we discussed in Chapter 5, involves examining negative statements a person may be making and encouraging the person to challenge the thought and think more realistically (see also the section on treatment later in the chapter).

For people with a depressive disorder, researchers have eval- uated relapse prevention programs (Bockting, Hollon, Jarrett, Kuyken, & Dobson, 2015). People with depression often need help identifying situations such as solitary settings that place them at risk for future depression, managing stress, coping with and resolving dif�cult situations such as marital con�ict, and enhancing self-con�dence (Biesheuvel-Leliefeld et al., 2015). Relapse prevention for depression also involves helping people remain on antidepressant medication and increasing mindful- ness regarding their behaviors (Shallcross et al., 2015).

Little work is available regarding prevention of bipolar dis- order, although youth whose parents have the disorder are cer- tainly at risk themselves. Early prevention research in this area has concentrated on youth just beginning to show symptoms of bipolar disorder or who have a positive family history for the disorder (Goldstein et al., 2014). For people with bipolar disor- der, relapse prevention focuses on learning about one’s symp- toms, maintaining medication, and increasing family and social support (Bond & Anderson, 2015).

Preventing suicide must also be a priority among people with depressive and bipolar disorders. General programs to prevent sui- cide focus on adolescents and involve school-based suicide aware- ness programs, screening teenagers at risk for suicide, enhancing problem-solving and coping skills, educating peers and teachers to identify high-risk behaviors, and providing crisis intervention to those at risk. Other suicide prevention strategies include com- munity-based crisis centers and hotlines. These programs do help reduce suicide rates among youth (Calear et al., 2015).

Suicide prevention programs for adults also focus on aware- ness and education among the public, such as helping people un- derstand risk factors associated with suicide and reducing stigma of mental disorder. These programs also focus on primary care

V THE CONTINUUM VIDEO PROJECT

Emilie / Bipolar Disorder

“When I’m feeling the worst, my brain tells me that I am worthless, that the kids would be better off without me . . . I’m just a drain.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

’m feeling the worst, my brain tells me that I am

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Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 201

other questions in unstructured or structured interviews. Struc- tured interviews usually cover diagnostic criteria and contain questions a therapist asks each client with a possible depressive or bipolar disorder.

Structured interviews for people with depressive and bipo- lar disorders include the Schedule for Affective Disorders and Schizophrenia and Schizophrenia and Schizophrenia Structured Clinical Interview (First, Williams, Karg, & Spitzer, 2015). The Schedule for Affective Disorders and Schizophrenia for School-Age Children is useful for youths (Bergman, Maayan, Kirkham, Adams, & Soares-Weiser, 2015). Other interview-format instruments determine how severe a person’s symptoms are or how a person is responding to treat- ment. Examples include the Brief Psychiatric Rating Scale and Brief Psychiatric Rating Scale and Brief Psychiatric Rating Scale Hamilton Rating Scale for Depression (see Table 7.11; Biancosino, Picardi, Marmai, Biondi, & Grassi, 2010; Bech, Paykel, Sireling, & Yiend, 2015; Sajatovic & Ramirez, 2012).

Katey’s therapist used the Hamilton Rating Scale for Depression to note Katey’s depressed mood, dif�culties sleep- ing, thoughts about inability to work, and agitation. The thera- pist saw that many of Katey’s sentences contained sadness or bleakness. Katey was also restless at night and disturbed by constant thoughts about her condition. Fortunately, however, Katey did not wish she were dead, although she did occasion- ally wonder if life was worth living. Following is an excerpt from Katey’s interview:

Katey: Yeah, I just �nd it so hard to get up in the morning sometimes.

Therapist: What do you think about in the morning? Katey: How hard the day will be, who I’ll have to meet,

what I have to do—it just seems so overwhelming at times.

Therapist: Do you think about ways you can cope with events during the day?

Katey: I don’t really see the point. What difference does it make? The day is going to be a big disaster no matter what I do.

Therapists commonly use unstructured interviews to assess people with depressive and bipolar disorders. Important topics to cover during such an interview include:

• Past and present mood symptoms • Risk factors such as interpersonal and cognitive factors • Medical and treatment history • Ongoing problems and comorbid diagnoses • Motivation for change • Social support • Suicidal thoughts and behaviors (see Assessment of Suicide

section)

Katey’s therapist asked many questions about her family and symptom history. Katey’s symptoms had been ongoing for some time, and her mother had some intense mood changes. Other questions related to Katey’s current ability to function and what daily social supports she could access. Many questions

bipolar disorder should always have a full medical examination as well. Medical conditions related to depression, for example, include neurological impairments, brain injuries, cardiovascular problems, hormonal changes, immune disorders, and terminal illnesses (see Table 7.10). Symptoms of depressive and bipolar disorders may also relate to drug intoxication, withdrawal, or side effects. If a physical condition or substance contributes to a person’s depressive or bipolar symptoms, then medical treat- ment or expanded psychological treatment is necessary to ad- dress the condition or drug problem.

Interviews and Clinician Ratings Katey’s therapist had many questions for her client, especially about her behaviors and thoughts during the day. The therapist was also interested in how Katey felt about her symptoms and what Katey would like to be doing weeks or months from now. Recall from Chapter 5 that therapists typically ask these and

TABLE 7.10

Disorders Associated with Depression

Neurological disorders Systemic disorders

Focal lesions:

Stroke

Tumor

Surgical ablation

Epilepsy

Endocrine disorders:

Hypothyroidism and hyperthyroidism

Adrenal diseases (Cushing’s, Addison’s)

Parathyroid disorders

Regional degenerative diseases:

Parkinson’s disease

Huntington’s disease

Pick’s disease

Fahr’s disease

Progressive supranuclear palsy

Carbon monoxide exposure

Wilson’s disease

In�ammatory/infectious diseases:

Systemic lupus erythematosus

Neurosyphilis

AIDS

Tuberculosis

Mononucleosis

Sjögren’s syndrome

Chronic fatigue syndrome

Diffuse diseases:

Alzheimer’s disease

AIDS dementia

Multiple sclerosis

Metabolic disorders:

Uremia

Porphyria

Vitamin de�ciencies

Miscellaneous disorders:

Migraine

Paraneoplastic syndromes

Miscellaneous disorders:

Medication side effects

Chronic pain syndromes

Sleep apnea

Cancer

Heart disease

CHAPTER 7 Depressive and Bipolar Disorders and Suicide202

were also devoted to Katey’s thought patterns and her willing- ness to take prescribed medication.

Therapists must also understand that people with depres- sive and bipolar disorders often speak at a different pace, bias their information in negative (depression) or positive (manic) ways, and may be uncomfortable sharing personal infor- mation. Building rapport is thus very important. Therapists can also examine nonverbal behaviors in an interview to help determine symptoms and severity of a depressive or bipolar disorder. Important nonverbal behaviors for depression, for ex- ample, include reduced facial expression and poor eye contact, slow movement, muted affect, low energy level, and minimal smiling or laughter (Annen, Roser, & Brune, 2012).

Self-Report Questionnaires Depressive and bipolar disorders involve severe changes in emotions and thoughts, so clients are often asked to rate their symptoms on questionnaires. Self-report questionnaires for people with depression focus on recent depressive symptoms, problematic thoughts, and hopelessness. A common self-report measure is the Beck Depression Inventory—II, which addresses negative attitudes toward oneself, level of impairment due to depression, and physical symptoms. A child version of this scale is also available; selected items are listed in Table 7.12 (Beck & Dozois, 2014; Kovacs, 2010). The Beck Hopelessness Scale asHopelessness Scale asHopelessness Scale - sesses level of pessimism about the future and strongly relates to suicidal behavior (Spokas, Wenzel, Brown, & Beck, 2012). The Automatic Thoughts Questionnaire—Revised assesses negative thoughts common to people with depression.

The interview remains a dominant psychological approach for assessing people with bipolar-related disorders. However, some measures assess self-reported symptoms of mania and hy- pomania. Examples include the General Behavior Inventory and

Instructions: For each item, select the number that corresponds to the statement that best characterizes the patient.

1. Depressed mood (sadness, hopeless, helpless, worthless)

0. Absent

1. These feeling states indicated only on questioning

2. These feeling states spontaneously reported verbally

3. Communicates feeling states non-verbally—i.e., through facial expression, posture, voice, and tendency to weep

4. Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and nonverbal communication

2. Feelings of guilt

0. Absent

1. Self reproach, feels he has let people down

2. Ideas of guilt or rumination over past errors or sinful deeds

3. Present illness is a punishment. Delusions of guilt

4. Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

3. Suicide

0. Absent

1. Feels life is not worth living

2. Wishes he were dead or any thoughts of possible death to self

3. Suicidal ideas or gestures

4. Attempts at suicide (any serious attempt rates 4)

4. Insomnia early

0. No dif�culty falling asleep

1. Complains of occasional dif�culty falling asleep—i.e., more than 1/2 hour

2. Complains of nightly dif�culty falling asleep

5. Insomnia middle

0. No dif�culty

1. Patient complains of being restless and disturbed dur- ing the night

2. Waking during the night—any getting out of bed rates 2 (except for purposes of voiding)

6. Insomnia late

0. No dif�culty

1. Waking in early hours of the morning but goes back to sleep

2. Unable to fall asleep again if he gets out of bed

Choose one:Choose one: • am sad once in a while.am sad once in a while. • am sad many times.am sad many times. • am sad all the time.

Choose one:Choose one: • do not think about killing myself.do not think about killing myself. • think about killing myself, but I would not do it.think about killing myself, but I would not do it. • want to kill myself.

Choose one:Choose one: • nobody really loves me.nobody really loves me. • am not sure if anybody loves me.am not sure if anybody loves me. • am sure that somebody loves me.

TABLE 7.11

Hamilton Rating Scale for Depression

TABLE 7.12

Sample Items from the Children’s Depression Inventory

From Hamilton M. (1967). Development of a rating scale for primary depressive illness, British Journal of Social & Clinical Psychology, 6(4):278-296. Reproduced with permission from The British Psychological Society. Reprinted with permission from John Waterhouse and the British Psychological Society.

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 203

commit suicide. We mentioned earlier that high-risk factors for suicide include being male, elderly, single, European American, unemployed, or socially isolated.

People at risk for suicidal behavior also tend to have a mental disorder, have experienced a recent and stressful life event, feel socially alienated and a burden to others, and are sad, agitated, or angry (Anestis, Bagge, Tull, & Joiner, 2011; Beghi, Rosenbaum, Cerri, & Cornaggia, 2013). People who feel a strong sense of hopelessness, or a feeling they have no options or control over situations in their lives, are at high risk for suicide (Hawton et al., 2013). This was true for Katey, although she did not currently have thoughts of harming herself. Still, her therapist continued to assess for possible suicidality during treatment.

Hirschfeld created a system for assessing suicide (see Figure 7.19). Following a consideration of major risk factors, therapists are encouraged to ask about recent symptoms of depression or anxiety and substance use. Risk can then be determined even further by asking speci�c questions about the detail of one’s plan to commit suicide. Someone who has a care- fully designed plan will tend to be at high risk for doing so. Questions should also surround access to weapons, willingness to die, psychotic symptoms such as hearing voices, previous suicide attempts, family history of suicide, and ability to resist the act of suicide (Hirschfeld, 2012; Simon & Hales, 2012). If a person is at high and imminent risk for committing suicide, a therapist must take drastic action to prevent the act. We discuss these clinical actions further in the later treatment section.

Researchers also use retrospective analysis to examine peo- ple who have attempted or completed suicide. Retrospective analysis, sometimes called a psychological autopsy, may involve interviewing family members and friends, examining suicide notes, and evaluating medical records (Norra, Schaub, Juckel, & Schmieder, 2015). Retrospective studies often reveal that physical or mental disorders, interpersonal con�icts, stressful life events, or job or �nancial or family loss are key risk factors in suicide (Moscicki, 2014).

Hypomanic Personality Scale (Pendergast et al., 2015; Sperry, Hypomanic Personality Scale (Pendergast et al., 2015; Sperry, Hypomanic Personality Scale Walsh, & Kwapil, 2015). Reports from signi�cant others in a per- son’s environment may also be useful, and we discuss these methods next.

Self-Monitoring and Observations from Others People with depressive and bipolar disorders can monitor and log their own symptoms on a daily basis. We discussed in Chapter 5 that daily self-monitoring reduces the need to recall events and increases focus and self-awareness on one’s symp- toms. For people with depressive and bipolar disorders, im- portant information to record each day may include ratings of sadness or euphoria, activities with others, attendance at work or school, negative or suicidal thoughts, eating and sleeping patterns, and unpleasant physical symptoms, among other top- ics. Others who know a client well can also record her more obvious mood symptoms, such as grandiosity like Katey’s one- time belief she could �y. This applies especially to people with bipolar disorder—Katey’s therapist made sure family members and friends helped monitor Katey’s mood and behavior be- tween treatment sessions.

Laboratory Assessment People with depressive disorders can have marked changes in hormones or neurotransmitters, so laboratory assessment tech- niques may apply. The dexamethasone suppression test (DST) dexamethasone suppression test (DST) dexamethasone suppression test involves injecting a person with dexamethasone, which is a cor- ticosteroid. Dexamethasone is similar to cortisol and decreases the pituitary gland’s release of adrenocorticotropic hormone, which in turn decreases release of cortisol from the adrenal gland. Recall that people with depression have differences in the hypothalamic-pituitary-adrenal axis. Cortisol levels from dexamethasone decline over time for most people but remain high—or not suppressed—in people with major depression (see Figure 7.18).

Some researchers have found DST results to relate closely to depression, but the results can also characterize people with other mental and medical or hormonal disorders such as Cushing’s syndrome (Lindholm, 2014). Other laboratory assess- ments for this population include tests for neurotransmitter and hormonal or thyroid levels as well as sleep studies. Laboratory assessments are costly and require a lot of time, however, and so are more common in research than clinical settings.

Assessment of Suicide Recall that suicidality is common in people with depression and mania, as it was for Katey. A critical area of assessing depressive and bipolar disorders, therefore, is suicidal thoughts and behav- iors. Therapists usually address suicidality by asking clients if they have thoughts of harming themselves. Most people accu- rately answer this question. Therapists also study a person’s his- tory and current risk factors to determine the likelihood he may

Pituitary gland

Adrenal gland

ACTH

DexamethasoneDexamethasone

Cortisol

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FIGURE 7.18 PRIMARY BRY BRY ODILY FLY FLY UNCTIONS INVOLVEDLVEDL IN THE DEXAMETHASONE SUPPRESSION TEST (DST).

CHAPTER 7 Depressive and Bipolar Disorders and Suicide204

reuptake of these neurotransmitters. Many antidepressants are thus called selective serotonin reuptake inhibitors, or SSRIs (see Table 7.14). SSRIs are popular because they affect serotonin- based areas of the brain speci�cally and not other neurotrans- mitter systems. Side effects thus tend to be limited, although they do exist.

Common side effects of SSRIs include nausea, headache, agitation, sweating, gastrointestinal problems, sexual dysfunc- tion, and insomnia (Anderson, Pace, Libby, West, & Valuck, 2012). SSRIs have been associated with increased risk of self-harm and suicide attempt, especially for children and adolescents

Biological Treatment of Depressive and Bipolar Disorders and Suicide Biological treatments for people with depressive and bipolar dis- orders include medication, electroconvulsive therapy, repetitive transcranial magnetic stimulation, and light therapy.

Medication Antidepressant medications are often helpful for people with depression. Recall from Chapter 2 that antidepressants increase serotonin and norepinephrine in the brain, often by blocking

Assess sociodemographic

risk factors.

Assess risk of suicide.

Screen for depression and

associated anxiety or agitation.

Ask about stressors

Screen for excessive

alcohol use.

• Elderly • Unmarried • White

• Male • Living alone

“Have you experienced sad, blue, or empty feelings and at least two of the following in the past two weeks: • trouble falling or staying asleep • feeling tired or having little energy • poor appetite or overeating • little interest or pleasure in doing things • feeling bad about yourself • trouble concentrating • feeling fidgety, restless, or unable to sit still” “Have you felt nervous, anxious, or on edge?” “Have you had anxiety or panic attacks recently?”

“Have you had thoughts about death, or about killing yourself?” If yes, ask: “Do you have a plan for how you would do this?” “Are there means available (e.g., a gun and bullets or poison)?” “Have you actually rehearsed or practiced how you would kill yourself?” “Do you tend to be impulsive?” “How strong is your intent to do this?” “Can you resist the impulse to do this?” “Have you heard voices telling you to hurt or kill yourself?” Ask about previous attempts, especially the degree of intent. Ask about suicide of family members.

“Have you ever felt you should cut down on your drinking?” “Have people annoyed you by criticizing your drinking?” “Have you ever felt bad or guilty about your drinking?” “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?”

Yes to two or more means probable excessive alcohol use.

“How are things going in your marriage, in your family, at home, at work?” (Cover health, financial, marital, family, legal, and occupational factors.)

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FIGURE 7.19 SCHEMATIC FOR ASSESSMENT OF SUICIDALITY.

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 205

St. John’s wort, an herbal extract found in any drugstore. How- ever, its effectiveness for depression seems limited (Sarris, 2013).

Antidepressants work well for people with depression, but they may take several weeks or more to achieve an adequate effect (Pringle & Harmer, 2015). Overdose of antidepressants is also a common method of suicide. Adding other crisis manage- ment procedures is thus indicated when a person is suicidal (see later section). Antidepressants may be less effective when a per- son’s depression has psychotic features, is seasonal in nature, or is extremely severe. Antidepressants by themselves are effec- tive in about 54 percent of cases compared with 37 percent for placebo control participants (Undurraga & Baldessarini, 2012). Medication is more effective for people with fewer comorbid dis- orders, less severe depression, and better social support (Uher et al., 2012).

Medication for people with bipolar disorder involves mood- stabilizing drugs (see Table 7.15; Grande & Vieta, 2015). Lithium is most effective for preventing future manic episodes and suicide because, as mentioned earlier, the drug reduces levels of dopamine and glutamate. The drug also affects thyroid and adrenocorticotropic hormones, which we mentioned earlier with respect to the dexamethasone suppression test (Manna, Roy, & Mugesh, 2013).

Lithium can be highly toxic, so periodic blood tests are necessary. Lithium’s toxicity and the fact that some people with bipolar disorder want to keep their euphoria or have poor insight can make compliance to the medication problematic (Sajatovic et al., 2015). Side effects of lithium can include vomiting, weak- ness, cardiovascular and urinary problems, thyroid abnormali- ties, dizziness, confusion, muscle tremor, and drowsiness.

If lithium is not effective alone, then divalproex may also be prescribed. Divalproex is an anticonvulsant drug that in- creases gamma-aminobutyric acid (GABA) levels and creates a sedating effect. The drug may be especially useful for people with rapid cycling and mixed features (Kemp et al., 2012). In severe cases of bipolar disorder, lithium and divalproex are used with another anticonvulsant such as carbamazepine or an- tipsychotic medications (Chapter 12; Ogawa, Tajika, Takeshima, Hayasaka, & Furukawa, 2014). Side effects of mood-stabilizing

(Smithson & Mitchell, 2015). SSRIs may relate to suicide attempt because a person with depression has more energy after taking the drugs but uses this energy for self-harm.

SSRIs have largely replaced tricyclic antidepressants (see Table 7.14) that produced the same neurotransmitter effect but had more side effects. Tricyclics affect serotonin as well as nor- epinephrine and other neurotransmitter systems. Side effects of tricyclics include a wide range of cardiovascular, muscular, al- lergic, gastrointestinal, endocrinological, and other symptoms. Tricyclics and SSRIs are both effective, but many physicians and patients prefer SSRIs because of their fewer side effects (Bet, Hugtenburg, Penninx, & Hoogendijk, 2013). Tricyclics may be used if a person does not respond well to an SSRI.

Other antidepressants are available if SSRIs or tricyclics are not effective (see Table 7.14). Monoamine oxidase inhibitors (MAOIs) enhance tyramine to increase norepinephrine and se- rotonin. Unfortunately, this also means a person on MAOIs must abstain from various foods such as aged cheese and substances such as cold medications, or a toxic reaction could occur. Severe side effects are common to these drugs as well, including agita- tion, manic-like symptoms, weakness, dizziness, and nausea.

In addition to SSRIs, tricyclics, and MAOIs, other antide- pressants include Wellbutrin (bupropion) and Effexor (venla- faxine) to increase norepinephrine (see Table 7.14; Maneeton, Maneeton, Eurviriyanukul, & Srisurapanont, 2013). Side effects of these drugs can be quite severe: side effects of Wellbutrin include dizziness, tachycardia (fast heart rate), nausea, weight loss, excessive sweating, severe headache, blurred vision, in- somnia, and agitation. Many people with depression also take

Selective serotonin reuptake inhibitors (SSRIs): Tricyclic antidepressants:

Citalopram (Celexa) Anafranil (Clomipramine)

Escitalopram oxalate (Lexapro) Elavil (Amitriptyline)

Fluoxetine (Prozac) Norpramin (Desipramine)

Fluvoxamine (Luvox) Sinequan (Doxepin)

Paroxetine (Paxil)

Sertraline (Zoloft)

Monoamine oxidase inhibitors (MAOIs): Others:

Marplan (Isocarboxazid) Effexor (Venlafaxine)

Nardil (Phenelzine) Wellbutrin (Bupropion)

Parnate (Tranylcypromine) Remeron (Mirtazapine)

Duloxetine (Cymbalta)

Carbamazepine (Tegretol)

Divalproex (Depakote)

Lamotrigine (Lamictal)

Lithium (Eskalith)

Olanzapine (Zyprexa)

Thorazine (Chlorpromazine)

TABLE 7.14

Common Medications for People with Depression

TABLE 7.15

Common Mood-Stabilizing Medications for People with Bipolar Disorder

CHAPTER 7 Depressive and Bipolar Disorders and Suicide206

ECT works is not completely clear, but some evidence points to changes in the brain circuits and neurotransmitters involved in mood (Anderson & Fergusson, 2013). ECT remains a common but still controversial treatment (see Box 7.3).

Repetitive Transcranial Magnetic Stimulation An alternative to ECT is repetitive transcranial magnetic stim- ulation (rTMS), which involves placing an electromagnetic coil on a person’s scalp and introducing a pulsating, high-intensity current. The current produces a magnetic �eld lasting 100 to 200 microseconds, and the procedure is less invasive than ECT. rTMS may increase the brain’s metabolism of glucose and blood �ow to the prefrontal cortex, but the procedure remains somewhat controversial and perhaps less effective than other treatment methods (Fitzgerald & Daskalakis, 2013). People with major depression respond better to rTMS (24.7 percent)

drugs include digestive problems, muscle tremor and weakness, dizziness, nausea, vomiting, diarrhea, and thrombocytopenia (low blood platelets, which could lead to bleeding).

Mood-stabilizing drugs are effective for 46 to 58 percent of people with acute mania compared with 30 percent for pla- cebo (Baldessarini, 2013). The combination of lithium and car- bamazepine seems more effective than either drug alone, and lamotrigine (another anticonvulsant) seems better for prevent- ing depression after a manic episode than treating mania per se (Trankner, Sander, & Schönknecht, 2013). People who respond best to these drugs have less severe bipolar disor- der and continue to take their medication (Arvilommi et al., 2014). Katey took lithium and divalproex and did appear calmer during treatment.

Electroconvulsive Therapy An unusual but often effective treatment for people with very severe or melancholic depression is electroconvulsive therapy, or ECT. Sometimes known as “shock therapy,” ECT involves placing one or two electrodes on a person’s head and delib- erately inducing a seizure into the brain via shock for 0.5 to 2.0 seconds. The person �rst receives sedative medication to prevent convulsions. People with severe depressive symptoms such as dif�culty moving who have not responded to medica- tion may receive ECT in an inpatient psychiatric setting. The process usually requires 6 to 12 sessions over 2 to 4 weeks, and common side effects include temporary memory loss and confu- sion (Charlson et al., 2012).

ECT is generally effective for people with very severe de- pression, even more so than medication, especially if two elec- trodes and higher dosage is used. Relapse rates can be high, however (Jelovac, Kolshus, & McLoughlin, 2013). People with mania can also bene�t from ECT, particularly those who do not respond to medication (Elias, Abidi, & Bhat, 2015). How

person fully informed of the bene�ts and risks of the procedure?), and justice (does the procedure preserve the person’s dignity?).justice (does the procedure preserve the person’s dignity?).justice

These principles can create ethical dilemmas. Fink outlined these dilemmas in vignettes. One vignette involves an elderly woman with cardiovascular prob- lems and severe depression. Even if ECT is the preferred choice of treatment in this situation, should it be used at the risk of worsening her cardiovascular symptoms? In another vignette, a person with severe depression is hospitalized after a suicide attempt and too distraught to speak with doctors. Even if ECT might work, would doing so be advisable because the person cannot give proper consent or understand the treatment? (Fink, Kellner, & McCall, 2014).

Other vignettes create additional questions. What if a person gives con- sent for ECT but family members adamantly oppose the treatment? What if ECT allows a person to become legally competent to stand trial for a terrible crime? What if a person refuses ECT but continues to be suicidal? Answering these questions is dif�cult and requires a thorough review of several ethical principles. What would you do in these situations?

Focus On

Electroconvulsive therapy (ECT) is an effective treatment for people with severe depression. Still, ECT remains controversial because many people view the procedure with alarm and because researchers are still unsure how ECT works. One researcher, Max Fink, outlined several ethical prin- ciples for therapists who consider ECT. These principles include bene�- cence (does the procedure help the person?), cence (does the procedure help the person?), cence nonmale�cence (does the nonmale�cence (does the nonmale�cence procedure harm the person in any way?), respect for autonomy (is the respect for autonomy (is the respect for autonomy

Law and Ethics Ethical Dilemmas in

Electroconvulsive Therapy

7.3

Light therapy may be especially useful for people with seasonal depression.

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Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 207

activities and exercise, and rewarding progress. Speci�c activi- ties a therapist may focus on include the following:

• Educational and creative activities, such as learning a musical instrument or engaging in photography

• Domestic activities, such as housecleaning or cooking • Health and appearance activities, such as going to the den-

tist and shopping for new clothes

• Leisure activities, such as walking in the park and increased exercise

• Religious activities such as going to church The overall goal of behavioral activation is to get a person

more involved with daily social activities that will help produce positive feelings of self-esteem (Balan, Lejuez, Hoffer, & Blanco, 2015; McIndoo, File, Preddy, Clark, & Hopko, 2016). Behavioral activation may be combined with other behavioral approaches as well:

• Contingency management may involve teaching signi�cant Contingency management may involve teaching signi�cant Contingency management others not to reinforce depressive behavior and instead re- inforce active, prosocial behavior.

• Self-control therapy may involve having a person reinforce herself for active, nondepressed behaviors.

• Social skills training may help a person, especially an Social skills training may help a person, especially an Social skills training adolescent with depression, improve methods of social in- teraction, including making eye contact, smiling more, and discussing topics other than depression.

• Coping or problem-solving skills training may be used to problem-solving skills training may be used to problem-solving skills training help people �nd effective solutions for problems instead of avoiding them.

Therapists often combine behavioral techniques with other psychological approaches such as reminiscence therapy (see Box 7.4) and cognitive therapy, which we describe next.

Cognitive Therapy Cognitive therapy is a main staple of treatment for people with depressive and bipolar disorders. We discussed in Chapters 5 and 6 that cognitive therapy involves examining a person’s neg- ative statements and encouraging her to challenge her thoughts. Cognitive therapy helps people change their ways of reasoning about the environment and see the positive and realistic side of things as well as the negative. A person also learns about the relationship between thoughts, emotion, and behavior. One may believe he will fail a test, become sullen and withdrawn from others, and fail to study or prepare for the test. Becoming aware of these kinds of sequences and using cognitive techniques will help him refrain from such catastrophic thinking and problem- atic behaviors.

Cognitive therapy for depression entails examining evidence for and against a certain thought, hypothesis testing to see the actual chances something bad will happen, and decatastrophiz- ing worst-case scenarios. The main goals of cognitive therapy for depression are to increase a person’s ability to challenge nega- tive thoughts and develop a sense of control over life events that

compared with placebo (6.8 percent; Berlim, Van den Eynde, & Daskalakis, 2012). rTMS may also be effective for people with mania (Pallanti et al., 2014).

Light Therapy An innovative treatment for people with seasonal depression, especially those primarily depressed in winter months, is light therapy. Light therapy generally consists of having a person sit before a bright light of 2,000 to 10,000 lux (a unit of illumina- tion) for 30 to 120 minutes per day during the winter. Traditional light therapy involved large light “boxes,” but modern devices include smaller towers a person can see while reading or work- ing on a computer. The therapy is usually administered in the morning or evening and may work by enhancing photon ab- sorption or by adjusting circadian rhythms or melatonin levels. People with seasonal depression generally respond positively to light therapy, and the procedure may also be useful for some people with nonseasonal depression (Oldham & Ciraulo, 2014).

Psychological Treatments for Depressive and Bipolar Disorders and Suicide Psychological treatments are quite effective for mild and mod- erate mood problems and include behavioral activation, cog- nitive therapy, mindfulness, interpersonal therapy, and family and marital therapy. Most of these apply best to depression but some can apply to bipolar disorder as well. We next discuss psychological treatments for depressive and bipolar disorders and suicide.

Behavioral Activation and Related Therapies People with depression often isolate themselves from others and lose interest in previously pleasurable activities. Others may then provide sympathy and attention and socially reinforce depressed behavior. Therapists rely on behavioral activation to address this process. Essential components of behavioral activa- tion include psychoeducation about depression, increasing daily

Repetitive transcranial magnetic stimulation (rTMS) is a treatment for people with depression.

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CHAPTER 7 Depressive and Bipolar Disorders and Suicide208

Mindfulness Recall from Chapter 5 that mindfulness is a relatively new ther- apy to help people understand and accept their symptoms but still live a normal life. We discussed how mindfulness for anxi- ety-related disorder involves greater awareness and acceptance of symptoms and how symptoms can be experienced without severe avoidance or other impairment. Therapists also apply mindfulness to people with depression and focus on helping people experience the present rather than dwell on past failures or negative expectations about the future. A therapist encour- ages a client to be aware of her body and movement in the here and now and to use meditation and other practices to enhance this awareness (van der Velden et al., 2015).

Some of the most problematic aspects of depression are trou- blesome emotions, thoughts, and physical behaviors. A therapist engaging in mindfulness thus encourages a client to view sad mood, thoughts, and physical feelings as events that pass through the mind and not as indicators of reality (Teasdale, Williams, & Segal, 2014). Clients are encouraged to disengage from habitual thoughts and focus on “being” in the moment. Therapists often combine mindfulness with cognitive therapy for individuals or groups. Mindfulness is effective for treating depression and may be especially helpful for preventing relapse (Shallcross et al., 2015).

Interpersonal Therapy Another psychological approach to treating depressive and bipolar disorders is interpersonal therapy, or IPT. The basis of

seem unpredictable and overwhelming. Cognitive therapy helps a person who believes he will fail an upcoming test to learn how to realistically appraise whether failure will actually happen and how to properly study so failure is less likely to happen.

Cognitive therapy for depression is certainly better than no treatment and appears to be as effective as medication. Cognitive therapy may produce better, longer term results than medication because clients have learned speci�c skills to combat depressive thoughts. Cognitive therapy with medication is a standard treat- ment for depression in many clinical settings, but the therapy may be less effective for people with severe depression or those actively suicidal (Cuijpers et al., 2013).

Cognitive therapy can also be effective for bipolar dis- order (Geddes & Miklowitz, 2013). One main goal of this approach, as with depression, is to challenge and change un- realistic beliefs. Many people with bipolar disorder mistakenly believe that euphoria will improve their quality of life when in fact it often leads to self-destructive behavior. Cognitive therapy for bipolar disorder also concentrates on improving problem-solving skills, organization, memory, social support, and safety behaviors; avoiding high-risk behaviors such as substance use; and recognizing early warning signs of ma- nia. This may also involve daily thought records, consulta- tions with friends and family members, and strategies to delay impulsive behaviors (Muraldidharan, Miklowitz, & Craighead, 2015). Cognitive therapy for bipolar disorder also aims to en- hance medication compliance.

age.” Third, symptoms of sadness may be dismissed as simple bereavement over friends who begin to pass away. Fourth, symptoms of depression often mimic those seen in dementia (see Chapter 14), especially slowed speech and movement and dif�culties in memory and concentration. What might initially appear to be Al- zheimer’s disease may actually be depression.

Treating depression in the elderly often involves cognitive and family therapy as well as medication. One treatment de- signed speci�cally for older people with depression is reminiscence therapy. Reminiscence therapy involves a systematic review and discus- sion of each phase of a person’s life, from birth to present, with a particular focus on trying to resolve con�icts and regrets. The therapy seems generally effective for older people with depression, but more research is needed to see what types of people might bene�t most (Elias, Neville, & Scott, 2015).

Focus On

Many people think of depression as a condition that largely affects ad- olescents and young adults, but researchers have focused on another population that has more than its share of depression: the elderly. Esti- mates are that 4.6 to 9.3 percent of people aged 75 years and older has major depression and that 10.4 percent of older adults have symptoms of minor depression (Luppa et al., 2012; Polyakova et al., 2014). In ad- dition, the rate of suicide among people aged 85 years and older is 17.8 deaths per 100,000 people, which is the second highest among all age groups (Wang & Blazer, 2015).

Depression among the elderly is sometimes dif�cult to detect for sev- eral reasons. First, many older people with depression focus on complaints of physical symptoms of their depression rather than mood. Second, symp- toms of depression such as withdrawal or motivation loss may be thought of by others as a desire to relax during retirement or simply signs of “old

Diversity Depression in the Elderly

7.4

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Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 209

Marital therapy is also commonly used to treat depression, especially in women. A marital therapist will try to improve communication and problem-solving skills and increase mutu- ally pleasurable and prosocial behavior such as scheduling ac- tivities that a husband and wife like to do. Cognitive-behavioral components for treating depression are used as well. Marital therapy can be an effective treatment for depression, espe- cially when marital issues are a main reason for depression and when medication is also used (Hewison, Clulow, & Drake, 2014). Intervention that includes partners may be useful as well for helping people with bipolar disorder remain on their medication (Reinares et al., 2016).

Psychological treatments for depression are quite effective by themselves but are commonly supplemented by medication. Psychological treatments for bipolar disorder, however, are al- most always supplemented with medication, as was true for Katey. In severe cases of depressive or bipolar disorder, biologi- cal treatments are often used �rst and may be much more effec- tive than psychological treatments.

Treatment of Suicidality What should a therapist do if someone is suicidal? Therapists usually determine if risk of suicide is imminent, meaning the person is likely to commit suicide if left alone. In cases of suicid- ality, ethical issues of therapist–client con�dentiality are not as important as client safety, so a therapist must do what is neces- sary to protect a client’s life. If suicide seems imminent, as was true for Katey, then a therapist typically arranges hospitalization in an inpatient psychiatric unit. If a person calls a therapist and threatens suicide, the therapist may call an ambulance or the po- lice to have the person transferred to a hospital. Often this also involves informing people close to the person, such as a spouse or partner, and working closely with hospital staff to help the person cope with their current crisis. Medication, group therapy, and constant supervision are strategies to address people in hos- pital settings who are suicidal (Kleespies, Hughes, Weintraub, & Hart, 2015).

IPT is that a person’s attachment or relationships with others are key to mental health. IPT focuses on repairing problematic rela- tionships or coping with loss of close relationships (Weissman, Rabinovitch, & Veredeli, 2013). IPT concentrates on four main categories of relationship dif�culty:

1. Grief due to the loss of a loved oneGrief due to the loss of a loved oneGrief

2. Role disputes with others such as a spouse, partner, parent, coworker, or friend

3. Role transitions or major changes in a person’s life, such as ending a relationship, starting a new job, coping with an illness, or retiring from one’s career

4. Interpersonal de�cits such as lack of social skill and trouble maintaining relationships with others

Interpersonal therapy is an eclectic approach, or one that eclectic approach, or one that eclectic uses techniques from different theoretical orientations such as psychodynamic, cognitive, behavioral, and family systems ap- proaches. Therapists who use IPT for depression concentrate on exploring a person’s unrealistic expectations of others, solving interpersonal problems effectively, �nding new friends, and im- proving methods of good communication. IPT is especially use- ful if a person’s depression stems from problematic relationships with others, but it is useful as well as part of an overall treat- ment plan with cognitive therapy and medication (Lemmens et al., 2015; Markowitz & Weissman, 2012). IPT may also be useful for people with bipolar disorder, especially when thera- pists link the approach to scheduling regular patterns of sleep (Goldstein et al., 2014).

Family and Marital Therapy Family and marital therapy for depressive and bipolar disor- ders may be conducted within the context of IPT or separately. Family therapy is especially helpful for families marked by high expressed emotion, or excessive hostility, criticism, and overin- volvement. Family therapy is particularly useful for adolescents with depression. Family therapists focus on improving com- munication and problem-solving skills among family members. Contingency management, in which a person with depression is encouraged to be active and associate with others, is a common ingredient of family therapy as well. Parents who show withdrawn behavior may also receive treatment for their de- pression or counseling regarding their child-rearing practices. Therapy focusing on family members or parents regarding depression is generally effective for parents and children (Diamond, Diamond, & Levy, 2014).

Katey’s treatment did include family members who pro- vided social and �nancial support and who helped her remain on medication. Katey’s mother also had symptoms of bipolar disorder, so family members learned about the condition and what symptoms to monitor. Katey eventually moved in with her parents to help stabilize her condition, so therapy also involved reducing role con�icts and improving communication among family members. Family therapy for bipolar disorder is often im- portant to prevent relapse, as was true for Katey (Muraldidharan et al., 2015).

Marital therapy is an effective treatment for depression, especially in women.

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If a person is not at imminent risk for suicide but might be so in coming hours or days, therapists may draft a no-suicide contract. This is an agreement, often signed by a therapist and client, in which the client agrees to contact and speak with the therapist before any self-destructive act. Contracts are not a perfect intervention, but clients may adhere to the contracts and refrain from impulsive behavior. Others argue that a client’s commitment to a treatment statement is more effective than commitment to a treatment statement is more effective than commitment to a treatment statement a no-suicide contract. A commitment to treatment statement represents an agreement between a therapist and client that the client will commit to the treatment process and to living, openly communicate about suicidal thoughts and urges, and access emergency care when needed (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013).

A therapist will also contact the person frequently during the week and encourage signi�cant others, with the client’s per- mission, to closely supervise the client and remove potentially lethal items such as �rearms and medications from the home. Issues related to thoughts of suicide, such as a recent stressful life event or substance use, are addressed as well (Jobes, Au, & Siegelman, 2015).

What If I Am Sad or Have a Depressive or Bipolar Disorder? The answers to some basic questions (Table 7.16) may help you decide if you wish further assessment or even treatment for a possible depressive or bipolar disorder. If you �nd the answer to most of these questions is yes, then you may wish to consult

a clinical psychologist, psychiatrist, or other mental health pro- fessional (Chapter 15). Additional professional information is available from the Association for Behavioral and Cognitive Therapies (www.abct.org) and the National Alliance for Re- search on Schizophrenia and Depression (www.narsad.org).

If you think you have a depressive or bipolar disorder, con- sult with a mental health professional that specializes in this problem. Do not diagnose yourself. If you think you have sad- ness or euphoria but not necessarily a depressive or bipolar disorder, then becoming more socially active, changing your thoughts, and resolving interpersonal con�icts may be best. Talk about your feelings with family and friends, or attend a depres- sion screening in your community. If you think you have severe symptoms, however, then be sure to seek consultation from a quali�ed therapist.

Long-Term Outcome for People with Depressive and Bipolar Disorders and Suicide What is the long-term picture, or prognosis, for people with de- pressive and bipolar disorders like Katey? Factors that predict good treatment outcome for depression include better treatment compliance and completion, longer and more complex treat- ment, early recovery from depression, and fewer past episodes of major depression and residual symptoms. Other factors re- lated to good outcome include fewer stressful life events and comorbid diagnoses, less rumination, more positive self-image, high self-esteem, good family and marital relationships, and older age of onset (Devries et al., 2013; Manicavasagar, Perich, & Parker, 2012; Rudenstine, 2014; Sowislo & Orth, 2013).

Major depressive episodes last an average of 20 to 30 weeks. Most people (50–70 percent) experiencing a major depres- sive episode recover within 1 year, but about 14 to 35 percent continue to experience depressive episodes, and 6 to 15 per- cent experience chronic depression over many years. Even af- ter recovery, up to 30 percent of those experiencing one major depressive episode will experience a second one. Those with dysthymic disorder often recover (74 percent), but time to re- covery is lengthy (52 months). People with depression are also more likely to die from cardiovascular and other problems than people without depression (Klein, 2016; Lichtman et al., 2014; Richards, 2011). Recurring depression is related to younger age and younger age of onset, number of previous episodes, severity of the previous episode, negative childhood experiences such as maltreatment, and continued impairment (Hardeveld, Spijker, De Graaf, Nolen, & Beekman, 2013).

For those in treatment for bipolar disorder, similar prognos- tic factors are evident. People with bipolar disorder who respond well to treatment tend to have more classic forms of the disor- der, with less rapid cycling. Good treatment outcome is related to medication compliance and effectiveness (especially early in early in early the disorder), better cognitive functioning, fewer comorbid diag- noses, less expressed emotion in families, ongoing contact with mental health professionals, good occupational status, and female gender (Arvilommi et al., 2014; Ellis et al., 2014; Fountoulakis et al., 2013; Leclerc, Mansur, & Brietzke, 2013).

Do you �nd any of the mood symptoms described in this chapter apply to you much more so than most people your age?

Are there many things you would like to do but cannot because you feel too sad?

Are you greatly troubled by your mood symptoms?

Do other people notice your sadness or euphoria or encourage you to seek help?

Does your sadness or euphoria last much of the time, even when nothing stressful is happening?

Has your work or social life or sleep suffered a lot because of sadness or euphoria?

Do you get extremely upset over even little things most of the time?

Have you experienced a stressful life event that you just cannot seem to put behind you?

Do you feel sad, irritable, tense, and pessimistic much of the time?

If you could make your life better, would it include feeling less sad?

TABLE 7.16

Screening Questions for Depressive and Bipolar Disorder

Depressive and Bipolar Disorders and Suicide: Assessment and Treatment 211

Depressive episodes in bipolar disorder tend to last 2.8 to 4.3 months, and manic episodes in bipolar disorder tend to last 2 to 4 months. Length of these episodes generally decreases, or gets faster, with each successive episode. About 50 percent of people with a �rst episode of bipolar disorder recover completely, but the remainder experience recurrent episodes. Recurring bipolar dis- order is related to younger age of onset, more severe depressive or psychotic symptoms, treatment delays, and cognitive de�cits. Better long-term outcome relates to employment, ability to live in- dependently, and marriage (Baldessarini et al., 2012; Hulvershorn & Nurnberger, 2014; Merikangas, Jameson, & Tohen, 2016).

What about people released from a hospital after suicidal behavior? Within 2 years after discharge in one study, about 67 percent engaged in additional suicidal behavior, 38 percent en- gaged in suicidal behavior with certain suicide attempt, and 6 per- cent completed suicide. Future suicidal behavior was predicted by younger age, number of past suicidal behaviors, childhood maltreatment, poor physical health, and comorbid diagnoses. Younger age and hopelessness predicted suicide attempt (Hayashi et al., 2012). Others have found as well that ongoing suicidal be- havior over several years relates closely to male gender, low so- cioeconomic status, poor adjustment, family history of suicide, and lack of outpatient treatment before hospitalization (Isometsa, Sund, & Pirkola, 2014; Soloff & Chiappetta, 2012). Repeated fol- low-up contacts with people after discharge appears to lower the risk of suicidal behavior (Luxton, June, & Comtois, 2015).

Katey’s long-term prognosis remains unclear. On the plus side, she was currently in treatment and sticking with it, and seemed to have good family support. On the minus side, her mental condition lasted for years without adequate treatment, she used alcohol and had suicidal behaviors, and she lost her life savings and job. Good outcome will likely have to include ongoing and intense medication and psychological treatment as well as strong support from signi�cant others.

➲ Interim Summary • Assessing people with depressive and bipolar disorders

often includes structured and unstructured interviews and self-report questionnaires.

• Observations and information from therapists, spouses, partners, children, parents, and others are important for assessing depressive and bipolar disorders.

• Laboratory assessments for depression include the dexamethasone test.

• Assessing risk of suicide is critical in depressive and bipo- lar disorders and often focuses on detail of suicide plan, access to weapons, and support from others.

• Biological treatment of depressive and bipolar disorders includes selective serotonin reuptake inhibitors (SSRIs), tricyclics, monoamine oxidase inhibitors (MAOIs), and mood-stabilizing drugs.

• Electroconvulsive therapy (ECT) involves deliberately in- ducing a brain seizure to improve very severe depression. Repetitive transcranial magnetic stimulation (rTMS) in- volves placing an electromagnetic coil on a person’s scalp and introducing a current to relieve depressive symptoms.

• Light therapy is often used for people with seasonal depression.

• Psychological treatment of depressive and bipolar disor- ders includes behavioral approaches to increase activity and reinforcement from others for prosocial behavior. Cognitive therapy is also a main staple for depressive and bipolar disorders and may be linked to mindfulness.

• Interpersonal and marital and family therapists concen- trate on improving a person’s relationships with others to alleviate symptoms of depressive and bipolar disorders.

• Addressing suicidal behavior, sometimes via hospitaliza- tion, is a critical aspect of treating people with depressive and bipolar disorders.

• Long-term outcome for people with depressive and bipolar disorders is best when they receive early treatment, re- main on medication, have fewer comorbid diagnoses, and experience good support from others.

➲ Review Questions 1. Outline major assessment techniques for depressive and bipo-

lar disorders, including interviews, self-report questionnaires, observations, and laboratory assessment.

2. What medications help control symptoms of depressive and bipolar disorders? How do they work?

3. Describe electroconvulsive, repetitive transcranial magnetic, and light therapies.

4. What psychological treatment strategies could a mental health professional use to help someone improve interper- sonal functioning and mood? How so?

5. What is the prognosis or long-term outcome for people with depressive and bipolar disorders?

CHAPTER 7 Depressive and Bipolar Disorders and Suicide212

Final Comments People with depressive and bipolar disorders suffer tremendous distress from swings of emotion, hopelessness, troubling thoughts, and self-destructive behavior. This is important to remember if you or someone you know feels sad or withdrawn from others. Occasional feelings of sadness and euphoria are normal, but they can sometimes linger and get out of control. If they do, then talking to someone about it or contacting a quali�ed mental health professional is a good idea. You can see how symptoms of depression and anxiety cause so much distress for people, and these symptoms occur together in people with eating disorders, which we discuss in the next chapter.

Thought Questions 1. Think about television shows or �lms you have seen that have characters with mood problems. Do

you think these characters display realistic or unrealistic symptoms of mood changes? How so?

2. Think about situations that make you most sad, such as illness of a loved one or breakup of a rela- tionship. Think about situations that make you most euphoric, such as a great test grade or a new baby relative. How do you feel physically, what do you think in those situations, and what do you do? Having read the chapter, would you change anything?

3. What would you say to a friend who might be very sad or euphoric and who might be considering suicide?

4. What separates “normal” from “abnormal” mood? Do you think depressive and bipolar disorders have more to do with personal, family, or other factors? Why?

5. What do you think family members and friends could do to reduce severe mood changes in people they know?

Key Terms depressive disorder 175 bipolar disorder 175 major depressive episode 175 major depressive disorder 177 persistent depressive disorder

(dysthymia) 178 manic episode 179 hypomanic episode 180 bipolar I disorder 181 premenstrual dysphoric disorder 182 peripartum depression 182

postpartum depression 182 bipolar II disorder 185 cyclothymic disorder 185 suicide 186 cognitive distortions 195 negative cognitive triad 195 automatic thoughts 195 hopelessness (attribution)

theory 195 learned helplessness 195 hopelessness 203

selective serotonin reuptake inhibitors (SSRIs) 204

tricyclic antidepressants 205 monoamine oxidase inhibitors

(MAOI) 205 mood-stabilizing drugs 205 electroconvulsive therapy (ECT) 206 repetitive transcranial magnetic

stimulation (rTMS) 206 reminiscence therapy 208 expressed emotion 209

215

Special Features

CONTINUUM FIGURE 8.1 Continuum of Body Dissatisfaction, Weight Concerns, and Eating Behavior 218–219

Personal Narrative 8.1 Kitty Westin (Anna’s mother) 220–221

• 8.1 FOCUS ON COLLEGE STUDENTS: Eating Disorders 223

• 8.2 FOCUS ON GENDER: Why Is There a Gender Difference in Eating Disorders? 223

V THE CONTINUUM VIDEO PROJECT Sara /Sara / Bulimia Nervosa 227

Personal Narrative 8.2 Rachel Webb 232

• 8.3 FOCUS ON LAW AND ETHICS: How Ethical Are Pro-Ana (Pro-Anorexia) Websites? 237

C Sooki / What Do You Think?

Weight Concerns, Body Dissatisfaction, and Eating Disorders: What Are They?

Eating Disorders: Features and Epidemiology

C Lisa

Stigma Associated with Eating Disorders

Eating Disorders: Causes and Prevention

Eating Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Eating Disorders 8

CHAPTER 8 Eating Disorders216

C / S/ S/ ooki

Sooki is a 19-year-old Asian American college student who is 5 feet 4 inches tall and weighs 90.4 pounds. Friends have not noticed that Sooki has lost so much weight over the past year (25 pounds!) because she wears baggy clothes. About a year ago, Sooki became extremely afraid of becoming fat. She was convinced that weight gain would be the worst thing pos- sible and that her college life would be ruined. Sooki began skipping meals and, when she did eat once or twice a day, consumed only a “salad” or other small items. Her salad consists of four lettuce leaves, part of a carrot, an apple slice, and no dressing. Sooki is preoc- cupied with food and calo- ries. Every bite of food she eats is carefully considered,

and she carries charts that list calories per serv- ing of many foods. She drinks only water and diet soda.

Sooki is obsessed with how much she weighs and how she looks. She owns two scales: one is near her bed, and one is in her bathroom. She weighs herself 10 or more times a day. Sooki has told others her butt is too big and her stomach is “poochy.” Sooki is markedly underweight but

frequently checks her body in the mirror to make sure she is not becoming fat. Her self-esteem depends heav- ily on her body weight. When Sooki weighs more than 90.0 pounds, she feels bad about herself; when she weighs less than 90.0 pounds, she is perk- ier. Sooki views weight loss as an impressive achievement in

self-discipline. Family members have noticed her weight change and have told Sooki she is under- weight. Still, Sooki does not see her eating and low weight as a problem. She hopes to lose more weight by eliminating “fattening” foods from her diet such as apple slices and diet soda. Sooki has kept to herself recently and leaves her room only to attend class.

What Do You Think? 1. Which of Sooki’s symptoms seem typical

for a college student, and which seem very different?

2. What external events and internal factors might be responsible for Sooki’s problems?

3. What are you curious about regarding Sooki?

4. Does Sooki remind you in any way of yourself or someone you know? How so?

5. How might Sooki’s eating problems affect her life in the future?

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Weight Concerns, Body Dissatisfaction, and Eating Disorders: What Are They?

Have you ever looked at yourself in the mirror and worried you were overweight? Have you ever been concerned about how much you eat? These questions are common for many people, especially in an age when the dangers of obesity seem always to be on the news. Concern about weight is normal and can be adaptive. Achieving and maintaining normal weight is important for reducing risk of heart disease, diabetes, stroke, and other potentially fatal conditions. Regular exercise and good eating habits also improve our mood and reduce stress. Most of us weigh ourselves every so often to check where we are, and this is normal.

Other people take concern about weight to a higher level. People with weight concerns feel overweight much of the time, even when they are not, and view their weight nega- tively. Perhaps you know someone with a thin physique who thinks a lot about weight and exercises vigorously. People with weight concerns focus on how much they weigh during differ- ent times of the day and often have a drive for thinness. People with weight concerns focus intently on certain areas of their body they would like to tone or decrease in size. Weight con- cerns are not a problem if a person is not distressed, remains in a normal weight range, and avoids physical damage from overexercising.

Some people with weight concerns adopt a negative self- evaluation of what their body looks like. Body dissatisfac- tion refers to dissatisfaction or distress with one’s appearance, an overinvestment in the way one appears, and avoidance of certain situations or things because they elicit body concerns (Heider, Spruyt, & DeHouwer, 2015). People with body dissatis- faction are more than just concerned about their weight. They are constantly unhappy about their weight and think about what could be different with their appearance. They spend substantial money on exercise equipment and gym memberships but avoid social and other situations in which people might judge their weight negatively. Sooki eventually avoided most situations other than class.

Weight concerns and body dissatisfaction are dimen- sional constructs, meaning we all have these characteristics to some degree. Some people have intense weight concerns and body dissatisfaction that escalate toward an eating dis- order. People with eating disorders have great worry and dis- tress about their weight and body. Sooki was quite fearful of gaining weight. Weight concerns and body dissatisfaction are two of the three key components of an eating disorder. The third major component is eating problems, which involve restricted eating or excessive dieting and lack of control of eating.

Restricted eating, or dieting, refers to deliberate attempts to limit food intake or change types of foods that are eaten. People with eating disorders focus intently on foods that result

Eating Disorders: Features and Epidemiology 217

in weight gain or loss. Such focus is driven by weight concerns or body dissatisfaction. Sooki rarely ate, and maintained very low calorie meals because she believed she was too fat.

Lack of control over eating involves inability to keep one- self from eating large amounts of food. People who lack control over eating consume excessive quantities of food. This feature thus has cognitive (believing one has lost control) and behav- ioral (eating too much) components. People who lack control over eating can gain substantial weight and be considered over- weight for someone of their height, age, and gender. Some peo- ple may develop obesity as a result, but obesity is not considered an eating disorder.

Weight concerns, body dissatisfaction, and eating prob- lems occur along a continuum (see Figure 8.1). Most of us have occasional weight concerns or body dissatisfaction that we address or can cope with. Intense weight concerns or body dissatisfaction cause some people, however, to go to extremes to control their weight. These extremes include se- verely restricted eating, excessive exercise, or taking medicine or laxatives that lead to weight loss. These people are highly distressed, limit their social activities, and experience signi�- cant emotional, behavioral, and even medical consequences. People with these characteristics, like Sooki, have an eating disorder.

Eating disorders can be less severe, as when people are highly bothered by their weight and appearance but still eat occasionally (Figure 8.1). Eating disorders can also be more severe, however, when a person stops eating and essentially starves herself to death. Severe eating disorders also involve intense distress and sadness. We cover next the major eating disorders that affect many people like Sooki.

Eating Disorders: Features and Epidemiology

This section summarizes the major features and other char-acteristics of the most common eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Anorexia Nervosa People with anorexia nervosa refuse to maintain a minimum, normal body weight, have an intense fear of gaining weight, and show disturbance in the way they view their body shape and weight (see Table 8.1; American Psychiatric Association [APA], 2013). Sooki likely met diagnostic criteria for anorexia nervosa because of her low body weight, intense fear of being fat, and disturbed body image. Severity of anorexia nervosa is based partly on body mass index (Table 8.1).

You might think people with anorexia nervosa have no ap- petite, but they do. In fact, people with anorexia nervosa of- ten think about food, as Sooki did, and even prepare elaborate meals for others. Unfortunately, people with anorexia nervosa have an intense dissatisfaction with their bodies and thus fear gaining weight. They are driven to thinness and often look for ways to reduce weight.

People with anorexia nervosa lose weight mainly by eating less and exercising excessively. If they do eat, they avoid foods with the most calories. Many people with anorexia nervosa ini- tially lose weight by eliminating soft drinks or fattening foods such as desserts from their diets. Over time, however, they elimi- nate more and more foods and increasingly skip meals. These

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TABLE 8.1 DSM-5

Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to

a signi�cantly low body weight in the context of age, sex, devel- opmental trajectory, and physical health. Signi�cantly low weight is de�ned as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persis- tent behavior that interferes with weight gain, even though at a signi�cantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue in�uence of body weight or shape on self- evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify if restricting or binge-eating/purging type, partial or full remission, and current severity as mild (BMI ≥17 kg/m2), moderate (BMI 16–16.99 kg/m2), severe (BMI 15–15.99 kg/m2), or extreme (BMI <15 kg/m2).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 8 Eating Disorders218

restricting behaviors form the basis for one subtype of an- orexia nervosa (Table 8.1). Sooki is a member of this restricting subtype.

Others with anorexia nervosa lose weight by binge eating (see later section) and purging. Purging refers to ridding one- self of food or bodily �uids (and thus weight) by self-induced vomiting, misusing laxatives or diuretics, or performing enemas. Binge eating and purging form the basis for a second subtype of anorexia nervosa (Table 8.1).

A particularly fascinating feature of anorexia nervosa is a person’s belief she is fat despite overwhelming evidence to the contrary. Sooki lost 25 pounds, nearly 20 percent of her body weight, but still saw her buttocks as large and her stomach as “poochy.” People with anorexia nervosa have extreme misper- ceptions about how they look, feeling fat even when clearly emaciated. A good analogy would be the accentuation and dis- tortion of body size and shape that happens to a re�ection in a fun house mirror.

People with anorexia nervosa may not appreciate the serious physical and medical consequences of their very low weight. In- dividuals with anorexia nervosa become emaciated, dehydrated, and hypotensive (low blood pressure). Anemia, kidney dysfunc- tion, cardiovascular problems, dental problems, electrolyte im- balance, and osteoporosis may result as well. Some people with anorexia nervosa eventually die by self-starvation or suicide (see Personal Narrative 8.1).

Bulimia Nervosa Have you ever eaten so much your stomach hurt? How about feeling guilty after a huge meal? Most of us have overindulged at a buffet or felt self-conscious about eating too many sweets, and this is normal. We are usually concerned about how much we eat and what the consequences might be if we eat too much. Most of us can control our eating and understand that overeating

occasionally happens. For others like Lisa, however, episodes of overeating are frequent and cause many problems.

Bulimia nervosa is marked by binge eating, inappro- priate methods to prevent weight gain, and self-evaluation greatly influenced by body shape and weight (see Table 8.2; APA, 2013). Binge eating means eating an amount of food in a limited time—such as 2 hours or less—that is much larger than most people would eat in that circumstance. Binge eating typically occurs in private and may be triggered by depression, stress, or low self-esteem. Binge eating is also accompanied by lack of control over eating. Many people

8.1 Continuum of Body Dissatisfaction, Weight Concerns, and Eating Behavior

NORMAL MILD

Emotions Positive feelings about oneself. Some anxiety about one’s body shape Some anxiety about one’s body shape and weight.

Cognitions “I feel pretty good about my body and about my weight.”“I feel pretty good about my body and about my weight.” “I wish I were more �t and weighed a little less. Maybe I could cut back a bit on my eating.” eating.”

Behaviors Eating without concerns. Tries to eat less at meals and may skip a meal every now and then.

Emotions

Cognitions

Behaviors

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Lisa is a 25-year-old woman in therapy for an eating disorder. She has been overconcerned about her body for many years and said she never felt good about school, friends, or herself if she thought she was overweight. Lisa was never skinny but was not overweight either—it just seemed to her that she was overweight. Lisa was constantly trying to limit her eating and weight by dieting. Unfortunately, her appetite would build over time and erupt into an eating feast. Lisa stocked her house with foods like whole cakes, quarts of ice cream, and packages of Oreos and ate these foods voraciously during her binges. Lisa felt panicked and out of control of her eating when this happened.

Lisa’s episodes of overeating became more frequent in the past year, oc- curring about �ve times a week. This made Lisa even more fearful of gaining weight. She was also embarrassed by the way she dealt with her overeating, which involved vomiting after each binge. She hid her vomiting from others, but her teeth were soon eroding as a result. Lisa’s binging and purging con- tinued until one day when she noticed a substantial amount of blood in her vomit. She realized she needed help.

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CONTINUUM FIGURE

Eating Disorders: Features and Epidemiology 219

who binge are ashamed of their eating problem and hide their symptoms.

People with bulimia nervosa use inappropriate behav- iors, or compensatory behaviors, to prevent weight gain (see Table 8.3). Lisa induced vomiting after a binge, and this method is used by 80 to 90 percent of those who seek treatment for bulimia nervosa. Vomiting is negatively reinforcing (Chapter 2) because it reduces stomach discomfort as well as fear of weight gain. Purging compensatory behaviors include vomiting, misPurging compensatory behaviors include vomiting, misPurging - use of laxatives or diuretics, or enemas. Nonpurging compenNonpurging compenNonpurging - satory behaviors include fasting for several days or exercising

MODERATE EATING DISORDER—LESS SEVERE EATING DISORDER—MORE SEVEREEATING DISORDER—LESS SEVERE EATING DISORDER—MORE SEVEREEATING DISORDER—LESS SEVERE EATING DISORDER—MORE SEVERE

Moderately anxious and feels down about body Moderately anxious and feels down about body shape and weight.

Intense anxiety and sadness over apparent inability to Intense anxiety and sadness over apparent inability to lose enough weight.

Severe anxiety and depression over one’s body Severe anxiety and depression over one’s body shape and weight.shape and weight.

“Wow, I feel fat. I need to start cutting back on “Wow, I feel fat. I need to start cutting back on eating. If I don’t cut back, I’m going to get even eating. If I don’t cut back, I’m going to get even fatter.”

“I feel fat all the time, and I wish my body were “I feel fat all the time, and I wish my body were thinner. I’ve got to get rid of all these awful calories in thinner. I’ve got to get rid of all these awful calories in my body!”

”I’m extremely fat, and I hate my body! I have to ”I’m extremely fat, and I hate my body! I have to stop eating now! No one understands.”stop eating now! No one understands.”

Regularly skips meals and eats low calorie foods only. Starts exercising more to lose weight.

Eats one meal a day, usually a salad with no dressing. Eats one meal a day, usually a salad with no dressing. May purge after meals or take laxatives.May purge after meals or take laxatives.

Eats only rarely and when forced to do so; exercises excessively and purges frequently to lose more weight.

Obesity, while not physically healthy, is not considered an eating disorder.

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TABLE 8.2 DSM-5

Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:

1. Eating, in a discrete period of time, an amount of food that is de�nitely larger than what most individuals would eat in a simi- lar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode.

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxa- tives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly in�uenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if partial or full remission and severity as mild (1-3 episodes of inappropriate compensatory behaviors per week), moderate (4-7 episodes of inappropriate compensatory behaviors per week), severe (8-13 episodes of inappropriate compensatory behaviors per week), or extreme (14+ episodes of inappropriate compensatory behaviors per week).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

excessively (Table 8.3). Compensatory behaviors can lead to serious physical and medical complications. Excessive vomit- ing can lead to dental problems, swelling of salivary glands, or esophageal problems. Overusing laxatives and diuretics can lead to chronic diarrhea or bowel problems.

CHAPTER 8 Eating Disorders220

People with bulimia nervosa, like those with anorexia nervosa, emphasize body shape and weight to evaluate them- selves. The major difference between the disorders is that people with anorexia nervosa are characterized by excessively low weight, whereas people with bulimia nervosa may be nor- mal weight or overweight. Severity of bulimia nervosa is based partly on number of episodes of compensatory behavior per week (Table 8.2).

Binge-Eating Disorder Some people have recurrent episodes of binge eating but with- out compensatory behaviors like purging, excessive exercise, or out compensatory behaviors like purging, excessive exercise, or out fasting. People with binge-eating disorder experience lack of

control over eating during a certain period that leads to dis- comfort (see Table 8.4; APA, 2013). To be diagnosed as such, binge eating must occur, on average, once a week for at least 3 months. Other features of binge eating episodes include eating more rapidly than normal, eating despite feeling uncomfortably full, eating large amounts even when not hungry, eating alone because of embarrassment over quantity of food consumed, and feeling disgusted, depressed, or guilty after overeating. Individu- als with binge-eating disorder are greatly distressed about their behavior. They typically have varying degrees of obesity and may have enrolled in weight control programs.

Binge-eating disorder is similar to bulimia nervosa except people with bulimia nervosa regularly engage in compensa- tory behaviors to prevent weight gain (Heaner & Walsh, 2013).

I remember Anna Selina Westin’s birthday like it was yesterday. She was a beautiful, healthy baby with bright blue eyes, curly blond hair, and a “rose bud” mouth. She grew and developed into a young woman full of life and love, and she had hopes, dreams, and a future full of promise until she became ill with a deadly disorder that affects millions: anorexia. When Anna was 16 years old, she was �rst diagnosed with anorexia. She committed suicide after struggling with the disorder for 5 years and was only 21 years old when she died.

I write about my experience with Anna hop- ing that people reading our story will better un- derstand the seriousness of the disorder and how it affects the family. But before I go on, I would like to say that my husband and I are very proud of Anna and the effort she put into �ght- ing her disorder. We feel no shame that she had the disorder or that she committed suicide. We both understand that anorexia is a disorder, not a choice. By telling our story honestly and open- ly we hope to dispel the stigma and shame often associated with an eating disorder and suicide. Since we made the decision to talk honestly about Anna’s life and death, we have opened ourselves up to questions—frequently asked questions are What were Anna’s symptoms? and What were Anna’s symptoms? and What were Anna’s symptoms? When did you �rst notice them?

In retrospect, Anna most likely showed signs of developing an eating disorder long before we

recognized them. When Anna was a young girl, she was perfectionis- tic and high achiev- ing and needed to get everything “just right.” She was dissatis�ed with herself when she had dif�- culties and was intolerant of her own perceived imperfections. She showed signs of anxiety and had periods of de- pression from a young age.

Anna was petite, and I remember that she began talking about her size and shape when she was about 15 years old. I recall the day she came home from school very upset be- cause an acquaintance had made a remark about the size of her thighs. This may have been the start of her obsession with being thin. Soon after that incident, she announced she had decided to become a vegetarian. At the time I was not concerned about this (although I was confused). I questioned her commitment to this “lifestyle,” and she as- sured me that she would eat a healthy and balanced diet. I did not know at the time that this behavior was the beginning of restricting and that within a few months Anna would re- strict almost all foods. It seemed that almost overnight Anna went from being a person- able, caring, and spirited adolescent to being

hostile, angry, withdrawn, and uncommunicative. Her weight dropped noticeably, and she avoided all situa- tions with the family that in-

volved food, including family meals. Anna continually denied that

she had any problems eating or is- sues with her size, but it became ap-

parent that she was ill and getting sicker by the day. We brought her to our family physi- cian for a checkup. The doctor referred her for an evaluation for an eating disorder. Anna was diagnosed with anorexia nervosa. Like most families suddenly faced with the trauma of caring for a seriously ill member, we were not prepared and woefully ignorant when we learned our daughter’s diagnosis. Unlike so many other problems like diabetes, cancer, and heart disease, there was little information and support available to help us understand anorexia. We did not know where to turn for education, support, and guidance. We were often confused, always afraid, and sometimes angry.

Anna was �rst diagnosed and treated for anorexia when she was 16 years old. She was treated successfully in an outpatient program and seemed to recover fully. At that time I did not understand that the relapse rate for eating

8.1 / Kitty Westin (Anna’s mother)

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Eating Disorders: Features and Epidemiology 221

People with binge-eating disorder also binge over a much lon- ger period of time and their binging may be less frantic than those with bulimia nervosa. Severity of binge-eating disorder is based partly on number of binge eating episodes per week (Table 8.4).

Epidemiology of Eating Disorders Eating disorders are not as common as the anxiety and de- pressive disorders we discussed in previous chapters, but they do occur frequently enough to be of great concern to mental health professionals. Lifetime prevalence rates for major eat- ing disorders are in Table 8.5 (Smink, van Hoeken, & Hoek, 2012). Symptoms of eating disorders are also common among

adolescents and young adults with other mental disorders. The medical complications of eating disorders can also be quite severe, so researchers have paid great attention to these problems.

Peak age of onset for anorexia nervosa is 19 to 20 years, and the disorder is more common in industrialized societies (Stice, Marti, & Rohde, 2013). Mortality is signi�cantly asso- ciated with anorexia nervosa in many countries, and eating disorder has the highest death rate of any major mental disor- der. These deaths may be the result of complications from the eating disorder but also include elevated suicide rates (Franko et al., 2013). Peak age of onset for bulimia nervosa is 16 to 20 years and for binge-eating disorder is 18 to 20 years (Stice et al., 2013).

disorders is high and that we should remain vigilant for a number of years. I wish that someone had told me that the average time between diagnosis and recovery is 7 years; that may have alerted me to the dangers of relapse and we may have done some things differently.

Anna seemed to do well after complet- ing her �rst treatment for anorexia and she graduated from high school and went on to college. During the ensuing years, she had bouts of depression and anxiety, especially when under stress, but overall she reported feeling healthy and happy. Her anorexia returned, however, and this time she was gravely ill by the time we were able to get her the care she needed. We have tried to deter- mine what triggered her relapse, and noth- ing has stood out, so we conclude that her biochemistry must have been the primary factor. We were able to get Anna admitted to a specialized eating disorders treatment program, and because she had responded so well the �rst time, we were not overly con- cerned and had no reason to doubt that she would fully recover.

Anna was a “typical” eating-disordered patient: resistant, angry, and in denial. How- ever, once she was in the program getting the support she needed and restoring her health, she realized the seriousness of her

sure their child takes the medicine required to treat a disorder?

In spite of these things, treatment seemed to be going well. We were able to maintain con�dence that Anna was on the road to re- covery. Then suddenly we ran into a roadblock we did not expect and it changed everything. The roadblock was our insurance company. They refused to pay for most of the care An- na’s medical team recommended, stating it was not medically necessary. Our family was forced to guarantee payment to keep her in the hospital. When Anna heard this, she felt guilty and like she was a burden on our fam- ily. We assured her that she needed to con- centrate and put her energy into healing and we would worry about the money, but I don’t think she was able to hear this. Anna commit- ted suicide a few months later. I don’t “blame” the insurance company for her death; I know that anorexia killed her. However, insurance did contribute to her death because they added to her feelings of worthlessness and hopelessness.

There are no adequate words to describe the grief and loss our family felt and contin- ues to feel since Anna died. However, we have been able to transform some of these powerful emotions into something positive by starting a foundation in Anna’s name and joining the �ght against eating disorders.

disorder and the importance of the treat- ment and she became much more coop- erative and receptive. Anna was getting the best care available and the program she was in used a multidisciplinary approach that included medical doctors, psychologists, psychiatrists, social workers, registered nurses, dietitians, tutors, physical and oc- cupational therapists, and care managers. In addition to Anna’s individual and group therapy, we were involved in family therapy and education groups. We finally felt like we were learning what we needed to know to help Anna. However, the effects anorexia was having on the family were enormous. My husband and I argued over many things including how best to deal with Anna, and our anger and frustration was often directed toward each other. Our younger daughters struggled to understand the disorder and found it difficult to accept that their sister was ill and could possibly die. We all walked on eggshells fearing that if we did or said the wrong thing, we would upset Anna and exacerbate the situation. It was hard to know when we should back off and when to get in- volved. We were advised not to watch Anna eat, but you tell me how we could do this when we were afraid that our child would die unless she ate? After all, food was the “medi- cine,” and aren’t parents supposed to make

personal narrative

Used with permission.

CHAPTER 8 Eating Disorders222

TABLE 8.3

Compensatory Behaviors

Compensatory behaviors to prevent weight gain after binge eating include the following:

• Misuse of laxatives

• Misuse of enemas

• Excessive exercise

• Misuse of diuretics

• Fasting

• Self-induced vomiting

TABLE 8.5

Lifetime Prevalence Rates (percent) for Major Eating Disorders

Eating disorder Women Men

Anorexia nervosa 0.9 0.3

Bulimia nervosa 1.5 0.5

Binge-eating disorder 3.5 2.0

Source: Smink, van Hoeken, & Hoek (2012).

TABLE 8.4 DSM-5

Binge-Eating Disorder A. Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:

1. Eating, in a discrete period of time, an amount of food that is de�nitely larger than what most people would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode.

B. The binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortable full. 3. Eating large amounts of food when not feeling physically

hungry. 4. Eating alone because of feeling embarrassed by how much one

is eating. 5. Feeling disgusted with oneself, depressed, or very guilty

afterward

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inap- propriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia or anorexia nervosa.

Specify if partial or full remission and severity as mild (1-3 binge- eating episodes per week), moderate (4-7 binge-eating episodes per week), severe (8-13 binge-eating episodes per week), or extreme (14+ binge-eating episodes per week).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Prevalence rates for eating disorders may seem low but con- sider other related facts. Many people have symptoms of eat- ing disorder that do not rise to the level of a formal diagnosis, including college students (see Box 8.1). Many people also do not seek treatment for their eating disorder. Only 23.2 percent of those with an eating disorder seek mental health care (Hart, Granillo, Jorm, & Paxton, 2011). People may shun treatment for eating disorders because they feel embarrassed or stigmatized. Many people with eating disorders are secretive about their symptoms and feel they do not have a problem. Sooki viewed restricted food intake and weight loss as a virtue and not a prob- lem to be acknowledged and treated.

Eating disorders are much more common among females than males. Several reasons may account for this gender differ- ence (see Box 8.2). A sociocultural role might contribute to eat- ing disorder symptoms in girls and women. Some theorists focus on “objecti�cation” of women, media models of thinness for women, stress from maltreatment and sexual harassment, poor recognition of achievements, and excessive attention to beauty and body shape (Ferguson, 2013). Self-objecti�cation, self-sur- veillance, and disordered eating are more common, for example, among ballet dancers (Nascimento, Luna, & Fontenelle, 2012). Symptoms of eating disorder have also been linked to actresses, models, and elite female athletes in sports requiring thinness (Blasczyk-Schiep, Sokoła, Fila-Witecka, & Kazen, 2015).

Males with eating disorders are not as well studied as fe- males, but some interesting �ndings have emerged. Eating disor- ders appear to be on the rise among male athletes, especially in sports in which leanness may lead to a competitive advantage. Ex- amples include wrestling, rowing, and running (Bratland-Sanda & Sundgot-Borgen, 2012). Males with eating disorders often display depression, self-injury, substance use disorder, and anxiety (Claes et al., 2012; Strother, Lemberg, Stanford, & Turberville, 2012).

Any racial or ethnic gap in eating disorders among Ameri- cans appears to be small. Rates of core eating disorder symptoms such as fear of being fat, body weight and shape concerns, and binge eating are similar for European American, Asian Ameri- can, Latina, and African American girls and women (Franko et al., 2012). Rates of risk factors for eating disorders—such as pressure to be thin, body dissatisfaction, and dieting—are also similar among these groups. Racial and ethnic differences for eating disorder in the United States appear minimal at this time.

Eating Disorders: Features and Epidemiology 223

major or other depression (23.9 percent), recent nonsuicidal self-injury (13.1 percent), and suicidal thoughts (4.0 percent). Unfortunately, only 20 percent of those who screened positive for an eating disorder sought treatment (Eisenberg, Nicklett, Roeder, & Kirz, 2011).

We described in Chapter 2 a selective prevention program that was designed to address eating problems in undergraduate students. Other researchers have also outlined procedures for college students with eating problems that parallel the treatment techniques described in this chapter. The researchers recommended screening students for low and high risk of eating problems. Low-risk students could receive online eating preven- tion programs and education about healthy avenues to stabilize and lose weight and prevent obesity. High-risk students, especially those at par- ticular risk for anorexia nervosa, could be referred to on-campus services for cognitive-behavioral or interpersonal therapy to address problematic eating restraint patterns, body mass index, eating attitudes, body image concerns, social support, emotional regulation, and binge eating, among others (Wil�ey, Agras, & Taylor, 2013). If you feel you are at high risk for an eating disorder, seeking consultation at a counseling center may be a good idea.

Focus On

Symptoms of eating disorders are prominent among young adults and espeSymptoms of eating disorders are prominent among young adults and espe- cially among college students. One study of thousands of college students revealed that 13.5 percent of women and 3.6 percent of men screened pos- itive for an eating disorder. In particular, women and men endorsed items such as, “Do you believe yourself to be fat when others say you are thin?” (33.8 and 9.2 percent, respectively), “Do you worry you have lost control over how much you eat?” (26.4 and 8.4 percent, respectively), “Would you say that food dominates your life?” (16.8 and 7.1 percent, respectively), and “Do you make yourself sick because you feel uncomfortably full?” (13.7 and 4.3 percent, respectively). Of those who screened positive for an eating disorder, many reported recent binge drinking (54.1 percent),

8.1

College Students Eating Disorders

may keep women from achiev- ing as much as men in their careers (Dour & Theran, 2011; Howlett, Pine, Cahill, Orakçıog ˘lu, & Fletcher, 2015).

Biological factors almost cer-Biological factors almost cer-Biological factors almost cer tainly contribute to eating disor- ders, but whether these factors contribute to the difference in eating disorder prevalence rates between the genders remains un- clear. Certain biological vulnerabil- ities may be expressed differently in women and men. Dieting to re- duce weight may lower serotonin functioning more in women than men (Smolak & Levine, 2015). Reduced serotonin is associated with overeating and carbohydrate craving. Another possible reason involves natural physical development. As boys and girls enter puberty, boys become more muscular and closer to the “ideal” for men, but girls obtain increased body fat and curves and move away from the “ideal” for women.

Focus On

Females have more eating disorders than males—but why? A prominent ex- planation for gender differences in eating disorders concerns gender roles. Our society values a female gender role resembling the “superwoman”—a woman with a great career, happy marriage and family, active social life, and good looks. The superwoman role emphasizes thinness, perfectionis- tic striving, and some autonomy from the family because of career. Striving for thinness, perfectionism, and loneliness or isolation are also correlates of eating disorders, so this role model may in�uence some females to de- velop symptoms of eating disorders (Richards & Barker, 2013).

The superwoman ideal intersects as well with how “ideal” women are portrayed in the media—thin—and this can affect how girls and women evaluate themselves. Women’s bodies are also more likely to be “objecti- �ed” by being looked at, evaluated, and sexualized. This reinforces the cul- ture of thinness, leads to more maltreatment and sexual harassment, and

Gender Why Is There a Gender Difference

in Eating Disorders?

8.2

Are we teaching young girls that thin is the way to be? Barbie embodies the tall, thin, glamorous look.

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CHAPTER 8 Eating Disorders224

countries. Bulimia nervosa may be a cultural syndrome (Keel & Forney, 2015).

Eating disorders are highly comorbid with other mental disorders, including other eating disorders. About 47.4 percent of those with an- orexia and 42.2 percent of those with bulimia have another eating disorder or symptoms of an- other eating disorder (Nagl et al., 2016). Eating disorders are also comorbid with depression, body dysmorphic disorder, emotional dysregula- tion, self-injurious behavior, and suicide (Laven- der et al., 2015; Li et al., 2015; Lule et al., 2014). People with anorexia nervosa like Sooki are often socially isolated, sad, and less interested in sex- ual activity. They often report problems getting close to others and experience shame and guilt. People with binge-eating disorder report their overeating often occurs during a depressed state and precedes guilt and shame. Obesity occurs in about 71 percent of those with binge-eating disorder (Dingemans & van Furth, 2012). People with eating disorders often exhibit symptoms of anxiety-related disorders as well. Anorexia ner-

vosa is often present with symptoms of obsessive-compulsive disorder, including obsessions about food and body shape and compulsive behavior such as hoarding food. Anxiety disorder symptoms prominent in bulimia nervosa include those related to social phobia such as fear of social situations and being eval- uated by others (Swinbourne et al., 2012).

Personality and substance use disorders are also common in people with bulimia nervosa and binge-eating disorder. These disorders likely overlap because they share the symptoms of emotional dysregulation and impulse-control problems. People

with bulimia nervosa have relatively higher rates of borderline personality disorder, a condition charac- terized by high levels of impulsivity (Chapter 10). Those with bulimia nervosa also experience higher rates of excessive alcohol and stimulant use. Use of stimulants may begin as a way of controlling weight and appetite but then becomes an addiction (Sachs & Mehler, 2015).

Stigma Associated with Eating Disorders

Attitudes about people with an eating disorder or related conditions can be quite harsh. One group of researchers asked hundreds of participants to read a vignette about someone with anorexia, bulimia, binge-eating disorder, obesity, or major depression and complete a stigma questionnaire (Table 8.6). Those described in the vignettes as having an eat- ing disorder were blamed for their condition much more than those described as having depression. Those described as having obesity were held more

The changing male body ideal. (Left) Actor Burt Lancaster circa 1946. (Right) Soccer player David Beckham, 2012.

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The changing female body ideal. (Left) Actress Jane Russell circa the mid-1950s. (Right) Actress Angelina Jolie.

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Eating disorders have been described as cultural syn- dromes, or problems that appear only in certain cultures and Western, industrialized nations. A deeper look, however, re- veals a more nuanced �nding. Anorexia nervosa is reported in most countries around the world and cannot be solely at- tributed to the in�uence of Western ideals favoring thinness. Rates of anorexia nervosa differ little in Western and non- Western countries. Cases of bulimia nervosa in non-Western countries, however, are linked to Western ideals, and preva- lence rates of bulimia are lower in non-Western than Western

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Eating Disorders: Causes and Prevention 225

responsible for their condition than the others. In particular, raters attributed lack of self-discipline more to obesity and binge-eating disorder. Only those with depression were rated as signi�cantly impaired (Ebneter & Latner, 2013). People often view eating dis- orders as “self-in�icted” and related to willpower. Recall from Chapter 1 that attitudes such as these result in viewing others as weak in character and “different” from the rest of us.

These results were mirrored in a survey of people with an eating disorder. Those with anorexia, bulimia, or related symp- toms were asked about stigmatizing attitudes and beliefs and their effect on personal well-being. Participants conveyed that two beliefs were particularly common and damaging: “I should be able to just pull myself together” and “I am personally re- sponsible for my condition.” Those with bulimia more often be- lieved that they had no self-control, and male participants often believed they were “less of a man.” Those with more symptoms, those who had an eating disorder longer, those with lower self- esteem, and those who were more reluctant to seek help were more likely to endorse some form of stigmatization (Grif�ths, Mond, Murray, & Touyz, 2014). The study indicates the powerful nature of self-stigma in preventing people from seeking help for a potentially life-threatening condition.

➲ Interim Summary • Major features of eating disorders include weight con-

cerns, body dissatisfaction, and eating problems. Eating problems include restricted eating or dieting and lack of control over eating.

• Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

• Women are much more likely to have anorexia nervosa or bulimia nervosa than men, and many people with an eating disorder do not seek treatment.

• Similar rates of eating disorder symptoms are found among many major racial and ethnic groups in the United States.

• Anorexia nervosa has been observed in countries around the world and does not appear to be a cultural syndrome; bulimia nervosa is primarily found in Western cultures and may be a cultural syndrome.

• People often view those with eating disorders as responsible for their behavior, which may stigmatize this population.

➲ Review Questions 1. How do Sooki’s symptoms differ from normal concern about

body shape or weight? 2. Identify main features of, and major differences between,

anorexia nervosa, bulimia nervosa, and binge-eating disorder. 3. Describe the epidemiology of eating disorders, including is-

sues of gender and culture. 4. How might people with eating disorder be stigmatized by

others?

Eating Disorders: Causes and Prevention

We turn our attention next to factors that cause eating disor-ders and discuss how knowing about these factors might help us prevent these conditions.

Biological Risk Factors for Eating Disorders Recall from previous chapters that mental disorders are often viewed from a diathesis-stress model, or a combination of bi- ological and environmental variables. Many people are born with a genetic or biological predisposition toward certain neu- rological features or personality characteristics. Environmental conditions or life events often in�uence or trigger these biologi- cal predispositions. Biological predispositions in people with eating disorders include genetics, brain features, neurochemi- cal features, and personality traits such as perfectionism and impulsivity.

Genetics Eating disorders do run in families. First-degree relatives of fam- ily members with anorexia are 7 to 12 times more likely to have the disorder themselves. In addition, family members of those with bulimia are 4 times more likely to have bulimia themselves (Hildebrandt & Downey, 2013). Modest heritability (0.42) has also been reported for eating disorder in general (Kendler et al.,

TABLE 8.6

Stigma Statements

1. Blame/personal responsibility

____ is to blame for her condition

People with a problem like ____’s could snap out of it if they wanted

A problem like ____’s is a sign of personal weakness

____ could pull herself together if she wanted to

____’s problem is not a real medical illness

2. Impairment/distrust

People with a problem like ____’s are dangerous

I would not employ someone if I knew they had had a problem like ____’s

I would not vote for a politician if I knew they had had a prob- lem like ____’s

____ is hard to talk to

People with a problem like ____’s are unpredictable

____ is less competent than peers

Ebneter & Latner, 2013

CHAPTER 8 Eating Disorders226

No one gene or set of genes leads directly to an eating dis- order, however. Studies to �nd genetic markers for eating disor- ders in general have produced inconsistent results, but drive for thinness may link to genes on chromosomes 1, 2, and 13 (Trace, Baker, Penas-Lledo, & Bulik, 2013). This may be especially true for females compared with males (Shih & Woodside, 2016). Genetics likely set the stage for brain or neurochemical features or temperaments that help lead to eating disorders or interact with environmental events to trigger eating disorders. We next discuss some brain features found in those with eating disorders.

Brain Features Recall from Chapter 2 that the hypothalamus is the brain struc- ture that regulates hunger and eating and is involved in appetite (see Figure 8.2). Eating disorder researchers thus focus on this structure. Damage to the lateral hypothalamus leads to weight and appetite changes in animals (Stuber & Wise, 2016). Others have focused on the connection of the lateral hypothalamus to the amygdala. This connection seems related to learned cues that surround eating. These cues override feelings of fullness and thus promote more eating (Sun et al., 2015).

The nucleus accumbens has also been implicated in eating disorders because this brain structure is linked to the lateral hypothalamus as well as sensory pleasure from food (Smith

et al., 2015). Other brain regions such as the prefrontal, orbitofrontal, and somato- sensory cortexes are associated with the rewarding aspects of food and may play a part in eating disorders (Frank, 2015). In addition, the thalamus is potentially involved in excess food intake (Urstadt & Stanley, 2015).

Animal models of brain structures and eating disorder may not completely relate to humans, however. Recall that people with anorexia nervosa do have an appe- tite—they just choose not to eat. An ani- mal model also does not explain body im- age disturbance or fear of becoming fat in anorexia nervosa or bulimia nervosa. The hypothalamus and amygdala and other key brain areas (Figure 8.2) are likely involved in eating disorders, but structural or func- tional problems with these brain structures cannot completely account for symptoms of these disorders.

Neurochemical Features The neurotransmitter most closely linked to eating disorders is serotonin (Bailer et al., 2013). Serotonin in�uences mood regulation, obsessive thinking, impulsiv- ity, and eating behavior. Serotonin is also responsible for satiety, or feeling full from eating. People with anorexia nervosa who engage in food restriction may disrupt their

Is it biological makeup or bad habits that lead to obesity?

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FIGURE 8.2 BRAIN AREAS IMPLICATED IN EATING DISORDERS.

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2011). Genes on chromosomes 1, 2, 4, 10, 13, and 14 may con- tribute to these predispositions (Wade et al., 2013). Genetic in- �uences may be stronger for certain subtypes of eating disorder, especially the restricting subtype of anorexia nervosa, and spe- ci�cally for areas surrounding appetite and energy regulation (Clarke, Weiss, & Berretini, 2012).

Eating Disorders: Causes and Prevention 227

serotonin functioning. People with bulimia nervosa and binge- eating disorder may have low levels of serotonin, which can cause malfunction in the body’s satiety feedback mechanism, leading to binges.

Anorexia nervosa and bulimia nervosa are character- ized by reduced serotonin activity, and people with anorexia nervosa and bulimia nervosa also show limited responsiv- ity to serotonin-stimulating medications (Flament, Bissada, & Spettigue, 2012). Serotonin dysfunction is also associated with features common to anorexia nervosa or bulimia nervosa, including self-destructive behavior, impulsivity, compulsivity, obsessive thinking, and depression. We discussed in Chapter 7 how serotonin closely relates to depression, and some research indicates a shared genetic risk between anorexia nervosa and major depression (Brandys, de Kovel, Kas, van Elburg, & Adan, 2015).

Dopamine may also play a role in eating disorders. DopaDopamine may also play a role in eating disorders. DopaDopamine - mine is linked to pleasurable aspects of food as well as motiva- tion to obtain food (Bailer et al., 2013). Dysfunction in the do- pamine system might lead those with anorexia nervosa to have less motivation to obtain food, whereas the opposite would be true for those with bulimia nervosa and binge-eating disorder. One might thus expect differences in dopamine functioning be- tween those with anorexia nervosa and those with other forms of eating disorders characterized by binging.

Endogenous opioids are bodily chemicals that reduce pain, enhance positive mood, and suppress appetite. These chemicals are released during starvation and after intense exercise, so they may have an impact on eating disorders. Endogenous opioid release is rewarding, so this may reinforce self-starvation and excessive exercise in anorexia nervosa. Low levels of endogenous opioids promote craving of food and thus may characterize bulimia. Craving food may lead to binges and then stress relief or euphoria, so binging is rein- forced (Mason et al., 2015). We turn next to more observable factors that may be in�uenced by neurochemical substances and that contribute to the development and maintenance of eating disorders.

Personality Traits Perfectionism is often cited as a risk factor for eating disor- ders, especially among people with an obsessive drive for

thinness. People with anorexia nervosa have �xed or rigid thoughts of ideal body type, compensatory and almost ritu- alistic behavior to lose weight, and strict adherence to cer- tain patterns of eating (or not eating). People with bulimia nervosa also have an ideal body type in mind and perfec- tionism often drives dieting that perpetuates the binge–purge cycle. Perfectionism appears to be associated with, but not necessarily a cause of, eating disorder (Boone, Soenens, & Luyten, 2014).

Impulsivity is another personality feature cited as a risk factor for bulimia nervosa. Binge eating is often characterized by a desperate, urgent quality. Those who binge describe these episodes as driven and uncontrollable. We also mentioned that substance use and personality disorders are comorbid with eat- ing disorders and especially bulimia nervosa. These substance use and personality disorders are characterized by high levels of impulsivity. Impulsivity does not likely lead directly to an eat- ing disorder but does seem to predispose some people to symp- toms of bulimia or to binge-eating disorder (Schag, Schönleber, Teufel, Zipfel, & Giel, 2013).

Environmental Risk Factors for Eating Disorders We turn our attention next to environmental risk factors that develop over a person’s lifetime. These include family factors, media exposure to the “thin ideal,” and cognitive and cultural factors.

Family Factors A leading set of risk factors for eating disorders is various transi- tions and dynamics that can occur among families. Several family

Perfectionism appears to be associated with, but not necessarily a cause of, eating disorder.

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V THE CONTINUUM VIDEO PROJECT

Sara / Bulimia Nervosa

“The refrigerator became my con�dante.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

he refrigerator became my con�dante.”

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CHAPTER 8 Eating Disorders228

transitions, especially if linked to poor support, appear to precipi- tate the onset of eating disorders. These transitions include death of a family member, illness or hospitalization, and substantial changes involving school, relationships, home, and job (Berge, Loth, Hanson, Croll-Lampert, & Neumark-Sztainer, 2011). Eating disorder in a parent, especially a mother, has also been found to predict body dissatisfaction and weight and shape concerns in adolescent girls as well as dieting in boys (Micali et al., 2015). In addition, mothers with an eating disorder often have restric- tive eating patterns that can translate into eating problems in children. Other key family risk factors for eating disorder include poverty and low paternal education (Mitchell & Bulik, 2014).

Another factor in eating disorder is substantial reinforce- ment given by family members to a person who has lost sig- ni�cant weight. An eating disorder may thus become accom- modated and enabled by family members (Treasure & Schmidt, 2013). Conversely, families of people with eating disorders are sometimes described as intrusive, controlling, hostile, disorga- nized, and unsupportive. Family dysfunction and con�ict often mark this population as well (Holtom-Viesel & Allan, 2014). Family members of people with eating disorders also make fre- quent and negative comments about body shape and weight (Eisenberg, Berge, Fulkerson, & Neumark-Sztainer, 2012).

Other family factors contribute to eating disorders and to many other major mental disorders we describe in this textbook. Expressed emotion, a concept involving hostility, con�ict, and overinvolvement (Chapter 7), relates to families of those with eating disorder (Schmidt, Tetzlaff, & Hilbert, 2015). Recall also from Chapter 7 that insecure attachment relates to depression and seems to relate to eating disorders as well. Many people

with eating disorders also report family history of childhood trauma such as neglect or emotional, physical, or sexual mal- treatment. Child maltreatment is not necessarily a risk factor speci�c to eating disorders, however. You will see throughout this textbook that many people with mental disorders report high rates of childhood maltreatment (Rohr et al., 2015).

Media Exposure to the “Thin Ideal” Another risk factor for eating disorder, especially in Western so- ciety, is media promotion of the “thin ideal.” American beauty queens, models, and Playboy bunnies have become increasingly thin over the past 50 years (see Figure 8.3). Young people, es- pecially young girls, are in�uenced by the media’s depiction of attractiveness and ideal body type—Selena Gomez and Taylor Swift are not overweight. Body types for many celebrities and athletes seem to set a standard, but many of these “models” are severely underweight and thin. Women on television and in mag- azines are generally much thinner than most American women.

This media ideal clashes with the fact that size and weight of the average woman have increased over the years. Many of us are not biologically inclined to be “wai�ike” either. The me- dia provides few examples of non-thin women comfortable with their weight and appearance. An adolescent girl thus sees a big difference between what is portrayed in the media and what she sees in the mirror. Some of these girls (and boys) try to achieve the media ideal but �nd they can only do so via se- verely restricted eating, excessive exercise, or purging. Media depictions do in�uence body dissatisfaction and eating disor- der symptoms in children as young as age 5 years (Damiano, Paxton, Wertheim, McLean, & Gregg, 2015).

FIGURE 8.3 PERCENTAGE OF EXPECTED WEIGHT REFERS TO THE RATIO OF ACTUAL WEIGHT TO WHAT IS TYPICAL FOR WOMEN OF A PARTICULAR HEIGHT AND AGE. Playboy centerfolds and Miss America contestants became thinner and farther below the norm over time. (Photos: left, NBC/NBCU Photo Bank/Getty Images; right, Ethan Miller/Getty Images)

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Eating Disorders: Causes and Prevention 229

Cognitive Factors Major cognitive risk factors for eating disorder include body dissatisfaction and body image disturbance. We have seen that family and media in�uences can affect body dissatisfaction. For some people, a discrepancy occurs between actual body size

and weight and a perceived “ideal” body size and weight equated with attractive- ness. Body dissatisfaction is a risk factor as well as a maintenance factor for eating disorders. Body image disturbance refers to faulty self-evaluation of one’s body weight and shape despite contradictory evidence (Smolak & Levine, 2015). Re- call that Sooki thought she was fat even though others told her she was under- weight. Distorted self-evaluation often leads to restricting diet and food con- sumption, as was true for Sooki.

Cultural Factors We mentioned that eating disorders are present worldwide and that bulimia nervosa may be seen more in Western cultures. Anorexia nervosa may also be less common in certain countries where food is scarce or where being “plump” or slightly overweight is valued. A mental disorder involving distorted body image

and self-starvation is less likely in these countries. Research into cultural factors of eating disorder is thus most prevalent in the United States.

As we noted earlier, few racial or ethnic differences in Amer- ica have been found for eating disorder. European American women do not differ from Latinas or Asian American women

Real or perceived pressure from others to look a certain way could spur excessive dieting and even eating disorder.

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How much do popular TV shows like Project Runway in�uence body image? Even young children can be in�uenced by media depictions of the thin ideal.

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CHAPTER 8 Eating Disorders230

with respect to body dissatisfaction. European American women do, however, report higher levels of body dissatisfaction than African American women. This may re�ect greater acceptance of body weight and shape among African American women as well as the possibility that African American women are raised to be more independent, strong, and self-reliant than other women of color (Bruns & Carter, 2015). This may make African American girls and women less susceptible to the thin ideal promoted by the media and more willing to accept themselves as they are.

Causes of Eating Disorders We discussed in earlier chapters how a diathesis-stress model could be used to integrate various risk factors to explain men- tal disorder, and the same model can apply to eating disorders (see Figure 8.4). Biological diatheses, or vulnerabilities, include genetics or brain or neurochemical features that lead some peo- ple to have trouble regulating mood or behavior and to react strongly when upset or stressed. Psychological vulnerabilities include low self-esteem, perfectionism, impulsivity, body dissat- isfaction, and a distorted body image. Environmental stressors such as child maltreatment, family con�ict, and social or media- based pressures to be thin also play a role (Stice, 2016).

Figure 8.4 shows how biological vulnerabilities, psychologi- cal vulnerabilities, and stressors or sociocultural factors inter- act to cause severely restricted eating. Two different paths then emerge—one leads to anorexia nervosa and one leads to bulimia

nervosa. Two subtypes of anorexia ner- vosa are characterized by restricted eat- ing and by binging and purging. Both subtypes, however, involve excessive weight loss. Binging and purging are also evident in bulimia nervosa but normal or above normal weight is maintained. Eating disorders thus involve interplay between diatheses and stressors.

Prevention of Eating Disorders Many risk factors for eating disorder occur at an early age, so prevention of these problems usually begins in child- hood or adolescence. Preventing eating disorder is important for two key rea- sons. First, eating disorders are associ- ated with signi�cant impairment, inpa- tient hospitalization, suicide attempts, and mortality. Second, less than one third of people with eating disorders receive treatment, and treatment is not effective for all those with eating disorders.

Eating disorder prevention pro- grams emphasize education about eating disorders and consequences, re- sisting sociocultural pressures for thin-

ness, healthy weight-control behaviors, and interactive exercises to address risk factors such as body dissatisfaction. National Eating Disorders Awareness Week involves a media campaign to educate people about eating disorder and quick screening assessments in selected clinics for those struggling with eating

Restriction of eating

Anorexia nervosa Bulimia nervosa

Psychological factors

• Low self-esteem • Body dissatisfaction • Distorted body image • Perfectionism

Biological factors

• Genetic • Neurobiology • Mood regulation • Stress reactivity • Impulse regulation

Sociocultural factors

• Family conflict • Maltreatment or trauma • Family emphasis on thinness • Cultural pressures to be thin • Media exposure

Retain weightExcessive weight loss

FIGURE 8.4 SAMPLE CAUSAL MODEL OF EATING DISORDERS.

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Eating Disorders: Assessment and Treatment 231

problems. People with problematic eating patterns or concerns can then be referred for professional treatment. Prevention efforts for eating problems have generally shown only modest effects. Prevention programs tend to be more effective if high- risk individuals are targeted, if body dissatisfaction is a key fo- cus, if multiple sessions are conducted, and if the efforts are interactive in nature (Stice, Becker, & Yokum, 2013).

“Student Bodies” is an 8-week program administered via the Internet (Jones, Jacobi, & Taylor, 2015). The program com- bines a structured cognitive-behavioral curriculum with a dis- cussion group. People are screened for risk factors and then invited to participate. Primary goals are to reduce excessive weight concerns and body dissatisfaction. Participants log onto a website with updated content each week. The program involves reading the content, completing assignments, and participating in a moderated online discussion group. Partici- pants also self-monitor and write entries in a Personal Journal of Body Image. College women report that this program does reduce weight concerns (Wilfrey, Agras, & Taylor, 2013). The program also reduced onset of eating disorders among people with an elevated body mass index (see Assessment of Eating Disorders section) and among some who use compensatory be- haviors to prevent weight gain. Prevention programs like this one hold promise for reducing the incidence of eating disorder symptoms.

➲ Interim Summary • Eating disorders have some genetic basis, but environ-

mental risk factors are also important in the development of these disorders.

• Brain structures likely involved in eating problems are the hypothalamus and amygdala. Neurochemicals such

as serotonin, dopamine, and endogenous opioids are also in�uential.

• Perfectionism and impulsivity are personality-based risk factors for eating disorders, as are certain family charac- teristics and media exposure to the thin ideal.

• Body dissatisfaction and body image disturbance are cog- nitive features that put people at risk for developing eating disorders.

• Cultural factors affect eating disorder as well; bulimia ner- vosa appears to be a cultural syndrome, whereas anorexia nervosa does not.

• The diathesis-stress model is a useful way of integrating various biological and environmental risk factors for eating disorders.

• Eating disorder prevention programs target one or more risk factors and are modestly successful at reducing risk for eating disorders.

➲ Review Questions 1. Describe data that support a genetic contribution to eating

disorders. 2. What key brain and neurochemical features relate to eating

disorders? What personality characteristics are associated with eating disorders?

3. What cognitive features are considered risk factors for eating disorders? Why?

4. How might family factors, media in�uences, and cultural backgrounds help cause eating disorders?

5. What topics are typically addressed in programs to prevent eating disorders?

Eating Disorders: Assessment and Treatment

We next discuss different methods of assessing and treating eating disorders. These methods are important for people like Sooki, Lisa, and Rachel (see Personal Narrative 8.2) who struggled with symptoms of eating disorders.

Assessment of Eating Disorders Mental health professionals use various methods to examine people with eating disorders. The primary methods they use include interviews, self-report questionnaires, self-monitoring, and physical assessment.

Interviews Mental health professionals who assess people with eating dis- orders often inquire about current height and weight, thoughts and physical feelings about eating, thoughts and feelings about body shape and image, behaviors to prevent weight gain, and long-term goals. This information is important for knowing how

African American women may be less susceptible to the thin ideal than other women in the United States.

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CHAPTER 8 Eating Disorders232

Ana and Mia are nicknames for anorexia ner-Ana and Mia are nicknames for anorexia ner-Ana and Mia are nicknames for anorexia ner vosa and bulimia nervosa.

Dear Mia, We’ve come a long way together, but I’m

afraid I’m going to have to ask you to leave. You have become that last drunken guest at the par- ty that is my life. I’m not sure who invited you, but every time I’ve almost pushed you out the door you come crashing back in.

You arrived early, long before I was con- scious of your presence. You waited in the corner, through years of taunting and abuse un- til my deeply buried self-hatred could no longer be ignored. That’s when you decided we needed each other.

I needed a way to deal with my world; a way to silently punish myself for my many shortcomings in a way no one else would see. You needed someone you could seduce and brainwash. You needed someone who would believe the things you whispered in her ear.

“You’re defective.” “You’re ugly.” “You’re stupid.” “You’re worthless.” Funny how the things you were telling me

were the same things I heard every day at school. It must have been most convenient for you that I already believed those things about myself.

You convinced me that despite the rosy sub- urban childhood my parents tried to give me, I was miserable. Despite my loving family and supportive adult friends, I was unlovable. De- spite my wall full of swimming medals and writ- ing awards, I was talentless. Despite my ability

to build a ca- reer, I was a failure.

Through all of that, you stayed. You were wait- ing for me to crash diet before I tried on bridal gowns for the wedding I would call off. You were wait- ing for my boyfriend to dump me. Waiting for me to have a bad day, or just to be tired and bored. The day my parents told me I was fat fully announced your arrival.

But our time is over. For all of our time to- gether, I have realized that I am stronger than you.

The beginning of the end came 2 years ago, on that morning when I was semiconscious on my bathroom �oor, covered in my own vomit. That’s when you went too far. The shadows in the corner parted, and I saw you for what you really are.

I decided then and there that you had to leave. But no matter how hard I try (cleaning up the dirty glasses, vacuuming the �oor, say- ing how early I have to get up in the morning), you refuse to leave and your presence is still puzzling.

All I know is you helped me start a war with my body. You prevented me from enjoying my- self and my family and my friends. From being able to eat meals like a normal person. From experiencing the normal cycle of being hungry, eating, and stopping when I felt full.

I’m not sure what I could have done to prevent our relationship. It really all goes back to �fth grade, doesn’t it? When I couldn’t get through a day at school with- out being ostracized or punched. You fol-

lowed me through my teenage years, and we �irted and played until you lucked out.

When I was in college, I dated a jerk, and all of the things I learned about myself in �fth grade were con�rmed.

Once we were well acquainted, you disin- tegrated my muscle tone until I couldn’t carry a bag of groceries, change the tank on my of- �ce water cooler, or walk more than a block or two without needing to sit down. You’ve given me an irregular heartbeat and low blood pres- sure that causes me to faint if I stand still for too long. I’m certain you’ve given me cavities, but I’m too afraid to go to the dentist. Time will only tell as to whether you’ve given me osteoporosis.

Somehow, after all this time, I have grown stronger than you. I have regained my muscle and am prepared to throw you out with an im- print of a combat-booted foot planted squarely in your backside. At this point, you need a will- ing host, and I am no longer willing.

So please, take your tingling �ngertips and bruised knuckles. Take your sunken eyes and your cracked lips. Take your perpetually sore throat and your raging headaches. Take the self-doubt and self-loathing that you brought with you.

And whatever you do, don’t come back. Be- cause I am stronger than you are, and I know how much you hate that.

8.2 / R / R / achel Webb personal narrative

Rachel Webb ing for me to When I was in college, I dated a jerk, and all of Phot

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to treat someone with an eating disorder because speci�c client characteristics can be identi�ed and addressed. Lisa’s therapist discovered some interesting information about what happens when her eating is out of control:

Therapist: What happens when you binge? Lisa: I eat lots of sweets, like cake, ice cream, cookies, and can-

dy bars. Therapist: What are you usually thinking about during a binge,

and what happens next?

Lisa: While I’m eating, I just don’t feel I can stop. I get mad at myself for not being able to stop my eating, and I feel depressed. The only thing I can do right after the binge to make myself feel better is to throw up. It’s embarrassing to admit throwing up so much, but it does make me feel better.

Therapist: What usually happens after you vomit? Lisa: Well, later, I start feeling guilty and thinking I’ll never get

any better. That’s when the depression kicks in . . . I won- der why I’m so messed up.

Used with permission.

Eating Disorders: Assessment and Treatment 233

Many therapists prefer unstructured interviews, but struc- tured interviews usually rely on diagnostic criteria and contain set questions a therapist asks each client with a possible mental disorder (see Chapter 4). A common structured interview for eating disorders and one used in treatment outcome studies is the Eating Disorders Examination (EDE 16.0D; Fairburn et al., 2015). The EDE provides eating disorder diagnoses as well as scores on four subscales relevant to eating disorder problems: restraint, eating concern, shape concern, and weight concern. Other interviews focused on general disorders have sections for eating disorder symptoms. The Structured Clinical Interview (First, Williams, Karg, & Spitzer, 2015) has questions about an- orexia nervosa and bulimia nervosa symptoms. Binge-eating disorder can also be assessed with this interview.

Self-Report Questionnaires Self-report questionnaires are often used to screen for eating problems. The Eating Disorder Diagnostic Scale (Krabbenborg Eating Disorder Diagnostic Scale (Krabbenborg Eating Disorder Diagnostic Scale et al., 2012) provides diagnostic information for eating disorders. Scores can be calculated for key components of eating disorders like body dissatisfaction and binge eating. Selected items from this scale are in Table 8.7. A list of other questionnaires that mental health professionals use when assessing people with eat- ing disorders is in Table 8.8.

Self-Monitoring People with eating disorders can monitor and record their daily symptoms and behaviors. Daily recording is likely more accurate than a retrospective report of the past week. A person can also focus on what happened immediately before or after a symptom or behavior. The act of self-monitoring itself can lead to fewer symptoms and behaviors—we generally do an excess behavior

TABLE 8.7

Sample Items from the Eating Disorder Diagnostic Scale

Body dissatisfaction/fear of gaining weight

Over the past 3 months . . .

• Have you felt fat?

• Have you had a de�nite fear that you might gain weight or become fat?

• Has your weight in�uenced how you think about (judge) yourself as a person?

• Has your shape in�uenced how you think about (judge) yourself as a person?

Note: Each of these items is rated as 0 (“not at all”), 1, 2 (“slightly”), 3, 4 (“moderately”), or 5 or 6 (“extremely”).

Binge Eating

During these episodes of overeating and loss of control did you . . .

• Eat much more rapidly than normal?

• Eat until you felt uncomfortably full?

• Eat large amounts of food when you didn’t feel physically hungry?

• Eat alone because you were embarrassed by how much you were eating?

• Feel disgusted with yourself, depressed, or very guilty after overeating?

• Feel very upset about your uncontrollable overeating or resulting weight gain?

Note: These questions are answered yes or no.

Source: Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological Assessment, 12, 123-131. Reprinted by permission of the authors.

less if we record each time it happens. We become more aware of our behaviors and gain better control over them.

Self-monitoring can be accomplished using a paper diary to indicate frequency of behaviors such as binge eating, purging, or excessive exercise; emotions and thoughts that preceded these behaviors; and consequences after the behavior such as stress relief, comfort, or guilt. Paper diaries can also be used to track and record meals eaten and calories consumed. This informa- tion can be extremely helpful for understanding one’s eating problem and for planning treatment.

A high-tech version of self-monitoring involves using electronic diaries such as Palm Pilots or certain smartphone ap- plications to record behavior. Sooki might be asked to carry an electronic diary to document meals, thoughts about her body,

Some prevention programs for eating disorders are administered over the Internet.

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CHAPTER 8 Eating Disorders234

and fear of becoming fat. She could also indicate her mood state before and after restricting her eating as well as events before and after skipping meals. Women with anorexia nervosa who use electronic diaries show many changes in mood throughout the day. They also endorse many eating disorder symptoms and rituals such as skipping meals, checking joints and bones for fat, and consuming �uids to curb appetite. Electronic diaries can thus provide rich data for mental health professionals who plan treat- ment (Stroe-Kunold, Wesche, Friederich, Herzog, & Wil, 2014).

Physical Assessment People with eating disorders should always have a thorough medical examination. Many eating disorder symptoms are phys- ical, such as low weight, and eating disorders can result in seri- ous medical symptoms and life-threatening outcomes. A physi- cal examination can focus on height and weight to determine body mass index (BMI; Table 8.9), heart rate and rhythm, and muscle tone and strength. Physical assessment can also help physicians and mental health professionals decide the �rst step of treatment. Someone with anorexia nervosa found to be se- verely malnourished may require inpatient hospitalization to insert and maintain a nasogastric tube for feeding. Common laboratory tests to assess people with eating disorders include the following:

• Metabolic panel to assess for electrolyte imbalance due to poor nutrition

• Blood count to check for anemia • Enzyme tests to rule out severe malnutrition • Serum amylase tests to suggest purging behavior • Bone scans to rule out calcium de�ciency or bone mass

loss

Treatment of Eating Disorders Recall that eating disorders have symptoms involving emotional, physical, cognitive, and behavioral features. The general aims of biological and psychological treatment for eating disorder are thus to (Lock & Le Grange, 2013):

• Return the person to a healthy weight • Treat physical complications • Increase motivation to restore healthy eating patterns • Educate the person about healthy eating patterns • Help the person recognize and change core problematic

feelings, thoughts, and behaviors about the eating disorder

• Enlist family support for change • Prevent relapse

Biological Treatments of Eating Disorders Biological treatments for eating disorders involve controlled weight gain and medication.

Controlled Weight Gain Many people with anorexia nervosa lose so much weight that their condition becomes life-threatening. People with severe anorexia nervosa who seek treatment are often �rst admitted to inpatient care involving controlled weight gain and nutrition

Electronic diaries can be used to monitor one’s mood, thoughts, and eating behavior.

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TABLE 8.8

Common Questionnaires for Assessing Eating Disorders

General Diagnosis of Eating Disorders

Eating Disorders Inventory—2 (EDI-2)

Kids Eating Disorders Survey (KEDS)

Body Dissatisfaction/Body Image Disturbance

Body Shape Questionnaire (BSQ)Body Shape Questionnaire (BSQ)Body Shape Questionnaire

Body Image Avoidance Questionnaire

Dietary Restraint

Dutch Eating Behavior Questionnaire (DEBQ)Dutch Eating Behavior Questionnaire (DEBQ)Dutch Eating Behavior Questionnaire

Three-Factor Eating Questionnaire (TFEQ-R)Three-Factor Eating Questionnaire (TFEQ-R)Three-Factor Eating Questionnaire

Binge Eating

The Binge Eating Scale

Source: Pike, K.M. (2005).

Eating Disorders: Assessment and Treatment 235

TABLE 8.9

Body Mass Index (BMI) Chart

BMI (kg/m2) Height (in.)

19 20 21 22 23 24 25 26 27 28 29 30 35 40

Weight (lb.)

58 91 96 100 105 110 115 119 124 129 134 138 143 167 191

59 94 99 104 109 114 119 124 128 133 138 143 148 173 198

60 97 102 107 112 118 123 128 133 138 143 148 153 179 204

61 100 106 111 116 122 127 132 137 143 148 153 158 185 211

62 104 109 115 120 126 131 136 142 147 153 158 164 191 218

63 107 113 118 124 130 135 141 146 152 158 163 169 197 225

64 110 116 122 128 134 140 145 151 157 163 169 174 204 232

65 114 120 126 132 138 144 150 156 162 168 174 180 210 240

66 118 124 130 136 142 148 155 161 167 173 179 186 216 247

67 121 127 134 140 146 153 159 166 172 178 185 191 223 255

68 125 131 138 144 151 158 164 171 177 184 190 197 230 262

69 128 135 142 149 155 162 169 176 182 189 196 203 236 270

70 132 139 146 153 160 167 174 181 188 195 202 207 243 278

71 136 143 150 157 165 172 179 186 193 200 208 215 250 286

72 140 147 154 162 169 177 184 191 199 206 213 221 258 294

73 144 151 159 166 174 182 189 197 204 212 219 227 265 302

74 148 155 163 171 179 186 194 202 210 218 225 233 272 311

75 152 160 168 176 184 192 200 208 216 224 232 240 279 319

76 156 164 172 180 189 197 205 213 221 230 238 246 287 328

Body weight in pounds according to height and body mass index.

BMI Weight class

18.5 or less Underweight

18.5–24.9 Normal

25.0–29.9 Overweight

30.0–34.9 Obese

35.0–39.9 More obese

40 or greater Extremely obese

CHAPTER 8 Eating Disorders236

guidance (Suarez-Pinilla et al., 2015). Controlled weight gain can include a nighttime nasogastric tube to increase basic nourish- ment, improve vital functioning, and provide a minimal amount of energy. Those with anorexia may also be given regular snacks and small meals under staff supervision as well as praise for their eating (Rocks, Pelly, & Wilkinson, 2014).

Controlled weight gain is often conducted in conjunction with a nutritionist who educates a person about healthy food choices. Physicians and mental health professionals should ex- pect only small gains in weight per week and focus more intently on body mass index than weight (Redgrave et al., 2015). People with anorexia who start to gain weight may become increasingly anxious, depressed, or irritable as they do so, so these mood states must also be managed. Controlled weight gain is thus often used in conjunction with the medications described next.

Medication We mentioned that serotonin changes contribute to eating dis- orders and that depression, which is associated with low sero- tonin, is highly comorbid with eating disorders. Medication for eating disorders has thus primarily involved selective serotonin reuptake inhibitors (SSRIs) like Prozac and others (Chapter 7). These medications are not overly helpful with people with an- orexia nervosa because the drugs do not necessarily increase weight (Mitchell, Roerig, & Steffen, 2013). SSRIs are helpful, however, for treating comorbid depression, anxiety, obsessional thinking, and purging (if present). Antipsychotic medications (Chapter 12) may also be used for cases involving severe obses- sional thinking or delusional body image disturbances. Research regarding antipsychotics for eating disorders has produced mixed results, however (Dold, Aigner, Klabunde, Treasure, & Kasper, 2015).

SSRIs and psychological treatment (discussed in the next section) do signi�cantly reduce binge eating and purging and help ease impulse control problems reported by many people with bulimia nervosa and binge-eating disorder (Brownley, Peat, La Via, & Bulik, 2015). Appetite suppressants are sometimes used to help with weight loss in these groups as well. The drugs reduce eating but mental health professionals must ensure that clients on these drugs monitor heart rate and blood pressure (McElroy, Guerdjikova, Mori, & O’Melia, 2012).

Psychological Treatments of Eating Disorders Psychological treatments for eating disorders involve family therapy and cognitive-behavioral therapy.

Family Therapy Family therapy is useful for many people with eating disorders but is particularly helpful for adolescents with anorexia ner- vosa. A popular form of family therapy for those with anorexia nervosa is a family systems or Maudsley model approach. This approach initially focuses on obtaining cooperation from all family members, examining family patterns of eating and attitudes toward a client’s symptoms, and improving eating and weight gain (Johnston, O’Gara, Koman, Baker, & Anderson,

2015). Family therapy can begin as early as the controlled weight gain program in an inpatient setting. Family members can praise an adolescent for gaining weight and refraining from pressures to stay thin.

Family therapy after a person has left the hospital may focus on reducing con�ict among family members and en- suring everyone can maintain appropriate patterns of food preparation and consumption. Family therapists also address expressed emotion to ease overinvolvement, criticism, and hostility among family members (Rienecke, Accurso, Lock, & Le Grange, 2016). Parents are initially encouraged to take con- trol of what their adolescent eats, but over time this respon- sibility shifts to the teen (Robinson, Dolhanty, & Greenberg, 2015). Family therapy generally lasts 6 to 12 months and tends to work better in the short term than the long term (Couturier, Kimber, & Szatmari, 2013). Family therapy may be more effec- tive if combined with medication or the cognitive-behavioral approaches we discuss next.

Cognitive-Behavioral Therapy Recall that we previously separated cognitive and behavioral approaches to therapy for anxiety-related, somatic symptom, and depressive and bipolar disorders. Therapists who treat eat- ing disorders, however, often combine cognitive and behavioral therapies into a singular approach we describe here. Cognitive- behavioral therapy (CBT) is a dominant approach for treating many different eating disorders and especially bulimia ner- vosa and binge-eating disorder (Spielmans et al., 2013). CBT often focuses on binging and purging cycles as well as cogni- tive aspects of body dissatisfaction, overconcern with weight and shape, and perfectionism. The therapy is often conducted in conjunction with a nutrition and medication program and possibly family therapy.

CBT for bulimia nervosa rests on cognitive and behavioral factors that in�uence development and maintenance of symp- toms (see Figure 8.5; Dalle Grave, Colugi, Sartirana, & Fairburn, 2015). People with bulimia nervosa have a rigid idea of an ideal body shape and weight, which leads them to overly restrict food intake to increase self-esteem. This rigid stance makes a per- son psychologically and physiologically vulnerable to periodi- cally lose control over their eating (binge). These episodes are negatively reinforced because they reduce distress and negative feelings from restrictive dieting. People then feel compelled to purge (vomit) to prevent weight gain after a binge. Purging is also negatively reinforced because anxiety after the binge is reduced. Unfortunately, those with bulimia often feel guilty and depressed after a binge–purge cycle, which leads again to low self-esteem. This cycle thus brings them back to the initial situation—excessive dieting to improve self-esteem.

We can see this cycle develop with Lisa. Lisa was preoc- cupied with her weight and often limited her eating and weight by dieting. Dieting made her feel good about herself in the short term, but pressures of daily life and continued worry about her weight led to high stress. Lisa reduced her stress by eating, which in her case led to loss of control and overeating. Lisa felt better after a binge but then panicked and felt deep shame about

Eating Disorders: Assessment and Treatment 237

and (3) developing normal eating patterns and habits. Several strategies are thus used, including the following:

• Self-monitoring eating, thoughts, urges, and behaviors • Education about the model for bulimia nervosa and need

for change

• Weekly weighing • Education about body weight regulation, adverse effects of

dieting, and consequences of purging

• Problem solving • Changing rigid dieting • Cognitive restructuring to address concerns about eating,

body weight, and body shape

• Exposure methods to increase acceptance of body weight and shape

• Relapse prevention training Cognitive-behavioral treatment for bulimia nervosa, often

enhanced to speci�cally focus on an individual’s eating habits and concerns, lasts about 20 weeks (Fairburn et al., 2015). In Stage 1, the therapist explains the cognitive-behavioral model of bulimia nervosa, begins weekly weighing, and teaches the client to self-monitor eating, drinking, the contexts in which these occur, and associated thoughts and feelings. A typical monitoring sheet is shown in Figure 8.6. A therapist will re- view these monitoring sheets and other homework assignments in subsequent sessions. The therapist also provides education about the nature of bulimia nervosa and gives feedback about eating as well as how to limit purging or vomiting. Lisa was

• Body mass and metabolic rate calculations • A message board or forum • A blog or live journal

Most would agree this seems like a disturbing trend, especially given what we know about influences on the development of anorexia nervosa in young girls. But what effect do these websites have on adults? Can harm actually be done? Some have found that those who view a pro- ana website, but not other websites, show decreased self-esteem and perceived attractiveness and appearance, as well as increased negative affect and perceptions of being overweight. Others have found no effect on body dissatisfaction, however (Delforterie, Larsen, Bardone-Cone, & Scholte, 2014). Still, a survey of adult pro–eating disorder website us- ers revealed that 70 percent had purged, binged, or used laxatives to control their weight. In addition, 24.8 percent were underweight, 20.9 percent were overweight or obese, and only 12.9 percent were in treat- ment. Level of website usage was found to be related to more severe symptoms of eating disorder (Peebles et al., 2012). The impact of pro- ana websites may thus be negative and possibly lead to enhanced risk for eating disorders.

Focus On

Some websites explicitly encourage extreme dieting and promote eating disorders like anorexia nervosa as a lifestyle. These “pro-ana” or “pro- anorexia” websites offer information about how to lose weight and pro- vide a sense of support and community for those with anorexia nervosa. Common features or content on pro-ana websites include the following (Rodgers, Lowy, Halperin, & Franko, 2016):

• Visual images such as thin celebrities, motivation quotes, and writings to promote extreme thinness as a lifestyle

• Methods to facilitate weight loss such as laxatives, diet pills, and fasting • Creative writings and expressions from those who aspire to be underweight

Law and Ethics How Ethical Are Pro-Ana (Pro-Anorexia) Websites?

8.3

her excess behavior. She then vomited to reduce her distress. Unfortunately, her usual stressors and worries about weight awaited her the next day and the cycle began again.

Cognitive-behavioral therapists try to interrupt this cycle by (1) questioning social standards for physical attractiveness, (2) challenging beliefs that encourage severe food restriction,

FIGURE 8.5 A BINGE-PURGE CYCLE IN BULIMIA NERVOSA.

Compensatory behaviors

(e.g., vomiting) to reduce fear

of weight gain

Low self-esteem Negative affect

Diet to feel better about

self

Restrict food intake too much

Diet broken

Binge

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CHAPTER 8 Eating Disorders238

taught to delay the time between a binge and her purging to see that her distress level would drop by itself without having to vomit.

Stage 2 of cognitive-behavioral treatment addresses all forms of dieting, concerns about weight and shape, perfection- ism, low self-esteem, and problem-solving skills. Lisa was taught to prepare healthy foods, limit types of food she brought into the house, discuss what she valued about herself other than weight, and how to avoid times and places that put her at risk for bing- ing. She also enlisted the help of friends who helped monitor her eating behavior. The aim of Stage 3 is to prevent relapse.

Individualized maintenance plans, like that outlined in Figure 8.7, can be developed so a client can anticipate and plan for future eating problems and setbacks. Nutritionists can also help with structured meal plans and exercise regimens to address weight control issues during these stages. Evidence supports the effectiveness of cognitive-behavioral treatment for binge eating but less so for weight control (Berkman et al., 2015).

What If I Have Weight Concerns or an Eating Disorder? People are often screened for eating disorders, and the answers to some basic questions may indicate whether further assessment

or even treatment is warranted. Some of these questions are listed in Table 8.10. If you �nd yourself answering “yes” to most of these questions, then you may wish to consult a clinical psychologist, psychiatrist, or other mental health professional (Chapter 15). Cognitive-behavioral therapy and/or medication may be best.

If you feel you have eating concerns but not neces- sarily an eating disorder, then teaching yourself to gain better control over your eating patterns and change your thoughts about your body may be best. Talk about your concerns with family members and friends or attend an eating disorders screening. Further information about screening and treatment for eating disorders can be found at the websites of the National Eating Disorders Associa- tion (www.nationaleatingdisorders.org) or the National Association of Anorexia Nervosa and Associated Eating Disorders (www.anad.org).

Long-Term Outcome for People with Eating Disorders What is the long-term picture, or prognosis, for people with eating disorders? The picture is not particularly bright for those with anorexia nervosa. Anorexia nervosa has the highest mortality rate of any mental disorder, including de- pression—about 7.5 percent of those with anorexia nervosa eventually die via starvation or suicide. Factors that predict early death include excessive alcohol use, low body mass index, and poor social adjustment (Franko et al., 2013). An-

other 30 percent remain chronically impaired, with symptoms waxing and waning over time. The better news is that many people with anorexia nervosa show improved though not to- tally absent symptoms over time (Smink et al., 2013). Sooki eventually sought treatment but dropped out after only a few sessions. Her prognosis over time is thus likely to be variable or poor.

Treatment outcomes for people with anorexia nervosa vary and can range from good (20–35 percent) to intermedi- ate (45–60 percent) to poor (20 percent). About 30 percent drop out of treatment, however (Zipfel et al., 2014). People who seek treatment for anorexia nervosa generally do better if they are in treatment at a younger age, have a shorter duration of the disorder, are employed, are not taking medication, and have better social adjustment. Other factors, such as depres- sion and frequency of binging, often affect treatment outcome as well (Le Grange et al., 2014). Many people with anorexia eventually develop bulimia nervosa or binge-eating disorder and must seek treatment for these conditions as well (Utzinger et al., 2015).

The picture is more optimistic for bulimia nervosa. People with bulimia nervosa can have an intermittent course involv- ing recurring symptoms and symptom-free periods. Symptoms of bulimia nervosa often diminish over time. Other people with bulimia nervosa have a more chronic course, however, in which symptoms persist. Remission rates for bulimia range

FIGURE 8.6 A MONITORING SHEET USED IN COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA NERVOSA.

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Time

Day Dy Date

Food and liquid consumed Place Context

7:35 15 1 1

2 1 a

2 2

1/2

1 1 1

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1 6 4 2 2

11:10

3:15

3:30

5:10

6:00

9:00

9:20

10:00

11:20

grapefruit cup black coffee

apple

Twix bread roll fruit cake

chocolate eggs bread rolls pint of milkof milkof

bowl of cerealof cerealof bowl of cerealof cerealof pita bread with cottage cheese glass water

baked potato can diet soda

cup soup ice cube cup coffee

coffee (black)

coffee (black) shortbread biscuits pieces of chocolateof chocolateof pieces of toastof toastof glasses of waterof waterof

Kitchen

Work

High St. ”

Market

” Kitchen

”

” ” ”

”

Outside ”

Kitchen ” ”

Sitting room

Kitchen ” ” ” ”

Feel really fat.

Everyone looked at me in the market. I’m out of control. I hate myself. I can’t stop crying.

Weighed myself lost 8 lbs – too heavy

Feel fat and ugly.

Weighed myself lost 7 lbs – fat

Took 24 Nylax.

Why do I do this? I want to be thin. I can’t help it

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Eating Disorders: Assessment and Treatment 239

from 63 to 92 percent (Nagl et al., 2016). The course of binge- eating disorder is also variable, with a 33 percent recurrence rate (Stice et al., 2013). Binge-eating disorder is associated with health problems such as obesity as well as cardiovas- cular, metabolic, and sleep-related conditions (Mitchell & Wonderlich, 2014).

About half of people who seek treatment for bulimia nervosa show full recovery, but the other half display stable symptoms over time. Treatment dropout rates for bulimia (10.3 percent) tend to be lower than for anorexia, however (Mitchell & Bulik,

2014; Waller et al., 2014). Some show various improvements in dysfunctional dieting, weight loss, and body image. Cognitive- behavioral treatment is more effective than medication or other psychological treatments for bulimia nervosa, though medica- tion is often used in conjunction with psychological treatment (Hay & Claudino, 2014). People who seek treatment for bulimia nervosa generally do better if they respond early to treatment, have better impulse control, and show less depression and com- pensatory behaviors (Accurso et al., 2016; Lock et al., 2013). Such was the case for Lisa.

8. 8.

1. If your eating problem is getting wo If your eating problem is getting wo If your eating problem is get rse

2. If you sense you are at risk of relapse

Eating problems may recur at times of stress. You should regard your eating problem as an Achilles’ heel: It is the way you are prone to react at times of difficulty. You discovered during treatment that certain techniques helped you regain control over eating. The techniques that you found most helpful are listed below. These should be reinstituted under two sets of circumstances:

At such times there will often be some underlying problem. You must therefore examine what is happening in your life and look for any events or difficulties that might be of relevance. If any problems seem relevant, you should consider all possible solutions in order to construct a plan of action. In addition, you should use one or more of the following strategies to address your eating:

Set some time aside so that you can reflect on the current situation. You need to devise a plan of action. Reckon on formally reevaluating your progress every day or so. Some strategies may have worked; some may not.

Restart monitoring everything you eat, when you eat it.

Confine your eating to three planned meals each day, plus two planned snacks.

Plan your days ahead. Avoid both long periods of unstructured time and overbooking. If you are feeling at risk of losing control, plan your meals in detail so that you know exactly what and when you will be eating. In general, you should try to keep one step ahead of the problem.

Identify the times at which you are most likely to overeat (from recent experience and the evidence provided by your monitoring sheets) and plan alternative activities that are not compatible with eating, such as meeting friends, exercising, or taking a bath or shower.

If you are thinking too much about your weight, make sure that you are weighing yourself no more than once a week. If necessary, stop weighing altogether. If you want to reduce weight, do so by cutting down the quantities that you eat at each meal rather than by skipping meals or avoiding certain foods. Remember, you should accept a weight range, and gradual changes in weight are best.

If you are thinking too much about your shape, this may be because you are anxious or depressed. You tend to feel fat when things are not going well. You should try problem solving in order to see whether you can identify any current problems and do something positive to solve, or at least minimize, them.

If possible, confide in someone. Talk through your problem. A trouble shared is a trouble halved. Remember, you would not mind any friend of yours sharing his or her problems with you.

Set yourself limited realistic goals. Work from hour to hour. One failure does not justify a succession of failures. Note down any progress, however modest, on your monitoring sheets.

FIGURE 8.7 A MAINTENANCE PLAN FOLLOWING COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA NERVOSA. From Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive behaviour therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 361-404). New York: Guilford. Copyright © 1993 by Guilford Publications, Inc. Reprinted by permission.

CHAPTER 8 Eating Disorders240

➲ Interim Summary • Major approaches to assess eating disorders include

interviews, self-report questionnaires, self-monitoring, and physical assessment.

• Treatments for eating disorders share some general aims: returning to a healthy weight; increasing motivation to restore healthy eating patterns; providing education about healthy eating; aiding recognition of problematic feelings, thoughts, and behaviors; enlisting support from others; and preventing relapse.

• Controlled weight gain and medication are prominent biological approaches to treating eating disorders.

• Family and cognitive behavioral therapies are the most ef- fective psychological treatments for eating disorders.

• Of the eating disorders, the prognosis, course, and treatment outcome for bulimia nervosa is most favorable, followed by binge-eating disorder and anorexia nervosa.

➲ Review Questions 1. Describe major assessment techniques for eating disorders, in-

cluding interviews, self-report questionnaires, self-monitoring, and physical assessment.

2. What different methods may be used to treat anorexia nervosa? 3. What different methods may be used to treat bulimia nervosa? 4. What strategies could a mental health professional use to

help someone with binge-eating disorder? 5. What is the long-term outcome for people with eating

disorders?

TABLE 8.10

Screening Questions for Eating Disorders

• Are you constantly thinking about your weight and food?

• Are you dieting strictly and/or have you lost a lot of weight?

• Are you more than 10 percent below your healthy weight?

• Are people concerned about your weight?

• Is your energy level down?

• Do you constantly feel cold?

• Are you overeating and feeling out of control?

• Are you vomiting, using laxatives or water pills, herbal agents, or trying to fast as a way to control your weight?

• Are you overexercising or do others consider your exercise excessive?

• Does your weight drastically �uctuate?

• Do any of the above interfere with your enjoyment of life, relationships, or everyday functioning?

Note: These questions are not intended to diagnose an eating disorder. They are simply designed to indicate that a person may be thinking too much about food, weight, etc., or engaging in potentially eating-disordered behaviors. Yes answers to more than �ve of these questions could indicate a problem that should be evaluated by a professional. For a list of mental health professionals and support groups in your area, visit the National Association of Anorexia Nervosa and Associated Eating Disorders at www.anad.org. Source: National Association of Anorexia Nervosa and Associated Eating Disorders (www.anad.org).

Final Comments Eating disorders are not as prevalent as other disorders we discuss in this textbook, but they are serious conditions with many adverse physical outcomes. These disorders are especially relevant to college-age, young adults. Eating problems lie on a continuum, so many people likely share eating concerns and symptoms with those who meet criteria for an eating disorder. Help is available, so if you or someone you know has concerns about body weight and shape or eating behaviors, talking to someone about it or contacting a quali�ed mental health professional is a good idea.

Thought Questions 1. Think about models or television or �lm stars that seem markedly underweight or overweight. Do

you think they have symptoms of an eating disorder? Which disorders, and why?

2. Have you ever been concerned about your body shape or weight? How about your own eating behavior? What factors may have in�uenced this? What information in this chapter seems most relevant to you?

3. What would you now say to a friend who might have concerns about her body weight or shape or about her eating behaviors?

4. What separates “normal” eating or weight concerns from “abnormal” eating or weight concerns?

5. Do you think eating disorders have more to do with biological, family, cultural, or other factors? Why?

241Key Terms

Key Terms weight concerns 216 body dissatisfaction 216 eating disorder 216 eating problems 216 restricted eating 216 dieting 216

lack of control over eating 217 anorexia nervosa 217 restricting behaviors 218 purging 218 bulimia nervosa 218 binge eating 218

compensatory behaviors 219 binge-eating disorder 220 satiety 226 endogenous opioids 227 electronic diaries 233

243

Special Features

CONTINUUM FIGURE 9.1 Continuum of Substance Use and Substance-Related Disorders 246–247

• 9.1 The Sam Spady Story 252

• 9.2 The “Meth” Epidemic 254

• 9.3 FOCUS ON GENDER: Date Rape Drugs 256

• 9.4 FOCUS ON VIOLENCE: Alcohol and Violence 264

V THE CONTINUUM VIDEO PROJECT Mark / Substance Use Disorder 264

• 9.5 FOCUS ON COLLEGE STUDENTS: Substance Use 268

Personal Narrative 9.1 One Family’s Struggle with Substance-Related Disorders 270–271

• 9.6 FOCUS ON LAW AND ETHICS: Drug Testing 273

C Elon / What Do You Think?

Normal Substance Use and Substance-Related Disorders: What Are They?

Substance-Related Disorders: Features and Epidemiology

Stigma Associated with Substance-Related Disorders

Substance-Related Disorders: Causes and Prevention

Substance-Related Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Substance-Related Disorders 9

CHAPTER 9 Substance-Related Disorders244

C / E/ E/ lon

Elon was a student at a large public college who enjoyed the party scene even more than his friend DeShawn (Chapter 3). DeShawn en- tered college with an eye toward academics, but Elon entered college with an eye toward so- cializing and having as much fun as possible. Elon was an 18-year-old African American male who achieved good grades in high school and received an academic scholarship for the �rst 2 years of college. Elon’s good performance in high school courses was due more to his intel- lectual talent than hard work. He was therefore able to enter college, but he found himself over- whelmed by professors’ demands for extensive writing projects, reading assignments, and oral presentations.

Elon was somewhat impulsive but also extroverted and gregarious. He blended into parties, made friends, and found sexual part- ners with ease. Elon drank alcohol excessively at these parties, as he had sometimes done in high

school, and smoked marijuana on occasion. Us- ing these drugs eased his concern about the de- mands of school and satis�ed his personal need for attention and companionship. Unfortunately, Elon failed all but one course his �rst semester.

Elon received academic probation and vowed to improve his reading and studying dur- ing his second semester. This strategy worked for the �rst 2 weeks, but Elon became bored with the course material and again started to attend campus parties. He also became bored with his usual social and party scene, however, and began to experiment with creative sexual practices and different drugs. Elon began using cocaine to boost effects of his alcohol use and used marijuana to calm himself after using too much cocaine.

Elon was soon almost out of money from buying alcohol and other drugs. He stopped attending classes and spent much of his day watching television, sleeping, and playing video- games. At night, Elon found a party or sought people who could give him illicit drugs. He re- mained sexually active but his ability to perform was impaired. He thus sought more powerful drugs and drug combinations to satisfy his need for a “high.”

Elon secured a loan from his parents and began spending more time in areas of the city with signi�cant drug activity. He tried different drugs and drug combinations, and he settled on a personal favorite called PNP—“party and

play”—that involved crystal methamphetamine and sildena�l (a drug such as Viagra or Cialis that helps men achieve penile erections). This combination allowed Elon to experience greatly enhanced mood, feelings of invulnerability, and sexual performance. The drug combination was quickly addictive and Elon eventually spent nearly all his time seeking or using the drug cocktail.

Elon continued his drug use despite an arrest for lewd conduct and a visit to the emergency room for a seizure (a side effect of methamphetamine with sildena�l). Elon’s par- ents �nally found their son sleeping half-naked in a downtown alleyway. Elon had no recollection of the past few days, and his parents took him to a drug rehabilitation facility. Elon was about to undergo the painful process of drug withdrawal and the even more painful process of admitting to his parents what happened to him.

What Do You Think? 1. Which of Elon’s symptoms seem typical for

a college student, and which seem very different?

2. What external events and internal factors might be responsible for Elon’s drug use?

3. What are you curious about regarding Elon? 4. Does Elon remind you in any way of

yourself or someone you know? How so? 5. How might Elon’s drug use affect his life

in the future?

case

Normal Substance Use and Substance- Related Disorders: What Are They?

How many people do you know who regularly use some kind of drug? The number might surprise you. Many of us have a glass of wine, smoke a cigarette, drink soda, or take pre- scribed pain or sleep medication during the day or night. Each substance contains a key drug—alcohol, nicotine, caffeine, or a morphine derivative in these cases—that affects behavior. Many people drink alcohol to unwind after a hard day, smoke ciga- rettes to relax, drink caffeinated beverages to boost energy, and take medication for pain. Many of us engage in substance use that somehow affects our behavior. Such use is normal and may not lead to signi�cant problems if we use the drug carefully.

Other people engage in substance use a bit more frequently. You may know someone who drinks a couple of alcoholic bever- ages or smokes a half-pack of cigarettes every day. This is sub- stance use on a grander scale but is not necessarily a problem if he can stop using the drug or if he is not physically addicted to the drug. Someone going through a rough time of life may drink alcohol more frequently than before but not necessarily drive and wreck a car when drinking. Or, a person may smoke cigarettes occasionally but have no daily cravings for nicotine. No impairment occurs in daily functioning, and no substantial physical harm takes place.

Some people continue to engage in substance use and do so to a greater degree, however. You may know people who get drunk more than once a week or who seem hooked on pain- killers. Daily functioning does seem impaired, or some physical

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Substance-Related Disorders: Features and Epidemiology 245

disorder because he was missing classes, withdrawing from old friends and family members, and driving while impaired.

Risky use means that the person continues taking the drug Risky use means that the person continues taking the drug Risky use despite the fact that it places him in hazardous situations. The person’s use of the drug continues even though he may know that doing so is harmful or that it creates physical or psycho- logical problems. Elon knew his lifestyle was destructive, but he could not stop using drugs.

Finally, people with substance use disorder often show tolerance and/or withdrawal. Tolerance refers to the need to ingest greater and greater quantities of a drug to achieve the same effect. Someone who regularly drinks three beers a day will �nd over time that the same physiological “high” from this amount no longer exists. The person must thus drink more beer or switch to another, more powerful drug to achieve

harm is taking place in these cases. A person may attempt to drive while drunk, �ght with others over use of painkillers, or have trouble getting up in the morning to go to work. A person may thus be engaging in substance use to a moderate or intense degree (see Figure 9.1).

For people like Elon, substance use becomes so severe that many areas of life are greatly impaired. Elon’s extensive and varied drug use caused his academic failure, �nancial ruin, and legal troubles. He was also endangering his life because of physical addiction to drugs. Elon was spending nearly all his time looking for and using legal and illegal drugs. He must have known his lifestyle was self-destructive, but he reached a point where he could not control his own drug-seeking behavior. Elon was experiencing substance use to a severe degree, or a sub- stance-related disorder. We discuss features of this tragic and rampant problem in this chapter.

Substance-Related Disorders: Features and Epidemiology

Substance-related disorders include substance use disorder as well as substance intoxication and withdrawal. Substance use disorder combines previous diagnostic categories of sub- stance abuse and substance dependence. We discuss these prob- lems next.

Substance Use Disorder Substance use disorder involves repeated use of substances to the point that recurring problems are evident. Diagnostic crite- ria for alcohol use disorder, for example, are listed in Table 9.1 (American Psychiatric Association [APA], 2013). Severity of sub- stance use disorder is based partly on the number of diagnostic criteria shown by a person (Table 9.1). Substance use disorders generally involve impaired control, social impairment, risky use, and tolerance and/or withdrawal.

Impaired control means the person has dif�culty cutting down on his substance use, ingests more and more of the drug over time, spends a great amount of time looking for the drug or recovering from its use, and has intense craving for the drug. DeShawn and Elon tried to reduce their substance use but were unsuccessful in doing so. Elon eventually spent so much time searching for drugs (drug-seeking behavior) that he gave up many of his academic and social activities. Drug-seeking be- havior sometimes relates to psychological dependence on a drug, psychological dependence on a drug, psychological dependence meaning a person believes she needs the drug to function effec- tively. A person may use cocaine at work because she feels she needs it to present well before others or accomplish a substan- tial amount of work in a short period.

Social impairment means the person is experiencing key probSocial impairment means the person is experiencing key probSocial impairment - lems in his life because of substance use. Such problems could include missing many work or school days, neglecting or other- wise maltreating children, driving or operating heavy machinery while impaired, legal troubles, �ghting, or arguing with partners or friends about intoxication. Elon clearly had a substance use

TABLE 9.1 DSM-5

Alcohol Use Disorder A. A problematic pattern of alcohol use leading to clinically signi�cant

impairment or distress, as manifested by at least two of the follow- ing, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period

than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down

or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain

alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to ful�ll major role

obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent

social or interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persis- tent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance, as de�ned by either of the following: a. A need for markedly increased amounts of alcohol to

achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the

same amount of alcohol. 11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol. b. Alcohol (or a closely related substance, such as a benzodiaz-

epine) is taken to relieve or avoid withdrawal symptoms.

Specify if in early or sustained remission and if in a controlled environ- ment as well as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6+ symptoms).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 9 Substance-Related Disorders246

may become aggressive, make inappropriate sexual advances, and show impaired judgment and rapid shifts in mood. Impaired judgment may lead to a poor decision to drive, and rapid shifts in mood may lead to depression.

An intoxicated person may also have dif�culty staying awake, thinking clearly, or even walking. Some people may be intoxicated for short periods, but others go on binges and remain intoxicated for lengthy periods. Elon later vaguely recalled to a drug counselor that he once used meth (methamphetamine) for 6 straight days. Keep in mind that intoxication is not generally considered abnormal without maladaptive behavioral changes. A without maladaptive behavioral changes. A without person who comes home after a long week at work, drinks sev- eral margaritas, and falls asleep, does not have a mental disorder.

Substance Withdrawal Substance withdrawal refers to maladaptive behavioral changes when a person stops using a drug. Diagnostic criteria for alcohol withdrawal, for example, are listed in Table 9.3 (APA, 2013). When a person stops taking a drug, severe physical and behavioral changes can occur. These changes are usually the opposite of the intoxicating effect of a drug and may include nausea, vomiting, tremors, fever, seizures, hearing voices or seeing things not actually there (hallucinations), and death. Behavioral changes, such as anxiety, depression, and other mood states, may also occur. A well-known feature of alcohol withdrawal is delirium tremens (DTs), which involves severe confusion and autonomic overactivity in the form of sweating, heart palpitations, and trembling (Schuckit, 2014a).

The DSM-5 lists many kinds of substances or drugs that a person could experience problems with (APA, 2013). Not all of these drugs necessarily involve a substance use disorder (e.g., caffeine), intoxication (e.g., tobacco), or withdrawal (e.g., hallu- cinogens), however. A list of substances and relevant diagnostic categories is in Table 9.4. We next discuss the speci�c charac- teristics of these substances.

the same effect. Withdrawal refers to maladaptive behavioral changes when a person stops using a drug (see Substance Withdrawal section).

Substance Intoxication Have you known someone who got drunk but, when you spoke to him the next day, seemed �ne despite a hangover? He perhaps experienced substance intoxication, a usually revers- ible condition brought on by excessive use of a drug such as alcohol. Diagnostic criteria for alcohol intoxication, for exam- ple, are listed in Table 9.2 (APA, 2013). A person who becomes intoxicated experiences maladaptive changes in behavior—he

9.1 Continuum of Substance Use and Substance-Related Disorders

NORMAL MILD

Emotions Stable mood. Mild discomfort about the day; feeling a bit irritable or down.Mild discomfort about the day; feeling a bit irritable or down.

Cognitions No concern about substance use.

Thoughts about the dif�culty of the day. Worry that Thoughts about the dif�culty of the day. Worry that something will go wrong at work.

Behaviors Occasional but appropriate alcohol use or use of medication.

Drinking a bit more than usual; relying on medication to sleep.

TABLE 9.2 DSM-5

Alcohol Intoxication A. Recent ingestion of alcohol.

B. Clinically signi�cant problematic behavioral or psychological changes that developed during, or shortly after, alcohol ingestion.

C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4. Nystagmus. 5. Impairment in attention or memory. 6. Stupor or coma.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

CONTINUUM FIGURE

PictureArt/Fotolia LLCPictureArt/Fotolia LLC

Substance-Related Disorders: Features and Epidemiology 247

chapters, such as anxiolytics in Chapter 5 and antidepressants in Chapter 7. We also brie�y mentioned neuroleptic, or antipsy- chotic, drugs in previous chapters (these are discussed in more detail in Chapter 12). Other main categories of drugs we discuss in this chapter include depressants, stimulants, opiates, halluci- nogens, marijuana, and others.

Depressants Depressant, or sedative, drugs are those that inhibit aspects of the central nervous system. Common depressants include alcohol, anesthetics for surgery, antiseizure medications for epilepsy, barbiturate drugs people use to calm themselves (largely replaced now by antianxiety drugs, discussed in Chapter 5), and hypnotic drugs people use to go to sleep. Popular examples of the latter include zolpidem (Ambien) and eszopiclone (Lunesta).

Alcohol is the most well-known and widely used depressant drug. You might be wondering why alcohol is classi�ed as a depressant when, after a couple of drinks, a person feels elated or relieved. This is because alcohol initially affects a neurotrans- mitter system most responsible for inhibition, the gamma- aminobutyric acid (GABA) system. Recall from Chapter 5 that impairment in the GABA system may relate to excess activity that manifests in the form of panic attacks. Alcohol is thus in- hibiting a key inhibitory brain system. This process is disinhibi- tion. A person may thus do things he might not do normally, such as talk a little more, dance, or make a sexual advance. He may feel a “high” or sense of well-being but is actually experi- encing reduced central nervous system activity.

Alcohol effects closely relate to blood alcohol level, or con- centration of alcohol in the blood. Various blood alcohol levels related to alcohol intake for males and females of different sizes are listed in Table 9.6. Common effects of alcohol use at dif- ferent levels are listed in Table 9.7. People usually start feeling intoxicated at a blood alcohol level of 0.08, which is the legal cutoff for “driving under the in�uence” (DUI). Lethal dose, or

Types of Substances A brief description of major substances that are used excessively as well as their street names and effects is listed in Table 9.5. Drugs fall into several main categories based on effects they have on behavior. Several categories were discussed in previous

MODERATE

SUBSTANCE-RELATED NCE-RELATED

DISORDER—LESS SEVEREDISORDER—LESS SEVERE

SUBSTANCE-RELATED NCE-RELATED

DISORDER—MORE SEVEREDISORDER—MORE SEVERE

Considerable stress and sadness (note that Considerable stress and sadness (note that opposite emotions occur when drug is used).opposite emotions occur when drug is used).

Intense stress, sadness, and feelings of emptiness; Intense stress, sadness, and feelings of emptiness; agitation about not having access to a speci�c drug agitation about not having access to a speci�c drug or drugs.

Extreme stress, sadness, and feelings of emptiness. Extreme stress, sadness, and feelings of emptiness. Extreme agitation when drug is not available.Extreme agitation when drug is not available.

Dwelling on negative aspects of the day; worry Dwelling on negative aspects of the day; worry about threats to one’s job or marriage. Thoughts about threats to one’s job or marriage. Thoughts about ways to hide excessive substance use.

Frequent thoughts about using substances and worry Frequent thoughts about using substances and worry about harm to personal health.about harm to personal health.

Thoughts focused almost exclusively on drug use Thoughts focused almost exclusively on drug use and self-destruction of one’s lifestyle.and self-destruction of one’s lifestyle.

Drinking alcohol regularly at night; occasionally missing work; heavy use of medication.

Regular intoxication such that many days are missed Regular intoxication such that many days are missed from work; arguments with spouse about substance from work; arguments with spouse about substance use; arrests for impairment.use; arrests for impairment.

Very frequent intoxication; loss of job or marriage; physical addiction to a drug; seeking to secure or use drugs most of the time.

TABLE 9.3 DSM-5

Alcohol Withdrawal A. Cessation of (or reduction in) alcohol use that has been heavy and

prolonged.

B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater

than 100 bpm). 2. Increased hand tremor. 3. Insomnia. 4. Nausea or vomiting. 5. Transient visual, tactile, or auditory hallucinations or illusions. 6. Psychomotor agitation. 7. Anxiety. 8. Generalized tonic-clonic seizures.

C. The signs or symptoms in Criterion B cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specify if with perceptual disturbances.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 9 Substance-Related Disorders248

LD, is the dose of a substance (alcohol in this case) that kills a certain percentage of test animals. LD1 is the dose at which 1 percent of test animals die at a certain blood alcohol level (McKim & Hancock, 2013). An LD50 kills about half and, in hu- mans, occurs at a blood alcohol level of 0.40. This blood alcohol level is therefore extremely dangerous.

As a person drinks more alcohol past the disinhibition stage, she becomes more intoxicated as excitatory areas of the brain become depressed or inhibited. These excitatory areas of the brain include the reticular activating system, the limbic system, and the cortex. You may notice that someone who continues to drink alcohol experiences changes in behavior and personality, perhaps becoming more surly or aggressive. Re�exes and other motor behaviors also become impaired, judgment and reasoning become clouded, and attention and concentration become dif- �cult to maintain. You can see this is a recipe for disaster should the person decide to drive.

Other common effects of alcohol at this stage include in- creased sexual desire but poor performance, an erroneous belief

TABLE 9.4

Diagnoses Associated with Substance Class

Psychotic disorders

Bipolar disorders

Depressive disorders

Anxiety disorders

Obsessive-compulsive and related disorders

Alcohol I/W I/W I/W I/W

Caffeine I

Cannabis I I

Hallucinogens

Phencyclidine I I I I

Other hallucinogens I* I I I

Inhalants I I I

Opioids I/W W

Sedatives, hypnotics, or anxiolytics

I/W I/W I/W W

Stimulants** I I/W I/W I/W I/W

Tobacco

Other (or unknown) I/W I/W I/W I/W I/W

Note: X= The category is recognized in DSM-5. I = The speci�er “with onset during intoxication” may be noted for the category. W = The speci�er “with onset during withdrawal” may be noted for the category. I/W = Either “with onset during intoxication” or “with onset during withdrawal” may be noted for the category. P = The disorder is persisting. *Also hallucinogen persisting perception disorders (�ashbacks). **Includes amphetamine-type substance, cocaine, and other or unspeci�ed stimulants. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Copyright ©2013. American Psychiatric Association. All Rights Reserved.

Binge drinking can lead to many untoward consequences.

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Substance-Related Disorders: Features and Epidemiology 249

Binge drinking involves ingesting large amounts of alcohol Binge drinking involves ingesting large amounts of alcohol Binge drinking in a short period and relates to many college student deaths and problems (Kanny, Liu, Brewer, & Lu, 2013). A college student at Colorado State University died after binge drinking over an 11-hour period (see Box 9.1). According to the National Institute of Alcoholism and Alcohol Abuse, binge drinking corresponds to 5 or more drinks for males and 4 or more drinks for females in a 2-hour period. A College Alcohol Study conducted by the Harvard School of Public Health surveyed 14,941 students at 140 American colleges and universities. Some of the study’s most important �ndings include the following:

Within the past 30 days, 22 percent of students drank on 10 or more occasions, 45 percent binged when drinking, 29 percent were drunk 3 or more times, and 47 percent drank to get drunk.

• Only 19 percent of students abstained from alcohol. • More students drank alcohol than used cocaine, marijuana,

or cigarettes combined.

that problem-solving ability is adequate as one is becoming so- ber, and memory impairment. You may have dif�culties remem- bering the name of a new person you met the night before while drinking. People who continue drinking may also mix their al- cohol with other drugs, which can lower the dose necessary for death. This is because mixing different drugs (polysubstance use) causes a synergistic or multiplicative, not additive, effect. synergistic or multiplicative, not additive, effect. synergistic Drinking 3 shots of whiskey and snorting 3 lines of cocaine, for example, does not add to 6 units of effect but rather multiplies to 9. Interaction effects of alcohol with other common drugs are shown in Table 9.8.

Because alcohol use intensi�es and a person becomes extremely drunk, strong changes in personality and behavior occur. Many people become depressed, stupe�ed, or uncon- scious. Walking and talking become dif�cult, and a person may have trouble breathing. As the alcohol depresses areas of the brain necessary for involuntary actions, such as the medulla that controls breathing, a person is at risk for asphyxi- ation and death.

DSM-5

Sleep disorders

Sexual dysfunctions Delirium

Neurocognitive disorders

Substance use disorders

Substance intoxication

Substance withdrawal

I/W I/W I/W I/W/P X X X

I/W X X

I/W I X X X

I X X

I I/P X X

I/W I/W I/W X X X

I/W I/W I/W I/W/P X X X

I/W I I X X X

W X X

I/W I/W I/W I/W/P X X X

CHAPTER 9 Substance-Related Disorders250

TABLE 9.5

Common Substances and Their Street Names

Drug Street names

Acid (LSD) Acid, blotter, and many others

Club drugs XTC, X (MDMA); Special K, Vitamin K (ketamine); liquid ecstasy, soap (GHB); roo�es (Rohypnol)

Cocaine Coke, snow, �ake, blow, and many others

Ecstasy/MDMA (methylene- dioxymethamphetamine)

XTC, X, Adam, hug, beans, love drug

Heroin Smack, H, ska, junk, and many others

Inhalants Whippets, poppers, snappers

Marijuana Pot, ganga, weed, grass, and many others

Methamphetamine Speed, meth, chalk, ice, crystal, glass

PCP/phencyclidine Angel dust, ozone, wack, rocket fuel, and many others

Prescription medication Commonly used opioids include oxycodone (OxyContin), propoxyphene (Darvon), hydrocodone (Vicodin), hydro- morphone (Dilaudid), meperidine (Demerol), and diphenoxylate (Lomotil); common central nervous system depres- sants include barbiturates such as pentobarbital sodium (Nembutal), and benzodiazepines such as diazepam (Valium) and alprazolam (Xanax); stimulants include dextroamphetamine (Dexedrine) and methylphenidate (Ritalin)

Source: National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism.

TABLE 9.6

Relationships among Gender, Weight, Alcohol Consumption, and Blood Alcohol Level

Blood alcohol levels (mg/100 ml)

Absolute alcohol (ounces) Beverage intake*

Female (100 lb)

Male (100 lb)

Female (150 lb)

Male (150 lb)

Female (200 lb)

Male (200 lb)

1/2 1 oz spirits†

1 glass wine 1 can beer

0.045 0.037 0.03 0.025 0.022 0.019

1 2 oz spirits 2 glasses wine 2 cans beer

0.090 0.075 0.06 0.050 0.045 0.037

2 4 oz spirits 4 glasses wine 4 cans beer

0.180 0.150 0.12 0.100 0.090 0.070

3 6 oz spirits 6 glasses wine 6 cans beer

0.270 0.220 0.18 0.150 0.130 0.110

4 8 oz spirits 8 glasses wine 8 cans beer

0.360 0.300 0.24 0.200 0.180 0.150

5 10 oz spirits 10 glasses wine 10 cans beer

0.450 0.370 0.30 0.250 0.220 0.180

*In 1 hour. †100-proof spirits. From Ray, O. (1978). Drugs, society, and human behavior (2nd ed.). St. Louis, MO: C.V. Mosby, p. 147. Reprinted by permission.

Substance-Related Disorders: Features and Epidemiology 251

risk for suicide, homicide, unprotected sexual activity, sexual assault, and traf�c and other accidents (Brady & Li, 2014; Branas, Han, & Wiebe, 2016). People who chronically and excessively use alcohol also commonly experience cirrhosis of the liver in which scar tissue replaces liver tissue, leading to loss of function and possibly death (Rehm, Samokhvalov, & Shield, 2013). Korsakoff’s syndrome, a problem also dis- cussed in Chapter 14, involves confusion, memory loss, and coordination dif�culties because of thiamine de�ciency from extended alcohol use (Oudman, Nijboer, Postma, Wijnia, & Van der Stigchel, 2015).

The harmful effects of alcoholism have a wide reach and include children of people with alcoholism. These children are at increased risk of neglect or other maltreatment and at risk for developing substance-related problems later in life (Park & Schepp, 2015). Some (1 percent) newborns exposed to mater- nal alcohol use during pregnancy have fetal alcohol syndrome.

• The strongest predictor of binge drinking was fraternity or sorority residence or membership.

• Other risk factors for binge drinking are male gender, ath- letic status, European American background, and age less than 24 years.

• Frequent binge drinkers are 17 times more likely to miss a class, 10 times more likely to vandalize property, and 8 times more likely to be injured because of their drinking.

• 10 percent of female students who are frequent binge drinkers were reportedly raped or subjected to noncon- sensual sex compared with 3 percent of female non–binge drinkers.

People addicted to alcohol (alcoholism) are clearly at risk for other health problems. Withdrawal symptoms can be particularly severe and include delirium tremens, mentioned earlier. Extensive alcohol use is also associated with increased

TABLE 9.7

Blood Alcohol Levels (BALs) and Expected Behavior

Percent BAL Behavior

0.01 Few overt effects, slight feeling of relaxation

0.03 Relaxed with slight exhilaration, decrease in visual tracking, minimal impairment in mental functions

0.05 Feeling relaxed and warm, some release of inhibition, some impaired judgment, lowered alertness, slight decrease in �ne motor skills, mild reduction in visual capability in tracking and glare recovery

0.06 Mild relaxation, slight impairment in �ne motor skills, increase in reaction time, slurred speech, poor muscle control, exaggerated emotions

0.08 Legal evidence of intoxication and DUI; vision impaired, increased loss of motor functions, may stagger

0.09 Judgment now clouded, lessening of inhibitions and self-restraint, reduced visual and hearing acuity, increased dif�culty in performing motor skills

0.10 Slowed reaction times, slurred speech, drowsiness, nausea, de�cits in coordination, impaired motor functioning, and dif�culty in focusing, judging moving targets, and glare recovery

0.15 Major impairment in physical and mental functions, dif�culty in standing, walking and talking; disturbed perception, blurred vision, large increases in reaction times, falling asleep, vomiting

0.20 Marked depression of sensory and motor functions, mentally confused, gross body movements can be made only with assistance, unable to maintain an upright position, incoherent speech, needs assistance to walk, has dif�culty staying awake, vomiting

0.25 Severe motor disturbance, sensory perceptions greatly impaired, staggering, as well as behaviors seen at 0.20

0.30 Stuporous but conscious, severe mental confusion, dif�culty in reacting to stimuli, general suppression of sensibility, little comprehension of what is going on, respiratory depression, brain functions severely depressed, repeatedly falling down, passes out, may be in coma

0.40 Almost complete anesthesia, re�exes are depressed, breathing and heartbeat may stop, unconscious and may be dead

0.50 Completely unconscious, deep coma if not dead

0.60 Death most likely; depression of brain centers that control heart rate and breathing

From R.J. Craig, Counseling the alcohol and drug dependent client: A practical approach (p. 93) New York: Pearson, 2004. Reprinted by permission of Pearson Education, Inc.

CHAPTER 9 Substance-Related Disorders252

TABLE 9.8

Alcohol–Other Drug Interactions

Drug Prescribed purpose Interaction

Anesthetics (e.g., Diprivan, Ethrane, Fluothane)

Administered before surgery to render a patient unconscious and insensitive to pain

• Increased amount of drug required to induce loss of consciousness

• Increased risk of liver damage

Antibiotics Used to treat infectious diseases • Reduced drug effectiveness • Nausea/vomiting • Headache • Convulsions

Antidepressants (e.g., Elavil) Used to treat depression and other forms of mental disorder

• Increased sedative effects • May decrease effectiveness of antide-

pressant • Potential for dangerous rise in blood

pressure

Antihistamines (e.g., Benadryl) Used to treat allergic symptoms and insomnia • Intensi�ed sedation • Excessive dizziness

Antiulcer medications (e.g., Tagamet, Zantac)

Used to treat ulcers and other gastrointestinal problems

• Prolonged effect of alcohol • Increased risk of side effects

Narcotic pain relievers (morphine, codeine, Darvon, Demerol)

Used to alleviate moderate to severe pain • Intensi�ed sedation • Increased possibility of a fatal overdose

Nonnarcotic pain relievers (aspirin, ibuprofen, acetaminophen)

Used to alleviate mild to moderate pain • Increased risk of stomach bleeding • Increased risk of the inhibition of blood

clotting • Increased effects of consumed alcohol Note: acetaminophen (Tylenol) taken during or after drinking may signi�cantly increase one’s risk of liver damage.

Sedatives and hypnotics (Valium, Dalmane, Ativan, sleeping pills)

Used to alleviate anxiety and insomnia • Severe drowsiness • Depressed cardiac and respiratory functions • Increased risk of coma or fatality

Adapted from the National Institute on Alcohol Abuse and Alcoholism. (1995, January). Alcohol Alert (Publication No. 27 PH 355). Bethesda, MD: NIAAA.

The Sam Spady Story An undergraduate student at Colorado State University died after binge drinking both beer and shots over an 11-hour period. The student, Samantha Spady, was a homecoming queen, cheerleading captain, and honor student in high school. She was a business major with big ambi- tions, but instead of ful�lling them, she became one of 1,825 college students aged 18 to 24 years who die from alcohol-related incidents each year (National Institute on Alcohol Abuse and Alcoholism, 2016). Her story is now the subject of a DVD documentary (Death by Alcohol: The Sam Spady Story) available via a website established to honor The Sam Spady Story) available via a website established to honor The Sam Spady Story Samantha and educate others about the dangers of binge drinking. The website (http://www.samspadyfoundation.org) also lists key signs

that someone might be suffering from alcohol poisoning after binge drinking and needs immediate help: • Unconscious or semiconscious • Breathing less than 10 times

per minute or irregular (check every 2 minutes)

• Cold, clammy, pale, or bluish skin • Can’t be awakened by pinching,

prodding, or shouting • Vomiting without waking up

9.1 Co

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Substance-Related Disorders: Features and Epidemiology 253

from increased serotonin following nicotine ingestion. Nicotine is an extremely addictive substance and can produce withdrawal symptoms of restlessness, irritability, and concentration and sleep problems. According to the Of�ce of National Drug Control Policy, 21.3 percent of college students have smoked cigarettes in the past month. Prevalence of alternative products includes dissolvable tobacco (0.4 percent), e-cigarettes (3.1 percent), cigarillos (5.0 percent), and hookah (10.8 percent; Latimer, Batanova, & Loukas, 2013).

Cocaine is a powerful stimulant usually ingested by snif�ng Cocaine is a powerful stimulant usually ingested by snif�ng Cocaine or snorting crystals or smoking in the form of crack. People may mix cocaine with other drugs, such as alcohol or heroin, the latter of which is known as a “speedball.” Cocaine stimulates dopamine, norepinephrine, and serotonin systems to produce euphoria, high energy similar to mania, and bizarre, paranoid, and occasionally violent behavior. High doses can lead to heart attacks and respiratory failure and death. Cocaine can be physi- cally addictive, and a strong psychological dependence devel- ops toward the drug. Withdrawal from cocaine can cause severe depression, overeating, and sleep problems. According to the National Institute on Drug Abuse, 5.1 percent of college students have tried cocaine and 2.7 percent have done so in the past year.

Amphetamines are also powerful stimulants that primarily increase dopamine and norepinephrine. About 90 percent of all excessive amphetamine use today involves methamphetamine, or crank (see Box 9.2). Methamphetamine can be snorted or smoked and results in a sudden “high” that can last hours. A person may feel empowered to do many things, as Elon did, or feel invulnerable to harm. Sexual desire may be enhanced as well. A person may become psychologically or physically addicted to methamphetamine after just a few doses. People addicted to methamphetamine are sometimes identi�able through “meth mouth,” which involves severe decay or loss of teeth from exposure to the drug’s toxic chemical composition (Rommel, Rohlede, Wagenpfeil, Haertel-Petri, & Kesting, 2015).

Fetal alcohol syndrome is a condition that produces facial ab- normalities (see Figure 9.2), slowed physical growth, cogni- tive impairment, and learning problems throughout elementary school (Roozen et al., 2016). Alcohol use by pregnant mothers, particularly binge drinking, can produce more general fetal al- cohol effects as well. These effects on the child include reduced verbal intelligence and increased delinquent behavior and learn- ing problems (Rangmar et al., 2015).

Stimulants Stimulant drugs activate or stimulate the central nervous system. Common stimulants include bronchodilators to ease breathing and treat asthma, methylphenidate to treat attention- de�cit/hyperactivity disorder (Chapter 13), and drugs that we focus on here: caffeine, nicotine, cocaine, and amphetamines.

Caffeine is a legal drug, of course, commonly found in soda, Caffeine is a legal drug, of course, commonly found in soda, Caffeine coffee, tea, and chocolate. Many people use caffeine to boost energy, as evidenced by a Starbucks on nearly every corner and a plethora of high-caffeine drinks, such as Red Bull and Mon- ster. Caffeine helps release epinephrine and norepinephrine, so mood, alertness, and cardiovascular activity become elevated. Moderate caffeine use is not dangerous, but someone who in- gests large amounts for an extended period is susceptible to withdrawal symptoms, including headaches, irritability, sleepi- ness, anxiety, vomiting, and muscle tension and pain (Meredith, Juliano, Hughes, & Grif�ths, 2013).

People generally ingest nicotine via cigarettes and other tonicotine via cigarettes and other tonicotine - bacco products. Most cigarettes contain about 0.5 to 2.0 mg of nicotine and about 10 percent of this is absorbed during smok- ing. Nicotine is an extremely deadly poison—if you ingested 30 to 60 mg of pure nicotine, you would die within minutes (Mayer, 2014). Nicotine’s effect on the brain is similar to caffeine, and many people who smoke �nd increased cardiovascular activity and motor tremors but also relaxation. The relaxation may come Cocaine is often smoked in the form of crack.

Epicanthal folds

Flat nasal bridge

Small palpebral fissures

Underdeveloped upper part of ear

Upturned nose

Smooth philtrum

Thin upper lip

Co py

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FIGURE 9.2 CHARACTERISTIC FACIAL FEATURES OF YOUTHS WITH FETAL ALCOHOL SYNDROME.

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CHAPTER 9 Substance-Related Disorders254

amygdala, thalamus, and locus coeruleus. Heroin is extremely addictive and can result in severe withdrawal symptoms of agitation, chills, drowsiness, cramps, vomiting, sweating, and diarrhea. According to the National Institute on Drug Abuse, 0.4 percent of college students have tried heroin and 0.3 percent have done so in the past year.

Modern-day painkillers are also related to morphine and can be highly addictive. Drugs such as OxyContin, Darvon, Vicodin, Percocet, and Percodan are narcotic-based medications that can cause addiction in only a few doses. Prescription drug use is becoming one of the fastest-growing forms of substance-related disorder. According to the National Institute on Drug Abuse, 4.4 percent of college students have used Vicodin in the past year, and 2.3 percent of college students have used OxyContin in the past year.

Hallucinogens Hallucinogens are drugs that cause symptoms of psychosis, such as hallucinations (seeing or hearing things not actually there), disorganized thinking, odd perceptions, and delirium (a cogni- tive state of confusion and memory problems). Hallucinogen use often involves peyote or LSD (lysergic acid diethylamide), the

People who use methamphetamine often use force to obtain another dose; violence and theft are common among users, as are anxiety, confusion, insomnia, and paranoia. In Las Vegas, home to one of your textbook authors, desperate methamphetamine us- ers sometimes wait in the desert for discarded meth labs so they can scrounge for drug remnants. Children of meth users are often neglected as well. Withdrawal from meth can be severe; common symptoms include depression, anxiety, fatigue, paranoia, and in- tense cravings for the drug. According to the National Institute on Drug Abuse, 0.9 percent of college students have tried metham- phetamine and 0.4 percent have done so in the past year.

Opiates Opiates (sometimes called narcotics or opioids) are drugs commonly used to relieve pain or cough, such as morphine or codeine. Morphine and codeine can be used excessively, but a related opiate, heroin, is overused more. Heroin is a derivative of morphine that is typically injected. The drug produces a sudden “rush” of euphoria followed by alternating periods of drowsi- ness and wakefulness. Long-term effects include increased risk for cancer and infertility. Opiates work by stimulating different types of opiate receptors in the brain across the hippocampus,

The “Meth” Epidemic Many drugs have been cause for concern in America’s “drug war,” but perhaps none is as insidious and dangerous as methamphet- amine. According to the Substance Abuse and Mental Health Services Administration, 569,000 Americans used methamphet- amine in the past month, which is more than for other drugs such as crack and heroin (Center for Behavioral Statistics and Quality, 2015). Unfortunately, treatment facilities speci�cally for methamphetamine use are not as prevalent as for other drugs. Many people desperate for methamphetamine, like Elon, thus resort to illegal activities and end up in prison.

Why has methamphetamine use become such an epidemic? The pleasurable effects of meth are extremely intense and include strong euphoria, enhanced sexual drive and stamina, and lowered sexual inhi- bition. The drug helps stimulate pleasure centers in the brain to release large amounts of dopamine. The drug is also becoming easier to obtain throughout the country. The physical downsides of using meth are nu- merous and severe, however, and include brain and liver damage, mal- nutrition, skin infections, immune system problems, convulsions, stroke, and death. Many people like Elon who use meth experience such a pow- erful high, however, that they completely ignore these physical effects.

9.2

State Meth Cocaine and Heroin

Arizona 3,301 1,691 Nevada 3,257 1,932

Arkansas 4,072 2,926 North Dakota 373 43

California 60,235 54,956 Oklahoma 3,876 2,281

Hawaii 2,381 433 Oregon 8,561 3,948

Idaho 2,299 142 South Dakota 668 146

Iowa 5,563 2,125 Utah 3,665 1,816

Montana 1,185 192 Wyoming 878 88

Nebraska 2,064 735

Source: Substance Abuse and Mental Health Services Administration

Substance-Related Disorders: Features and Epidemiology 255

latter of which seems to spur dopamine in the brain (a phenom- enon also linked to psychoses such as schizophrenia). Another drug, ecstasy (MDMA or methylenedioxymethamphetamine), acts as both stimulant and hallucinogen. According to the National Institute on Drug Abuse, 8.1 percent of college students have tried MDMA, and 5.3 percent have done so in the past year.

Hallucinogens produce powerful changes in perception; a person may “hear” colors or experience sounds in the form of light. Many psychological effects of hallucinogens are unique and unpredictable, however. Tolerance to LSD develops and dissipates quickly, so most people who use the drug do so spo- radically. Withdrawal symptoms are not usually seen, though a person with a history of LSD use may experience sudden “�ash- backs” that resemble the drug-induced state. According to the National Institute on Drug Abuse, 7.8 percent of college students have tried hallucinogens, and 4.5 percent have done so in the past year.

Marijuana Marijuana comes from Cannabis sativa, or the hemp plant, that contains an active ingredient known as THC (delta-9-tetrahydro- cannabinol). Marijuana is typically smoked but can be baked into edible pastries as well. Marijuana stimulates cannabinoid recep- tors throughout the brain and especially the cortex, hippocampus, basal ganglia, and hypothalamus. The drug creates feelings of joy, well-being, humor, and a dreamlike state. Time often feels distorted; attention, vigilance, and short-term memory diminish; creativity is enhanced; and motor behavior is impaired. Long- term use can also produce infertility (Gundersen et al., 2015).

Marijuana may not be physically addictive for everyone because tolerance is not always present, but heavy users are more at risk. Minor withdrawal symptoms, such as sleep

Many people who take LSD reportedly experience psychedelic hallucinations marked by bright colors and shapes. Some artists have tried to represent their experiences with the drug in art, as highlighted in this edition of Life magazine.

These are booking photographs of a woman arrested for methamphetamine use.

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CHAPTER 9 Substance-Related Disorders256

problems, anxiety, and irritability, may occur. Marijuana is a medical treatment for glaucoma and may quell nausea, vomit- ing, convulsions, and pain. According to the National Institute on Drug Abuse, 47.7 percent of college students have tried marijuana and 35.5 percent have done so in the past year. Mari- juana use can be a gateway to other illicit drug use, although life stress is also a contributing factor (Hurd, Michaelides, Miller, & Jutras-Aswad, 2014).

Other Drugs Other drugs also relate to excessive substance use:

• Designer drugs or club drugs represent manmade modi�- cations of psychoactive drugs, such as amphetamines and heroin. Phencyclidine (PCP) induces strong perceptual disPhencyclidine (PCP) induces strong perceptual disPhencyclidine - tortions and often highly violent and dangerous behavior. Club drugs may also include date rape drugs (see Box 9.3).

• Inhalants are volatile liquids stored in containers that give off strong fumes; users inhale the fumes to produce feelings of euphoria and lightheadedness. Examples include glue, spray paint, cleaning agents, paint thinner, and gasoline. According to the National Institute on Drug Abuse, 4.3 per- cent of college students have tried inhalants and 0.5 percent have done so in the past year.

• Steroids are synthetic substances to enhance muscle growth and secondary sexual characteristics but are sometimes used excessively by adolescents and athletes to gain a com- petitive edge. According to the National Institute on Drug Abuse, 0.8 percent of college students have used steroids.

Epidemiology of Substance-Related Disorders You can see that substance use is common among college students. Among the general population, use of legal drugs such as alcohol and tobacco is also common. According to the Department of Health and Human Services, 52.7 percent of

Angel Raich is seen with cannabis buds at her home in Oakland, California. She began smoking after her doctor suggested it might ease pain she suffers from an inoperable brain tumor.

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drugs are generally tasteless, odorless, and colorless and can be slipped into a person’s drink. Alcohol also intensi�es the effects of these drugs and can lead to serious physical problems such as slowed heart rate and blood pressure.

What can you do to protect yourself? According to the Center, open all containers yourself, do not share or accept drinks from others, do not drink from open containers such as punch bowls, always be with a nondrinking and trusted friend, and always keep your drink with you, even if using the restroom. If you have to leave a drink behind, then assume the worst and do not drink it again. If you feel you have been drugged and raped—possibly evidenced by memory lapses or genital or other body bruising or other signs—then contact the police or go to an emergency room as soon as possible. Provide a urine sample for a physician as soon as possible (the drugs may still be in your system) and do not urinate, bathe, or change clothes before getting help.

Focus On

According to the National Women’s Health Information Center, date rape drugs are used to induce dizziness, disorientation, and loss of inhibition and consciousness so a woman can be sexually assaulted. Other crimes, such as robbery, may be committed as well while a woman is in a drugged state. Date rape drugs generally include ketamine (“special K”), ketamine (“special K”), ketamine rohypnol (“roo�es”), and GHB (gamma hydroxybutyrate or “liquid ecstasy”). These GHB (gamma hydroxybutyrate or “liquid ecstasy”). These GHB

Gender Date Rape Drugs

9.3

Substance-Related Disorders: Features and Epidemiology 257

Americans aged 12 years or older currently use alcohol, and 23.0 percent engaged in binge drinking in the past 30 days. Re- cent alcohol use is more common among men (57.1 percent) than women (47.5 percent), and among European Americans (57.7 percent) than Hispanics (43.0 percent), African Americans (43.6 percent), American Indians/Alaska Natives (37.3 percent), and Asian Americans (34.5 percent). In addition, 10.9 percent of Americans had recently driven a motor vehicle under the in�u- ence of alcohol (see Figure 9.3). Some (9.4 percent) pregnant women also drink alcohol and 2.3 percent engaged in binge drinking in the past month.

Tobacco use is also common. Of Americans aged 12 years and older, 25.2 percent use some tobacco product (82.5 percent of this is cigarette use). This rate rises for adults aged 18 to 25 years (35.0 percent) and males (31.1 percent) compared with fe- males (20.2 percent). Cigarette smoking is more common among American Indians/Alaska Natives (36.5 percent) than African Americans (23.0 percent), European Americans (22.7 percent), Hispanics (16.8 percent), and Asian Americans (8.5 percent). People with more education and income smoke less. People liv- ing in Midwestern states smoke the most (24.6 percent); people living in Western states smoke the least (17.6 percent).

The Department of Health and Human Services reports that 10.2 percent of Americans aged 12 years and older cur- rently use illicit drugs. This drug use is more common for males (11.5 percent) than females (7.3 percent) and for people aged 18 to 20 years (see Figure 9.4). Recent illicit drug use is par- ticularly common among American Indians/Alaska Natives (12.3 percent) compared with African Americans (10.5 percent), European Americans (9.5 percent), Hispanics (8.8 percent), and Asian Americans (3.1 percent). Marijuana is the most commonly used illegal drug, but nonmedical use of therapeutic medications is also frequent (see Table 9.9).

FIGURE 9.3 DRIVING UNDER THE INFLUENCE OF ALCOHOL IN THE PAST YEAR AMONG PEOPLE AGED 16 YEARS AND OLDER.

FIGURE 9.4 PAST MONTH ILLICIT DRUG USE AMONG PEOPLE AGED 12 YEARS AND OLDER.

2525

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16-17 16-17

18-20 18-20

21-25 21-25

26-29 26-29

30-34 30-34

35-39 35-39

40-44 40-44

45-49 45-49

50-54 50-54

55-59 55-59

60-64 60-64

6511

3. 8

10 .8

19 .7

20 .7

17 .6

14 .3

12 .7

12 .5

12 .3

8. 2

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Age in years

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16-17 16-17

14-15 14-15

12-13 12-13

18-20 18-20

21-25 21-25

26-29 26-29

30-34 30-34

35-39 35-39

40-44 40-44

45-49 45-49

50-54 50-54

55-59 55-59

60-64 60-64

6511

2. 6

7. 8

15 .8

22 .6

20 .9

15 .9

14 .7

9. 3

7. 7

7. 3 7. 9

5. 7

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TABLE 9.9

Types of Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older: Percentages, 2013

Drug Lifetime Past year Past month

Illicit drugs 48.6 15.9 9.4

Marijuana and hashish 43.7 12.6 7.5

Cocaine 14.3 1.6 0.6

Crack 3.4 0.2 0.1

Heroin 1.8 0.3 0.1

Hallucinogens 15.1 1.7 0.5

LSD 9.4 0.4 0.1

PCP 2.5 0.0 0.0

Ecstasy 6.8 1.0 0.3

Inhalants 8.0 0.6 0.2

Nonmedical use of psychotherapeutics

20.3 5.8 2.5

Pain relievers 13.5 4.2 1.7

OxyContin 2.7 0.5 0.2

Tranquilizers 9.0 2.0 0.6

Stimulants 8.3 1.3 0.5

Methamphetamine 4.7 0.5 0.2

Sedatives 2.9 0.2 0.1

Illicit drugs other than marijuana

29.8 7.6 3.3

CHAPTER 9 Substance-Related Disorders258

rates of the major substance-related disorders. According to the Department of Health and Human Services, substance use dis- order is much more common among males (10.8 percent) than females (5.8 percent) and among people aged 18 to 25 years (16.3 percent). Substance use disorder is higher among American Indians/Alaska Natives (14.9 percent) compared with multira- cial individuals (10.9 percent), Hispanics (8.6 percent), European Americans (8.4 percent), African Americans (7.4 percent), and Asian Americans (4.6 percent). People with substance use disor- der are also much more likely to be unemployed than employed full-time.

Substance-related disorders are comorbid with many other mental disorders, especially anxiety-related, depressive, and personality disorders. Substance-related disorders also relate closely to severe psychological stress, especially among 18- to 25-year-olds. Many more people with a major depressive episode experience substance use disorder compared to people without a major depressive episode. People overusing one drug also commonly overuse another drug (polysubstance use). Approxi- mately two thirds (67.0 percent) of people with a substance- related disorder use alcohol only, but 12.1 percent of people with a substance-related disorder use alcohol and an illicit drug.

Stigma Associated with Substance-Related Disorders

People with substance-related disorders often face social dis-crimination with respect to employment, housing, and inter- personal rejection. One survey of people with substance-related disorder revealed that many felt stigmatized. Many in the sample believed that once others knew of the person’s substance prob- lem, they treated them unfairly (60 percent) or were afraid of them (46 percent). Many in the sample also believed that some family members gave up on them (45 percent), some friends re- jected them (38 percent), and employers paid them a lower wage (14 percent). Participants in the survey reported that hearing oth- ers say unfavorable or offensive things about people in treatment for substance use was a common stigmatizing experience. Others have found as well that stigma toward individuals with substance- related disorders negatively affects attempts to access treatment services (Luoma, Kulesza, Hayes, Kohlenberg, & Larimer, 2014; van Boekel, Brouwers, van Weeghel, & Garretsen, 2013).

Several interventions have been designed to reduce stigma associated with substance-related disorders. These interven- tions often involve learning about substance-related disorders, accepting dif�cult feelings, emphasizing human connection and mutual acceptance, focusing more on the process of thinking (i.e., thinking about how thinking happens in the mind) rather than the content of negative thoughts, exploring goals and values in life, communicating positive stories of people with substance-related disorders, and boosting employment skills. Such interventions have been found effective for reducing self- stigma, shame, and social isolation among those with a substance- related disorder as well as improving public attitudes regarding this population (Livingston, Milne, Fang, & Amari, 2012).

Of particular interest regarding these statistics is what type of illegal drug people used for the �rst time in the past 12 months for the �rst time in the past 12 months for the �rst time (see Figure 9.5). Drugs tried for the �rst time most commonly include prescription medications and marijuana. The average age at which people use certain drugs for the �rst time is out- lined in Figure 9.6. Inhalants and marijuana tend to be illegal drugs of choice for teenagers and prescription medications tend to be drugs of choice with increased age. All drug use, however, is most common during ages 12 to 30 years.

The lifetime prevalence of any substance-related disorder is 14.6 percent and, for the past 12 months, 8.1 percent. Alcohol use disorder has the highest 12-month and lifetime prevalence

FIGURE 9.5 PAST YEAR FIRST-TIME USE OF DRUGS.

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Substance-Related Disorders: Causes and Prevention 259

that people whose family members overused alcohol were 3 to 4 times more likely to overuse alcohol themselves compared with people without such a family history. A problem with family studies, however, is that environmental in�uences could explain the effect. Children could be modeling parental misuse of alco- hol instead of receiving a genetic predisposition for the problem. Genetic in�uences may be stronger for males than females and for severe compared with less severe cases of alcoholism. Alco- holism is likely predisposed by many genes working together (Nieratschker, Batra, & Fallgatter, 2013; Schuckit, 2014b).

Genetic models for alcoholism are modest, but variables related to alcoholism may have a stronger genetic effect. Genet- ics may affect a person’s metabolism of alcohol—some people process alcohol faster than others and may be less susceptible to alcoholism (Rietschel & Treutlein, 2013). Genetics may also affect a person’s sensitivity to alcohol. Genetics in�uence low level of response to alcohol, and this can predict alcoholism in offspring of people with alcoholism (Schuckit, 2014b). People with low response to alcohol must drink more to achieve the same psychological effects and are therefore more at risk than the general population for developing alcoholism. Genetics may also affect the brain’s neurochemistry to induce craving for craving for craving alcohol or increase disinhibition and sensitivity to alcohol (see neurochemical section later in the chapter; Agrawal et al., 2013).

What about other substances? Heritability appears stron- gest for dependence on cocaine and opiates such as heroin or prescription painkillers such as OxyContin (Bryant, Guido, Kole, & Cheng, 2014). Relatives of people with substance-related dis- orders have been found to be 8 times more likely than control participants to have a substance-related disorder themselves. This was especially true for opiates and cocaine but also for marijuana. Many genes are likely responsible for this effect (Merikangas & McClair, 2012). Genes may in�uence receptors, such as opiate receptors, that increase responsiveness to certain drugs (Bruchas & Roth, 2016). Genes may also in�uence devel- opment of key brain structures implicated in substance-related disorders. We discuss these brain features next.

Brain Features Many brain features link to substance-related disorders. Brain changes in substance-related disorders coincide with several inducements toward compulsive drug use: priming, drug cues, cravings, and stress (Hone-Blanchet, Ciraulo, Pascual-Leone, & Fecteau, 2015). Priming refers to a situation in which a single Priming refers to a situation in which a single Priming drug dose, such as a drink of alcohol or snorted line of cocaine, leads to an uncontrollable binge. Drug cues refer to stimuli as- sociated with drug use, such as friends, favorite hangouts, and other things that stimulate further drug use. Cravings refer to an obsessive drive for drug use, much as Elon had a consuming desire to seek and use drugs to the exclusion of almost all other activities. Stress is a common trigger of relapse in people with substance-related disorders. Recall that drug use is commonly associated with anxiety and depression.

Brain features related to each of these areas are primarily part of the mesolimbic system, a major dopamine pathway and one strongly implicated in sensations of pleasure, reward, and

➲ Interim Summary • Substance-related disorders include substance use

disorder, intoxication, and withdrawal.

• Substance use disorder refers to repeated use of sub- stances that lead to recurring problems.

• Substance intoxication is a usually reversible condition brought on by excessive use of alcohol or another drug.

• Tolerance refers to the need to ingest greater amounts of a drug to achieve the same effect.

• Withdrawal refers to maladaptive behavioral and physi- ological changes when a person stops taking a drug.

• Substances may be categorized by the effect they have on people. Depressants inhibit the central nervous system, whereas stimulants activate the central nervous system.

• Opiates are drugs commonly used to relieve pain, and hal- lucinogens are drugs that cause psychosis-like symptoms.

• Marijuana works by stimulating cannabinoid brain recep- tors and is the most commonly used illicit drug.

• Substance use is extremely common, and substance- related disorders are among the most common mental disorders.

• People with substance-related disorders are often stigma- tized via social discrimination with respect to employment, housing, and interpersonal rejection.

➲ Review Questions 1. What is the difference between substance use and substance

use disorder? 2. What is substance intoxication and withdrawal? 3. Identify major classes of drugs and their psychological effects. 4. Describe what to do if you ingest a date rape drug. 5. How common are substance-related disorders, and what

populations are most at risk?

Substance-Related Disorders: Causes and Prevention

We turn our attention now to factors that cause substance-related disorders. We also discuss how knowing about these factors might help us prevent substance-related disorders.

Biological Risk Factors for Substance-Related Disorders Biological risk factors in people with substance-related disorders include genetics, brain features, and neurochemical characteristics.

Genetics Genetics in�uence substance-related disorders, especially alco- holism. The heritability estimate for alcoholism is about 0.49 (Verhulst, Neale, & Kendler, 2015). Early family studies revealed

CHAPTER 9 Substance-Related Disorders260

relevant to emotional salience or excessive preoccupation with particular drugs (Marhe, Luijten, van de Wetering, Smits, & Franken, 2013).

• Bed nucleus of the stria terminalis, which you may recall from Chapter 5 is involved in stress reactions and may be involved in drug-seeking behavior to cope with stress (Stamatakis et al., 2014). The amygdala and bed nucleus of the stria terminalis are key aspects of the hypothalamic- pituitary-adrenal axis so heavily implicated in anxiety-related disorders. This may help explain the high association of substance-related and anxiety-related disorders.

• Hippocampus, which is involved in acquiring new informa- tion and forming new memories and may be instrumen- tal for storing powerful memories of emotionally arousing stimuli such as drug use (Han et al., 2015).

• Insular cortex or insula, which is involved in pain process- ing, and stimulation of which has been linked to drug crav- ing (Droutman, Read, & Bechara, 2015).

• Prefrontal cortex, which is involved in upper-level cognitive processes such as control and regulation and that may be

desire (see neurochemical section later in the chapter). Rats will constantly press a lever to stimulate brain areas related to this pathway (Bardo, 2013). The mesolimbic system generally begins in the brain’s ventral tegmental areaventral tegmental area and ends in the nucleus accumbens (see Figure 9.7). Drugs such as crack co- caine greatly stimulate this system and often lead to priming effects and intense cravings (Areal et al., 2015). Continued drug use that stimulates the mesolimbic system can then become associated with certain cues—for example, a particular bar or group of friends that help per- petuate someone’s addiction (Volkow, Wang, Fowler, & Tomasi, 2015).

The mesolimbic pathway links as well to other brain areas central to ad- diction (see Figure 9.8; adapted from Adinoff, 2004):

• Amygdala, which is involved in assigning a high “reward value” to stimuli, such as drugs, stress- induced pursuit of drug use, and conditioning place preferences for drug use, such as a particular area of town.

• Anterior cingulate, which is in- volved in self-control and problem solving and may be particularly

FIGURE 9.7 MESOLIMBIC PATHWAY IN THE BRAIN. PATHWAY IN THE BRAIN. PA

FIGURE 9.8 MAJOR BRAIN AREAS IMPLICATED IN SUBSTANCE-RELATED DISORDERS.

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Changes in brain function also occur in children with fe- tal alcohol syndrome whose mothers ingested alcohol during pregnancy. Damage to the corpus callosum, basal ganglia, and cerebellum can contribute to substantial cognitive and learning problems seen in this population (Muralidharan, Sarmah, Zhou, & Marrs, 2013). General reduction in brain size in newborns with fetal alcohol syndrome is evident as well (Figure 9.11).

Neurochemical Features The mesolimbic dopamine pathway appears to be the main neural base for the reinforcing effects of many drugs, especially alcohol, stimulants, opiates, and marijuana. These drugs in- crease dopamine release in the nucleus accumbens by stimulat- ing D2 (specialized dopamine) receptors or blocking reuptake of dopamine. Some people with substance-related disorders have fewer D2 receptors (Volkow & Baler, 2014). This means they may not be able to obtain much reward from everyday life events and so resort to excesses such as drug use to obtain suf- �cient rewards. This is known as reward de�ciency syndrome (Blum et al., 2015).

Opiates like heroin and morphine act directly on opioid re- ceptors in the nucleus accumbens as well as other areas of the brain and spinal cord. Excess dopamine release in the nucleus accumbens relates also to drug relapse and overwhelming drug- seeking behavior (Moreira & Dalley, 2015). Stress may activate the prefrontal cortex that, you may recall, has a strong connec- tion to key components of the mesolimbic dopamine pathway: the ventral tegmental area and nucleus accumbens.

Other neurotransmitters in�uence substance-related disor- ders as well, but even these neural pathways affect dopamine release in the mesolimbic system. Glutamate, GABA, acetylcho- line, serotonin, and norepinephrine have excitatory or inhibi- tory connections to the mesolimbic dopamine system (Volkow &

altered by drug use, thus leading to continued drug craving and use. The prefrontal cortex may also become extremely responsive to stimuli that predict drug availability (Jasinska, Chen, Bonci, & Stein, 2015).

• Orbitofrontal cortex, which is involved in decision making in unpredictable or uncertain situations and in which drug- induced changes could result in impulsive behavior, the latter clearly related to drug use, as described later in the section on personality (Smith et al., 2015).

Neuroimaging studies support these �ndings. Figure 9.9 il- lustrates a brain scan of a person with a history of excessive cocaine use and one with no such history. Blood �ow to the prefrontal cortex, illustrated by brighter colors, diminishes in the person who uses a substance excessively. Euphoria often accompanies less activity in this area, so people may not engage in high-level thinking and reasoning while intoxicated. The pre- frontal cortex does, however, become highly stimulated when surrounding stimuli predict drug availability, and this is likely due to a strong connection between the prefrontal cortex and the mesolimbic system and nucleus accumbens. The result is someone who cares little for stimuli other than drugs and whose excitatory brain responses are not well controlled. Craving and drug-seeking behavior are thus enhanced, but capability to re- duce drug intake is impaired (Volkow et al., 2015).

People who excessively use substances for long periods also have reduced brain size and altered activity (see Figure 9.10; Crunelle et al., 2014). This could lead to greater cognitive and memory decline than is normal with age. Reduced brain size oc- curs in other heavily cognitive disorders we discuss in this text- book, such as psychotic disorders (Chapter 12) and Alzheimer’s disease (Chapter 14). Excessive alcohol use over time can also produce brain changes that lead to motor, visual, and speech problems.

FIGURE 9.9 BRAIN IMAGE OF PERSON WHO USES COCAINE EXCESSIVELY COMPARED WITH A NORMAL CONTROL PARTICIPANT. Normal metabolic activity, indicated by bright red and yellow, is blunted in the person using drugs. Image is from Science Source/Photo Researchers.

FIGURE 9.10 BRAIN IMAGE OF PERSON WITH ALCOHOLISM GOING THROUGH DETOXIFICATION. Alcohol is a depressant. Brain activity increases (yellow) with increasing time without alcohol. Image is from Science Source.

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CHAPTER 9 Substance-Related Disorders262

using methamphetamine. Over time, the reward system becomes speci�cally attuned to availability of speci�c drugs. This helps ex- plain why people abstinent from a drug for many years can easily and quickly relapse toward exces- sive drug use.

Environmental Risk Factors for Substance-Related Disorders We turn our attention next to environmental risk factors for substance-related disorders. These include stress, cognitive factors, learning, personality factors, and family factors. We also discuss cul- tural and evolutionary in�uences.

Stress Stress is an important trigger for many of the mental disorders we discuss in this textbook; for sub-

stance-related disorders this is especially true. Stress can clearly trigger substance use, such as when people have a glass of wine to relax, smoke a cigarette to unwind, or snort a line of co- caine to enhance mood. Recall that people with anxiety and depression often engage in substance use to cope with stressors such as interacting with others and feeling miserable. Ongoing use of substances to cope with stressors can lead to a pattern of overuse. Excessive substance use is closely associated with early physical and sexual maltreatment, poor parental and social support, and chronic distress (Sinha & Jastreboff, 2013; Widom, Horan, & Brzustowicz, 2015).

Stress is important as well regarding relapse toward substance-related disorders, as when a person has been abstinent for some time but regresses back to old drinking or drug-using habits (falling “off the wagon”). Stress-induced relapse involves an activation of certain brain substances related to stress, such as corticotropin-releasing hormone and cortisol, that help us cope but also increase dopamine activity in the mesolimbic pathway. Stress also increases norepinephrine, which helps stimulate key components of the mesolimbic pathway: the bed nucleus of the stria terminalis, nucleus accumbens, and amygdala (Belujon & Grace, 2015). Environmental stress thus triggers dual responses in the brain: coping and desire for reward. Maybe that is why we crave chocolate so much when stressed!

Stress may enhance drug relapse in other key ways as well. Increased glutamate from stress may produce a state of sadness from dopamine depletion to trigger cravings for increased do- pamine by using drugs (Bauer et al., 2013). Chronic stress may also weaken a person’s ability to cope effectively with dif�cult situations by creating damage to the prefrontal cortex (Volkow

Baler, 2014). GABA appears to have an inhibitory effect on dopa- mine release in the mesolimbic system. Drugs that suppress this inhibitory effect, therefore, such as alcohol or morphine, may thus help stimulate dopamine release (Setiawan et al., 2014). Keep in mind that much of these data come from animal studies, so extrapolating results to humans may be problematic.

Dopamine release acts as a powerful reward (euphoria), thus providing an incentive to increase and maintain drug use. Dopamine release also promotes reward-related learning so a person is often seeking rewards such as drugs (Barker, Torregrossa, & Taylor, 2013). Such conditioning or learning might explain Elon’s extremely driven behavior toward seeking and

FIGURE 9.11 BRAIN DAMAGE TO A NEWBORN WITH FETAL ALCOHOL SYNDROME COMPARED WITH A NORMAL CONTROL.

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Substance-Related Disorders: Causes and Prevention 263

Learning Recall from Chapter 5 that many people learn to develop se- vere anxiety through classical and operant conditioning as well as modeling behavior of others. These learning processes also apply to substance-related disorders. Classical conditioning es- sentially refers to learning by association, and many people with substance-related disorders associate certain environmental cues with drug use. If a person always seems to use metham- phetamine with friends at a local park, he is more likely in the future to use the drug when surrounded by these cues. Treat- ment for substance use disorder can thus be dif�cult—a person may become “clean” in a drug rehabilitation center but then relapse quickly when he returns to old stomping grounds where cues for substance use are strong.

A stunning example of classical conditioning was the large- scale remission of heroin addiction by Vietnam veterans. Many Vietnam-based soldiers in the 1960s and 1970s were thought addicted to heroin, spurring a �restorm of concern about what would happen when they returned to the United States. Remark- ably, however, the addiction rate in these soldiers dropped con- siderably after they came home. One explanation is that cues surrounding heroin use—such as intense stress, completely dif- ferent geography, and certain peer groups—disappeared once the soldiers returned home. This story is not a completely happy one, however, because many veterans continued to experience other problems such as PTSD (Marmar et al., 2015).

Drug use can also be rewarding, of course, and therefore maintained by operant conditioning. Recall that reward centers of the brain are highly stimulated by drug use and people can become particularly vulnerable to drug-conditioned stimuli. Positive reinforcers of drug use include �tting in with peers, a sense of euphoria and invulnerability, and feelings of sexual prowess, as was true for Elon. Drug use can also serve as a

et al., 2015). A person’s ability to sustain attention, recall appro- priate coping skills learned in therapy, and inhibit maladaptive responses such as drinking and driving may be impaired.

Cognitive Factors Recall our discussions in earlier chapters of cognitive distortions or biases as risk factors for anxiety-related and depressive disor- ders. These refer to erroneous beliefs one has about oneself and the surrounding world that can lead to maladjustment. Cogni- tive distortions are also a part of substance-related disorders. One common misperception among people with substance- related disorders is increased positive expectancies about effects of various substances and minimization of negative effects. A person may discount or dispute the addictive qualities of a drug and claim she “can stop anytime I want.”

Some people believe that using certain substances will lead to grand experiences or life changes, such as enhanced personal or social functioning. A person may falsely believe drug use will increase his social skill with women or facilitate his accomplish- ments at work. Positive expectancies about alcohol are also evi- dent. College students often have several positive expectancies regarding alcohol use, including enhanced sociability, courage, sexuality, and calmness. These expectancies, however, relate closely to hazardous alcohol use before a social gathering or event (McBride, Barrett, Moore, & Schonfeld, 2014).

Recall from Chapter 3 that another misperception among many people with substance-related disorders, especially col- lege students, is that other people use alcohol and other drug amounts similar or in excess to their own (Miller & Prentice, 2016). Such a misperception seemed evident for DeShawn and Elon, who felt their initial drinking was in line with the typical college experience. Such misperception, however, reinforces a person’s belief that his drinking or other drug use is not a problem.

People with alcoholism also selectively attend to cues that indicate alcohol is nearby, such as seeing a favorite drinking buddy. People with alcoholism or other drug use problems attend longer to words and pictures that depict substance-related constructs (Dickter, Forestell, Hammett, & Young, 2014). Such selective attention relates to the brain and neurochemical features we discussed earlier and seems particularly relevant to strong emotional cravings for certain drugs. This may lead to a hard-to-break cycle in which selec- tive attention, emotional craving, and dopamine release rein- force each other.

Cognitions affect substance use, but consider also that se- vere substance use may itself create cognitive changes by alter- ing the prefrontal cortex. Alcohol and other drugs can create massive changes in the brain that affect attention, perception, judgment, memory, problem solving, decision making, and other higher cognitive processes. People with alcoholism often have blackouts, in which they remember nothing during a pe- riod of heavy drinking, or grayouts, in which they can remember events during a heavy period of drinking only when someone reminds them of what happened or if they drink heavily again (McKim & Hancock, 2013).

A long-term consequence often minimized by smokers is emphysema. Color enhanced frontal x-ray of the chest showing emphysema. The lungs are colorized blue. A large cavity (right) is infected and �lled with �uid.

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Researchers have also linked substance use disorder and impulsive aggression in general with domestic violence, vio- lent crime, and suicide in particular. Knowing which comes �rst, however, substance use or violence, has not been clearly established (see Box 9.4). Psychopathy also relates closely to substance-related disorders. Psychopathy refers to antisocial behavior, lack of remorse for aggressive behavior, and need for immediate grati�cation. People with substance use disorder are generally less likely to inhibit their behavior and delay grati- �cation (Ashe, Newman, & Wilson, 2015).

Why might psychopathy or impulsive aggression link to substance-related disorders? People with psychopathy or sub- stance use disorder may react quickly or impulsively to stress- ors by aggressively facing a perceived threat and/or by using drugs to cope with a threat. Certain brain changes may also be similar in both groups (Yang et al., 2015). Another possibility is that people with antisocial and impulsive tendencies have lower thresholds for deviant behaviors such as excessive risk-taking and substance use (Alcorn et al., 2013).

powerful negative reinforcer in that stress, pressure, depression, negative reinforcer in that stress, pressure, depression, negative reinforcer and withdrawal symptoms recede. Negative reinforcers serve as strong indicators of craving and relapse (Wise & Koob, 2014).

Furthermore, the negative effects or punishers of drug use are often distant. People who smoke cigarettes enjoy the im- mediate sense of relief and relaxation but may worry little about far-off consequences such as lung cancer and emphysema (a emphysema (a emphysema lung disease marked by damage to air sacs and dif�culty breath- ing). Nicotine in particular may become associated with other nondrug rewards as well (Bjork, 2015). How many people do you know smoke cigarettes in certain pleasurable situations, such as eating a big meal, drinking alcohol, or after sex?

Modeling or imitating the behavior of others can also be a signi�cant learning-based factor for substance-related disorders. People do not generally pick up a crack pipe or inject heroin themselves but usually model the behavior from others. Mod- eling may be especially pertinent to adolescents. Adolescents who use substances excessively tend to cluster with deviant, substance-using peer groups, especially if low parent monitor- ing occurs (Van Ryzin & Dishion, 2014). Drug use among peers also facilitates social interaction and a sense of belonging.

Personality Factors Have you heard the phrase “addictive personality”? The media often adopt this phrase, which refers generally to people who compulsively seek certain things—food, sex, shopping, gam- bling, drugs—to enhance mood. Researchers who study sub- stance-related disorders do focus on personality traits, though the term “addictive personality” has yet to be supported. One personality trait closely related to substance-related disorder, one we discussed in Chapter 3, is impulsivity. Impulsivity gen- erally refers to risk taking, lack of planning, chaotic lifestyle, desire for immediate grati�cation, and explosiveness. Impulsive sensation seeking is particularly associated with heavy alcohol use in adolescents (Stautz & Cooper, 2013).

of victims of domestic violence say alcohol was involved in the violent incident. About 23 percent of suicide deaths are attributable to alcohol as well. Among assailants at an emergency room, alcohol was involved in 52.3 percent of cases.

Little information is available as to the direction of these effects. Drinking alcohol may precede domestic assault but may also follow marital problems. Other factors are also present, such as other mental disorder, access to weapons, and stress. Still, some research studies as well as media reports of extreme cases of domestic violence do point to alcohol misuse as a sub- stantial mitigating factor (Ferrari et al., 2016). On one recent Independence Day, for example, a man in California killed himself and his four children after arguing with his wife—empty beer bottles were strewn in the backyard. On the same day in Portland, Maine, a man killed his wife after his 17-year- old son refused his demands to buy more beer. Despite con�icting research evidence about the causal direction of alcohol and domestic violence, these incidents clearly indicate the need for extensive education and prevention.

Focus On

Alcohol and violence do seem to go hand in hand. According to the U.S. Centers for Disease Control and Prevention, approximately 40 percent of violent and nonviolent crimes were committed under the in�uence of alcohol, and 40 percent of people convicted of rape and sexual assault claimed they were under the in�uence of alcohol at the time of the crime. Furthermore, 72 percent of college campus rapes occur when victims are too intoxicated to consent to or refuse sex. Nearly 50 percent of child maltreatment cases are associated with parental drug use, and two thirds

Violence Alcohol and Violence

9.4

V THE CONTINUUM VIDEO PROJECT

Mark / Substance Use Disorder

“That’s what drugs are, they are your savior but also they are also there to kill, maim, and destroy you. It’s awesome, but true.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

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Substance-Related Disorders: Causes and Prevention 265

�re-related injuries, and sudden infant death syndrome (crib sudden infant death syndrome (crib sudden infant death syndrome death; Chen, Clifford, Lang, & Anstey, 2013).

Risk of substance use disorder increases with permissive parent attitudes about drug use. College students whose parents are permissive and approving with respect to alcohol use tend to drink more (Varvil-Weld, Turrisi, Scaglione, Mallett, & Ray, 2013). In addition, according to the Department of Health and Human Services, 5.1 percent of youths who said their parents would strongly disapprove of their using marijuana actually used strongly disapprove of their using marijuana actually used strongly disapprove the drug in the past month. In contrast, 30 percent of youths who said their parents would only somewhat disapprove or nei- ther approve nor disapprove of their using marijuana actually ther approve nor disapprove of their using marijuana actually ther approve nor disapprove used the drug in the past month.

Another family factor linked closely to adolescent drug use is parent psychopathology, especially substance use disorder and antisocial behaviors. Parents who are not well involved in their child’s life, who supervise their children poorly, and who do not have affectionate interactions with their children also place their children at much higher risk for substance use disorder (Calafat, Garcia, Juan, Becona, & Fernandez-Hermida, 2014). Family con�ict can also predict excessive substance use in adolescents (Telzer, Gonzales, & Fuligni, 2014).

The popular media are especially enamored of one particu- lar family factor involved in substance-related disorders; you have probably read about or heard the term codependency. Codependency generally refers to dysfunctional behaviors that spouses, partners, children, and others engage in to cope with the stress of having a family member with a substance-related disorder. Codependency often involves intense care of a per- son with a substance-related disorder to the detriment of one’s own health. Spouses and children of a father with alcoholism may constantly help him to bed or call his workplace to explain his absence. Family members thus inadvertently reward—or enable—the behavior of the person with alcoholism. People in

Excessive substance use also seems related to disinhibited, depressed, and anxious personality features (Pihl & Shakra, 2015). Recall from Chapters 5 and 7 that people with anxiety- related and depressive and bipolar disorders commonly use substances such as alcohol to reduce stress in general and social phobia in particular. Stress is also a key reason for relapse among people with substance-related disorders (Xu et al., 2013).

Family Factors Family factors play an important role in the onset and main- tenance of substance-related disorders. Children of parents with substance-related disorders are much more likely than the general population to use substances themselves. Having a par- ent who smokes is also associated with greater risk of smok- ing among adolescents (Kandel, Griesler, & Hu, 2015). Children raised in homes where parents smoke are also at increased risk for health problems associated with secondhand smoke, such as chronic ear infections, asthma, bronchitis, pneumonia,

Impulsivity is a key personality trait associated with substance-related disorders.

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may in�uence the frequency at which people develop alcohol- ism, but this remains unclear. Heavy episodic drinking tends to occur more in Europe and the Americas (World Health Organization, 2014).

One group of cultures with historically low rates of alcohol- ism is in Asia and, in particular, Japan, China, and Korea. Asians are more predisposed to facial �ushing and other unpleasant facial �ushing and other unpleasant facial �ushing physical reactions when drinking alcohol, which tends to sup- press desire for alcohol (Lee at al., 2014). Facial �ushing and sensitivity to alcohol relate to elevated levels of acetaldehyde, a metabolite of alcohol. Among Asians, genetic predispositions may cause acetaldehyde to generate quickly and remain in the body for longer periods. This process produces and prolongs un- pleasant physical reactions and may thus provide greater protec- tion from alcoholism (Gross et al., 2015). Others, however, have not found this to be so, and rates of alcoholism have increased in certain parts of Asia such as Taiwan (Ting et al., 2015).

Evolutionary In�uences Some have proposed evolutionary theories for substance-related disorders. One evolutionary theory is that the mesolimbic do- pamine system is not strictly a reward-based system but one intricately involved in survival motivation. People who view chemical substances as threats to their reproductive ability are generally apt to avoid these substances, whereas people who view chemical substances as boosting their reproductive ability accept these substances (Newlin, Regalia, Seidman, & Bobashev, 2012). Many people such as Elon engage in alcohol and other substance use because they believe it will enhance their social desirability and attractiveness to others.

Another evolutionary view of addiction is that individu- als within societies generally pursue positions of dominance and submission to maintain social order. Some advantages to submission exist, such as avoiding aggressive behavior, but such a position also causes stress because one can be excluded from group resources at any time. Coping with such stress may involve drug use and may be a factor in high drug use in disadvantaged communities. Submission may also lead to a socially dependent relationship with a dominant individual, which may cause maltreatment and subsequent feelings of depression assuaged by substance use (Lende & Downey, 2012).

Causes of Substance-Related Disorders Substance-related disorders are quite complicated in terms of risk factors that help cause the problems. To arrange risk factors into a general model of addiction, many theorists and research- ers adopt a biopsychosocial approach that incorporates aspects of the diathesis-stress model we discussed for other disorders (Myers, McLaughlin, Wang, Blanco, & Stein, 2014). Biological factors may predispose a person toward substance use, and en- vironmental factors may trigger this predisposition to produce a substance-related disorder. Some researchers argue as well that we will eventually need different theories of cause because many kinds of substance-related disorders may exist.

codependent relationships may also feel responsible for a per- son’s substance problem and tightly control their relationships with others to avoid rejection. Codependent relationships are thus generally considered unhealthy.

Do children whose parents use drugs excessively grow to have signi�cant problems in adulthood? Much of the literature has focused on children of parents with alcoholism, and the answer to this question seems to be yes, to some extent. Adult children of parents with alcoholism are at signi�cant risk for excessive substance use, antisocial behavior such as aggres- sion, anxiety-related disorders and distress, depression, low self-esteem, and dif�cult family relationships. Adult children of parents with alcoholism tend to have more marital con�ict and stress during parenting and lower social support and fam- ily cohesion. This group also tends to marry at a younger age and divorce more than the general population. However, these results do not apply to all adult children of parents with alcohol- ism. Many adult children of parents with alcoholism, particu- larly those now in college, report few dif�culties (Stone, Becker, Huber, & Catalano, 2012). The latter �ndings raise questions about the validity and utility of the concept of codependency.

Cultural Factors Aside from American Indians/Alaska Natives, rates of substance use disorder are fairly equal among European Americans, African Americans, Hispanics, and Asian Americans. The reasons why some American Indians/Alaska Natives have such high rates of substance-related disorder is not completely clear. Substance use disorder in this population may be associated with high rates of trauma (Heart et al., 2016). Others suggest “craving- for-alcohol” genes on chromosomes 12, 15, and 18 that may be speci�c to some members of this population (Ehlers, Gizer, Gilder, & Wilhelmsen, 2011).

As mentioned earlier, rates of drug use for European Ameri- cans, African Americans, and Hispanics are similar. However, African Americans and Hispanics are disproportionately more likely than European Americans to experience severe conse- quences from drug use. In particular, African Americans and Hispanics are overrepresented with respect to imprisonment and HIV/AIDS among those who inject drugs (Barskey, Surendera Babu, Hernandez, & Espinoza, 2016). African Americans and Hispanics, who are more likely to inject drugs than European Americans, may also be at greater risk for hepatitis B and C in- fections and overdose (Des Jarlais, McCarty, Vega, & Bramson, 2013). Ethnic minority communities may be predisposed to sub- stance use disorder because of high poverty and unemployment, easier access to alcohol and other drugs, poor schools, and lim- ited access to mental health services (Cummings, Wen, Ko, & Druss, 2014; Molina, Alegría, & Chen, 2012).

Rates of alcohol consumption and alcoholism also differ around the world. Attitudes toward drinking and whether mem- bers of a culture commonly engage in heavy drinking have much to do with these differences. Some cultures integrate alcohol into daily life and meals, as occurs in Mediterranean nations. Other cultures exemplify more abstinence to alcohol and less daily consumption. Increased or decreased daily consumption

Substance-Related Disorders: Causes and Prevention 267

Prevention of Substance-Related Disorders Given the terrible personal and health-based consequences of extended drug use, prevention efforts for substance-related dis- orders have received much attention. Prevention efforts include those for adults and those for children and adolescents. Recall from Chapter 3 our discussion of a prevention program spon- sored by the University of Missouri’s Wellness Resource Center. Program components included promoting responsible decision making and providing accurate information about alcohol con- sumption by college students. Once misperceptions are cor- rected about the extent and acceptability of student drinking, binge and heavy drinking typically decline (see also Box 9.5).

Prevention programs also aim to reduce alcohol and other drug intake in pregnant mothers to prevent fetal alcohol effects in newborns. These programs focus on screening for alcohol and other drug use, educating mothers about ill effects of such use, managing stress and reducing depression, increasing social sup- port, and visiting the mother’s home (Shannon, Alberg, Nacul, & Pashayan, 2014). Similar techniques help reduce excessive substance use among the elderly, health care professionals, hos- pital patients, victims and perpetrators of violence, and people with comorbid mental disorders (El-Guebaly, Carra, & Galanter, 2015; Kuerbis & Sacco, 2013). Other prevention programs target children and adolescents so drug use does not begin in the de- velopmental period. These programs typically focus on:

• Reducing availability of illegal drugs • Increasing legal consequences for drug use

Comprehensive models of addiction often di- vide biological and environmental risk factors into distal or proximal ones (Feingold, Capaldi, & Owen, 2015). Distal factors are background factors that in- directly affect a person and can generally contribute to a mental disorder. Biological distal factors with re- spect to substance-related disorders include genetic predisposition and perhaps temperaments such as an impulsive personality. Environmental distal factors include association with deviant peers, problematic family relationships, parental drug use, culture, and early learning and drug experiences.

Proximal factors are more immediate factors that directly affect a person and more speci�cally contribute to a mental disorder. Biological proxi- mal factors include activation of the mesolimbic dopamine pathway upon drug use. Environmental proximal factors include stress, depression, peer pressure, positive expectancies about substance use, and availability of substances. Proximal factors may also include consequences of drug use, both posi- tive (e.g., enhanced mood and relief from stress) and negative (e.g., ill physical effects and occupa- tional and legal troubles).

Some of these factors interact to propel a person toward substance use disorder (see Figure 9.12). Re- call that craving for substances often involves selec- tive attention to cues that remind a person of drug use. This selective attention also appears to have a biological basis in that dopamine is released from brain features of the mesolimbic pathway. This highly rewarding event further rein- forces a person’s drug-seeking behavior (Volkow et al., 2015). Ongoing stress in a person’s life may also lead to long-term ex- cessive alcohol use that creates key changes in the prefrontal cortex. These brain changes can then help produce even more stress as a person’s memory and concentration suffer and can lead to even greater focus on obtaining rewarding substances. Key neuronal and other brain changes can also make a person particularly sensitive to craving and desire for future drug use (Hone-Blanchet et al., 2015).

Various factors seemed to swell into a “perfect storm” that set the stage for Elon’s excessive alcohol and other drug use. His distal biological risk factors included an impulsive personal- ity and high levels of arousal assuaged by alcohol use. A family history of alcoholism may have been present as well. Proximal risk factors included entry into college and substantial stress following intense academic demands. Elon also greatly enjoyed the pleasurable aspects of sex and drug use and was clearly exciting key areas of the brain such as the mesolimbic pathway. Elon later expanded and increased his drug use and focused solely on drug-seeking behavior. Many people with substance- related disorders experience a phenomenon they describe as rock-bottom, meaning their brain function and behavior are almost singularly geared toward seeking and using drugs. Such devastating effects underscore the need for prevention, and we describe these efforts next.

Substance-related disorder

Distal factors

Genetic predisposition Impulsive personality

Deviant peers Culture

Family conflict Parental drug use

Drug/learning experiences

Reinforcers

Mood enhancement Relief from stress

Belonging to a peer group Avoidance of withdrawal

symptoms

Punishers

Ill physical effects Legal problems

Cognitive decline Divorce and loss of job

Tolerance

Proximal factors

Activation of mesolimbic pathway

Daily stress and depression Peer pressure

Positive expectancies about drug use

Availability of drugs

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FIGURE 9.12 SAMPLE CAUSAL MODEL OF SUBSTANCE-RELATED DISORDER.

CHAPTER 9 Substance-Related Disorders268

a crisis plan if alcohol or other drugs are used again (Blodgett, Maisel, Fuh, Wilbourne, & Finney, 2014). Medication to reduce the pleasurable nature of a speci�c drug and regular attendance at self-help group meetings may also be useful for relapse pre- vention (see later treatment section; Maisel, Blodgett, Wilbourne, Humphreys, & Finney, 2013). Relapse prevention strategies are generally effective for delaying time to substance reuse, as well as reducing days of substance use and heavy drinking (Bowen et al., 2014).

➲ Interim Summary • Biological risk factors for substance-related disorders

include genetic contributions, especially for metabolism, low response to alcohol, and craving.

• Brain features implicated in substance-related disorders are those closely linked to the mesolimbic pathway and primarily include the amygdala, anterior cingulate, bed nucleus of the stria terminalis, and prefrontal cortex.

• Neurochemical features implicated in substance-related disorders primarily involve dopamine release from the mesolimbic pathway.

• Stress is a major environmental trigger for excessive substance use and often leads to relapse.

• Cognitive factors—especially positive expectancies about substance use and misperceptions about life changes brought about by substance use—help increase substance use.

• Classical and operant conditioning and modeling are important learning processes implicated in substance- related disorders.

• Impulsive personality and related traits can predispose some people toward substance use disorder.

• School-related media programs to educate youth and change drug-related attitudes

• Programs to increase work and leisure opportunities to de�ect youths from drug-seeking opportunities

• Peer-based programs to enhance methods of saying no to offers to use drugs

Universal efforts to prevent substance use disorder often target the public. Examples include raising the minimum drink- ing age, lowering the legal limit for de�ning driving while im- paired, airing antidrug commercials, banning advertisements for tobacco in some media, engaging in drug testing in the work- place, and implementing heavy taxation on alcohol and tobacco products. The general effectiveness of these policies for reducing drug use, especially for children and adolescents, has been rela- tively modest, however (Agabio et al., 2015).

A controversial approach to preventing extended health problems in those addicted to drugs is to reduce needle sharing by supplying new, clean needles or syringes. Needle exchange or harm reduction programs provide unused needles and syringes to intravenous drug users, cleansing materials such as bleach or skin ointment, education about communicable dis- eases such as AIDS, and access to mental health services. Some criticize needle exchange programs for potentially maintaining excessive drug use habits, but the programs do effectively re- duce bloodborne diseases and risk factors associated with HIV (Abdul-Quader et al., 2013).

Relapse prevention is also a key way of reducing further drug use in someone with a substance-related disorder. Relapse pre- vention involves reducing exposure to alcohol and other drugs, improving motivation to continue abstinence, self-monitoring daily mood and tempting situations, recognizing and coping ap- propriately with drug cravings, reducing anxiety and depression, modifying irrational thoughts about drug use, and developing

feedback about one’s drinking also seems especially effective for people who drink for social reasons and for heavy drinkers (Palfai, Winter, Lu, Rosenbloom, & Saitz, 2014).

Treatment for problematic drinking in college students is important given the substantial negative consequences that can result. Tyler and colleagues (2015) surveyed hundreds of college students about drinking behavior, social and physically pleasurable alcohol expectancies, and sex- ual victimization. Sexual victimization was generally associated with child sexual maltreatment, hooking up more often, and heavier drinking. Greater alcohol expectancies were associated with sexual victimization in women, including forced sexual contact or intercourse, and especially those in so- rorities. In addition, men who hooked up more often and had close friends who consumed much alcohol were more likely to drink heavily and experi- ence sexual victimization. Beliefs that alcohol will increase happiness or power, and heavy drinking subsequently, can thus lead to many damaging consequences.

Focus On

Treatment for college students with drinking problems is relatively suc- cessful. Many programs use motivational interviewing, alcohol education, normative comparisons, and moderation strategies. Programs tailored to college students also include changing positive expectancies about alcohol use and increased use of designated drivers. Most studies reveal signi�- cant improvements in alcohol-related knowledge, attitudes toward drink- ing, normative beliefs about drinking, and intentions to reduce alcohol intake (Scott-Sheldon, Carey, Elliot, Garey, & Carey, 2014). Personalized

9.5

College Students Substance Use

Substance-Related Disorders: Assessment and Treatment 269

from the measure are excellent predictors of substance use dis- order (Denis, Cacciola, & Alterman, 2013). Motivational inter- viewing is an assessment and treatment strategy that involves obtaining information about a person’s substance-related prob- lem and providing feedback to help increase his readiness for change. An interviewer provides empathy, illustrates discrepan- cies between what a person is currently doing and what his long- term goals are, and helps a person believe change is possible. Clinicians who use motivational interviewing ask open-ended questions, listen and re�ect information carefully, provide treat- ment choices, outline problems associated with current drug use, support a person’s statements about wanting to change, and set speci�c treatment goals. A motivational interviewer actively gives advice and reinforces a person’s willingness to change current behavior. Motivational interviewing is effective at reducing alcohol consumption (Riper et al., 2014).

Elon underwent a motivational interview regarding his drug use during his initial days at a drug rehabilitation facility. Following is a brief vignette from the interview:

Elon: I just don’t know if I can change. The stuff I was taking was . . . I just think about using it all the time.

Therapist: You could change if you wanted to, but if you continue the path you’re on you will kill yourself.

Elon: I understand that, and sometimes I do want to go back to the way things were.

Therapist: That’s an excellent choice, and there are different ways we can offer you to get back to that point.

Elon: It just seems as though I’ve been using for so long now . . .

Therapist: Let’s talk about some times in your life when you didn’t use drugs but still did pretty well in school and with your friends.

Psychological Testing Therapists also use psychological tests to screen and assess for drug use. A well-known test is the Minnesota Multipha- sic Personality Inventory (MMPI-2) we discussed in Chapter 4. The MMPI-2 has three subscales that assess for drug use. Items on the Addictions Acknowledgement Scale detect sub- stance use among people willing to admit such use. Items on the Addiction Potential Scale are those typically endorsed by people who use substances more so than those who do not. Items on the MacAndrew Alcoholism Scale are general MMPI-2 items sometimes used to measure impulsive substance use (Gizer et al., 2012).

Another scale we discuss at more length in Chapter 10 is the Millon Clinical Multiaxial Inventory—IV. This scale as- sesses personality disorders but has two subscales for alcohol dependence and drug dependence. Items on these subscales center on diagnostic criteria and concern drug use as well as behaviors associated with drug use. These subscales success- fully predict risk for increased or decreased drug use (Hopley & Brunelle, 2016).

• Family factors such as con�ict and poor cohesion are good predictors of later substance use disorder and perhaps codependent relationships.

• Some cultural differences with respect to drug use are present, but the reasons for these differences remain unclear.

• Evolutionary theories of substance use include enhance- ment of reproductive �tness and easing anxiety and depression from submissive relationships.

• The cause of substance-related disorders is likely multi- varied and involves several proximal and distal factors and reinforcers.

• Prevention of substance-related disorder can occur at the adult level, as with relapse prevention, or at the youth level to prevent excessive drug use before it begins.

➲ Review Questions 1. Describe data that support a genetic contribution to

substance-related disorders. 2. What key brain and neurochemical changes relate to

substance-related disorders? 3. Describe cognitive and learning factors associated with

substance use. 4. How do personality and family factors help cause substance-

related disorders? 5. Describe an overall causal model for substance-related

disorders. 6. What factors might be important for preventing substance-

related disorders?

Substance-Related Disorders: Assessment and Treatment

Substance-related disorders are among the most rampant and dangerous mental disorders we discuss in this text- book. The disorders can ravage an entire family (see Personal Narrative 9.1). The accurate assessment and effective treat- ment of these disorders is therefore critical. We next describe key methods, such as interviews, psychological testing, ob- servations from others, and laboratory testing, for assessing substance-related disorders.

Interviews Interviews are a frequent means of assessing many mental disorders. Common types of interviews for substance-related disorders include screening interviews and motivational inter- views. Screening interviews are speci�cally designed to assess recent and lifetime problems with respect to substance use. One commonly used screening interview is the Addiction Severity Index—6. The ASI—6 contains structured questions about medi- cal status, employment, social support, alcohol and other drug use, and legal, family, and psychiatric status. Composite scores

CHAPTER 9 Substance-Related Disorders270

these questions relates to high risk for substance use disorder (Brousse et al., 2014):

• Have you ever felt you needed to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever felt you need a drink �rst thing in the morning

(Eye-opener) to steady your nerves or get rid of a hangover?

Other commonly used screening measures include the Michigan Alcoholism Screening Test and the CAGE. These scales are particularly useful for assessing recent and severe use of alcohol. The Michigan Alcohol Screening Test is a 24-item measure of drinking habits, interpersonal and legal problems related to drinking, and treatment for alcohol- ism. The CAGE is a four-item measure that includes variations CAGE is a four-item measure that includes variations CAGE of the following questions. Answering yes to two or more of

The Father I dreamed that my daughter, Carrick, was perched on the edge of a dock on a lake. I stood behind her. As she slipped into the water, it dawned on me that she was taking a swimming test and I was the only one observing her. Her back arched and her arms plunged in a graceful butter�y stroke, but her head did not emerge. Her skin suddenly blanched, and I sensed she was in trouble. I jumped into the gray chop, landing beyond where her efforts had carried her. As I faced her, she sank feet �rst, her long hair swirling in the water. She was just inches away but it seemed an in�nite distance. I felt responsible, as if my thinking that she might drown made it happen. I wanted to change the direction the dream was taking, but couldn’t do it. I knew she would plunge faster than I could dive after her, and that I would not be able to bring her to the surface even if I managed to catch her.

I woke up. My chest felt raw and empty, as if my ribcage had been ripped open. At �rst I thought the dream was about my feel- ing that I have something to lose again. But as I’ve thought about it, I realize that my subcon- scious was con�rming what I’ve learned the hard way. I cannot “save” my daughter. If she wants, I can only try to help her learn to swim. When it comes to addiction, that’s all anybody can do.

Thom Forbes, Father For several years, I’ve lived with the spec- ter of my daughter killing herself. It haunted me whenever the phone rang at a time when it didn’t normally, or if a holiday passed with- out our having heard from her, or when I saw or heard Deirdre, my wife, weeping. However her death happened—a heroin overdose,

hypothermia, murder, suicide, AIDS—I knew I would have to �nd the words to express what had happened, and why.

Carrick started smoking marijuana when she was 12 years old, and worked her way to a heroin addiction by 17. She sees her drug dependencies, as do I, as the inevitable out- come of genes and other in�uences. We have had a trying journey. When Carrick was using drugs, she often overwhelmed Deirdre, our son Duncan, and me—individually and collectively. We all have different ways of coping. My way has been to try to �nd some connections to the experiences of others. And so, as part of this journey, I have been writing The Elephant on Main Street: An Interactive Memoir of Addic- tions, which became a website (www.elephan- tonmain.com).

Thanksgiving Day was the �rst that Carrick spent at home in 5 years. Four years earlier, she was in a wilderness therapy program in the high desert of Utah. Three years earlier, she was living on the streets of Philadelphia with a lost soul who called himself Chaos Destruction. Two years earlier, she was hang- ing with Pete, who had just been released from state prison for drug dealing. She and Pete were either incarcerated on Riker’s Island or about to be—she was so strung out on heroin and cocaine that one day blended into the next.

After Thanksgiving dinner, our 15-year-old son Duncan surprised us with a box of choco- lates and a greeting card. He wrote: “Mom, Dad, Carrick, Pete. I love you guys all. We stick through the hardest times as a family.” That’s what this small piece of the narrative is all about: sticking together through the hardest times— and telling the story.

The Mother I have alcoholism, which has been in remission since I had my last drink. My husband, to whom I have been married almost 30 years, is in re- covery and has been sober for many years. My father was a high-functioning alcoholic, and my 21-year-old daughter is in recovery, having suf- fered an addiction to heroin, since the age of 17. When I was 10 years sober, I developed severe treatment-resistant major depression. I took ref- uge in sleep, �nding even routine activities too overwhelming to accomplish. There seemed no reason to continue living. Suicidal ideation �lled my waking hours. Eventually I was hospitalized. After electroconvulsive therapy, a uniquely de- signed regimen of antidepressant medications, and talk therapy, I began down another road to recovery.

Today I feel better than I ever have about waking up in the morning and facing life’s chal- lenges and joys. I’ve concluded that I want to devote the remainder of my working life to bat- tling the effect of chemical dependency, which often coexists with mental disorder, on individu- als, families, and communities. I want people to know the damage addiction and mental disorder can do, but I also want them to see and under-can do, but I also want them to see and under-can do, but I also want them to see and under stand that recovery works. I want people to see I am unusual only because I am part of a minority

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Substance-Related Disorders: Assessment and Treatment 271

Then my parents told me she was just using the money to buy drugs. That’s when I just felt like punching a wall. I felt like I should have known why she wanted the money so badly. When I stopped giving her money, she started stealing from me. Then she would deny stealing from me, and that’s when Carrick’s problem started becoming my problem.

Sleep. There were some nights when my sis- ter and my parents would just argue throughout the whole night, nonstop yelling, and I couldn’t sleep at all. They would argue on school nights, and I just wanted to get the hell out of there.

Communication. I could barely talk with my parents because they were always mindful of my sister. If I asked them to do something for me, they would just say things like “Well, after when Carrick comes home,” or “I have to take Carrick somewhere.” It was always “Carrick, Carrick, Carrick.”

Random �ghts on small things. Sometimes �ghts would start about the most random things, like television shows. After the problem was resolved, I usually realized it wasn’t clean Carrick who was arguing with me over television, it was the mean Carrick, who was high, �ghting with me.

I didn’t really understand how serious my sister’s problem was until I grew older. During

from work, time away from home, family arguments over drug use, and binges, among other things. This must be done with great care and with knowledge and consent of the person with a substance-related disorder. Observations like these are often part of family therapy for people with substance-related disor- ders (see section on treatment later in the chapter).

Observations from Others Excessive drug use is often a hidden problem, and many peo- ple do not accurately report their alcohol or other drug use. Therapists may thus conduct observations and solicit reports from others. Family members, partners, coworkers, and friends can help monitor a person’s behavior and report days missed

who speak out about their recovery, not because I am in recovery. Stigma and discrimination keep many in recovery from doing so.

The Child and Brother Being the ghost child wasn’t that bad in the be- ginning of the drama between Carrick and my parents. I had freedom really; I got to do what- ever I wanted. Like a ghost, I was there but no one really saw me. But I didn’t realize that why I was so free was because all of the attention was on my sister. I didn’t care at all because everything was going �ne for me. I didn’t care . . . not yet.

There were times where my sister’s prob- lems wouldn’t bother me at all, but then there would be other times where I would be in the middle of an argument and be overwhelmed with the drama and tension between my par- ents and my sister. All I wanted to do was just to walk away from it, let them deal with the problem because hey, it doesn’t concern me, it’s not my problem, it’s Carrick’s problem. Or so I thought. But it became my problem, too, in at least four ways:

Money. As the problem got worse, Carrick started asking me for money. Most of the time I would give it to her because I wanted to be a good little brother and I wanted to help her out.

her downfall, I thought she was just in a little trouble that wouldn’t have a giant effect on her future, and that the problem would eventually go away. As we grew up, and Carrick started controlling her problem and pushing herself to go to school, the attention started shifting toward me. They were afraid that I might head down the wrong road and might end up messing up my life. When I’d go out with my friends, they asked questions like “who, what, when, why, where?” I have to admit; I guess those antidrug commercials re- ally do work for parents.

Overall, Carrick’s problem didn’t just concern her. It concerned the whole family. Anyone’s actions in the family will certainly affect another person’s life. A family is like a chain. If you break the chain, you break the family. We all depend on each other. We all need each other.

I also learned a lot from this problem. I’m able to help out people in my school who might have similar problems, or who might be heading down the wrong road. I think I got a lot smarter when it comes to drugs and drinking.

After seeing what drugs have done to my sister, mentally and physically, it gives me a perfect reason to say “No.” I’m thankful that I don’t have to learn what trouble drugs can cause by doing them. I can just look at what they did to my sister. After all I’ve been through, I feel like a better man who is able to make the right decisions.

I guess if it weren’t for Carrick, I probably wouldn’t have any reason not to try drugs or drink. But I’m thankful for my sister, because I have learned so much from her. And I real- ized that anyone who has a problem in a family always affects someone else in the family.

Duncan Forbes, BrotherDeirdre Forbes, Mother Cou

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Used with permission.

CHAPTER 9 Substance-Related Disorders272

• Spectral methods detect certain luminescence various drugs emit under �uorescent light.

• Immunoassays assess for antibodies generated from a substance.Immunoassays assess for antibodies generated from a substance.Immunoassays Blood tests also assess for recent drug use, especially alco-

hol. Blood alcohol tests are used when a person is suspected of driving under the in�uence of alcohol, when a person’s memory or thinking ability seems impaired, for adolescents, and for peo- ple in a drug rehabilitation facility. Earlier we provided a table of different blood alcohol levels and typical behavior associated with those levels (Table 9.7).

A quicker method of assessing recent alcohol use and blood alcohol level is via one’s breath, as when a police of�cer uses a toximeter or toximeter or toximeter Breathalyzer test that a person breathes into. Breathalyzer test that a person breathes into. Breathalyzer test Several handheld Breathalyzer devices are now available so a person can test herself before driving. Blood alcohol levels will tend to rise more quickly if you are female, have drunk hard liquor, have drunk substantial amounts of alcohol (such as more than one drink per hour), weigh less, are older, have not eaten recently, are using other drugs or medications, or mix alcohol with carbonated beverages, which speeds absorption. For some people, drinking an abundance of water during and after alco- hol use slows alcohol absorption and helps them avoid a severe hangover. Drinking lots of water and lots of alcohol, however, will still leave you grossly impaired.

Hair analysis is becoming a preferred method of drug testing because someone can detect illicit drug use months after a person ingested a drug. Strands of hair close to the scalp are analyzed to detect drug use in the past few months (Xiang, Shen, & Drummer, 2015). Hair analysis is popular because substances to hide drug use cannot easily contaminate results. Downsides to hair testing are that the amount of drug a person took, and when the person took the drug, cannot be clearly established. Racial bias may also be a factor (see Box 9.6). Saliva and Saliva and Saliva sweat tests for drug use have sweat tests for drug use have sweat also been developed. Studies of drivers whose saliva was tested reveal that common drugs found are cannabis, cocaine, and methamphetamine (Davey, Armstrong, & Martin, 2014; Van der Linden, Wille, Ramirez-Fernandez, Verstraete, & Samyn, 2015).

Laboratory Testing Laboratory tests involve analyzing urine, blood, breath, hair, saliva, or sweat to detect recent drug use. Potential employers and drug treatment facilities often use these measures to determine abstinence from drugs. Urine screens are perhaps the most com- mon laboratory measure of recent substance use, though periods of detection differ by drug (see Table 9.10). Some drugs such as phencyclidine can be detected as much as 8 days after use, but other drugs such as alcohol cannot be detected past 10 hours.

Urine screens detect presence or absence of certain drugs and are a good initial screening method. A downside of urine screens is the prevalence of wrong results, so the tests may precede other laboratory measures. Urine screens consist of the following processes:

• Chromatography separates chemicals into their individual components.

• Spectrometry identi�es exact molecular structure of certain chemicals and usually follows chromatography.

TABLE 9.10

Periods of Detection for Illicit Drugs by Urinalysis

Drug Period of detection

Alcohol 6–10 hours

Amphetamine 1–2 days

Barbiturates 2–10 days

Benzodiazepines 1–6 weeks

Cocaine 1–4 days

Codeine 1–2 days

Hashish 1 day–5 weeks

Heroin 1–2 days

LSD 8 hours

Marijuana 1 day–5 weeks

MDMA (ecstasy) 1–2 days

Mescaline 2–3 days

Methadone 1 day–1 week

Methamphetamine 1–2 days

Morphine 1–2 days

Nicotine 1–2 days

Phencyclidine (PCP) 2–8 days

Tetrahydrocannabinol (THC) 1 day–5 weeks

From R.J. Craig, Counseling the alcohol and drug dependent client: A practical approach (p. 91), New York: Pearson, 2004. Reprinted by permission of Pearson Education, Inc.

Handheld Breathalyzers are available for self-testing one’s alcohol level.

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Substance-Related Disorders: Assessment and Treatment 273

another, although the patch is the easiest to use and the inhaler the most dif�cult. These devices also help reduce cravings and withdrawal symptoms, and their strength can be gradually re- duced until a person is no longer addicted (Stead et al., 2012).

Antagonists Antagonists are drugs that block pleasurable effects of an addic- tive drug, with the expectation, and hope, that this will reduce cravings for the addictive drug. A good example is naltrexone (Revia), which blocks opiate receptors in the brain, and spe- ci�cally the nucleus accumbens, to decrease craving for alcohol and reduce its pleasurable effects. The drug is effective for re- ducing alcohol consumption and craving (Garbutt et al., 2014). A combination of naltrexone with acamprosate, a drug that may also have some antagonist properties, is effective as well for preventing relapse in people with alcoholism (Maisel, Blodgett, Wilbourne, Humphreys, & Finney, 2013). A related antagonist, naloxone (Narcan), is used in emergency rooms to treat opiate naloxone (Narcan), is used in emergency rooms to treat opiate naloxone overdose (Clark, Wilder, & Winstanley, 2014).

Partial Agonists Partial agonists are drugs that may act as an agonist or antago- nist depending on how much of a neurotransmitter is produced. Dopamine has a close association with substance-related dis- orders, so a partial agonist will increase dopamine levels when this neurotransmitter is not highly produced in the brain and decrease dopamine levels when this neurotransmitter is highly produced in the brain (Moreira & Dalley, 2015).

A common partial agonist for substance-related disorders is buprenorphine (Subutex), which acts as an agonist at certain buprenorphine (Subutex), which acts as an agonist at certain buprenorphine opiate receptors but an antagonist at other opiate receptors. The drug helps control craving for opiates by binding to key opiate

Biological Treatment of Substance-Related Disorders You might think it odd that other substances or medications could treat substance-related disorders. Many now believe a combination of medication and psychological treatment may be best to address stubborn substance-related problems. Medica- tions for these disorders include agonists, antagonists, partial agonists, and aversives.

Agonists Agonists are drugs that have a similar chemical composition as the excessively used drug. Agonist drug treatment thus takes advantage of cross-tolerance, or tolerance for a drug one has never taken. A good example of agonist drug treatment is metha- done for people addicted to heroin or related opiates such as done for people addicted to heroin or related opiates such as done morphine or oxycodone. Methadone shares a chemical compo- sition with opiate drugs and so binds to opiate receptors in the brain as opiates do. Methadone treatment is given as a person reduces opiate use so cravings for, and withdrawal symptoms from, the opiate are less severe. Once a person is fully cleansed of the addictive drug, methadone doses are gradually reduced as well. Another drug, a methadone derivative known as levo- alpha-acetyl-methadol (LAAM), lasts longer in the body and may need to be taken only three times a week compared with daily doses for methadone. LAAM is thus more effective than methadone for helping people end opiate addiction (Mattick, Breen, Kimber, & Davoli, 2014).

Agonist agents are also used for nicotine addiction. Nicotine replacement therapy refers to ingesting safe amounts of nicotine without smoking tobacco. The alternative ingestion comes in the form of a nicotine patch (Nicoderm), gum (Nicorette), in- haler, or nasal spray. No one form is greatly more effective than

also show bias if the type of hair sample identi�es a person as a likely ethnic minority.

Others argue that employers have a right to know if an employee is im- paired on the job and might harm others. You would not want airplane pilots or truckers to be drunk when �ying or driving. Some have taken a middle ground on this issue, claiming that drug testing is ethical under strict condi- tions such as establishing policies acceptable to workers and employers, and employers, and engaging in selective but not universal drug testing, providing prior notice of testing, notifying employees of test results, and carefully maintaining con�- dentiality of drug testing results (Kintz, Salomone, & Vincenti, 2015).

Ethical questions regarding drug testing apply to other populations as well. Some claim mandatory drug testing of high school athletes is coercive, lacks informed consent and con�dentiality, and unfairly targets a speci�c group of people (Bahrke, 2015). Many parents also disagree with profes- sional association statements that drug test results for teenagers be com- pletely con�dential—does a parent have a right to know about her son’s drug use? Finally, some express concern that drug testing on pregnant women could lead to prosecution for harm to the fetus (Paltrow & Flavin, 2013).

Focus On

Sophisticated methods of drug testing such as hair and saliva analyses are now available, so important ethical questions arise. A key ethical dilemma is one’s right to privacy versus a public’s right to know of poten- tially dangerous situations. A �ashpoint in this dilemma has been drug testing of current employees for substance use. Some argue employees have a right to safeguard personal information, especially about legal drug use such as alcohol or tobacco. Drug testing may also be humiliat- ing for a person who must urinate before a supervisor, or the testing may be discriminatory if people are chosen because of some visible charac- teristic such as disability or race. A person conducting hair analysis might

Law and Ethics Drug Testing

9.6

CHAPTER 9 Substance-Related Disorders274

cognitive-behavioral therapy, family and marital therapy, group therapy, and self-help groups.

Inpatient and Residential Treatment Elon eventually entered a drug rehabilitation facility after sub- stantial drug use and dangerous behavior. People who are in- toxicated or dependent on a particular substance often must �rst undergo inpatient or residential treatment in which the residential treatment in which the residential treatment major focus is detoxi�cation and rehabilitation. Detoxi�cation involves withdrawing from a drug under medical supervision, which may include medications mentioned previously. A person may be gradually withdrawn from heroin use by using meth- adone and sedatives to quell intense withdrawal symptoms. Detoxi�cation also involves providing good nutrition, rest, ex- ercise, and a stress-free environment to cleanse the body of all addicted drugs. Elon was asked to engage in low-temperature saunas, replace vitamins and minerals missing from his diet in the past few months, drink plenty of water, and adhere to a normal routine with set times for sleeping and waking.

Rehabilitation from drug use is the next phase of inpatient or residential treatment. Many rehabilitation treatment pro- grams rely on the Minnesota model, which emphasizes complete abstinence, education about substance-related disorder and its consequences, effects of addiction on family members, and cognitive-behavioral techniques to prevent relapse (discussed in a later section). Individuals with substance-related disor- ders often share their experiences with professionals and other residents and confront problems currently facing them. Elon eventually realized the full consequences of his actions, such as expulsion from college, and how much pain he caused his par- ents. Residential treatment programs tend to be more effective for people with severe substance-related disorders, comorbid mental disorders, and fewer social resources (Blonigen, Finney, Wilbourne, & Moos, 2015).

Brief Interventions Brief interventions for substance-related disorders include short-term strategies to change behavior as much as possible in a limited time. Brief interventions include the motivational interviewing technique we discussed earlier, which includes providing feedback about one’s excessive substance use and negotiating and setting a goal for change. A therapist may try to get a client to commit to drinking only on weekends or allow a family member or trusted coworker to monitor his alcohol use at home or work. Brief interventions can be as short as 5 to 15 minutes in length.

Brief interventions also focus on identifying high-risk situ- ations for excessive substance use, especially when a person is stressed, lonely, bored, or depressed. Exploring the pros and cons of substance use, providing information about substance use and its negative consequences, and bolstering social sup- port are important as well. The goal of brief interventions is not necessarily to achieve complete abstinence but to stabilize or reduce a person’s substance use enough so she can pursue the more thorough types of therapy we discuss next. Brief interven- tions are often used in primary care medical settings, especially

receptors but has fewer side effects such as sedation than pure agonists such as methadone. Buprenorphine also appears to be nearly if not equally effective as methadone, so the drug may be given if methadone does not work well, or as a transition between methadone and abstinence (Mattick et al., 2014).

Aversives Aversive drugs are those that make ingestion of an addic- tive drug quite uncomfortable. A good example is disul�ram (Antabuse). When someone takes this drug, there are no ill effects until he drinks alcohol. After alcohol intake, the person experiences nausea, vomiting, diarrhea, and blood pressure changes that essentially punish him for alcohol use or create a learned taste aversion. Think about what happens when you eat something at a restaurant and then get sick—you do not want to go back to that restaurant for quite a while!

Disul�ram is an aldehyde dehydrogenase inhibitor, mean- ing that high levels of acetaldehyde build up quickly. Recall from our discussion of cultural factors that high levels of ac- etaldehyde may cause several unpleasant symptoms and deter certain people from using alcohol. A person with alcoholism does not take disul�ram every day, but he may take the drug during “high-risk” times such as going on vacation or during a holiday season. Disul�ram is also effective for treating cocaine use (Kalra, De Sousa, & Shrivastava, 2014). A related drug, calcium carbimide (Temposil), has similar but milder effects than disul�ram.

Another aversive drug is silver acetate, a substance placed in gum, lozenges, or mouthwash (Carson et al., 2013). Silver acetate has no major side effects when used alone. When mixed with nicotine, however, as when a person smokes a cigarette after using the mouthwash, mucous membranes are irritated and a foul taste occurs in the person’s mouth. Punishment of the response (smoking) or creating a learned taste aversion is thus key. Disul�ram and silver acetate only work if a person is suf�ciently motivated to use the substances to deter alcohol and tobacco use.

Other Medications Other medications are used to treat substance-related disorders as well, especially antianxiety and antidepressant drugs (dis- cussed in Chapters 5 and 7). The drugs combat comorbid anxi- ety and depressive symptoms that may trigger excessive alcohol and other drug use, and the medications may even help reduce some alcohol and cocaine consumption by themselves. Research continues as well on medications to speed drug metabolism to cleanse the body quickly, and vaccines for substance-related disorders (Raleigh & Pentel, 2016). The best treatment for sub- stance-related disorders is likely a combination of medication with psychological approaches, which we discuss next.

Psychological Treatment of Substance-Related Disorders Psychological treatment of substance-related disorders generally involves inpatient and residential treatment, brief interventions,

Substance-Related Disorders: Assessment and Treatment 275

drug use and may combine the training with other approaches such as mindfulness (Ury, Flack, & Dakwar, 2015).

A key aspect of behavior therapy for substance-related disorders is contingency management, or rewarding positive behaviors via praise and other reinforcers from family mem- bers, friends, and close associates. Elon’s parents veri�ed and rewarded their son’s abstinence after regular drug screens. Con- tingency management may also involve incentives in which therapists provide vouchers for various goods and services after drug-free urine or other screening. Contingency management is particularly effective for reducing opiate, nicotine, alcohol, cocaine, and marijuana intake. A downside to contingency management, however, is that effects may diminish if outside rewards do not continue (Benishek et al., 2014).

A community reinforcement approach to substance- related disorders is similar to contingency management. A per- son with substance use disorder is not only rewarded by others for abstinence but also encouraged to change conditions in his environment—such as those at work, home, and recreationally— to make them more rewarding than substance use. Therapists often combine this approach with vouchers, medication, and ongoing drug testing. The approach helps boost abstinence and engagement in the treatment process (Blonigen et al., 2015).

Family and Marital Therapy Substance-related disorders involve great harm to family mem- bers, and better treatment outcomes for people with these disorders usually relate to good marital and family environ- ments. Family and marital therapies are thus important com- ponents of treatment. These treatments involve the spouse or partner or other family members of a person with a substance- related disorder to help motivate a person to seek treatment, increase positive communications within the family, solve prob- lems effectively, and monitor a person’s substance use. The gen- eral goal of these techniques is to foster a living environment that helps prevent relapse to excessive alcohol or other drug use and that reduces the “enabling” behaviors we discussed earlier (O’Farrell & Clements, 2012).

Films and reality television shows sometimes portray family members having an “intervention” with someone with a sub- stance use or other problem. Such intervention usually involves suddenly confronting or shocking a person with a family meet- ing to increase insight and encourage the person to seek help for a substance use problem. Unfortunately, this strategy has shown to be more harmful than helpful because the identi�ed person may feel threatened or singled out as a “scapegoat” for family or marital problems. Many families also fail to follow through with intervention plans (O’Farrell & Clements, 2012).

Clinicians often use family therapy to treat adolescents with substance use problems, and multidimensional family therapy is a popular form. Multidimensional family therapy consists of a 12-week program that focuses on developing a strong adolescent–parent bond, enhancing good negotiation and family problem-solving skills, improving supervision of the adolescent, and correcting learning and school-based problems. The therapy has been shown to be as or more effective than

for men, but may be less effective for those with severe sub- stance use problems (O’Donnell et al., 2015).

Cognitive-Behavioral Therapy We have discussed various aspects of cognitive-behavioral therapy for anxiety-related, somatic symptom, depressive, bipo- lar, and eating disorders. Cognitive therapy essentially refers to challenging and changing irrational thoughts about a given situ- ation. Recall that one cognitive mistake commonly made by peo- ple who engage in heavy drinking, especially college students, is that others drink as much or more than they do. Correcting this misperception is thus important. Cognitive therapy may also in- volve modifying cognitive distortions we discussed in Chapters 5 and 7, especially those related to catastrophization. A person with substance use disorder may mistakenly believe if she does not take a certain drug such as cocaine, her performance on a work task will be terrible and she will be �red. Cognitive ther- apy is thus important for addressing psychological dependence and is usually incorporated into behavior therapy techniques.

Behavior therapy refers to changing learning patterns and other maladaptive behaviors associated with a given disorder. Skills training is a key behavioral treatment for substance- related disorders. Skills training involves helping a person un- derstand antecedents and consequences of drug use (recall functional analysis from Chapter 4) and recognizing what situ- ations represent a high risk for return to drug use. The stress of school was a strong trigger or antecedent of Elon’s drug use, and elation and sexual prowess were potent consequences. He also came to see that certain situations were quite risky for him, especially association with drinking buddies and college parties.

Following this step, a person is encouraged to avoid high- risk situations or somehow cope with them effectively (stimulus control). In a high-risk situation, a person may be taught how to appropriately decline offers for alcohol or other drugs, un- derstand one’s limit and adhere strictly to it, leave a situation (party) after a certain time, bring a friend to help monitor alco- hol or other drug use, or think about negative consequences to drug use. People can also learn to plan for emergencies, such as who to contact when tempted by drug use, and control physical arousal and strong emotions tied to cravings for drugs. People with substance-related disorders must also understand that even small events, such as taking a wrong turn when driving and seeing a liquor store, can produce strong cravings that require an adaptive response like calling a friend (Witkiewitz, Bowen, Douglas, & Hsu, 2013).

Skills training may also involve self-monitoring in which a person constantly records the amount of drug taken or various situations and emotions that lead to urges for drug use. The idea here is to make a person as aware as possible of antecedents to drug use as well as actual drug use—the more we are aware of our excess behaviors, the less we tend to engage in them. Thera- pists may combine skills training with cue exposure therapy in which a person is exposed to cues such as the sight and smell of alcohol or a cigarette and then uses skills such as relaxation or discussion to successfully decline drug use (Unrod et al., 2014). Therapists use skills training to prevent relapse to excessive

CHAPTER 9 Substance-Related Disorders276

other ways of coping with stress and other triggers may be suf�cient. Substance-related problems can be devastating, how- ever, and can easily lead to severe consequences such as a car accident, arrest, or loss of a job. If you or someone you know has a serious substance-related problem, such as with cocaine, methamphetamine, or alcohol, then seeking medical and psy- chological help as soon as possible is very important. We rec- ommend consulting a quali�ed professional who specializes in substance use treatment.

Long-Term Outcome for People with Substance-Related Disorders Treating people with substance-related disorders can be com- plicated and involves many pharmacological and psychological components. Relapse is also common in this population. Con- tingency management and cognitive behavioral approaches to treatment seem more effective than other interventions. Success rates, however, vary widely between 30 and 100 per- cent depending on the study (Timko, Moos, & Finney, 2016). Greater success is related to quality of coping skills, a belief that one can remain abstinent, length of treatment, medication compliance, employment, and social connectedness and sup- port (Blonigen et al., 2015).

What is the long-term outcome of people with substance- related disorders? Much of this literature has focused on people with alcoholism. Longitudinal studies indicate that remission rates for alcoholism over several decades are 27 to 69 percent. Approximately 4 to 5 percent of those with an alcohol use dis- order remit each year (Timko et al., 2016). Signi�cant illness and mortality is associated with chronic alcohol use. Long-term dependence on alcohol relates closely to intense craving for alcohol, family history of alcoholism, greater alcohol intake, his- tory of other drug use, and presence of legal and other problems related to drinking (Schuckit & Smith, 2011; Trim, Schuckit, & Smith, 2013).

Long-term follow-up of injection drug users indicates that many enter paths of either cessation or persistent use and re- lapse. Those with early cessation tended to have used a single drug, injected less frequently, and entered treatment (Ahern & Leslie, 2014). Remission rates for those with marijuana depen- dence are about 70 to 97 percent. Those with cocaine, opioid, or amphetamine use often remit as well, although about 4 percent display persistent use (Timko et al., 2016). Those who remit from substance use tend to be more socially stable, have more social and marital support, consume fewer drugs, have fewer life stressors, and rely less on avoidance to cope with dif�culties (Finney, Moos, & Timko, 2013).

➲ Interim Summary • Assessing people with substance-related disorders often

includes screening and motivational interviews as well as psychological testing and observations from others.

• Laboratory testing for substance-related disorders includes urine, blood, hair, saliva, and sweat screens for toxins.

cognitive-behavioral therapy for improving family cohesion and peer relations and for reducing future arrests and excessive sub- stance use. Establishing a strong adolescent-parent alliance ap- pears to be crucial for family members to remain in treatment and complete the program successfully (Liddle, 2014).

Group Therapy Group therapy has always been a popular form of treatment for Group therapy has always been a popular form of treatment for Group therapy people with substance-related disorders. The group meets to- gether with a therapist with the goal of helping to reduce alcohol and other drug use. Group therapy approaches can differ widely based on the orientation of the therapist, but common practices include providing education about the consequences of excessive drug use, encouraging commitment to change, enhancing social support, recognizing cues that lead to excessive substance use, restructuring destructive lifestyles and relationships, and identify- ing alternative ways of coping with stress. The effectiveness of group therapy is not necessarily better than individual treatment but may improve if comorbid psychological problems such as bor- derline personality disorder are addressed (Blonigen et al., 2015).

Self-Help Groups Self-help groups are similar to group therapy in that several people with a substance-related disorder meet to support one another and encourage abstinence. Self-help groups are thus a highly cost-effective means of assisting people with sub- stance-related disorders. Most self-help groups are led not by a professional therapist but by people with a particular sub- stance use problem. Perhaps the most well-known self-help group is Alcoholics Anonymous, which relies on a Twelve Step and Twelve Tradition program that (hopefully) leads one to abstinence under the guidance of a sponsor or senior mem- ber (see Table 9.11). The general philosophy of Alcoholics Anonymous is that alcoholism is a disease controlled only by complete abstinence.

People are more likely to bene�t from Alcoholics Anony- mous if their drinking is particularly severe and if they have a sponsor and attend more meetings (Kelly & Yeterian, 2013). Women, African Americans, those connected to religious and social activities, and those with more education and extraversion tend to be less likely to drop out of Alcoholics Anonymous (Krentzman, Robinson, Perron, & Cranford, 2011). Related Twelve Step groups include Narcotics Anonymous or Cocaine Anonymous for mind-altering substances, as well as groups for family members of people with alcoholism or other substance-related disorder, including Al-Anon/Alateen and Nar-Anon. Many groups, such as Double Trouble in Recovery, address people with substance-related disorders and another mental disorder such as depression.

What If I or Someone I Know Has a Substance-Related Problem or Disorder? If you or someone you know wants to cut down on drinking or smoking, then working with family members to monitor substance use, consulting self-help guides, and discovering

Substance-Related Disorders: Assessment and Treatment 277

use and identifying and changing high-risk situations that could lead to relapse.

• Family, marital, and group therapies provide social support and reinforcement for abstinent behavior.

• Self-help groups involve meetings of people with similar substance use problems who share support and experi- ences to maintain abstinence.

• Many people who seek treatment for a substance-related disorder successfully control the problem, but some experience severe problems much of their life.

• Biological treatment for substance-related disorders includes medications such as agonists, antagonists, partial agonists, and aversives.

• Inpatient and residential treatment for substance-related dis- orders focuses on short-term detoxi�cation and rehabilitation.

• Brief interventions for substance-related disorders involve stabilizing or reducing substance use enough so more thorough forms of treatment can be applied.

• Cognitive-behavioral therapy for substance-related disor- ders involves modifying irrational cognitions about drug

TABLE 9.11

The Twelve Steps and Traditions of Alcoholics Anonymous

The Twelve Steps of Alcoholics Anonymous The Twelve Traditions of Alcoholics Anonymous

We admitted we were powerless over alcohol—that our lives had become unmanageable.

Our common welfare should come �rst; personal recovery depends upon A.A. unity.

Came to believe that a Power greater than ourselves could restore us to sanity.

For our group purpose, there is but one ultimate authority—a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.

Made a decision to turn our will and our lives over to the care of God as we understood Him.

The only requirement for A.A. membership is a desire to stop drinking.

Made a searching and fearless moral inventory of ourselves. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.

Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.

Were entirely ready to have God remove all these defects of character.

An A.A. group ought never endorse, �nance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.

Humbly asked Him to remove our shortcomings. Every A.A. group ought to be fully self-supporting, declining outside contributions.

Made a list of all persons we had harmed, and became willing to make amends to them all.

Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.

Made direct amends to such people whenever possible, except when to do so would injure them or others.

A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.

Continued to take personal inventory and when we were wrong promptly admitted it.

Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.

Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowl- edge of His will for us and the power to carry that out.

Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and �lms.

Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Source: The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (“AAWS”). Permission to reprint the Twelve Steps does not mean that AAWS has reviewed or approved the contents of this publication, or that AAWS necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise.

CHAPTER 9 Substance-Related Disorders278

3. Describe inpatient therapy for substance-related disorder. 4. What psychological treatment strategies could a mental

health professional use to help someone achieve absti- nence? How so?

5. What is the long-term outcome for people with substance- related disorders?

➲ Review Questions 1. Outline major assessment techniques for substance-related

disorders, including interviews, psychological testing, and laboratory assessment.

2. What medications help control symptoms of substance-related disorders? How do they work?

Final Comments Substance use is common and accepted in our society, as demonstrated by widespread use of caffeine, alcohol, and tobacco. Some people thus “cross the line” into using more dangerous drugs or using legal drugs to a severe extent. Many of us might think of the typical person with alcoholism as the “old, homeless guy,” but the reality is that substance use disorder could easily be affecting the person next to you. This is why we always consider the person �rst and the disorder second—saying, for example, people with alcoholism instead of alcoholics!

Thought Questions 1. Think about television shows or �lms you have seen that have characters with substance use

problems. Do you think these characters display realistic or unrealistic symptoms of substance use problems? How so?

2. Think about situations where you engage in substance use. What factors propel you to do so? Why do you think people you know use legal (or illegal) drugs? Having read the chapter, would you change anything about your substance use?

3. What would you now say to a friend who might be using substances too much?

4. What separates “normal” from “abnormal” substance use? Do you think excessive substance use has more to do with biological, personal, family, or other factors? Why?

5. What do you think family members and friends could do to reduce excessive substance use in people they know?

Key Terms substance use 244 substance-related disorder 245 substance use disorder 245 tolerance 245 withdrawal 246 substance intoxication 246 substance withdrawal 246 depressant 247 disinhibition 247 blood alcohol level 247 lethal dose 247 cirrhosis of the liver 251 Korsakoff’s syndrome 251 fetal alcohol syndrome 251

stimulant 253 opiates 254 hallucinogens 254 marijuana 255 mesolimbic system 259 reward de�ciency syndrome 261 stress-induced relapse 262 codependency 265 distal factors 267 proximal factors 267 screening interviews 269 motivational interviewing 269 agonists 273 cross-tolerance 273

antagonists 273 partial agonists 273 aversive drugs 274 detoxi�cation 274 rehabilitation 274 skills training 275 self-monitoring 275 cue exposure therapy 275 contingency management 275 community reinforcement approach 275 multidimensional family therapy 275 self-help groups 276

281

Special Features

CONTINUUM FIGURE 10.1 Continuum of Normal Personality and Personality Disorder Traits Related to Impulsivity 282–283

• 10.1 FOCUS ON COLLEGE STUDENTS: Personality Disorders 292

• 10.2 FOCUS ON VIOLENCE: Personality Disorders and Violence 292

• 10.3 FOCUS ON GENDER: Mirror Images of Personality Disorders? 296

• 10.4 FOCUS ON LAW AND ETHICS: Personality and Insanity 305

V THE CONTINUUM VIDEO PROJECT Tina /Tina / Borderline Personality Disorder 307

Personal Narrative 10.1 Anonymous 308–309

C Michelle / What Do You Think?

Personality Traits, Unusual Personality, and Personality Disorder: What Are They?

Organization of Personality Disorders

Odd or Eccentric Personality Disorders: Features and Epidemiology

C Jackson

Dramatic Personality Disorders: Features and Epidemiology

C Duane

Anxious/Fearful Personality Disorders: Features and Epidemiology

C Betty

Stigma Associated with Personality Disorders

Personality Disorders: Causes and Prevention

Personality Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Personality Disorders 10

CHAPTER 10 Personality Disorders282

C / Michelle

Michelle was 23 years old when she was ad- mitted to a psychiatric inpatient unit after her sixth suicide attempt in 2 years. She told her ex-boyfriend that she swallowed a bottle of aspirin, and he rushed her to the emergency room. Michelle had a 5-year history of depres- sive symptoms that never seemed to ease. She was sad and had poor appetite, low self- esteem, dif�culty concentrating, and hopeless- ness. Michelle’s symptoms of depression were never severe enough to warrant hospitalization or treatment, however.

Michelle also had great dif�culty controlling her emotions. She became intensely sad, irri- table, or anxious almost at a moment’s notice.

These intense negative feelings were often trig- gered by setbacks or arguments but rarely lasted more than 4 to 5 hours. Michelle also had a long history of impulsive behaviors, such as exces- sive drug use, indiscriminant sexual activity, and binge eating.

Michelle’s anger was also unpredict- able and intense. She once used a hammer to smash a wall after receiving a bad grade on a test. Michelle’s relationships with her friends, boyfriends, and parents were intense and unstable as well. People often complained that Michelle became angry with them and criticized them for no apparent reason. She also frequently expressed her fear that oth-

ers (including her parents) might leave or abandon her. Michelle once aggres- sively clutched a friend’s leg to convince her to stay for dinner. Separation was obviously dif�cult for Michelle. She tried to leave home and attend college four times but always returned home within a few weeks. She told her ex-boyfriend before her hospital admission, “I want to end it all” and “No one loves me.”

What Do You Think? 1. Which of Michelle’s behaviors seem typical

of a stressed-out 23-year-old, and which seem very different?

2. What external events and internal factors might be responsible for Michelle’s troubles?

3. What are you curious about regarding Michelle?

4. Does Michelle remind you in any way of yourself or someone you know? How so?

5. How might Michelle’s unusual behaviors affect her life in the future?

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10.1 Continuum of Normal Personality and Personality Disorder Traits Related to Impulsivity

NORMAL MILD

Emotions Stable mood and low levels of impulsive urge. Occasional mood swings and impulsive urges.Occasional mood swings and impulsive urges.

Cognitions Occasional thoughts of spontaneity in a socially adaptive Occasional thoughts of spontaneity in a socially adaptive way.way.

Occasional thoughts of spontaneous activity such as Occasional thoughts of spontaneous activity such as stealing.stealing.

Behaviors Acts different in different situations depending on the social Acts different in different situations depending on the social context.

Occasionally acts inappropriately in work or social situations.Occasionally acts inappropriately in work or social situations.

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

CONTINUUM FIGURE

Personality Traits, Unusual Personality, and Personality Disorder: What Are They? 283

Personality Traits, Unusual Personality, and Personality Disorder: What Are They?

All of us have personality traits that make up who we are. A personality trait can be thought of as a disposition or a readiness to act in a certain way. Think about someone with great integrity. You know this person can be trusted because she is likely to be honest and reliable in what she does. You may also know someone who is shy, which means he is more willing to shun social contacts and pursue solitary activities. Common personality traits that everyone has to some degree include the following:

• Openness: active imagination and sensitivity; opposite is practicality and routine-oriented

• Conscientiousness: self-disciplined and achievement-oriented; opposite is less goal-oriented and more laid-back

• Extraversion: socially gregarious behavior; opposite is introversion

• Agreeableness: compassionate and cooperative; opposite is suspiciousness and antagonism

• Neuroticism: tendency to express negative emotional states; opposite is emotional stability

Some people show extreme levels of personality traits that cause problems. Perhaps you know people who have trouble controlling their emotions, who always �ght with family mem- bers, or who are impulsive or suspicious of others. However, many people with intense personality traits still function fairly well because others tolerate their idiosyncrasies or because their behavior does not signi�cantly interfere with their job or

marriage. Intense personality traits can even be adaptive, as when someone who is overly pushy does well in a sales career.

For people like Michelle, however, personality traits are so extreme, they cause many problems. These people often have unusual, intense, and severe personality traits that appear in many situations. Michelle showed intense impulsivity, anger, and separation anxiety that prevented her from having stable relationships or going to college. People with extreme levels of personality traits that cause great impairment in functioning, especially social and occupational functioning, have a person- ality disorder. Personality disorders lie at the end of a dimen- sional spectrum (see Figure 10.1; Skodol, 2012, 2014; Widiger & Presnall, 2013).

People with a personality disorder have unusual ways of thinking about themselves and others (cognitive feature), expe- riencing and expressing emotions (affective feature), interact- ing with others (interpersonal feature), and controlling impulses (impulse control; see Table 10.1). Think about someone who is overly suspicious. Suspiciousness is a personality trait with cognitive (“Other people want to hurt me”), affective (angry or hostile outbursts), and interpersonal (keeping others at “arm’s length”) features. A suspicious person may also show impulse control problems by sending angry, “�aming” e-mails to others at work if he feels threatened.

Personality disorders involve stable, long-standing, and in- �exible traits. People like Michelle who have a personality disor- der often say their traits can be traced back to childhood or ado- lescence. In�exible traits are a key aspect of personality disorder. The traits are dif�cult for a person to change and appear across many situations. Think about someone’s impulsive behavior at a party—being spontaneous and taking some risks might seem normal in this situation. Being impulsive and goo�ng around at a job site or during a funeral, however, would be maladaptive

MODERATE

PERSONALITY DISORDER—PERSONALITY DISORDER—

LESS SEVERE

PERSONALITY DISORDER—PERSONALITY DISORDER—

MORE SEVEREMORE SEVERE

Frequent mood swings and some impulsive Frequent mood swings and some impulsive urges but little impairment at work or with urges but little impairment at work or with relationships.

Intense mood swings and impulsive urges with Intense mood swings and impulsive urges with signi�cant impairment at work or with relationships.signi�cant impairment at work or with relationships.

Extreme mood swings and impulsive or aggressive Extreme mood swings and impulsive or aggressive urges that lead to self-harm, arrest, or violence.urges that lead to self-harm, arrest, or violence.

Frequent odd thoughts or thoughts of Frequent odd thoughts or thoughts of dangerous activity such as harming self or dangerous activity such as harming self or dangerous activity such as harming self or dangerous activity such as harming self or others.

Intense thoughts of suicide, paranoia, Intense thoughts of suicide, paranoia, abandonment, attention from others, abandonment, attention from others, abandonment, attention from others, vengeance, or work.

Extreme and constant thoughts of Extreme and constant thoughts of suicide, paranoia, abandonment, suicide, paranoia, abandonment, suicide, paranoia, abandonment, attention from others, vengeance, or work.

Problematic personality trait such as Problematic personality trait such as impulsivity or emotional reactivity shown in impulsivity or emotional reactivity shown in many situations.

Problematic personality traits and dangerous behavior shown in most situations.

Problematic personality traits and dangerous behavior shown in almost all situations with intense distress and impairment.

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CHAPTER 10 Personality Disorders284

and inappropriate. People with a personality disorder have great dif�culty changing their behavior from one situation to another and from one interpersonal context to another. Such in�exibility causes signi�cant distress or impairment in social, occupational, or other areas of functioning.

Personality disorders involve traits that deviate signi�cantly from the expectations of a culture. This is important to remem- ber because what may appear to be strange or deviant from the perspective of one culture may be quite normal and adaptive in another (Skodol, 2012; Wake�eld, 2012). Being “reserved” or “shy” in one culture can be seen as “courteous” and “digni�ed” in another culture. Clinicians who assess people for possible per- sonality disorder must consider someone’s cultural background. We discuss next how personality disorders are organized accord- ing to different clusters of traits.

Organization of Personality Disorders

The �fth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) organizes personality disor- ders into three main clusters based on similarity of traits (see Table 10.2). The �rst cluster is the odd/eccentric group, which odd/eccentric group, which odd/eccentric includes paranoid, schizoid, and schizotypal personality disor- ders. People with odd/eccentric personality disorders display features that seem bizarre to others. The second cluster is the

dramatic/erratic/emotional group that includes antisocial, bor- derline, histrionic, and narcissistic personality disorders. People with dramatic/erratic/emotional personality disorders display features that seem exaggerated to others. The third cluster is the anxious/fearful group, which includes avoidant, dependent, and obsessive-compulsive personality disorders. People with anxious/fearful personality disorders display features that seem apprehensive to others. We discuss each of these clusters sepa- rately in this chapter.

The DSM-5 also contains an alternative model of person- ality disorder that is based on dimensions of functioning and requires further study (Skodol, 2012, 2014). This dimensional model emphasizes impairments in personality functioning and traits rather than speci�c categories of disorder. For example, a person could have one or two personality traits that are in�ex- ible and maladaptive. The person could show these traits across many situations and experience great impairment. Think about someone who is often impulsively aggressive toward others at work and in personal relationships.

This dimensional model involves four key elements of per- sonality functioning that could be impaired:

• Identity (e.g., have boundaries with others and regulate one’s emotions)

• Self-direction (e.g., pursue life goals or self-re�ect) • Empathy (e.g., understand others’ perspectives and the

effects of one’s own behavior on others)

• Intimacy (e.g., be close with others and desire to be with others)

This dimensional model also involves personality traits that can be pathological:

• Negative affectivity (e.g., presence of many negative emotions)

• Detachment (e.g., avoidance of others and restricted emotions) • Antagonism (e.g., callousness toward others or self-importance) • Disinhibition (e.g., impulsive behavior and immediate grati-

�cation)

• Psychoticism (e.g., odd behaviors and thoughts)

TABLE 10.2 DSM-5

Personality Disorders

Odd/eccentric Dramatic/erratic/ emotional Anxious/fearful

Paranoid Antisocial Avoidant

Schizoid Borderline Dependent

Schizotypal Histrionic Obsessive-compulsive

Narcissistic

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 10.1 DSM-5

General Personality Disorder A. An enduring pattern of inner experience and behavior that devi-

ates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).

2. Affectivity (i.e., the range, intensity, lability, and appropriate- ness of emotional response).

3. Interpersonal functioning. 4. Impulse control.

B. The enduring pattern is in�exible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not attributable to the physiological ef- fects of a substance or another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Odd or Eccentric Personality Disorders: Features and Epidemiology 285

A dimensional model of personality disorders thus involves impairment in personality functioning and one or more patho- logical personality traits. As such, speci�c categories of person- ality disorder are emphasized less, and a continuum of personal- ity constructs is emphasized more. The categorical approach to personality disorders remains popular among researchers and therapists, however, and thus provides the structure for the rest of the chapter.

Odd or Eccentric Personality Disorders: Features and Epidemiology

Odd or eccentric personality disorders include paranoid, schizoid, and schizotypal personality disorders. Paranoid Personality Disorder Many of us have moments when we do not trust certain people or are cautious around others because we fear harm. Moments of suspiciousness can be realistic and adaptive at times, as when a stranger suddenly approaches you. Other people, however, are constantly mistrustful and suspicious of others, even those they know well. Paranoid personality disorder involves a general distrust and suspiciousness of others (see Table 10.3; American Psychiatric Association [APA], 2013; Furnham & Crump, 2015).

People with this disorder often read harmful intentions from neutral interactions or events and assume the worst. They blame others for their misfortunes and have trouble working collabora- tively or closely with others. Someone with paranoid personality disorder may be rigid, controlling, critical, blaming, and jeal- ous. This person may engage in lengthy and acrimonious legal disputes that are dif�cult to resolve. People with paranoid per- sonality disorder are sometimes not good coworkers or spouses because they are highly argumentative, hostile, and sarcastic.

Schizoid Personality Disorder Many people like to be alone and seem a little awkward around others. Shyness is a personality trait generally accepted in our society as normal and tolerable. In addition, many people who are shy still desire social relationships. Other people, however, show extreme social detachment and isolation and may have schizoid personality disorder (see Table 10.4; APA, 2013; Triebwasser, Chemerinski, Roussos, & Siever, 2012). People with this disorder have little interest in establishing or maintaining relationships with others and show little emotional expression. They have few, if any, friends, rarely marry or have sex, and often do not express joy, sadness, warmth, or intimacy. People with schizoid personality disorder generally do not show the suspiciousness or paranoid ideation of those with paranoid per- sonality disorder but often prefer to work in isolation and may �nd jobs that involve minimal social contact. If they do marry or become parents, they show little warmth and emotional support and appear neglectful, detached, and disinterested.

Schizotypal Personality Disorder Perhaps you know someone who is quirky and unusual in how he acts or dresses. The behavior of some people we meet may seem quite odd or even bizarre. This is not necessarily a problem, however, because different forms of behavior and dress are common to our society. Other people like Jackson (whose story appears shortly), however, have extremely

TABLE 10.3 DSM-5

Paranoid Personality Disorder A. A pervasive distrust and suspiciousness of others such that their

motives are interpreted as malevolent, beginning by early adult- hood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Suspects, without suf�cient basis, that others are exploiting, harming, or deceiving him or her.

2. Is preoccupied with unjusti�ed doubts about the loyalty or trustworthiness of friends or associates.

3. Is reluctant to con�de in others because of unwarranted fear that the information will be used maliciously against him or her.

4. Reads hidden demeaning or threatening meanings into benign remarks or events.

5. Persistently bears grudges. 6. Perceives attacks on his or her character or reputation that

are not apparent to others and is quick to react angrily or to counterattack.

7. Has recurrent suspicions, without justi�cation, regarding �del- ity of spouse or sexual partner.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physi- ological effects of another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. People with paranoid personality disorder are prone to be suspicious

and have dif�culty working with others.

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CHAPTER 10 Personality Disorders286

unusual behaviors, perceptions, and thoughts that cause them signi�cant problems. Schizotypal personality disorder involves interpersonal de�cits, cognitive and perceptual ab- errations, and behavioral eccentricities (see Table 10.5; APA, 2013; Chemerinski, Triebwasser, Roussos, & Siever, 2013; Rosell, Futterman, McMaster, & Siever, 2014). People with schizotypal personality disorder have extreme social anxiety and perhaps paranoia. They are odd, eccentric, or peculiar in their behavior or appearance; display inappropriate or con-

stricted affect; and have few (if any) friends or con�dants outside their immediate family. Schizotypal personality disorder differs from paranoid and schizoid personality disorders in that people with schizotypal personality disorder are usually more odd or eccentric in their behavior and more often have percep- tual and cognitive disturbances.

Many people with schizotypal personal- ity disorder have unusual ideas, beliefs, and communication. They misinterpret or over- personalize events, have unusual ideas that in�uence their behavior (they may think it possible to communicate via telepathy, for ex- ample), and have dif�culty being understood by others. They may show ideas of reference where they believe everyday events some- how involve them when actually they do not (Hummelen, Pedersen, & Karterud, 2012). People with schizotypal personality disorder may drift toward “fringe” groups that sup- port their unusual thinking and odd beliefs. These activities can provide structure for some people with schizotypal personality disorder but also contribute to greater deterioration if psychotic-like or dissociative experiences are encouraged.

case Jackson is a 27-year-old man who just started college after taking time off to “explore himself.” Jackson entered school to study sociology, philosophy, anthropology, and psychology so he could “explain the human race.” Jack- son comes to class with blue spiky hair and dressed in dirty T-shirts and long pants. He often talks to classmates when his instructor is speaking and has alienated most of his peers. Jackson has few friends, poor hygiene, and odd mannerisms. He sometimes stands in class to take notes in the middle of the room, asks questions that have little to do with the class topic, and speaks in a monotone voice. Jackson’s instructor was concerned when his student claimed events on the local news were about him. Jackson said stories involv- ing �re, abduction, and a car accident mirrored what happened to him that day. He also expressed sadness because his classmates would not work on a group project with him.

C / JacksonTABLE 10.4 DSM-5

Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships

and a restricted range of expression of emotions in interper- sonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Neither desires nor enjoys close relationships, including being part of a family.

2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with

another person. 4. Takes pleasure in few, if any, activities. 5. Lacks close friends or con�dants other than �rst-degree

relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or �attened

affectivity.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Schizoid personality disorder involves a strong desire to be alone.

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Odd or Eccentric Personality Disorders: Features and Epidemiology 287

People with schizotypal personality disorder are most likely to seek treatment for anxiety-related or depressive disor- ders. They may show brief or transient psychotic episodes in response to stress. These episodes are relatively short, how- ever, lasting a few minutes to a few hours, and do not typically indicate a psychotic disorder (Chapter 12). Only a small por- tion of people with schizotypal personality disorder develop schizophrenia, but many develop depression. Some of those with schizotypal personality disorder remain marginally em- ployed, withdrawn, and transient throughout much of their lives.

Epidemiology of Odd or Eccentric Personality Disorders Personality disorders occur in about 4 to 15 percent of the general population, although estimates are much higher among psychiatric outpatients. Personality disorders are as- sociated with signi�cant social and occupational dysfunction, comorbid psychopathology, lower quality of life, and suicidal- ity (Trull, Jahng, Tomko, Wood, & Sher, 2010; Tyrer, Reed, & Crawford, 2015). Maladaptive personality traits are also pres- ent in many people with a major mental disorder (Crego & Widiger, 2016).

Researchers estimate that odd or eccentric personality disorders occur in 2.1 percent of the general population. Specific prevalence rates have been reported for paranoid

(1.9 percent), schizoid (0.6 percent), and schizotypal (0.6 percent) personality disorders (Trull et al., 2010). Many people with odd or eccentric personality disorders either do not seek treatment or seek treatment for other prob- lems. These personality disorders are highly comorbid with anxiety-related, depressive, bipolar, substance use, and psy- chotic disorders, as well as disruptive behavior disorders such as attention-deficit/hyperactivity disorder. Findings are mixed with respect to gender differences related to odd or eccentric personality disorders (Links & Eynan, 2013; Trull et al., 2010).

Racial and ethnic differences are not prominent in personality disorders. Race and ethnicity should be closely considered, however, when assessing a client for an odd or eccentric personality disorder. Someone who is angry, frus- trated, and guarded does not necessarily have paranoid per- sonality disorder. Consider a recent immigrant to the United States who is unfamiliar with English and American customs. This person would be understandably cautious and suspi- cious of others. Some people may also appear introverted, isolated, or aloof when these behaviors are a natural part of their culture. A diagnosis of schizoid personality disorder would not apply. Clinicians must also be sure not to confuse symptoms of schizotypal personality disorder with religious experiences, folk beliefs, or linguistic peculiarities shown by certain cultural groups. For example, the ghost dance is performed by many Native Americans who believe the ritual allows them to visit relatives or friends who have left their bodies. Such a belief should not be mistaken for evidence of a personality disorder.

TABLE 10.5 DSM-5

Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal de�cits marked by

acute discomfort with, and reduced capacity for, close relation- ships as well as by cognitive or perceptual distortions and eccen- tricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by �ve (or more) of the following:

1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that in�uences behavior and is

inconsistent with subcultural norms. 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech. 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or con�dants other than �rst-degree

relatives. 9. Excessive social anxiety that does not diminish with familiarity

and tends to be associated with paranoid fears rather than negative judgments about self.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

People with schizotypal personality disorder may seek out others who share their odd beliefs. Although it is not known whether they had schizotypal personality disorder, members of the Heaven’s Gate cult showed characteristic behavior of this disorder. Thirty-nine Heaven’s Gate members committed mass suicide because they believed that after their deaths, a UFO that was hiding behind the Hale-Bopp comet would pick them up. Their leader, Marshall Applewhite (pictured), claimed to be an alien from outer space.

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CHAPTER 10 Personality Disorders288

➲ Interim Summary • Personality disorders involve dysfunctional and in�exible

personality traits that deviate signi�cantly from cultural expectations and are shown across many situations.

• Personality disorders include traits that are odd or ec- centric; dramatic, erratic, or emotional; and anxious or fearful.

• Odd or eccentric personality disorders include paranoid, schizoid, and schizotypal personality disorders.

• Paranoid personality disorder involves general distrust and suspiciousness of others.

• Schizoid personality disorder involves social isolation and restricted emotional experience and expression.

• Schizotypal personality disorder involves social anxiety, paranoid fears, and eccentric behavior, perceptions, and thoughts.

• Personality disorders are prevalent throughout the general population, but odd or eccentric personality disorders are more common in clinical samples.

• Odd or eccentric personality disorders are comorbid with other mental disorders such as anxiety-related and depres- sive disorders but are not highly linked to gender, race, or ethnicity.

➲ Review Questions 1. What are the main features of a personality disorder? 2. What are the main clusters of personality disorder? 3. What are the main odd or eccentric personality disorders and

their features? 4. How common are odd or eccentric personality disorders? 5. What mental disorders are most associated with odd or

eccentric personality disorders?

Dramatic Personality Disorders: Features and Epidemiology

Recall that a second cluster of personality disorder involves dramatic, erratic, or overly emotional behavior that seems exaggerated to others. This group includes antisocial, border- line, histrionic, and narcissistic personality disorders. Consider the case of Duane for antisocial personality disorder.

Antisocial Personality Disorder Duane exhibits many features of antisocial personality disor- der. Antisocial personality disorder involves a pattern of be- havior that re�ects an extreme disregard for and violation of the rights of others (see Table 10.6; APA, 2013; Black, 2013; Glenn, Johnson, & Raine, 2013). Antisocial personality disor- der involves deceitfulness, impulsivity, irritability/aggressive- ness, criminal acts, and irresponsibility. Not all people with antisocial personality disorder have criminal records, however. People with the disorder often commit reckless acts that ne- glect the safety of others, and they lack remorse for harm they in�ict. Those with antisocial personality disorder are unlikely to maintain steady employment. Some people with the disor- der can obtain professional and criminal success as long as their violations and deceptions are undiscovered. Their suc- cess may unravel at some point, however, because of their im- pulsivity, negligence, and lack of foresight. People with antiso- cial personality disorder may at �rst appear charming, fun, and engaging, but many of their social relationships eventually fail because of poor empathy, in�delity, and lack of responsibility as well as episodes of maltreatment, exploitation, and angry hostility.

Antisocial personality disorder is evident in childhood in the form of conduct disorder (Chapter 13). Conduct disorder involves aggression toward people and animals, property de- struction, deceitfulness or theft, and serious violations of laws and rules. Evidence of conduct disorder before age 15 years is required for a diagnosis of antisocial personality disorder. Not all children with conduct disorder will eventually meet criteria for antisocial personality disorder, although some do (Jaffee & Odgers, 2014).

Psychopathy is a diagnostic construct related to anti- social personality disorder. Psychopathy involves little re- morse or guilt, poor behavioral control, arrogance, super�cial charm, exploitativeness, and lack of empathy (Kiehl & Sinnott- Armstrong, 2013). Many people with psychopathy are intensely goal-directed toward money, sex, and status. Many people with antisocial personality disorder like Duane display psychopa- thy (Anderson, Sellborn, Wygant, Salekin, & Krueger, 2014).

case Duane was a man in his 20s whose father had left when he was a child. Duane frequently encountered trouble as a youth that led to extended stints in reform school or prison. He earned respect from others, however, be- cause of his fearlessness, self-con�dence, and intelligence. He eventually became a pilot and businessman and was adept at construction. Duane was charming, especially to women, and helped break up several marriages

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among his friends and relatives. Duane was also aggressive toward others and impulsive. He once broke into a friend’s safe and traded gunshots with a police of�cer.

Duane used his charm to become a successful businessman in con- struction but had little capacity for love or empathy and little interest in the truth. He exaggerated his prowess in hunting and shooting but lacked insight that others could notice his lies. Duane enjoyed being admired and respected by others, but those who knew him well understood he was a manipulator and that his good fellowship was false. Duane used his charm to swindle people out of money and often found dangerous situations such as �ying through fog to be thrilling. Lykken, D.T. (1995). The antisocial personalities. Hillsdale, NJ: Erlbaum.

Dramatic Personality Disorders: Features and Epidemiology 289

Antisocial personality disorder and psychopathy overlap with respect to antisocial behaviors and impulsivity (Wygant et al., 2016; see Box 10.2 on page 292).

Borderline Personality Disorder Some people are dramatic in their behavior but still maintain good social and occupational relationships. Other people like Michelle (the �rst case study), however, have features of bor- derline personality disorder (see Table 10.7; APA, 2013; Trull, 2015). Borderline personality disorder involves a pattern of impulsivity and unstable affect, interpersonal relationships, and self-image. The term “borderline” re�ects a traditional view that the disorder was on the “borderline” of neurosis and psychosis. People with borderline personality disorder frequently experi- ence strong, intense negative emotions and are prone to suicidal threats, gestures, or attempts. They are unsure of their self-image as well as their views of other people. They harbor intense abandonment fears and feelings of emptiness, as Michelle did. Stressful situations may lead to transient paranoid ideation or dissociation. Associated features include self-defeating behavior such as making a bad decision that destroys a good relation- ship, depressive or substance use disorder, and premature death from suicide. Approximately 10 percent of those with borderline personality disorder commit suicide and 60 to 70 percent at- tempt suicide (Carpenter, Tomko, Trull, & Boomsma, 2013; see Box 10.2 on page 292).

Histrionic Personality Disorder Have you ever known someone who always had to be the center of attention? Some people have quite an entertaining presence and are the life of the party. Other people, how- ever, take attention-seeking behaviors to an extreme. People

TABLE 10.6 DSM-5

Antisocial Personality Disorder A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the

following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal pro�t or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical �ghts or assaults. 5. Reckless disregard for safety or self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor �nancial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

The �lm character Anton Chigurh in No Country for Old Men exhibited many features of psychopathy.

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CHAPTER 10 Personality Disorders290

with histrionic personality disorder display pervasive and excessive emotionality and attention seeking (see Table 10.8; APA, 2013; Ferguson & Negy, 2014). Hallmarks of histrionic personality disorder include actions that place oneself in the center of attention, provocative or inappropriately intimate behavior, �eeting and super�cial emotional expression, and suggestibility. Histrionic personality disorder is different than borderline personality disorder in that the latter typically involves self-destructive behavior, feelings of deep empti- ness and identity disturbance, and angry disruptions in close relationships.

People with histrionic personality disorder experience dif- �cult romantic relationships and friendships. They have trouble balancing strong needs for attention and intimacy with the real- ity of a situation. They have trouble delaying grati�cation and tend to act impulsively. People with this disorder have an in- tense need to be loved, desired, and involved with others on an intimate basis and will use various means toward this end. They may use their physical appearance to draw attention to themselves and be melodramatically emotional or inappropri- ately seductive. They may perceive a relationship as being more intimate than it is because of their need for romantic fantasy.

Narcissistic Personality Disorder Have you ever known someone who talked endlessly about his accomplishments? Some people who promote themselves have a healthy level of self-con�dence that might be annoying but not pathological. Other people, however, have such a strong need to impress others that they experience many social problems.

TABLE 10.7 DSM-5

Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by �ve (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. 2. A pattern of unstable and intense interpersonal relationships

characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self- image or sense of self.

4. Impulsivity in at least two areas that are potentially self- damaging.

5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.

6. Affective instability due to a marked reactivity of mood. 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or dif�culty controlling anger. 9. Transient, stress-related paranoid ideation or severe

dissociative symptoms.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Self-harm is a common feature of borderline personality disorder.

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Dramatic Personality Disorders: Features and Epidemiology 291

People with narcissistic personality disorder display grandios- ity, need for admiration, and lack of empathy for others (see Table 10.9; APA, 2013; Roepke & Vater, 2014; Skodol, Bender, & Morey, 2014). People with this disorder have an exaggerated sense of self-importance and believe they are so unique they can only be understood by similarly “special” people. These views lead to distasteful interpersonal behaviors, such as arrogance, exploitation, and a sense of entitlement (Pincus, Cain, & Wright, 2014). Narcissistic personality disorder differs from borderline and histrionic personality disorders in that those with narcis- sistic personality disorder have marked grandiosity but less self- destructiveness, impulsivity, or concerns about abandonment.

People with narcissistic personality disorder seem to have high self-con�dence and self-esteem but are actually quite vul- nerable to real or perceived threats to their status (Pincus et al., 2014). People with the disorder may express rage or become vengeful if challenged. They tend to have “serial friendships,” meaning relationships end when others no longer express ad- miration or envy. People with the disorder cannot tolerate crit- icism or defeat, and this may keep them from high levels of achievement.

Epidemiology of Dramatic Personality Disorders Researchers estimate that dramatic personality disorders occur in 5.5 percent of the general population. Speci�c prevalence rates have been reported for antisocial (3.8 percent) and bor- derline (2.7 percent) personality disorders (Trull et al., 2010). Features of borderline personality disorder also commonly occur in college students (Box 10.1). Many researchers believe

histrionic and narcissistic personality disorders are more rare, however. Speci�c prevalence rates have been reported for his- trionic (0.3 percent) and narcissistic (1.0 percent) personality disorders (Trull et al., 2010).

People with antisocial personality disorder are commonly found in substance use treatment, forensic, and prison settings (Zlodre, Yiend, Burns, & Fazel, 2015). In general, antisocial per- sonality disorder shows the strongest association with a wide range of criminal offenses, compared with other personality dis- orders (Ogloff, Talevski, Lemphers, Wood, & Simmons, 2015). Antisocial personality disorder is more common among men (Trull et al., 2010) and among those from lower socioeconomic classes and urban settings. People with antisocial personality disorder may migrate to urban settings and become socially or economically impoverished, or impoverishment may contribute to the development of antisocial traits. The diagnosis does not apply to someone whose antisocial behavior represents a protec- tive survival strategy, especially in extreme poverty.

Borderline personality disorder is the most frequently diag- nosed personality disorder in inpatient and outpatient settings. More women than men reportedly meet criteria for borderline personality disorder, but this is based primarily on clinical stud- ies. Rates of borderline personality disorder in men and women appear to be similar in the general population (Busch, Balsis, Morey, & Oltmanns, 2015). Borderline personality may be misdi- agnosed among adolescents who sometimes become angry and �ght with family members. Many youth eventually “grow out” of these behaviors and become responsible adults. People with true borderline personality disorder, however, show chronic and pervasive maladaptive traits into adulthood.

TABLE 10.8 DSM-5

Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by �ve (or more) of the following:

1. Is uncomfortable in situations in which he or she is not the center of attention.

2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

3. Displays rapidly shifting and shallow expression of emotions.

4. Consistently uses physical appearance to draw attention to self.

5. Has a style of speech that is excessively impressionistic and lacking of detail.

6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.

7. Is suggestible. 8. Considers relationships to be more intimate than they

actually are.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 10.9 DSM-5

Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by �ve (or more) of the following:

1. Has a grandiose sense of self-importance. 2. Is preoccupied with fantasies of unlimited success, power, bril-

liance, beauty, or ideal love. 3. Believes that he or she is “special” and unique and can only

be understood by, or should associate with, other special or high-status people (or institutions).

4. Requires excessive admiration. 5. Has a sense of entitlement. 6. Is interpersonally exploitative. 7. Lacks empathy: is unwilling to recognize or identify with the

feelings and needs of others. 8. Is often envious of others or believes that others are envious of

him or her. 9. Shows arrogant, haughty behaviors or attitudes.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 10 Personality Disorders292

Histrionic personality disorder is more prevalent among women (Trull et al., 2010), but cultural, gender, and age norms must be considered to determine whether a certain behavior indicates this disorder. The diagnostic criteria for this disorder closely resemble traits that de�ne stereotypic femininity, so clini- cians may misdiagnose histrionic personality disorder in women (Boysen, Ebersole, Casner, & Coston, 2014). Cultural groups also differ with respect to emotional expression (Ryder, Sunohara, Kirmayer, 2015). Histrionic personality should be considered only if a person’s emotional expression is excessive within her cultural group and causes distress or impairment. Histrionic per- sonality disorder is likely to be diagnosed in some cultural groups more than others. The disorder may be less frequent in Asian cul- tures and more frequent in Hispanic and Latin American cultures

because of cultural differences in the overt expression of sexual interest and seductiveness (Paniagua, 2014).

Narcissistic personality disorder appears to be more preva- lent among men (Roepke & Vater, 2014; Trull et al., 2010). The disorder is a controversial one for several reasons. First, ideal- ism is characteristic of many adolescents and young adults and should not be mistaken for the traits and behaviors of narcissis- tic personality disorder. The disorder should be diagnosed only when such beliefs are extremely unrealistic and cause signi�- cant distress or impairment. Second, not all mental health pro- fessionals worldwide recognize narcissistic personality disorder. Pathological narcissism may be a manifestation of a modern, Western society that is self-centered and materialistic and less centered on familial or interpersonal bonds (MacDonald, 2014).

and neglect, tends to predict features of borderline personality disorder (Hong & Lishner, 2016). Others have also found that rejection sensitivity, or the tendency to anxiously anticipate and readily perceive social rejec- tion, helps explain why borderline features lead to less social support among some college students (Zielinski & Veilleux, 2014).

Pistorello and colleagues (2012) thus tested a dialectical treatment program for college students with nonsuicidal self-injury and features of borderline personality disorder. Treatment included individual and group therapy that focused on distress tolerance, emotional regulation, interper- sonal effectiveness, and mindfulness. Those who completed treatment showed improvements in suicidality and suicidal thoughts, depression, so- cial adjustment, and symptoms of borderline personality disorder. Others have found that briefer dialectical behavior therapy can also be successful for college students (Chugani, Ghali, & Brunner, 2013). Treatment for sui- cidality, depression, and features of borderline personality disorder is thus effective for college students and adaptable to campus counseling centers.

Focus On

A common set of problems in college students includes depression, suiA common set of problems in college students includes depression, sui- cidal ideation, nonsuicidal self-injury, and features of borderline personal- ity disorder. About 15 percent of college students have substantial features of borderline personality disorder, and about 4 percent have a probable or de�nite diagnosis (Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012). A key predictor of symptoms of borderline personality disorder in college students is a history of child sexual maltreatment. In addition, pervasive invalidation by a primary caregiver, which may include rejection, hostility,

10.1

College Students Personality Disorders

or suicidal behavior. Violence committed by those with antisocial per- sonality disorder, however, is typically directed toward others. Antisocial behavior may be marked by psychopathy as well.

Studies of the relationship between psychopathy and violence have pro- duced some interesting �ndings regarding the nature of violent acts asso- ciated with this condition (Blais, Solodukhin, & Forth, 2014). People with psychopathy, compared with nonpsychopathic criminals, are more likely to commit violence that is predatory (e.g., stalking), callous or cold-hearted, less emotionally driven, and more premeditated; in addition, psychopathy is associated with reactive (emotional) violence as well (Blais et al., 2014). However, some evidence suggest that people with prominent features of a type of psychopathy—consisting of a chronic antisocial and socially deviant lifestyle—appear more likely to commit crimes of passion and engage in reac- tive (emotionally driven) violence than their counterparts (Blais et al., 2014).

Focus On

The personality disorders most often associated with violence are the The personality disorders most often associated with violence are the dramatic personality disorders, especially borderline personality disorder and antisocial personality disorder (Howard, 2011; Paris, 2015). These personality disorders involve high levels of impulsivity and risk taking. Violence committed by those with borderline personality disorder is typi- cally directed toward themselves in the form of self-harm, self-mutilation,

Violence Personality Disorders and Violence

10.2

Anxious/Fearful Personality Disorders: Features and Epidemiology 293

Dramatic personality disorders are highly comorbid with psychological problems and other mental disorders. People with antisocial personality disorder are at signi�cant risk for unem- ployment, poverty, injury, violent death, excessive alcohol and other drug use, incarceration, recidivism (parole violation), and substantial relationship instability (Black, 2013; Davison & Janca, 2012; Glenn et al., 2013). Borderline personality disorder is closely associated with substance use, depression, and suicid- ality (Trull, 2015; Wedig et al., 2012).

➲ Interim Summary • Dramatic, erratic, or emotional personality disorders

include antisocial, borderline, histrionic, and narcissistic personality disorders.

• Antisocial personality disorder involves an extreme disre- gard for and violation of the rights of others.

• Psychopathy involves problematic interpersonal styles, such as arrogance, lack of empathy, and manipulativeness.

• Borderline personality disorder involves impulsivity, unstable affect and interpersonal relationships, and suicidality.

• Histrionic personality disorder involves an excessive need for attention, super�cial and �eeting emotions, and impulsivity.

• Narcissistic personality disorder involves grandiosity, need for admiration, and lack of empathy for others.

• The most common dramatic personality disorders are antisocial and borderline personality disorders, but all disorders of this group involve substantial distress and/or impairment.

➲ Review Questions 1. What are the main features of antisocial personality disorder

and psychopathy? 2. What are key features of borderline, histrionic, and narcissis-

tic personality disorders? 3. Describe the epidemiology of the dramatic personality disor-

ders, including issues of gender and culture.

Anxious/Fearful Personality Disorders: Features and Epidemiology

Recall that a third cluster of personality disorder involves anxious or fearful behavior that seems apprehensive to others. This group includes avoidant, dependent, and obsessive- compulsive personality disorders.

Avoidant Personality Disorder Have you ever known someone who was shy and seemed uncom- fortable at parties or other social events? We mentioned earlier

that shyness is common in our society and usually tolerated well. Many people who are shy have a good self-image. Other people, however, have intense fears of inadequacy and nega- tive evaluation. These people want relationships with others but have extreme dif�culty initiating contact. Avoidant personal- ity disorder involves a pervasive pattern of anxiety, feelings of inadequacy, and social hypersensitivity (see Table 10.10; APA, 2013; Lampe, 2016).

People with avoidant personality disorder often avoid jobs or situations that require signi�cant interpersonal contact; they are seen as “shy” or “loners.” People with the disorder avoid others because they see themselves as inept, unappealing, or inferior. They are also afraid of being embarrassed or rejected by others. People with avoidant personality disorder become in- volved with others only in situations in which they feel certain of acceptance. Those with the disorder want close relationships, so this aspect makes them different from people with schizoid personality disorder. Other features of avoidant personality dis- order include hypervigilance in social situations and low self- esteem.

People with avoidant personality disorder often do well at their jobs as long as they can avoid public presentations or leadership. Social functioning and social skills development are usually greatly impaired, however. If a person with avoidant personality disorder does develop a close relationship, he will likely cling to the person dependently. Many people with avoid- ant personality disorder also have anxiety-related disorders such as social phobia as well as depression.

TABLE 10.10 DSM-5

Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Avoids occupational activities that involve signi�cant interper- sonal contact because of fears of criticism, disapproval, or rejection.

2. Is unwilling to get involved with people unless certain of being liked.

3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

4. Is preoccupied with being criticized or rejected in social situations.

5. Is inhibited in new interpersonal situations because of feelings of inadequacy.

6. Views self as socially inept, personally unappealing, or inferior to others.

7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 10 Personality Disorders294

Dependent Personality Disorder

case Betty is a 47-year-old woman who has been married 27 years. She has �ve children aged 8, 12, 16, 20, and 24 years. Her husband insisted on having children every 4 years in their marriage, and Betty complied. Betty has been a homemaker during her marriage, taking care of her children and husband by assuming all household chores. Her few friends describe Betty as meek, quiet, and subservient. She is not the kind of person who “rocks the boat,” and she usually complies with others’ requests in PTA, Scout, and church meetings. Betty rises at 5 a.m. and will not go to sleep before 11 p.m. unless all her tasks are completed. She was recently hospitalized for depression and exhaustion but left against medical advice to prepare dinner for her family at home.

C / Betty

Have you ever known someone who was a “follower” and al- ways seemed to conform to what others wanted to do? Many of us occasionally bend to our friend’s wishes to go someplace or do something we are not thrilled about doing. At other times, however, we speak up and assert what we want. For people like Betty, however, conformity is a way of life. Dependent person- ality disorder involves a pervasive, excessive need to be cared for, leading to submissiveness, clinging behavior, and fears of separation (see Table 10.11; APA, 2013; Disney, 2013).

People with dependent personality disorder “give their lives over” to others—they ask for advice and guidance about even the smallest of decisions, seem helpless, and readily abdicate responsibility for most areas of their lives. Their fear that oth- ers may reject or leave them is so intense, they will not ex- press disagreements with others. They may even volunteer to do unpleasant, demeaning tasks to gain nurturance and ap- proval. People with dependent personality disorder are prone to low self-esteem, self-doubt, self-criticism, and depression and anxiety-related disorders. Their neediness and desperation often prevents them from carefully selecting a person who will protect them and be supportive. The result may be bad choices—they may choose their partners indiscriminately and become quickly attached to unreliable, uncaring, and abusive people.

Obsessive-Compulsive Personality Disorder Have you ever known someone who was very organized and attended to all details of a task with great passion? Perhaps you have known someone with a type A personality marked by competitiveness, time-consciousness, impatience, and “worka- holism.” Attention to detail and organization are considered positive traits in our society, although some aspects of type A personality have been linked to heart disease in men. Other people, however, spend inordinate amounts of time on detail and organization. Obsessive-compulsive personality disorder involves a preoccupation with orderliness, perfectionism, and control (see Table 10.12; APA, 2013; Diedrich & Voderholzer,

TABLE 10.11 DSM-5

Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by �ve (or more) of the following:

1. Has dif�culty making everyday decisions without an excessive amount of advice and reassurance from others.

2. Needs others to assume responsibility for most major areas of his or her life.

3. Has dif�culty expressing disagreement with others because of fear of loss of support or approval.

4. Has dif�culty initiating projects or doing things on his or her own (because of a lack of self-con�dence in judgment or abili- ties rather than a lack of motivation or energy).

5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

6. Feels uncomfortable or helpless when alone because of exag- gerated fears of being unable to care for himself or herself.

7. Urgently seeks another relationship as a source of care and support when a close relationship ends.

8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 10.12 DSM-5

Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of �exibility, openness, and ef�ciency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

2. Shows perfectionism that interferes with task completion. 3. Is excessively devoted to work and productivity to the exclusion

of leisure activities and friendships (not accounted for by obvi- ous economic necessity).

4. Is overconscientious, scrupulous, and in�exible about matters of morality, ethics, or values (not accounted for by cultural or religious identi�cation).

5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.

6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

8. Shows rigidity and stubbornness.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Stigma Associated with Personality Disorders 295

2015). Despite the similarity in name, this personality disorder is different from obsessive-compulsive disorder (Chapter 5) in that those with the personality disorder do not generally have obsessions or compulsions.

People with obsessive-compulsive personality disorder are rigid, stubborn, and perfectionistic to the point that tasks never get completed. Their preoccupation with rules, details, and mo- rality cause them trouble at work and outside of work. They are seen as in�exible and miserly and may be described by others as “control freaks.” Other features of this personality disorder include hoarding, indecisiveness, reluctance to delegate tasks, low affection, rumination, and anger outbursts.

Many people with obsessive-compulsive personality disor- der are successful at their career. They can be excellent workers to the point of excess, sacri�cing their social and leisure activi- ties, marriage, and family for their job. People with this disorder tend to have strained relationships with their spouse and chil- dren because of their tendency to be detached and uninvolved but also authoritarian and domineering. A spouse or partner may complain of little affection, tenderness, and warmth. Re- lationships with colleagues at work may be equally strained by excessive perfectionism, domination, indecision, worrying, and anger. Jobs that require �exibility, openness, creativity, or diplo- macy may be particularly dif�cult for someone with obsessive- compulsive personality disorder.

People with obsessive-compulsive personality disorder may be prone to various anxiety and physical disorders because of their worrying, indecision, and stress. People with the disorder who are angry and hostile may be prone to cardiovascular disor- ders. Depression may not develop until a person recognizes the sacri�ces that have been made by their devotion to work and productivity, which may not occur until middle age. Most people with this personality disorder experience early employment or career dif�culties and even failures that may result in depression.

Epidemiology of Anxious/Fearful Personality Disorders Researchers estimate that anxious/fearful personality disorders occur in 2.3 percent of the general population. Speci�c preva- lence rates have been reported for avoidant (1.2 percent), de- pendent (0.3 percent), and obsessive-compulsive (1.9 percent) personality disorders (Trull et al., 2010).

Avoidant personality disorder occurs more frequently in women (Trull et al., 2010). Religious and cultural in�uences may be responsible for submissive and self-effacing behaviors in some individuals (Hsu et al., 2012). People from an extremely funda- mentalist religious background may appear to “avoid” socializing with others, especially at events in which alcoholic beverages are served. One must understand the “avoidant” behavior in the context of someone’s strong religious beliefs and prohibitions.

Dependent personality disorder is more common in women (Trull et al., 2010). The prevalence and diagnosis of dependent per- sonality disorder may also vary across cultures, however, because many societies value dependency-related behaviors (Disney, 2013). Western societies place more emphasis and value on expressions

of autonomy and self-reliance, so people in these cultures may be more prone to a diagnosis of dependent personality disorder (Mulder, 2012). Interpersonal connectedness and interdependency are highly valued in Japanese and Indian cultures, so dependency may be seen as pathological less often.

Obsessive-compulsive personality disorder also occurs more frequently in women (Trull et al., 2010). Mental health professionals must be careful not to misdiagnose this disor- der because many people are conscientious, devoted to their work, organized, and perfectionistic. Only when these features produce signi�cant distress or impairment can they be consid- ered indicators of obsessive-compulsive personality disorder. Anxious/fearful personality disorders are often comorbid with anxiety-related, depressive, and somatic symptom disorders.

Stigma Associated with Personality Disorders

Many people with personality disorders have strong emo-tions and impulsive behavior. This kind of behavior can increase the chances of being stigmatized. Paris (2015) high- lighted several reasons why those with personality disorders may be stigmatized. First, despite that fact that we all have a personality, we tend to assume those with personality problems bring it on themselves, whereas we attribute our own personal- ity dif�culties to challenging situations or events. Second, many mental health professionals (and laypeople as well) still hold the view that personality disorders are incurable, despite evidence to the contrary. Evidence indicates that some mental health professionals believe that clients with personality disorders are more dif�cult to manage than clients without personality disor- ders (Sansone & Sansone, 2013). Such negative perceptions may

Obsessive-compulsive personality disorder is characterized by perfectionism, excessive dedication to work, and in�exibility.

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CHAPTER 10 Personality Disorders296

lead some mental health professionals to withdraw or keep their emotional distance from those with powerful affective states such as anger or troublesome behaviors such as self-injury or multiple suicide attempts. Finally, Paris argued that many pa- tients with personality disorder are misdiagnosed and often receive ineffective psychological treatment or medication. The result is often a continuation of symptoms and dif�culties, lead- ing to the individual experiencing self-stigmatizing thoughts like “I am untreatable” or “I am will never get better.”

Imagine a scenario in which negative perceptions of a client with borderline personality disorder can actually worsen symp- toms. The cycle may begin when a mental health professional expects that a certain client will be dif�cult and manipulative. The therapist may then withdraw emotionally to avoid being manipulated and assume that the client’s behavior is something the client can control but chooses not to. Unfortunately, the unresponsiveness of the therapist can actually trigger a client’s tendency to be self-critical and this may lead to self-destructive behavior. This behavior may induce the therapist to withdraw even more, and the client may eventually leave treatment pre- maturely (Richardson-Vejlgaard, Broudy, Brodsky, Fertuck, & Stanley, 2013). Antistigma interventions for mental health pro- fessionals may thus focus on greater acceptance of and commit- ment to clients with personality disorders as well as enhanced skills training to address dif�cult behaviors and reduce social distance (Sheehan, Nieweglowski, & Corrigan, 2016).

➲ Interim Summary • Anxious/fearful personality disorders include avoidant,

dependent, and obsessive-compulsive personality disorders.

• Avoidant personality disorder involves a pervasive pattern of anxiety, feelings of inadequacy, and social hypersensitivity.

• Dependent personality disorder involves a pervasive, excessive need to be cared for, leading to submissiveness, clinging behavior, and fears of separation.

• Obsessive-compulsive personality disorder involves a preoccupation with orderliness, perfectionism, and control.

• The most common anxious/fearful personality disorders are avoidant and obsessive-compulsive personality dis- orders, but all disorders of this group involve substantial distress and/or impairment.

• Strong emotions and impulsive behavior often associated with personality disorders can be a source of stigma for this population.

➲ Review Questions 1. What are the main features of avoidant personality disorder? 2. What are key features of dependent and obsessive-

compulsive personality disorders? 3. Describe the epidemiology of the anxious/fearful personality

disorders, including issues of gender and culture.

Personality Disorders: Causes and Prevention

We turn our attention next to risk factors and how our knowledge of these factors might help us prevent person- ality disorders. Researchers of personality disorders often focus on genetic, neurobiological, family environment, cognitive, and personality factors. The following discussion is organized by cluster of personality disorder; for each cluster, we explore bio- logical risk factors, environmental risk factors, and causes.

personality disorders reveal that both groups suffered more child maltreat- ment than control participants. Those who eventually develop borderline personality disorder often have cognitive schemas related to detachment from others, emotional expression, need grati�cation, helplessness and pow- erlessness, and feeling worthy of punishment. Those who eventually develop antisocial personality disorder often have cognitive schemas related to at- tacking, bullying, and humiliating others (Lobbestael & Arntz, 2015; Lobbes- tael, Cima, & Arntz, 2013).

Certain precursors to personality disorders may also be evident in chil- dren, some of which may be more pertinent to boys or girls. Precursors to personality disorder that may be more present in boys include restricted emotion, distant relationships, exaggerated sense of self, and lack of con- cern for others’ needs. Precursors to personality disorder that may be more present in girls include expressive emotion, overly close relationships, nega- tive sense of self, and overconcern for others’ needs. These patterns may have important rami�cations for preventing and treating personality disor- ders (De Fruyt & De Clercq, 2014).

Focus On

A long-standing debate is whether personality disorders essentially derive from the same causes but go in different directions for men and women. Some disorders do seem more particular to men, especially paranoid, schiz- oid, schizotypal, antisocial, narcissistic, avoidant, and obsessive-compulsive personality disorders. Other disorders seem more particular to women, espe- cially borderline, histrionic, and dependent personality disorders.

Are certain personality disorders “mirror images” of one another after some childhood trauma? Evaluations of people with antisocial and borderline

Gender Mirror Images of Personality

Disorders?

10.3

Personality Disorders: Causes and Prevention 297

Biological Risk Factors for Odd or Eccentric Personality Disorders Recall that odd or eccentric personality disorders include para- noid, schizoid, and schizotypal types. Genetics likely play a lim- ited role in the development of odd or eccentric personality dis- orders, with heritability estimates of just 0.29 to 0.38 (Kendler et al., 2011). Schizotypal personality disorder may share a com- mon genetic risk factor with schizophrenia. This is consistent with the theory that schizotypal personality disorder lies on the “schizophrenia spectrum,” a continuum of schizophrenia-like syndromes and symptoms. Schizotypal personality disorder may represent a less severe and less dysfunctional form of schizo- phrenia (Rosell et al., 2014).

Genetics may set the stage for cognitive and perceptual problems important in odd or eccentric personality disorders, especially schizotypal personality disorder. This is known as a psychobiological theory of personality disorders (Millon & Strack, 2015). Many people with these disorders have trouble attend- ing to and selecting relevant stimuli in the environment (Rosell et al., 2014). This results in misunderstandings, suspiciousness of others, extreme social detachment, and trouble separating what is real and what is imagined. These problems appear to be somewhat biologically based.

Twin studies of personality traits also suggest a genetic in- �uence on the development of odd or eccentric personality dis- orders. The personality traits of restricted emotional expression, suspiciousness, and cognitive distortion appear to be in�uenced by genetic factors. These three traits are central to odd or ec- centric personality disorders (Perez-Rodriguez, New, & Siever, 2013). Genetics may also in�uence changes in the neurotrans- mitter dopamine that can predispose a person to odd or eccen- tric behaviors (Mohr & Ettinger, 2014).

Environmental Risk Factors for Odd or Eccentric Personality Disorders Family factors are also thought to in�uence the development of odd or eccentric personality disorders. Parental maltreatment, neglect, and emotional withdrawal relate closely to these per- sonality disorders as well as other mental disorders we describe in this textbook (Laulik, Chou, Browne, & Allam, 2013). Odd or eccentric personality disorders are clearly in�uenced as well by cognitive distortions (Rosell et al, 2014). Paranoid personality disorder may develop when paranoid beliefs are reinforced by a cognitive set that leads a person to focus on signs of malicious intent in others (Triebwasser et al., 2013). Examples of cognitive beliefs that underlie odd or eccentric personality disorders are in Table 10.13.

Causes of Odd or Eccentric Personality Disorders Odd or eccentric personality disorders are likely caused by some genetic predisposition as well as stressors that emerge in a per- son’s life (see Figure 10.2). A genetic predisposition such as a family history of schizophrenia may in�uence later changes that

TABLE 10.13

Examples of Cognitions Associated with Odd or Eccentric Personality Disorders

1. My privacy is more important to me than is closeness to people (schizoid, schizotypal).

2. I shouldn’t con�de in others (schizoid, schizotypal).

3. I cannot trust other people (paranoid).

4. Other people have hidden motives (paranoid).

5. It isn’t safe to con�de in other people (paranoid).

Reprinted from Beck et al. (1990), pp. 359-363.

FIGURE 10.2 SAMPLE CAUSAL MODEL OF CLUSTER A PERSONALITY DISORDERS.

Possible odd/eccentric personality disorderPossible odd/eccentric personality disorderPossible odd/eccentric personality disorder

Biological vulnerabilities/early predispositions

Early family problems

Stressful life events

Cognitive-stress and behavioral vulnerabilities

• Adverse family environment (e.g., maltreatment, emotional withdrawal)

• Family conflict, trauma

• Cognitive schemas (e.g., distrust, autonomy) • Personality traits (e.g., restricted expression,• Personality traits (e.g., restricted expression, suspiciousness) suspiciousness)

• Genetic vulnerability (e.g., family history of schizophrenia) • Neurobiological vulnerability (e.g., cognitive and perceptual deficits; dopaminergic dysfunction)

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help produce an odd or eccentric personality disorder. A genetic diathesis may in�uence family environment—parents who are emotionally withdrawn themselves may become physically or emotionally abusive to a child. A genetic diathesis may also set the stage for dysfunction in the dopamine neurotransmitter sys- tem that leads to cognitive and perceptual de�cits associated with odd or eccentric personality disorders.

CHAPTER 10 Personality Disorders298

Neurobiology and family environment also in�uence each other. Some parents may become withdrawn from a child with odd cognitions or behaviors brought about by dopamine dys- function. Neurobiological vulnerabilities also in�uence the de- velopment of cognitive beliefs such as mistrust and personality traits such as suspiciousness or restricted emotion that charac- terize odd or eccentric personality disorders. Cognitive beliefs and personality traits in�uence each other as well, as when a person who believes coworkers mean him harm becomes gener- ally paranoid and suspicious.

Biological Risk Factors for Dramatic Personality Disorders Recall that dramatic personality disorders include antisocial, borderline, histrionic, and narcissistic types. Dramatic personal- ity disorders have moderate genetic predispositions, with herita- bility estimates of 0.32 to 0.50 (Kendler et al., 2011). Impulsiv- ity/aggression is most associated with borderline and antisocial personality disorder. People high on the impulsive/aggressive dimension, such as Duane with antisocial personality disorder, have a low threshold for action and often act without deliberat- ing. They do not anticipate well the potential negative conse- quences of their actions and do not pro�t from past experience

or knowledge of negative consequences. Impulsive aggression is associated with reduced serotonin (Coccaro, Fanning, Phan, & Lee, 2015).

Psychopathy in adults and conduct disorder in boys are also associated with reduced brain size in areas that may be related to moral development. These areas include the amygdala, fron- tal and temporal cortexes, superior temporal gyrus, and hip- pocampus (Del Casale et al., 2015). Impulsivity in borderline personality disorder may relate as well to dysfunction of the orbitofrontal cortex (Krause-Utz, Winter, Niedtfeld, & Schmahl, 2014).

Another dimension important to dramatic personality dis- orders is affective instability (Carpenter & Trull, 2013). People high on this trait are prone to rapid, intense mood shifts when frustrated, criticized, or separated from others. The noradrener- gic neurotransmitter system is most closely associated with these mood shifts. People given substances that release catecholamine, which operates on the noradrenergic system, show intense emo- tional reactivity. People with signi�cant mood shifts may be hypersensitive to �uctuations in the noradrenergic neurotrans- mitter system. Affective instability in borderline personality dis- order may relate as well to poor functioning in the frontal cortex and other areas important for emotion (see Figure 10.3; Ruocco, Amirthavasagam, Choi-Kain, & McMain, 2013).

Antisocial behavior and affective instability, which are large parts of the dramatic personality disorders, also appear to have signi�cant genetic predispositions (Broome, He, Iftikhar, Eyden, & Marwaha, 2015). Antisocial behavior in particular demonstrates a strong family history (McCuish, Lussier, & Corrado, 2015). Genetic predispositions exist for many other behaviors associated with these conditions as well. These behaviors include anxiety, anhedonia (severe depression), disin- hibition, and oppositionality (Kendler, Aggen, & Patrick, 2012).

Environmental Risk Factors for Dramatic Personality Disorders Child maltreatment relates closely to dramatic personality disorders. Antisocial personality dis- order may develop because of traumatic child- hood experiences, such as physical or sexual maltreatment, aggressive parents, divorce, and in- consistent parental discipline (Glenn et al., 2013; Shi, Bureau, Easterbrooks, Zhao, & Lyons-Ruth, 2012). Borderline personality disorder relates to childhood sexual maltreatment and poor parental bonding with a child due to perceived abandon- ment or actual separation (Trull, 2015).

Various parent–child relationships likely in- �uence histrionic personality disorder, including one in which parental love and attention depends on a child’s attractiveness and sexual provoca- tiveness (Sperry, 2015). One result might be that

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a daughter’s self-worth depends primarily on how her father relates to her, and this pattern may repeat itself in adulthood with other men. Psychosocial theories of narcissistic personality disorder primarily focus on underlying feelings of inadequacy that drive one to seek recognition from others (Roepke & Vater, 2014).

Several cognitive beliefs also underlie symptoms of dramatic personality disorders (see Table 10.14). Some believe that de- ception, lying, cheating, and seductiveness are acceptable ways of securing one’s needs. These beliefs can lead to aggressive or provocative interpersonal styles and problems that characterize antisocial and other dramatic personality disorders.

Causes of Dramatic Personality Disorders Dramatic personality disorders are likely caused by genetic predispositions and family-based stressors (see Figure 10.4). A family history of depressive, bipolar, substance use, or anti- social personality disorder likely serves as a genetic diathesis. This genetic diathesis directly in�uences family environmental (child maltreatment or poor parental bonding) and neurobiolog- ical (impulsive aggression, affective instability) factors related to dramatic personality disorders. Family environmental factors in�uence, and are in�uenced by, cognitive beliefs such as “I need what I want now” and personality traits such as emotional dysregulation that comprise dramatic personality disorders. Neurobiological factors such as noradrenergic dysfunction also in�uence these cognitive beliefs and personality traits.

Biological Risk Factors for Anxious/Fearful Personality Disorders Recall that anxious/fearful personality disorders include avoid- ant, dependent, and obsessive-compulsive types. Genetics play a modest role in the development of anxious/fearful personality disorders, with heritability estimates of 0.34 to 0.47 (Kendler et al., 2011). Other dimensions of anxious/fearful personality disorders that may have some genetic basis include behavioral

inhibition, tendency to anticipate harm or future negative events, excessive sensitivity to negative events, heightened arousal, and a tendency to read threat or potential harm into benign events (Ross, Keiser, Strong, & Webb, 2013).

People with anxious/fearful personality disorders may in- herit neurobiological vulnerabilities as well, especially those involving the noradrenergic and gamma-aminobutyric acid (GABA) neurotransmitter systems. These vulnerabilities lead to heightened fearfulness and sensitivity to potential threat. Inher- ited personality traits may also contribute to the development of these disorders. Inhibition (avoidant personality disorder), com- pulsivity (obsessive-compulsive personality disorder), anxious- ness, insecure attachment, social avoidance, and submissive- ness are traits central to anxious/fearful personality disorders. Twin studies suggest a strong genetic component for these traits (Balestri, Calati, Serretti, & De Ronchi, 2014).

Environmental Risk Factors for Anxious/Fearful Personality Disorders Avoidant personality disorder may result when an anxious, introverted, and uncon�dent person experiences repeated epi- sodes of embarrassment, rejection, or humiliation in childhood (Lampe, 2016). Adolescence may be a particularly dif�cult time

TABLE 10.14

Examples of Cognitions Associated with Dramatic Personality Disorders

1. I should be the center of attention (histrionic).

2. I cannot tolerate boredom (histrionic).

3. Other people should satisfy my needs (narcissistic).

4. Lying and cheating are okay as long as you don’t get caught (antisocial).

5. If I want something, I should do whatever is necessary to get it (antisocial).

Reprinted from Beck et al. (1990), pp. 359-363.

Possible dramatic personality disorderPossible dramatic personality disorder

Biological vulnerabilities/early predispositions

Early family problems

Stressful life events

Cognitive-stress and behavioral vulnerabilities

• Adverse family environment (e.g., maltreatment, poor parental bonding, inconsistent parenting)

• Family conflict, trauma

• Cognitive schemas (e.g., immediate gratification, dramatic) • Personality traits (e.g., emotional dysregulation, impulsivity, callousness) dysregulation, impulsivity, callousness) dysregulation, impulsivity, callousness)

• Genetic vulnerability (e.g., family history of mood or impulsive diorders) • Neurobiological vulnerability (e.g., impulsive aggression; affective instability; serotonergic or noradrenergic dysfunction)

FIGURE 10.4 SAMPLE CAUSAL MODEL OF CLUSTER B PERSONALITY DISORDERS.

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CHAPTER 10 Personality Disorders300

for these individuals because of the importance of attractiveness, popularity, and dating. The interaction of these temperamental traits and negative experiences may lead to cognitive schemas such as excessive self-consciousness or feelings of inadequacy or inferiority that comprise avoidant personality disorder (Beck & Haigh, 2014).

Dependent personality disorder may result from an inter- action between an anxious/fearful temperament and insecure attachment to parents (Disney, 2013). People with the disorder, such as Betty, rely on others for reassurance, help, and a sense of security because they see themselves as weak and ineffec- tual. They are also preoccupied with threats of abandonment, and they feel helpless. These cognitive schemas set the stage for those with dependent personality disorder to become depressed when faced with interpersonal loss or con�ict (see Table 10.15).

Less is known about family or environmental in�uences re- garding obsessive-compulsive personality disorder (Diedrich & Voderholzer, 2015). Children who ultimately develop obsessive- compulsive personality disorder may have been well behaved and conscientious but perhaps overly serious and rigid (De Caluwé, Rettew, & De Clercq, 2014). Cognitive schemas asso- ciated with obsessive-compulsive personality disorder include hyper-responsibility for oneself and others, perfectionism, ex- cessive attention to detail, and catastrophic thinking when faced with perceived failure or setback (Beck & Haigh, 2014).

Causes of Anxious/Fearful Personality Disorders Anxious/fearful personality disorders are likely caused by ge- netic predispositions and family environment problems (see Figure 10.5). A family history of anxiety-related disorder serves as the genetic diathesis for anxious/fearful personality disor- ders and in�uences the development of family environment, neurobiological, cognitive, and personality risk factors. Insecure attachment to parents or rejection from parents relate to un- derlying neurobiological vulnerabilities of anxiety or inhibition. Family environment and neurobiological factors in�uence the development of cognitive beliefs such as those related to low

self-esteem or catastrophizing events. These factors also in�u- ence personality traits such as anxiousness or inhibition that underlie anxious/fearful personality disorders.

Prevention of Personality Disorders Prevention efforts for personality disorders are rare. Researchers have focused, however, on three major risk factors of personality disorders that may be the focus of future prevention efforts in this area. One of these risk factors is child maltreatment (Chanen & McCutcheon, 2013). Efforts to prevent child maltreatment may help in�uence the development of personality disorders. Suc- cessful prevention of child maltreatment often involves frequent home visits, reducing maternal stress, increasing social support, and parent training (Selph, Bougatsos, Blazina, & Nelson, 2013). Skills commonly taught to parents to reduce maltreatment are summarized in Table 10.16.

Another main risk factor for personality disorders is poor interpersonal skills. Many people with personality disorders ex- perience great dif�culty in interpersonal contexts such as fam- ily relationships, friendships, and work situations (Lazarus, Cheavens, Festa, & Rosenthal, 2014). Many are socially with- drawn, aggressive, impulsive, insecure, dependent, and highly attention seeking. Efforts to enhance a person’s social skills may

TABLE 10.15

Examples of Cognitions Associated with Anxious/Fearful Personality Disorders

1. I am needy and weak (dependent).

2. I am helpless when I’m left on my own (dependent).

3. I am socially inept and socially undesirable in work or social situations (avoidant).

4. It is important to do a perfect job on everything (obsessive- compulsive).

5. Any �aw or defect of performance may lead to catastrophe (obsessive-compulsive).

Reprinted from Beck et al. (1990), pp. 359-363.

FIGURE 10.5 SAMPLE CAUSAL MODEL OF CLUSTER C PERSONALITY DISORDERS.

Possible anxious/fearful personality disorderPossible anxious/fearful personality disorder

Biological vulnerabilities/early predispositions

Early family problems

Stressful life events

Cognitive-stress and behavioral vulnerabilities

• Adverse family environment (e.g., insecure attachment to parents; rejection by parents)

• Family conflict, trauma

• Cognitive schemas (e.g., low self-esteem, tend to catastrophize) • Personality traits (e.g., anxiousness, inhibition, submissiveness)

• Genetic vulnerability (e.g., family history of anxiety disorders) • Neurobiological vulnerability (e.g., anxiety or inhibition; noradrenergic or GABA dysfunction)

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help prevent troublesome interpersonal styles that characterize personality disorder.

Interpersonal skills training is especially relevant to de�cits seen in avoidant personality disorder such as extreme shyness and dif�culty initiating relationships. Social skills that are taught can include listening and attending, empathy, appropriate self- disclosure, and respectful assertiveness (Weinbrecht, Schulze, Boettcher, & Renneberg, 2016). Training in each of these skills involves educating a client about the skills, modeling appropriate social inter- actions, and asking the client to practice the skills.

A third major risk factor for person- ality disorder is emotional dysregulation. Problems in emotional responsiveness such as restricted affect or affective in- stability characterize many personality disorders. Prevention efforts help people identify, cope with, change, and control negative emotional states. Treatment procedures for borderline personality disorder (discussed in a later section) might be modi�ed for prevention efforts (Chanen & McCutcheon, 2013). People can learn to describe emotional states (love, joy, anger, sadness, fear, shame), identify events or interpretations that prompt these emotions, understand how an emotion is experienced or expressed, and attend to the aftereffects of an emo- tion. A training plan for emotional regu- lation of anger is outlined in Table 10.17.

TABLE 10.16

Prevention of Child Maltreatment

Skills taught

Basic problem solving Parents are taught to recognize and de�ne typical life problems, list a goal, develop options and plans, and evaluate the outcome.

Positive parenting: enjoying the child

Parents are taught about normative development and how to enjoy the child’s unfolding abilities. In addition, parents learn to engage in child-led play and to see the world through the child’s eyes.

Parenting skills Parents are taught how to recognize developmentally appropriate goals for the child, how to make re- quests in a way that ensures compliance, how to decrease unwanted behaviors from the child, and how to increase desired behaviors through reward and praise.

Extending parenting Parents are taught about child safety. Instruction includes material on discipline and maltreatment, selecting safe caregivers, childproo�ng to prevent injury, and supervising children.

Anger management This module teaches parents to see themselves through the eyes of their children, to recognize and control anger, to relax, and to build in options that can be used if they feel anger is coming on (for example, distracting oneself, taking deep breaths, removing oneself from the situation).

Source: Adapted from “Integrating Child Injury and Abuse-Neglect Research: Common Histories, Etiologies, and Solutions,” by L. Peterson and D. Brown, 1994, Psychological Bulletin, 116, 293-315. Copyright © 1994 by the American Psychological Association. Reprinted with permission.

Programs designed to prevent child maltreatment may decrease the likelihood of personality disorder symptoms in these children when they grow up.

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➲ Interim Summary • Genetic in�uences may be particularly strong for schizo-

typal personality disorder because of its place on the schizophrenia spectrum.

• A psychobiological theory of personality disorder suggests that genetics set the stage for cognitive and perceptual problems that underlie odd or eccentric and other person- ality disorders.

CHAPTER 10 Personality Disorders302

• Parental maltreatment and withdrawal as well as cognitive distortions comprise major environmental risk factors for odd or eccentric personality disorders.

• Dramatic personality disorders have signi�cant genetic predispositions, especially with respect to impulsive/ aggressive behavior and affective instability.

• Dramatic personality disorders also relate closely to child- hood traumas such as severe maltreatment as well as cognitive distortions.

• Anxious/fearful personality disorders may be caused by genetic factors that underlie anxiety and inhibi- tion as well as dif�culties in interpersonal contexts such as relationships with parents, friendships, and coworkers.

• Prevention of personality disorders might focus on reduc- ing major risk factors such as child maltreatment, poor interpersonal skills, and emotional dysregulation.

➲ Review Questions 1. What aspects of personality disorders have a genetic predis-

position? 2. What brain and neurochemical features relate to personality

disorders? 3. What personality characteristics relate to personality disorders? 4. What cognitive features relate to personality disorders? 5. What topics might be addressed in programs to prevent

personality disorders?

TABLE 10.17

Emotion Regulation Training

1. Prompting events for feeling anger—examples • Losing power or respect • Being insulted • Not having things turn out the way you expected • Experiencing physical or emotional pain • Being threatened with physical or emotional pain by someone

2. Interpretations that prompt feelings of anger—examples • Expecting pain • Feeling that you have been treated unfairly • Believing that things should be different • Rigidly thinking “I’m right” • Judging that the situation is illegitimate, wrong, or unfair

3. Experiencing the emotion of anger—examples • Feeling out of control or extremely emotional • Feeling tightness in your body • Feeling your face �ush or get hot • Teeth clamping together, mouth tightening • Crying; being unable to stop tears • Wanting to hit, bang the wall, throw something, blow up

4. Expressing and acting on anger—examples • Gritting or showing your teeth in an unfriendly manner • A red or �ushed face • Verbally or physically attacking the cause of your anger;

criticizing • Using obscenities or yelling, screaming, or shouting • Clenching your hands or �sts • Making aggressive or threatening gestures • Pounding on something, throwing things, breaking things • Brooding or withdrawing from contact with others

5. Aftereffects of anger—examples • Narrowing of attention • Attending only to the situation making you angry and not be-

ing able to think of anything else • Remembering and ruminating about other situations that

have made you angry in the past • Depersonalization, dissociative experience, numbness

ANGER WORDS—examples

anger disgust grumpiness rage

aggravation dislike hate resentment

agitation envy hostility revulsion

annoyance exasperation irritation scorn

bitterness ferocity jealousy spite

contempt frustration loathing torment

cruelty fury mean-spiritedness vengefulness

destructiveness grouchiness outrage wrath

Personality Disorders: Assessment and Treatment 303

Personality Disorders: Assessment and Treatment

We divided our discussion of features and risk factors for personality disorders into the three main clusters. As- sessment and treatment in this area, however, often cuts across many personality disorders; therefore, we present this section as a general overview.

Assessment of Personality Disorders Clinicians often use self-report questionnaires, unstructured clinical interviews, semistructured clinical interviews, and in- formant reports to assess personality disorders. We discuss each of these methods and their advantages and disadvantages (see Table 10.18).

Self-Report Questionnaires Self-report questionnaires include items that assess symptoms of personality disorder. Personality disorder questionnaires are easy to administer and economical with respect to time and ef- fort. Self-report instruments are generally used as screening in- struments and not as diagnostic measures because they do not assess level of impairment or distress. Self-report instruments also do not typically assess whether symptoms were evident since young adulthood.

A popular self-report of various personality constructs is the Millon Clinical Multiaxial Inventory—IV (Millon, Millon Clinical Multiaxial Inventory—IV (Millon, Millon Clinical Multiaxial Inventory—IV Grossman, & Millon, 2015). The measure consists of 24 scales related to all personality disorders and other prob- lems such as depression and excessive substance use. Child and adolescent versions are also available. Recall as well from Chapter 4 that the Minnesota Multiphasic Personality

Inventory—2 is a well-used self-report measure that can sug- gest diagnoses but also indicates various problematic be- haviors and personality styles. Sample items from another popular personality disorder measure, the Personality Diag- nostic Questionnaire—4, are shown in Table 10.19 (Bouvard, Vuachet, & Marchand, 2011).

TABLE 10.18

Advantages and Disadvantages of Four Major Methods of Personality Disorder Assessment

Questionnaire Unstructured clinical interview

Structured clinical interview Informant ratings

Advantages Quick, not time-consuming Easily integrated into stan- dard clinical practice

Tied to diagnostic criteria Not subject to self-portrayal “bias”

Useful as a screening measure

Natural “�ow” Most empirically supported Can provide historical perspective

Disadvantages Overdiagnoses Not directly tied to diagnostic criteria

Potentially long and tedious Often fails to agree with self-report

Potentially subject to self- portrayal bias

Subject to clinician bias or error

May seem awkward to introduce into typical clinical session

Dependent on extent of informant’s knowledge of the target

TABLE 10.19

Examples of Personality Diagnostic Questionnaire — 4 (PDQ-4) Items

Disorder Example

Avoidant Over the past several years . . . I avoid working with others who may criticize me.

Dependent Over the past several years . . . I can’t make decisions without the advice, or reassurance, of others.

Borderline Over the past several years . . . I either love someone or hate them, with nothing in between.

Antisocial Over the past several years . . . I do a lot of things without considering the consequences.

Paranoid Over the past several years . . . I keep alert to �gure out the real meaning of what people are saying.

Schizotypal Over the past several years . . . I get special messages from things happening around me.

Reprinted with permission from Steven E. Hyler, M.D.

CHAPTER 10 Personality Disorders304

Interviews Many clinicians use unstructured clinical interviews to assess personality disorders, although researchers prefer the structured interview. Unstructured interviews allow a mental health profes- sional to ask any question about personality disorder symptoms. Unstructured interviews are often less reliable and more sus- ceptible to interviewer bias than structured interviews, however (Trull & Prinstein, 2013). Mental health professionals who use unstructured clinical interviews or case review also routinely fail to assess speci�c personality disorder diagnostic criteria or they express cultural bias (Paniagua, 2013).

Structured interviews take more time but are systematic, comprehensive, replicable, and objective. Structured interviews for personality disorder provide a mental health professional with useful suggestions for inquiries about various symptoms. One example is the Structured Clinical Interview for DSM-5 Per-Structured Clinical Interview for DSM-5 Per-Structured Clinical Interview for DSM-5 Per sonality Disorders (First, Williams, Benjamin, & Spitzer, 2016). Structured interviews may focus more on diagnostic than di- mensional aspects of personality disorders, however, and so could be supplemented by other instruments that measure per- sonality traits (Westen, Waller, Shedler, & Blagov, 2014).

Informant Reports A disadvantage of self-report questionnaires and interviews is their emphasis on a person’s self-report. This is a problem because many people with personality disorders have distorted self-image and self-presentation that can color their answers on these measures. An alternative method of assessing personal- ity disorder is the informant report (Busch, Balsis, Morey, & Oltmanns, 2015). Informants such as family members or close friends can provide an important historical perspective on a person’s traits, especially if the informants themselves have no mental disorder.

Informant reports do have some downsides, however. These reports often con�ict with self-reports, and so a clini- cian may be unsure which perspective is most truthful (Busch et al., 2015). Relatives and close friends will not know ev- erything about a person that would be necessary to provide a valid description, they may be biased, and they may have false assumptions about or expectations of a person. Infor- mant report of personality disorder features remains a promis- ing assessment method, however (Markon, Quilty, Bagby, & Krueger, 2013).

Biological Treatments of Personality Disorders People with personality disorders appear to bene�t to some degree from various medications. Medication use has been tar- geted primarily toward those with borderline personality dis- order. Medications for this population include antidepressant, antianxiety, and antipsychotic drugs. The bene�cial effects of these drugs are usually limited to one area of functioning such as impulsivity or affective instability. Not all studies indicate positive results, however, and many people drop out of medi- cation treatment. Some even argue that patients with person- ality disorder might be better off not taking any medications, given current empirical evidence (Paris, 2015). No �rm con- clusions can be drawn regarding a speci�c medication for a speci�c personality disorder (Bateman, Gunderson, & Mulder, 2015).

Medication may be more effective for speci�c groups of symptoms and not an overall personality disorder. Three main symptom groups that may respond to medication include cogni- tive-perceptual, affect, and impulsive aggression (Bateman et al., 2015). Cognitive-perceptual symptoms of odd or eccentric per- sonality disorders may be treated with antipsychotic drugs such as perphenazine, tri�uoperazine, or haloperidol (Chapter 12).

Affective (emotional) symptoms of dramatic personality disorders may be treated with se- lective serotonin reuptake inhibitors such as �uoxetine or mood stabilizers such as topi- ramate or lamotrigine (Chapter 7). Impulsive aggressive problems of people with dramatic personality disorders may be treated with selective serotonin reuptake inhibitors, mood stabilizers (Chapter 7), or antipsychotic drugs.

Psychological Treatments of Personality Disorders Personality disorders are among the most dif- �cult mental disorders to treat because their symptoms are severe, chronic, long-standing, and associated with intense dysfunction, dis- tress, and impairment. Clinicians in this area usually focus on maladaptive personality traits (Paris, 2015).

Not everyone with a personality disorder seeks treatment, but some do. Some people Structured interviews are the gold standard for personality disorder assessment.

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with personality disorder, particularly those with borderline personality disorder, seek many forms of treatment such as individual, group, and family/couple therapy; day treatment; hospitalization; halfway houses; and medication. People with borderline personality disorder also pursue lengthy treatment (Gunderson et al., 2014). Many treatment studies in personality disorder thus focus on borderline personality disorder; common therapies used include short-term psychodynamic, cognitive- behavioral, and dialectical behavior therapies (Bateman et al., 2015; Paris, 2015).

Short-Term Psychodynamic Therapy Short-term psychodynamic therapy involves frequent meetings with a therapist to develop a close alliance and help clients transfer negative emotions. This therapy focuses on con�icts or themes that impede a person’s life, such as abandonment, emptiness, jealousy, or aggression. A psychodynamic therapist will explore historical events in a person’s life that may have led to problematic personality traits. Issues of child maltreatment or other trauma may also be discussed to help a client develop insight into her symptoms. Interpersonal con�ict resolution, ap- propriate emotional experience, and less self-destructive behav- ior are key aspects of short-term psychodynamic therapy as well (Luyten & Fonagy, 2015).

Cognitive-Behavioral Therapy Cognitive-behavioral therapy for personality disorders often fo- cuses on easing symptoms of anxiety and depression (Chapters 5 and 7). Clinicians may use cognitive therapy to modify irrational thoughts, social skills training to improve interpersonal relation- ships, relaxation training to ease high levels of physical arousal, and behavioral activation to increase social contacts. Marital

and family therapy may be used as well to improve communica- tion and problem-solving skills (Ogrodniczuk, Uliaszek, Lebow, & Piper, 2014).

Dialectical Behavior Therapy One form of cognitive-behavioral treatment, dialectical behav- ior therapy, is quite useful for people with borderline personal- ity disorder (Linehan et al., 2015). Dialectical behavior therapy addresses symptoms commonly associated with this disorder, including suicidal gestures/attempts, self-injury, and self-muti- lation. Clients learn various skills to change behavioral, emo- tional, and thinking patterns that cause problems and extreme distress. Treatment strategies address each of the following areas:

• Interpersonal effectiveness skills training: Clients learn to manage interpersonal con�ict, appropriately meet their desires or needs, and say no to unwanted demands from others.

• Emotional regulation skills training: Clients learn to iden- tify different emotional states, understand how emo- tions affect them and others, engage in behavior likely to increase positive emotions, and counteract negative emotional states.

• Distress tolerance skills training: Clients learn to tolerate or “get through” stressful situations using distraction exercises (to ultimately gain a better perspective), self-soothing strat- egies such as listening to beautiful music, and techniques to improve their experience of the current moment such as imagery or relaxation.

• Mindfulness skills training: Clients learn to self-observe their attention and thoughts without being judgmental.

Impairments and comorbid disorders found in some personality disor- ders can be so severe that they lessen criminal responsibility (Loveless, 2014). An example is someone with borderline personality disorder and a history of severe maltreatment who harmed someone but did so during symptoms of posttraumatic stress disorder and paranoid psychosis.

Gray areas such as this have thus led some states to modify the verdict a jury may give when a defendant asserts an insanity defense. One alterna- tive verdict is guilty but mentally ill, which assumes that the defendant is guilty of a crime and that he should receive punishment for the crime. However, the court has discretion to order psychiatric treatment before or after incarceration. Another alternative is diminished capacity. This means a person did not have a mental disorder that absolves him or her for respon- sibility for a crime but did have a diminished mental capacity. Excessive alcohol use or trauma, for example, may have led a defendant to the point that she did not possess the mental state or intent relevant to the crime. Diminished capacity may mean that a person is convicted of a lesser offense (e.g., manslaughter instead of murder) or given a lighter sentence (Gardner & Anderson, 2015).

Focus On

Some people with personality disorders may be prone toward criminal acts. Could they claim a personality disorder as the basis for an insan- ity defense? People with antisocial personality disorder generally cannot use this condition as an insanity defense (Johnson & Elbogen, 2013). For example, serial killers cannot claim that being a “psychopath” or “sociopath” is grounds for an insanity plea. However, aspects of a cer- tain personality disorder could mitigate responsibility for a criminal act. Recall from Chapter 3 that a common standard for insanity is that a per- son was unable to distinguish right from wrong at the time of the crime.

Law and Ethics Personality and Insanity

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CHAPTER 10 Personality Disorders306

Clinicians often conduct dialectical behavior therapy in a group format, and clients often remain in treatment for several months to a year. Dialectical behavior therapy is effective for reducing suicidal behaviors, excessive substance use, number of days of psychiatric hospitalization, and treatment dropout. The therapy may also improve depression and hopelessness in some clients (Gutteling, Montagne, Nijs, & van den Bosch, 2012). Michelle, our case from the beginning of the chapter, would be a good candidate for dialectical behavior therapy because of her suicidality and her feelings of sadness and hopelessness.

A good way to illustrate dialectical behavior therapy is to present portions of a transcript of an actual therapy session.

The client in this scenario was a 30-year-old woman with borderline personality disorder who was hospitalized 10 times in the previ- ous 2 years for suicidal ideation and self-harm in the form of drinking Clorox bleach, cutting and burning herself, and one suicide attempt. A dialectical behavior therapist (T) explains therapist (T) explains therapist the program and goals to the client (C) in the client (C) in the client following segment (Linehan & Kehrer, 1993, pp. 428–429):

T: Now, the most important thing to un- derstand is that we are not a suicide-preven- tion program, that’s not our job. But we are a life enhancement program. The way we look at it, living a miserable life is no achievement. If we decide to work together, I’m going to help you try to improve your life so that it’s so good that you don’t want to die or hurt yourself. You should also know that I look at suicidal behavior, including drinking Clorox, as prob- lem-solving behavior. I think of alcoholism the same way. The only difference is that cutting, burning, unfortunately, it works. If it didn’t work, nobody would do it more than once. But it only works in the short term, not the long

term. So quitting cutting, trying to hurt yourself, is going to be exactly like quitting alcohol. Do you think this is going to be hard?

C: Stopping drinking wasn’t all that hard. T: Well, in my experience, giving up self-harm behavior is

usually very hard. It will require both of us working, but you will have to work harder. And like I told you when we talked brie�y, if you commit to this, it is for 1 year. Individual therapy with me once a week, and group skills training once a week. So the question is, are you willing to commit for 1 year?

C: I said I’m sick of this stuff. That’s why I’m here. T: So you’ve agreed to not drop out of therapy for a year,

right? C: Right. T: And you do realize that if you don’t drop out for a year,

that really does, if you think about it, rule out suicide for a year? C: Logically, yeah. T: So, we need to be absolutely clear about this, because

this therapy won’t work if you knock yourself off. The most fundamental mood-related goal we have to work on is that, no matter what your mood is, you won’t kill yourself, or try to.

C: Alright. T: So that’s what I see as our number one priority, not our

only one, but our number one, that we will work on that. And getting you to agree, meaningfully of course, and actually fol- lowing through on staying alive and not harming yourself and not attempting suicide no matter what your mood is. Now the question is, whether you agree to that.

C: Yes, I agree to that. The therapist reinforces the client for using distress toler-

ance skills when her request for pain medication was refused An important component of dialectical behavior therapy involves training in various emotional and interpersonal skills.

Family members can provide useful information about someone’s personality traits and problems.

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Personality Disorders: Assessment and Treatment 307

by her physician in this next segment (Linehan & Kehrer, 1993, p. 433):

T: That’s good thinking. That’s when you’re thinking about the advantages and disadvantages of doing it. OK, so at that point the advantages of making it worse were outweighed by the disadvantages. OK. So you keep up the good �ght here. Now what else did you try?

C: I tried talking about it with other patients. T: And what did they have to say? C: They said I should get pain medication. T: Right. But did they say you should cut yourself or hurt

yourself if you didn’t get it? C: No. And I tried to get my mind off my pain by playing

music and using mindfulness. I tried to read and do crossword puzzles.

T: Um hmm. Did you ever try radical acceptance? C: What’s that? T: It’s where you sort of let go and accept the fact that you’re

not going to get the pain medication. And you just give yourself up to that situation. You just accept that it ain’t going to happen, that you’re going to have to cope in some other way.

C: Which I did yesterday. I needed a little Ativan to get me there but I got there.

T: Yesterday? C: Yeah. I took a nap. When I woke up I basically said,

“Hey, they’re not going to change, so you’ve just got to deal with this the best that you can.”

T: And did that acceptance help some? C: I’m still quite angry about what I believe is discrimina-

tion against borderline personalities. I’m still very angry about that.

T: OK. That’s �ne. Did it help though, to accept? C: Um hmm. T: That’s good. That’s great. That’s a great skill, a great

thing to practice. When push comes to shove, when you’re re- ally at the limit, when it’s the worst it can be, radical acceptance is the skill to practice.

What If I or Someone I Know Has a Personality Disorder? People are sometimes screened for personality disorders, and the answers to some basic questions may indicate whether further assessment or even treatment is warranted. Some of these ques- tions are in Table 10.20. If you �nd yourself answering “yes” to most of these questions, then you may wish to consult a clinical psychologist, psychiatrist, or other mental health professional (Chapter 15). Cognitive-behavioral therapy or medication may be best.

If you feel concerned about how you relate to others, but do not necessarily have a personality disorder, then teaching yourself to gain better control over moods and impulses and communicating and relating better to others may be help- ful. Discuss your concerns with family members and friends as well. Further information about screening and treatment for personality disorders is available from several websites

(e.g., http://www.tara4bpd.org/dyn/index.php; http://www .borderlinepersonalitydisorder.com/).

Long-Term Outcomes for People with Personality Disorders Personality disorders are generally best treated by cognitive- behavioral and some psychodynamic treatments that reduce symptoms and improve social functioning (Ahmed et al., 2012; Paris, 2015). However, long-term changes in personality struc- ture are much more dif�cult to achieve (Yeomans, Clarkin, & Kernberg, 2015). Therapy for antisocial personality disorder in particular has not been highly effective (Bateman et al., 2015). In addition, about one-third of those with personality disorders do not complete treatment (Clarke, Jinks, Huband, & McMurran, 2014). Factors that do predict treatment completion include commitment to change, good therapeutic relationship, and low impulsivity (Bedics, Atkins, Harned, & Linehan, 2015; Gagnon, Leblanc, & St-Amand, 2015).

Treatment effectiveness for personality disorders may improve if speci�c treatments are tailored to speci�c skills and

TABLE 10.20

Screening Questions for Personality Disorders

• Do you often have dif�culty maintaining boundaries with others or managing your emotions?

• Do you often have trouble directing yourself toward your life goals or engaging in self-re�ection?

• Do you have problems understanding the emotions of other people and the effects of your behavior on others?

• Are you unable to be close with others?

• Do you �nd yourself to be often impulsive, aggressive, detached, callous, or odd toward others?

V THE CONTINUUM VIDEO PROJECT

Tina / Borderline Personality Disorder

“I kinda get high off of making people as uncomfortable as they make me. It’s almost my way of really connecting with myself.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

CHAPTER 10 Personality Disorders308

behaviors (Paris, 2015). Behavioral treatments to lower social fear and improve interpersonal skills are most effective for avoid- ant personality disorder. Dialectical behavior therapy seems par- ticularly effective for borderline personality disorder (Linehan et al., 2015). Other personality disorders may be amenable to speci�c treatments as well. Examples include empathy train- ing for psychopathy, social problem-skills training for antisocial adults, and assertiveness skills training for people with depen- dent personality disorder (Livesley, Dimaggio, & Clarkin, 2016). Greater research is needed in these areas, however.

Symptoms of personality disorder often affect outcome for people with other mental disorders (Tyrer et al., 2015). People with anxiety, depressive, and substance use disorders and symptoms of personality disorder generally have poorer long- term outcome than people without symptoms of personality dis- order (Bateman et al., 2015; Crits-Christoph & Barber, 2015). Un- derlying beliefs related to personality disorders—such as those listed in Tables 10.13, 10.14, and 10.15—may predict negative outcome for cognitive therapy for depression (Newton-Howes et al., 2014).

I suffer from borderline personality disorder, and because it is often dif�cult for individuals who don’t have a mental disorder to understand what all the intricacies are of living with such a condition, I’m hoping that the following account will shed some light on the matter. More than anything else, the most important point I wish to convey is that individuals with a mental disorder are very much like anyone else—they wish to be treated with respect and understanding and given the opportunity to share their knowledge and talents to make the world a better place.

Living with a mental disorder has probably been the most dif�cult, and at the same time rewarding, aspect of my life. Even though I’ve made great strides to learn to manage my dis- order over the past several years, I would have to say that I am still at a point where much of my self-de�nition is determined by my mental disorder. My hopes are that someday I will move beyond this narrowed de�nition of who I am and be able to more adequately self-identify with as- pects that do not include my disorder and that more positively identify the other competencies that I possess.

If I recall correctly, my disorder dates all the way back to the �rst memories I have. For some reason, I’ve always sort of felt biologically “off.” I can remember experiencing “weird” feelings, but I still to this day cannot identify exactly what they were. I only know that as I was given the proper medication, these feelings decreased substantially. I was 17 when I saw my �rst psychiatrist.

My parents would now say that, all through my childhood and especially during my

adolescence, something was very wrong, but they couldn’t put their �nger on it. I experienced a fair amount of negative affect, which often seemed to them a bad “attitude.” I was never able to clarify for my parents what was wrong, and because I tended to be a rather compliant child in most ways and didn’t verbalize my dif- �culties, they had no idea the extent of my pain.

From the very �rst moments of my life, it was obvious that I was a very “sensitive” child. Temperamentally, I was hurt by the smallest of things, needed help dealing with very strong emotions (especially negative), needed help in calming myself, was clingy, and felt overly stimulated by certain environments. I sensed subtleties that others did not pick up on. I hated school because teachers I had often were expe- rienced as too harsh, and even the smallest of correction felt painful to me. My perceptions of others (like a teacher getting mad) were mag- ni�ed because of my enhanced sensitivity, and the pain of even these normal childhood occur- rences was too much for me.

I would not say I had any “traumatic” events happen in my life—at least not anything that many others haven’t experienced. My par- ents divorced when I was 5, and my mother remarried when I was 11. I was not abused or neglected, although I only saw my father on weekends, and he usually was too busy with work to pay much attention to me. I had a dif- �cult time living with my mother and stepfa- ther, never really feeling able to adjust. I think the hardest things for me were the fact that my emotional makeup and that of my family’s were very different, and I did not get very important

emotional needs met that were imperative to my overall functioning. I was a very expres- sive child, and my parents were very much the opposite in many ways—they were more reserved, didn’t feel the need to talk about feel- ings as much, and thought that I should be able to “control” my emotions the same way they did. Unfortunately, because of my disor- der, this was not possible, and so my pain went underground and unrecognized, and my life got progressively worse.

When I �nally did see my �rst therapist and psychiatrist, I was given some degree of help, but ultimately was never diagnosed properly and therefore never received the appropriate treatment. My parents continued to seek help for me, took me to a plethora of therapists, and still found that no one seemed able to really do anything to help me get better. It was not until many years later (at the age of 25), after years of hospitalizations, one suicide attempt, one unsuccessful treatment of electroconvul- sive therapy (ECT), and a failed marriage, that I was �nally given the correct diagnosis. And it was my good fortune that, at that time, the treatment I needed was being provided by the county mental health system that I had entered.

After my divorce, I quali�ed for SSI and entered the county mental health system of care. I had only ever utilized private insurance, so having to go to the county mental health clinic was quite a change—they only served the most severely disturbed and economically challenged of the population. I had grown up in a very educated, middle-class environment,

10.1 / A / A / nonymous

Personality Disorders: Assessment and Treatment 309

The research on long-term outcome of personality disorders is primarily con�ned to antisocial and borderline personality disorders (Paris, 2015). Antisocial behavior develops as conduct disorder in a child and about 45 to 75 percent of youth with conduct disorder later develop antisocial personality disorder (Jaffee & Odgers, 2014). People with antisocial personality dis- order experience high rates of mortality, criminality, excessive substance use, unemployment, relationship dif�culties, and imprisonment (Black, 2013). Many with antisocial personality disorder show fewer symptoms in their 40s; they tend to be less

impulsive and commit fewer acts that could lead to arrest or incarceration (Black, 2013; Paris, 2015). Some with antisocial personality disorder continue a chronic pattern even past age 40 years, however, and continue to commit criminal acts or die prematurely (Black, 2013).

People with borderline personality disorder often show a waxing and waning course for their symptoms. Most people with borderline personality disorder improve with time but still expe- rience impairment in school and work situations (McMain, Gui- mond, Streiner, Cardish, & Links, 2012; Zanarini, Frankenburg,

and for me to get on SSI and receive services from the county was a hard adjustment. The ironic thing is that it wasn’t until I reached this level of economic need that I �nally was offered the proper treatment. None of the private insurances offered this treatment, and knew very little about the diagnosis I had and how to treat it. Unfortunately, to this day, my mental disorder still remains highly stigmatized in the therapeutic community, and many clinicians will not treat individuals like me because they feel our problems to be wearing and intractable.

As I entered the county system, I was given the diagnosis of borderline personality disorder (BPD). Past therapists I had seen had toyed with the idea that I might have this disorder, but few wanted to label me with such a seem- ingly harsh diagnosis. (Some therapists think that to label someone a borderline is thought to be akin to giving someone the death sentence!) Unfortunately, it was to my detriment. When I started obtaining services from the mental health system, I was told they were just starting a new program for individuals with this disorder and asked me if I would be interested. At that point I was willing to try anything, so I said yes. The treatment was called dialectical behavior therapy (DBT), and is still to this day one of the few empirically supported treatments that work for this population of individuals. I was the �rst of three individuals to enter this program, and I continued the treatment intensively for the next 4 years.

Because behaviors exhibited by those with BPD can seem outrageous and confusing

accept that during periods of intense emotion (which is much of the time), life may appear hopeless, but the negative feelings will eventu- ally pass.

Currently, I am in the process of �nishing my master’s degree in marriage and family therapy. I have told no one in my program about my disorder. Unfortunately, because there remains so much stigma regarding BPD, it would not be in my best interests to divulge my condition at this time. Ironically, the fact that I am entering a profession that purports to treat individuals like myself with compas- sion, and yet continues to berate and ridicule us doesn’t seem to make much of a differ- ence at this time. Because of the present gap in transfer of information that so often resides between the research community and the ev- eryday experiences of the practicing clinician, I currently remain unable to come forward. However, even though prejudice runs strong right now, I don’t believe this will always be so. As individuals like myself enter the �eld and use our own successes to help others in similar situations, I do think there will be a reduction in prejudice and a recognition that therapists and patients alike, really aren’t all that different after all.

And with that, I’d like to leave a quote that signi�cantly re�ects my personal beliefs about what truly constitutes a “life worth living”:

I have learned that success is to be mea- sured not so much by the position that one has reached in life, as by the obstacles which he has overcome while trying to succeed. —Booker T. Washington

to many who witness them, analogies may prove helpful to fully understand what these individuals experience. The analogy that resonates closest with my own experience of the disorder relates to the life of a third- degree burn victim. Because burn victims obviously have virtually no skin, any move- ment or touch may prove excruciatingly pain- ful—great care and sensitivity is needed in all contact. An individual with BPD is very much like a third-degree burn victim, only with no “emotional” skin. Unfortunately, be- cause no one can “see” the condition, the extreme sensitivity and heightened reactivity of people with BPD seem irrational to those around them. Because the smallest of things affect these individuals, our current stressful and fast-paced society is often not conducive to their particular needs.

Another helpful analogy can be described by thinking about the lens of a telescope. Be- cause individuals with BPD constantly struggle with their perceptions of reality due to such frequent and intense emotional states, their ability to retain clarity of thought is much like constantly looking through a telescope lens that is out of focus. You may be aware that the lens is out of focus, but try as you might, those darn emotions keep wanting to run the show! So even though the reality is that “most people I meet like me,” my actual perception is often very different. Most of the time I see myself as extremely �awed, utterly incompetent, and deserving of punishment regardless of the fact that others discount these notions of my reality on a daily basis. It’s almost like I just have to

personal narrative

Used with permission.

CHAPTER 10 Personality Disorders310

Reich, Conkey, & Fitzmaurice, 2015). Better functioning over time is related to absence of childhood sexual maltreatment, no family history of substance use disorder, and a good work his- tory. Poorer functioning over time is related to unstable rela- tionships, depression, and suicidal and self-injurious behavior (Gunderson et al., 2014; Skodol, 2014). Unfortunately, the sui- cide rate is 10 percent over time in people with borderline per- sonality disorder (Turnbull, Cox, Oleski, & Katz, 2013). Suicide attempts in this population are closely related to depression, excessive substance use, posttraumatic stress, sexual assault, af- fective instability, and dissociation (Wedig et al., 2012).

Long-term outcome for other personality disorders has been studied on a more limited basis. Some problems tend to be more stable over time than others, especially the odd/eccentric clus- ter of paranoid, schizoid, and schizotypal personality disorders. Less stable problems include histrionic, narcissistic, and depen- dent personality disorders. Personality traits related to these dis- orders that tend to be most persistent over time include rigidity, detachment, mistrust of others, impulsivity, manipulativeness, self-harm, and eccentric perceptions (Debast et al., 2014; Hop- wood et al., 2013). Negative temperament and neuroticism in general also appear to be quite stable over time and can predict problems such as anxiety disorders, depression, and cognitive decline (Conway, Craske, Zinbarg, & Mineka, 2016; Newton- Howes, Clark, & Chanen, 2015).

➲ Interim Summary • Clinicians who assess symptoms of personality disorder

typically use self-report questionnaires, interviews, and informant reports.

• Biological treatments for personality disorders involve medications to ease anxiety and depression, stabilize mood, and reduce comorbid psychotic symptoms.

• Psychological treatments for personality disorders include short-term psychodynamic therapy, cognitive-behavioral interventions, and dialectical behavior therapy.

• Psychological treatment for personality disorders is moder- ately effective but less so than for other major mental dis- orders. Effectiveness may improve if speci�c treatments are tailored to speci�c personality disorders.

• Personality disorders may remit over time but many people experience a chronic course marked by impairment or suicide.

➲ Review Questions 1. Describe the major assessment techniques for personality

disorders. 2. What medications are primarily used to treat personality

disorders? 3. What general psychological approaches may be used to treat

personality disorders? 4. What treatment approaches may be useful for speci�c

personality disorders? 5. What is the long-term outcome for people with personality

disorders?

Final Comments Personality disorders are prevalent in clinical settings and the general population. The disorders pro- duce great distress, social and occupational problems, and serious negative outcomes such as suicide or incarceration. Most symptoms and features of personality disorders develop by young adulthood, so they are especially relevant to young adults. The traits and features that comprise these disorders lie on a continuum, so most of us to some degree, or at least on occasion, experience problems like those with a personality disorder. Personality disorders, unlike many mental disorders we discuss in this textbook, can be chronic. This makes it even more important for those with personality disorders to seek help from a mental health professional.

Thought Questions 1. Think about television or �lm characters that portray someone with many interpersonal problems

or con�icts. Is this character a good example of a personality disorder? Which disorder, and why?

2. Have you ever been concerned about the way you interact with others? Are you too shy, outgoing, or abrasive? What factors may have in�uenced the way you are with other people? What informa- tion in this chapter seems most relevant to you?

3. What would you now say to friends who might have concerns about their interpersonal style, emo- tions, or problems with impulse control?

4. What separates “normal” personality quirks from “abnormal” personality traits?

5. Do you think personality disorders have more to do with biological, family, cultural, or other fac- tors? Why?

311Key Terms

Key Terms personality trait 283 personality disorder 283 paranoid personality disorder 285 schizoid personality disorder 285 schizotypal personality disorder 286 antisocial personality disorder 288 psychopathy 288

borderline personality disorder 289 histrionic personality disorder 290 narcissistic personality disorder 291 avoidant personality disorder 293 dependent personality disorder 294 obsessive-compulsive personality

disorder 294

informant report 304 dialectical behavior therapy 305 guilty but mentally ill 305 diminished capacity 305

313

Special Features

CONTINUUM FIGURE 11.1 Continuum of Sexual Behavior and Sexual Dysfunctions 314–315

• 11.1 FOCUS ON GENDER: Gender Biases in Sexual Dysfunctions and Disorders 319

• 11.2 FOCUS ON COLLEGE STUDENTS: Sexual Dysfunctions 322

CONTINUUM FIGURE 11.4 Continuum of Sexual Behavior and Paraphilic Disorders 328–329

• 11.3 FOCUS ON COLLEGE STUDENTS: Sexual Fantasies and Paraphilic Interests 335

• 11.4 FOCUS ON VIOLENCE: Rape 336

• 11.5 FOCUS ON LAW AND ETHICS: Sex Offender Notification and Incarceration 341

V THE CONTINUUM VIDEO PROJECT Dean / Gender Dysphoria 346

Personal Narrative 11.1 Sam 346–347

Normal Sexual Behavior and Sexual Dysfunctions: What Are They?

C Douglas and Stacy / What Do You Think?

Sexual Dysfunctions: Features and Epidemiology

Stigma Associated with Sexual Dysfunctions

Sexual Dysfunctions: Causes and Prevention

Sexual Dysfunctions: Assessment and Treatment

Normal Sexual Desires, Paraphilias, and Paraphilic Disorders: What Are They?

Paraphilic Disorders: Features and Epidemiology

C Tom / What Do You Think?

Paraphilic Disorders: Causes and Prevention

Paraphilic Disorders: Assessment and Treatment

Normal Gender Development and Gender Dysphoria: What Are They?

C Austin

Gender Dysphoria: Features and Epidemiology

Gender Dysphoria: Causes and Prevention

Gender Dysphoria: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria 11

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria314

C / D/ D/ ouglas and Stacy

Douglas and Stacy were referred to a therapist for marital problems that largely stemmed from lack of intimacy. The couple said their sex life declined substantially in quan- tity and quality since the birth of their �rst child several months ago. Both were ex- hausted from their new life- style of child care and work, felt little desire for sex and were now having problems when sex was attempted. Douglas reported failure to maintain an erection during

foreplay and Stacy said she felt little arousal during sex. The couple was drifting apart

emotionally and rarely had an extended conversation. Douglas privately

admitted to the therapist that he considered hav- ing an affair but wanted to repair his marriage. Stacy felt overwhelmed by many new demands on her time and was be- coming depressed about lack of support from her husband.

What Do You Think? 1. How do Douglas and Stacy’s issues differ

from a typical married couple with a new child? Which behaviors seem normal for their situation and which seem unusual?

2. What external events and internal factors might be responsible for Douglas and Stacy’s sexual problems?

3. What are you curious about regarding Douglas and Stacy?

4. Do Douglas and Stacy remind you in any way of yourself or someone you know? How so?

5. How might Douglas and Stacy’s behaviors affect their lives in the future?

case

Normal Sexual Behavior and Sexual Dysfunctions: What Are They?

One of the most basic human drives is sex. Almost everyone desires sexual activity, and many people fantasize regularly about sexual activity. Most people engage in regular sexual ac- tivity with spouses, boyfriends or girlfriends, or others. Regular sexual activity usually means a cycle of wishing to have sex, becoming aroused during early stages of sexual intercourse, and achieving orgasm. Sexual desire and intercourse are thus natural and normal human activities.

Problems can develop during this normal sexual cycle, however. Sexual dysfunctions refer to problems that occur during regular sexual activity. Unusual sexual activiregular sexual activity. Unusual sexual activiregular - ties are thus not the problem. Sexual dysfunctions gener- ally refer to problems of sexual desire, arousal, or orgasm as well as pain during intercourse (Figure 11.1). Sexual dys- functions are considered to be a problem if they cause much distress and interfere with sexual or interpersonal function- ing. Sexual dysfunctions may be lifelong or recent, applicable to many or just a few sexual situations, and mild, moderate, or severe in intensity (American Psychiatric Association [APA], 2013).

11.1 Continuum of Sexual Behavior and Sexual Dysfunctions

NORMAL MILD

Emotions Regular arousal and desire to have regular sexual behavior.

Lessened sexual desire or arousal before or during sexual Lessened sexual desire or arousal before or during sexual behavior.

Cognitions Thoughts about sexual behavior.

Occasional concern about sexual desire, arousal, orgasm, or Occasional concern about sexual desire, arousal, orgasm, or performance.

Behaviors Engaging in regular sexual behavior.

Occasionally engaging in less sexual behavior or less satisfying sexual behavior.

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Sexual Dysfunctions: Features and Epidemiology 315

does not desire to have sex, which may be problematic for the person’s partner.

Female Sexual Interest/Arousal Disorder Female sexual interest/arousal disorder involves lack of inter- est or arousal in most sexual encounters, which may include reduced physical sensations (see Table 11.2; APA, 2013). Female sexual interest/arousal disorder may be problematic if marital intimacy is affected. This disorder does not apply if a substance or medical condition, such as pregnancy or reduced blood �ow, affects a woman’s level of arousal.

Sexual Dysfunctions: Features and Epidemiology

Sexual dysfunctions involve a disturbance of the normal sexual response cycle—desire, arousal, and orgasm—or pain during intercourse. Sexual dysfunctions may be lifelong, meaning they have been present since a person began sexual relations, or ac- quired, meaning they began after a time when a person had no problem in sexual relations. Douglas and Stacy’s sexual problems began after the birth of their child. Sexual dysfunctions may gen- eralize to almost all sexual situations or be limited to speci�c situations or partners. Sexual dysfunctions are organized as well by intensity, which may involve mild, moderate, or severe symp- toms. Finally, sexual dysfunctions must be considered within the context of other factors that might be relevant to cause and treat- ment. These include partner, relationship, individual vulnerabil- ity (e.g., history of sexual maltreatment, depression), cultural/ religious, and medical factors (APA, 2013). We next describe features of the main psychosexual dysfunctions.

Male Hypoactive Sexual Desire Disorder Some sexual dysfunctions involve problems with the desire and arousal phases of sexual relations. Male hypoactive sexual desire disorder is a lack of fantasies or desire to have sexual relations (see Table 11.1; APA, 2013). The disorder thus has cog- nitive and motivational components (McCabe et al., 2016). If a person is not particularly distressed by this fact, a diagnosis would not apply. Clinicians are encouraged to consider several factors that might affect a person’s sexual desire, such as age, living environment, cultural background, and stress level. A diagnosis would not generally be made if a person was unable to have sex or had other problems that prevented adequate sex- ual activity. The disorder instead refers to someone who simply

MODERATE

SEXUAL DYSFUNCTION — LESS SEXUAL DYSFUNCTION — LESS

SEVERE

SEXUAL DYSFUNCTION — MORE SEXUAL DYSFUNCTION — MORE

SEVERE

Substantially lessened sexual desire or arousal Substantially lessened sexual desire or arousal before or during sexual behavior.before or during sexual behavior.

Substantial lack of sexual desire or arousal.Substantial lack of sexual desire or arousal. Lack of any desire or arousal for sex.Lack of any desire or arousal for sex.

Greater worry about sexual desire, arousal, Greater worry about sexual desire, arousal, orgasm, or performance.orgasm, or performance.

Substantial worry about sexual desire, arousal, Substantial worry about sexual desire, arousal, orgasm, or performance that causes distress.orgasm, or performance that causes distress.

Obsession-like worry about sexual desire, arousal, Obsession-like worry about sexual desire, arousal, orgasm, or performance that causes great distress.orgasm, or performance that causes great distress.

Sometimes avoiding sexual behavior due to lack of desire or arousal, or performance concerns.

Constant problems in sexual behavior due to Constant problems in sexual behavior due to problems in desire, arousal, or performance or pain problems in desire, arousal, or performance or pain during intercourse.during intercourse.

Avoiding all sexual behavior or experiencing severe pain during intercourse.

Sexual dysfunctions involve problems with the human sexual response cycle or pain during intercourse.

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria316

Erectile Disorder Some men experience erectile disorder, or impotence, which refers to dif�culty obtaining and maintaining an erection during sexual relations (see Table 11.3; APA, 2013). Some men cannot attain an erection at all, even during masturbation or rapid eye movement sleep, but others can attain an erection during mas- turbation but not with a partner (Shamloul & Ghanem, 2013). Other men attain an erection for a partner but cannot main- tain the erection for long or prior to penetration, and still others attain only a partial erection or cannot attain a full erection all the time (like Douglas). Erectile disorder is only diagnosed if the person is highly distressed by the condition. Erectile disor- der is not diagnosed if the dysfunction is due to a substance or medical condition.

Female Orgasmic Disorder Some sexual dysfunctions involve the orgasmic phase of sexual orgasmic phase of sexual orgasmic relations. Female orgasmic disorder refers to a delay or absence of orgasm during sexual relations (see Table 11.4; APA, 2013). The experience of orgasm is subjective, of course, meaning it

Sexual dysfunctions can cause great distress for a couple.

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TABLE 11.1 DSM-5

Male Hypoactive Sexual Desire Disorder A. Persistently or recurrently de�cient (or absent) sexual/erotic

thoughts or fantasies and desire for sexual activity. The judgment of de�ciency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio- cultural contexts of the individual’s life.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other signi�cant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.2 DSM-5

Female Sexual Interest/Arousal Disorder A. Lack of, or signi�cantly reduced, sexual interest/arousal, as

manifested by at least three of the following:

1. Absent/reduced interest in sexual activity. 2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, and typically unreceptive

to a partner’s attempts to initiate. 4. Absent/reduced sexual excitement/pleasure during sexual

activity in almost all or all sexual encounters. 5. Absent/reduced sexual interest/arousal in response to any

internal or external sexual/erotic cues. 6. Absent/reduced genital or nongenital sensations during sexual

activity in almost all or all sexual encounters.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship dis- tress (e.g., partner violence) or other signi�cant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Sexual Dysfunctions: Features and Epidemiology 317

TABLE 11.3 DSM-5

Erectile Disorder A. At least one of the three following symptoms must be experienced

on almost all or all occasions of sexual activity:

1. Marked dif�culty in obtaining an erection during sexual activity. 2. Marked dif�culty in maintaining an erection until the completion

of sexual activity. 3. Marked decrease in erectile rigidity.

B. The symptoms in Criterion A have persisted for a minimum dura- tion of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.5 DSM-5

Delayed Ejaculation A. Either of the following symptoms must be experienced on almost

all or all occasions of partnered sexual activity, and without the individual desiring delay:

1. Marked delay in ejaculation. 2. Marked infrequency or absence of ejaculation.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.4 DSM-5

Female Orgasmic Disorder A. Presence of either of the following symptoms and experienced on

almost all or all occasions of sexual activity:

1. Marked delay in, marked infrequency of, or absence of orgasm. 2. Markedly reduced intensity of orgasmic sensations.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe. Specify if never experienced an orgasm.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

cannot be directly measured. Orgasm in a woman with orgas- mic disorder should generally be one less intense than what is considered typical for the average woman, and this is based largely on self-report. Female orgasmic disorder must cause considerable distress and must not be caused by a substance or medical condition. Orgasm that can be obtained periodically via intercourse or masturbation is usually enough to exclude a exclude a exclude

diagnosis of female orgasmic disorder unless the woman remains distressed about the situation (Laan, Rellini, & Barnes, 2013).

Delayed Ejaculation Delayed ejaculation refers to delay or absence of orgasm in males during sexual activity with a partner (see Table 11.5; APA, 2013). The experience of orgasm is subjective, so one must see if a person is under psychological stress or has other problems that interfere with orgasm. Delayed ejaculation must cause consider- able distress and must not be caused by a substance or medical condition. Some men can obtain orgasm via masturbation but not with a partner, so generalized and situational subtypes are considered.

Premature (Early) Ejaculation Men with orgasmic problems may also have premature (early) ejaculation, which refers to orgasm that occurs before the person wishes, such as before or very soon after penetration (see Table 11.6; APA, 2013). Premature (early) ejaculation is often diagnosed when a sexual partner is dissatis�ed with the man’s response (Rosen, Heiman, Long, Fisher, & Sand, 2016). A man’s environment must be considered as well as his sexual his- tory and experience. Premature (early) ejaculation is usually not a problem during masturbation but can be common during in- tercourse. If the situation does not interfere with sexual relations and does not cause distress, then a diagnosis is not necessary. If the situation is a frustrating one for the man, then help may be necessary. Premature (early) ejaculation must not be due to a substance or medical condition.

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria318

Genito-Pelvic Pain/Penetration Disorder Sexual dysfunction may also involve pain during intercourse. Genito-pelvic pain/penetration disorder (termed dyspareunia and vaginismus in DSM-IV) involves pain during vaginal penDSM-IV) involves pain during vaginal penDSM-IV - etration and/or fear of pain before penetration (see Table 11.7; APA, 2013). The severity of the pain can vary—some women can have sex with some discomfort, but others must refrain from sex altogether. Even the expectation or fear of penetration can cause discomfort, and many women with the condition avoid sexual relations or engage only in oral sex (Wrobel, Nowosielski, Sodowska, & Sodowski, 2015). The disorder must cause signi�- cant distress, as when a woman wants to become pregnant but cannot, and must not result from a substance or medical condi- tion. Debate remains as to the nature of this disorder, however (see Box 11.1).

Epidemiology of Sexual Dysfunctions General sexual problems are common in women and men, and prevalence generally increases with age (Clayton & Harsh, 2016; see Tables 11.8 and 11.9). Prevalence rates for formal sexual dysfunctions, however, are dif�cult to obtain because of the sub- jective nature of the problems and because people with sexual dysfunctions are not often referred for psychological treatment unless marital con�ict or pain occurs. Many cases of erectile disorder are not referred for treatment until a couple wishes to become pregnant or seeks marital therapy. Females with sexual pain usually refer themselves to gynecologists and not mental health professionals (Kottmel, Ruether‐Wolf, & Bitzer, 2014; Shamloul & Ghanem, 2013).

Prevalence rates for formal sexual dysfunctions vary considerably. In women, prevalence rates vary for prob- lems of interest and desire (33–35 percent), arousal (21–28 percent), orgasm (16–25 percent), and pain (5–22 percent). In men, prevalence rates vary for problems of desire and in- terest (15–25 percent), erectile dysfunction (1–10 percent in those younger than age 40 years and then steadily increasing), ejaculation dysfunction (1–10 percent), orgasm (2–8 percent), and pain (16.8 percent; McCabe et al., 2016a). Prevalence rates vary widely because of cultural variables and response

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TABLE 11.6 DSM-5

Premature (Early) Ejaculation A. A persistent or recurrent pattern of ejaculation occurring during

partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activi- ties, speci�c duration criteria have not been established for these activities.

B. The symptoms in Criterion A must have been present for at least 6 months and must be experienced on almost all or all occasions of sexual activity.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.7 DSM-5

Genito-Pelvic Pain/Penetration Disorder A. Persistent or recurrent dif�culties with one (or more) of the

following:

1. Vaginal penetration during intercourse. 2. Marked vulvovaginal or pelvic pain during vaginal intercourse or

penetration attempts. 3. Marked fear or anxiety about vulvovaginal or pelvic pain in

anticipation of, during, or as a result of vaginal penetration. 4. Marked tensing or tightening of the pelvic �oor muscles during

attempted vaginal penetration.

B. The symptoms in Criterion A have persisted for a minimum dura- tion of approximately 6 months.

C. The symptoms in Criterion A cause clinically signi�cant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress or other signi�cant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify if generalized or situational.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Sexual Dysfunctions: Features and Epidemiology 319

depression and anxiety, marital problems, and past sexual trauma (Meana, Maykut, & Fertel, 2015). For some women, the problem they experience is not just sexual and isolated to them, but rather pain-related and linked to stress in their partner relationships. Successful therapy for some of these women requires active involvement of their sexual partner.

Conversely, women rarely if ever are diagnosed with transvestic disorder (cross-dressing for sexual excitement; see later section in paraphilic disor- ders), perhaps because women are generally allowed to wear masculine or feminine clothing in public. Men, however, are generally penalized if they publicly wear feminine apparel, often receiving stares or negative comments from others. With respect to exhibitionistic disorder (sexual arousal by exhib- iting genitals to strangers, see later section in paraphilic disorders), men tend to be penalized more if they reveal more skin than women, for whom such behavior is often considered attractive. Some men clearly commit offenses due to their paraphilic disorder, but others may be viewed as abnormal sim- ply because they choose to express themselves in legal, androgynous ways.

Focus On

Sexual dysfunctions and disorders are among the most controversial diagnoses. Part of the reason for this is that possible bias exists against women and men with respect to some of the disorders. Genito-pelvic pain/ penetration disorder is an example. Many women are “blamed” by their partners for being “frigid” or for avoiding sexual contact. Some researchers suggest, however, that a condition like genito-pelvic pain/penetration disor- der may be linked to important psychological factors such as symptoms of

Gender Gender Biases in Sexual

Dysfunctions and Disorders

11.1

TABLE 11.8

Prevalence of Sexual Problems by Demographic Characteristics (Women)

Lacked interest in sex

Unable to achieve orgasm

Experienced pain during sex

Sex not pleasurable

Anxious about performance

Trouble lubricating

Age, years

18–29 32% 26% 21% 27% 16% 19%

30–39 32% 28% 15% 24% 11% 18%

40–49 30% 22% 13% 17% 11% 21%

50–59 27% 23% 8% 17% 6% 27%

Marital status

Currently married 29% 22% 14% 21% 9% 22%

Never married 35% 30% 17% 25% 18% 17%

Divorced, separated, or widowed 34% 32% 16% 25% 15% 19%

Education

Less than high school 42% 34% 18% 28% 18% 15%

High school graduate 33% 29% 17% 23% 12% 20%

Some college 30% 24% 16% 23% 12% 21%

College graduate 24% 18% 10% 18% 10% 22%

Race or ethnicity

White 29% 24% 16% 21% 11% 22%

Black 44% 32% 13% 32% 16% 15%

Hispanic 30% 22% 14% 20% 12% 12%

Other 42% 34% 19% 23% 23% 17%

Data are from National Health and Social Life Survey (Laumann et al., 1999).

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria320

rates to surveys (see differences worldwide in Table 11.10; Lewis, 2013).

Racial and ethnic differences in the United States for sex- ual dysfunctions are few, although some speci�c �ndings have been reported. Older European American women tend to re- port more lack of interest in sex than older African American women (Hughes, Rostant, & Pelon, 2015). In addition, older African American veterans tend to be at higher risk for sexual dysfunction than other ethnic groups (Hosain, Latini, Kauth, Goltz, & Helmer, 2013). Most contend, however, that racial and ethnic differences in sexual dysfunctions are better explained by broader risk factors, such as stress, trauma, and health (McCabe et al., 2016b).

Sexual dysfunctions tend to co-occur with one another and with anxiety-related and depressive disorders (Forbes, Baillie, & Schniering, 2015). Making distinctions among these disorders

can be quite dif�cult. A person may be primarily depressed and potentially more interested in sex if his mood were better. Trauma-related experiences and posttraumatic stress disorder can also affect sexual dysfunctions (Lehrner et al., 2016). Dis- tinguishing arousal, desire, and orgasmic problems can also be challenging (Sarin, Amsel, & Binik, 2013).

Sexual dysfunctions can also relate closely to physical conditions. Women may experience pain because of poor vaginal lubrication or diminished elasticity, scar tissue, infection, or anatomical problems or diseases affecting the sexual organs (Strassberg, Mackaronis, & Perelman, 2015). Erectile disorder is often related to diabetes and hypertension (Skeldon, Detsky, Goldenberg, & Law, 2015). Sexual dysfunctions may link to certain substances as well. Examples include men with low sexual arousal due to antidepressant medication and erectile dysfunction due to smoking (Cao et al., 2013; Clayton, Croft, & Handiwala, 2014).

TABLE 11.9

Prevalence of Sexual Problems by Demographic Characteristics (Men)

Lacked interest in sex

Unable to achieve orgasm

Climax too early

Sex not pleasurable

Anxious about performance

Trouble maintaining or achieving erection

Age, years

18–29 14% 7% 30% 10% 19% 7%

30–39 13% 7% 32% 8% 17% 9%

40–49 15% 9% 28% 9% 19% 11%

50–59 17% 9% 31% 6% 14% 18%

Marital status

Currently married 11% 7% 30% 6% 14% 9%

Never married 19% 8% 29% 11% 21% 10%

Divorced, separated, or widowed

18% 9% 32% 13% 26% 14%

Education

Less than high school 19% 11% 38% 14% 23% 13%

High school graduate 12% 7% 35% 6% 18% 9%

Some college 16% 8% 26% 9% 19% 10%

College graduate 14% 7% 27% 6% 13% 10%

Race or ethnicity

White 14% 7% 29% 7% 18% 10%

Black 19% 9% 34% 16% 24% 13%

Hispanic 13% 9% 27% 8% 5% 5%

Other 24% 19% 40% 9% 21% 12%

Data are from National Health and Social Life Survey (Laumann et al., 1999).

Stigma Associated with Sexual Dysfunctions 321

Stigma Associated with Sexual Dysfunctions

As you might guess, stigma associated with sexual dysfunc-tions can be quite powerful (see Box 11.2). Stigma associ- ated with “impotence” or erectile dysfunction in men is clearly linked to denial of the problem and failure to seek treatment (McGraw et al., 2015). Men are often embarrassed to discuss the issue, so some researchers have proposed that medical professionals should initiate conversations about erectile dys- function with their male patients, particularly those with risk factors such as medication use for diabetes or heart disease (Jannini et al., 2014). In addition, a majority of men with pre- mature ejaculation do not discuss with a physician alternatives to prolong the sexual experience (Teloken & Mulhall, 2014).

Stigma with respect to sexual dysfunction can apply to women as well. Recurrent painful intercourse is not uncom- mon among women. However, many women are initially con- fused about the source of pain, try to pursue strategies for relief that do not work, and are reluctant to seek professional help. In addition, health care providers rarely raise this topic with their patients (Leeners, Hengartner, Ajdacic-Gross, Rössler, & Angst, 2015). Some argue that sexual pain is a problem that

has many concurrent issues and should not be considered a sexual dysfunction (Farmer, Davis, & Binik, 2015). Another source of stigma comes from secondary problems that can re- sult because of sexual pain. These problems include infertil- ity, marital problems, and divorce. Fertility specialists should thus consider these painful conditions when counseling couples (Peterson et al., 2012).

➲ Interim Summary • Sexual dysfunctions involve disturbance of the sexual

response cycle and may be lifelong or acquired.

• Male hypoactive sexual desire disorder and female sexual interest/arousal disorder involve lack of fantasies or desire to have sexual relations.

• Erectile disorder refers to dif�culty obtaining or maintain- ing a full erection during sex.

• Female orgasmic disorder and delayed ejaculation refer to delay or absence of orgasm during sex.

• Premature (early) ejaculation refers to orgasm that occurs before a man wishes it.

• Genito-pelvic pain/penetration disorder involves problems of pain during intercourse.

TABLE 11.10

Prevalence of Sexual Dysfunctions by Geographical Area for Sexually Active Participants

Sexual dysfunction

Northern Europe

Southern Europe

Non-European West

Central/South America Middle East East Asia

South East Asia Total

Men

Early ejaculation 10% 13% 16% 22% 8% 19% 25% 14%

Erection dif�culties 8% 8% 11% 9% 8% 15% 22% 10%

Lack of interest in sex

7% 6% 9% 9% 13% 12% 20% 9%

Inability for orgasm 5% 7% 8% 8% 7% 10% 15% 7%

Sex not pleasurable 4% 5% 6% 4% 8% 7% 12% 6%

Women

Lack of interest in sex

17% 21% 19% 20% 29% 27% 34% 21%

Inability for orgasm 10% 17% 16% 16% 17% 23% 34% 16%

Lubrication dif�culties

13% 12% 19% 18% 12% 28% 28% 16%

Sex not pleasurable 10% 15% 12% 14% 22% 21% 28% 15%

Painful intercourse 5% 8% 8% 14% 14% 20% 22% 10%

Source: Lewis, R. W. (2013). A critical look at descriptive epidemiology of sexual dysfunction in Asia compared to the rest of the world-a call for evidence-based data. Translational Andrology and Urology, 2, 54-60.

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria322

• Sexual dysfunctions are common, increase with age, as- sociate with one another and with anxiety and depression, and may link to many medical conditions and substances.

• Sexual dysfunctions can be highly stigmatizing and can affect people’s decisions to seek treatment.

➲ Review Questions 1. What sexual dysfunctions affect sexual desire and arousal? 2. What sexual dysfunctions affect sexual orgasm? 3. What sexual dysfunction involves pain during intercourse? 4. Discuss the epidemiology of sexual dysfunctions. 5. Discuss stigma surrounding some sexual dysfunctions.

Sexual Dysfunctions: Causes and Prevention

Risk factors for sexual dysfunctions have not been explored at length but likely include biological and environmental variables. We next discuss these risk factors and prevention of sexual dysfunctions.

Biological Risk Factors for Sexual Dysfunctions We mentioned that biological factors, such as medical conditions and substances, affect sexual performance. Sexual dysfunctions must not be caused exclusively by a medical condition or a sub- stance; however, researchers often investigate sexual problems that are related to medical conditions or substance use. Medical conditions that impair sexual performance in men include pros- tate cancer and subsequent treatment as well as cardiovascular problems. Medical conditions that impair sexual performance in women include cervical and other gynecological cancers as well as menopause. Some medical conditions that may affect sexual functioning could also be present in either gender, such

as diabetes, general pain, renal disease, multiple sclerosis, and spinal cord injuries or paralysis (Strassberg et al., 2015). These medical conditions can lead to sexual pain or dif�culties with arousal or orgasm.

Various substances also interfere with normal sexual func- tioning. Examples include legal substances, such as alcohol, nico- tine, and some prescription medications and illegal substances, such as opioids and marijuana. Alcohol use impairs male and female sexual performance (Maisto, Galizio, & Connors, 2015). Drugs for psychiatric conditions like depression and schizo- phrenia can also impair sexual response (de Boer, Castelein, Wiersma, Schoevers, & Knegtering, 2015).

Psychological Risk Factors for Sexual Dysfunctions Psychological factors also impair the sexual response cycle. One key factor is anxiety or worry during sexual performance about satisfactorily pleasing oneself and one’s partner. Men may worry about obtaining an erection, ejaculating prematurely, or having enough energy to complete the act. Such was true for Douglas. Women may worry about pain during intercourse and lack of orgasm. Worry about performance may lead to failure that cre- ates more anxiety and avoidance of sex (Birnbaum, Mikulincer, Szepsenwol, Shaver, & Mizrahi, 2014).

Men and women may also distract themselves during sex to monitor their own performance. The spectator role involves greater concern with evaluating performance than enjoying relaxed sexual activity. Sexual experience becomes less enjoyable and less likely to produce a satisfactory sexual response when a person is distracted from erotic thoughts by criticizing his sexual behavior. Men often try to delay ejaculation by thinking of negative or posi- tive sexual experiences or by thinking about irrelevant items like baseball statistics, but this is usually unhelpful (Berry, 2013).

Failures during sexual performance can also result from poor interactions between partners during sex. Many couples do not speak during sex when a conversation about what a person enjoys and does not enjoy would greatly enhance the

treatment. This was especially the case for men and religious partici- pants. In addition, males were more likely to seek help from a family phy- sician, whereas females were more likely to seek help from a gynecologist or urologist (Bergvall & Himelein, 2014).

Others have found that sexual dysfunctions in college students often relate to experiences of sexual victimization. One group of researchers found that college women who had experienced sexual coercion or rape reported more sexual dysfunctions related to desire, arousal, and pain compared with nonvictims (Turchik & Hassija, 2014). In addition, college males who had been sexually victimized also report sexual functioning dif�culties (Turchik, 2012). Male survivors of sexual assault are especially unlikely to disclose the event, which means they may be less likely to seek help for subsequent sexual dysfunction as well (Allen, Ridgeway, & Swan, 2015).

Focus On

Sexual dysfunctions often increase in prevalence with age, especially for men, so many college students may not think much about these problems. If a young adult does experience a sexual problem, substantial stigma may therefore apply. One group of researchers surveyed college students in the United States and Sweden and found that self-stigma for a sexual problem was signi�cantly related to less likelihood for seeking professional

11.2

College Students Sexual Dysfunctions

Sexual Dysfunctions: Causes and Prevention 323

experience. A man may wish for more oral grati�cation and a woman may wish for more manual clitoral stimulation. These in- terests should be shared with one another, even during intercourse. Marital or relationship problems can also interfere with adequate sexual activity (Bois, Bergeron, Rosen, McDuff, & Grégoire, 2013). Problems may include �ghting, stress, sexual boredom, dif�culty with intimacy or fertility, or impulsive behavior.

Historical psychological variables can be important as well for determining sexual dysfunctions. Early sexual experiences for someone may have been traumatic, as when a child or adolescent is sexually maltreated, when a �rst sexual experience goes badly, or when fear of pregnancy is intense (Zollman, Rellini, & Desro- cher, 2013). Future sexual experiences may thus be painful physi- cally and psychologically. Another early factor is family treatment of sex as a “dirty” or repulsive act that was not to be discussed or practiced. Strict religious practices that may lead to punishment of masturbation or other sexual activity may also be a factor. These family practices could lead to ignorance about the normal sexual process and problems when sex is attempted, such as attempting intercourse too quickly (Greenberg, Bruess, & Oswalt, 2014).

General knowledge about sex over time is important as well, as many aging men require greater stimulation for an erection and many women experience less vaginal lubrication (Hillman, 2012). Acknowledging these normal changes and making adjustments in one’s sexual activity to compensate for them is therefore important. People with mental disorders such as depression or anxiety commonly experience sexual dysfunc- tions as well. These disorders can help cause sexual dysfunc- tions and help maintain them over time (Forbes et al., 2015).

Cultural Factors Sexual dysfunctions are common across various cultures. As noted earlier (Table 11.10), erectile dysfunction is common worldwide and especially in East and Southeast Asia (Lewis, 2013). Part of this may be explained by a strong emphasis on sex as important in intimate relationships, lack of verbal com- munication about sex, and the presence of multigenerational family members in one household (Liong, 2013; Woo, Fok-Trela, & Brotto, 2014). Overall, however, attitudes about erectile dys- function are quite similar across various cultures—most men believe erectile dysfunction is a source of sadness, that they are not “too old for sex,” that knowledge about erectile dysfunction is important, and that they would try virtually any remedy for the condition (Soni, Pastuszak, & Khera, 2014).

Women of different cultures also experience sexual dys- function, although the perceived cause of dysfunction can vary. Moroccan and Danish women with diabetes tend to have high levels of sexual dysfunction, as do Korean women with heart disease. In addition, cultures that emphasize female genital mu- tilation or cutting are obviously responsible for elevated rates of sexual dysfunction (McCabe et al., 2016b). Other factors that are more common to women in certain cultures, such as violence, depression, and harsh sexual attitudes, can also affect sexual dysfunction (Colucci & Hassan 2014).

In the United States, African American women are more likely than European American women to report concern about vaginal

lubrication, sex appeal, sexually transmitted disease, thinking much about sex, and having an affair. Asian American women show less concern than European American women about lack of interest in sex, orgasm dif�culty, sex appeal, unsatis�ed sex- ual needs, and sexual concerns from a partner. Asian American women may be more concerned, however, about sexually trans- mitted disease and penetration dif�culties (see Table 11.11).

Causes of Sexual Dysfunctions Integrated causal models for sexual dysfunctions have been pro- posed, and a common one is in Figure 11.2 (Wincze & Weisberg, 2015). People with dysfunctional sexual performance respond to sexual demands in several negative ways. A person may expect bad things to happen, such as anxiety, lack of erection, or pain. The person may then focus on failure to perform rather than en- joyment of the experience, feel helpless or threatened in sexual situations, and avoid many sexual interactions. Avoiding sexual experiences may not allow a person to experience or practice pos- itive sexual interactions. A cycle is thus created that leads to anxi- ety, lack of control, expectation of failure, and more avoidance.

Causal factors for sexual dysfunction have also been or- ganized along a “balancing scale” that tilts toward successful or dysfunctional sexual performance (see Figure 11.3; Wincze & Weisberg, 2015). This model includes various biological and psychological risk factors, the presence of which can “tilt” the scale toward one end or another. A person who is depressed, who has negative interactions with a partner, who does not en- joy sexual activity, and who has certain medical conditions may have a certain sexual dysfunction. Douglas and Stacy’s sexual experience became dominated by a new, uncomfortable envi- ronment that involved exhaustion from child care.

Prevention of Sexual Dysfunctions Prevention of sexual dysfunctions has focused primarily on relapse prevention with couples. Much of this involves booster sessions or other methods to help couples continue to practice psychological treatment techniques for sexual dysfunction and/or manage comorbid physical or psychological problems. Successful prevention of later problems during sex will continue to require effort from both sexual partners as well as good com- munication. Constant pressure from one partner is not produc- tive and should be avoided (Wincze & Weisberg, 2015).

➲ Interim Summary • Biological risk factors for sexual dysfunctions commonly

include illnesses and legal and illegal substances.

• Psychological risk factors for sexual dysfunctions include worry during performance, marital problems, traumatic early sexual experiences, strict family practices regarding sex, and poor sexual knowledge.

• An integrated causal approach to sexual dysfunctions likely involves a combination of biological events and expectations that negative events will occur during sex.

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria324

• Preventing sexual dysfunctions primarily involves relapse prevention after a couple completes treatment.

➲ Review Questions 1. What biological risk factors may in�uence sexual dysfunctions? 2. What psychological risk factors may in�uence sexual

dysfunctions? 3. What is the spectator role? 4. How might a “balancing scale” help us understand sexual

dysfunctions? 5. How might one help a couple prevent future episodes of

sexual dysfunction?

TABLE 11.11

Prevalence of Sexual Concerns among White, African American, and Asian American Women

Sexual concerns White African

American Asian

American

Lack of interest in sex 89 84 72

Dif�culty having orgasm 87 79 72

Vaginal lubrication 76 63 74

Lack of sex appeal 72 62 47

Sexual pain 72 77 69

Unsatis�ed sexual needs 69 73 54

Need sex information 65 70 55

Desires different than partner’s 62 53 51

Contraception, family planning, fertility

62 73 48

Inability to have orgasm 61 60 61

HIV/AIDS 52 76 54

Safe sex/sexually transmitted diseases

52 68 51

Partner sexual dif�culties 49 41 41

Dif�culty inserting penis 48 44 56

Thinking too much about sex 39 44 37

Adult sexual coercion 36 46 21

Adult emotional/physical maltreatment

36 32 22

Childhood emotional/ physical maltreatment

34 36 19

Want to have/have had an affair

34 52 21

Hard to control sexual urges 30 32 25

Sexual orientation 25 28 29

Sexual interest in women 20 23 20

Childhood sexual coercion 17 20 12

Wish to be opposite sex 16 14 15

Sexually abusive towards others

15 4 8

Numbers are percentages. From Nusbaum, M. R., Braxton, L., & Strayhorn, G. (2005). The sexual concerns of African Americans, Asian Americans, and white women seeking routine gynecological care. Journal of the American Board of Family Medicine, 18(3), 173, Table 2. Reprinted by permission of the American Board of Family Medicine.

Demands or expectations for sexual performance

Positive mood and expectancy about gaining an

erection

Negative mood and expectancy about gaining an

erection

Focus on erotic cues

Focus on consequences of inability to

perform

Increased physical arousal

Intense focus on

erotic cues

Intense focus on consequences of inability to

perform

Erectile function and approach

toward sex

Erectile dysfunction and avoidance of sex

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FIGURE 11.2 SAMPLE MODEL OF ERECTILE DYSFUNCTION.

Sexual Dysfunctions: Assessment and Treatment 325

Sexual Dysfunctions: Assessment and Treatment Assessment of Sexual Dysfunctions Sexual dysfunctions involve many psychological and medical ingredients, so a comprehensive assessment is important. A full health assessment should also precede a psychological one to rule out or medically address any physical problem.

Interviews Interviews for people with sexual dysfunctions must be done carefully given the highly sensitive nature of the material being covered. Important areas to cover during an interview include sexual history, knowledge, beliefs, desires, and practices. Other relevant information would necessarily involve relation- ship issues such as marital con�ict, medical history and current medications, stress, lifestyle changes, comorbid psychological problems such as depression, and goals for treatment (Wincze & Weisberg, 2015). The interview should also help build rapport with clients who may �nd such discussions dif�cult.

Questionnaires Self-report questionnaires with respect to sexual dysfunctions generally surround issues of sexual satisfaction, arousal, anxi- ety, preferences, attitudes, and knowledge. These measures are useful but should only be used in conjunction with other as- sessment measures because self-report may be biased. Common self-report questionnaires for sexual dysfunctions include the Female Sexual Function Index (Table 11.12) and International Index of Erectile Function (Rosen, 2015).

Self-Monitoring Couples may also record information about their daily sexual history. This could involve descriptions of sexual activity,

degree of desire or arousal, type of affection- ate behaviors, orgasm frequency and qual- ity, satisfaction with the sexual experience, and emotional states and thoughts about the sexual experience. Monitoring information from both partners is important and can be compared to see if large discrepancies exist. Self-monitoring is obviously used instead of direct observation by others given the sensi- tive nature of the behavior (Lupton, 2015). A therapist’s observations of other relevant variables such as marital communication can be important, however (Weeks, Gambescia, & Hertlein, 2016).

Physiological Assessment Physiological assessment of sexual dysfunc- tions overlaps to some degree with procedures we mention later for paraphilic disorders, such as the penile plethysmograph. Physiological assessment of sexual dysfunctions remains

underdeveloped, but a common strategy for assessing erectile disorder is nocturnal penile testing. Erections during sleep are monitored physiologically because no sexual anxiety or demands for performance are present. If a man continues to have erec- tile dif�culties during sleep, he may be diagnosed with erectile disorder. If erections occur without dif�culty during sleep, then psychological factors such as performance anxiety may need to be addressed. Nocturnal penile testing can be done at a sleep laboratory or using a portable device at home (Lin et al., 2015).

Biological Treatment of Sexual Dysfunctions Medical treatment for sexual dysfunctions has concentrated most on drugs for erectile dis- order. The most well known of these drugs is sildena�l, which helps to increase blood �ow to the penis and thus to form an erection. Sildena�l— sold under the brand names Viagra, Levitra, and Cialis— comes in pill form, but other drugs may be injected directly into the penis to cause the same effect. The most com- mon is prostaglandin E1, which relaxes muscles in the penis to assist an erection.

Other methods to im- prove erectile quality include implants surgically inserted into the penis. These im- plants may be in�atable,

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rs � No smoking � No excess alcohol � No medications that affect sex � Good physical health � Regular, appropriate exercise � Good nutrition

� Good emotional health � Attraction toward partner � Positive attitude toward partner � Positive sex attitude � Focus on pleasure � Newness � Good self-esteem � Comfortable environment for sex � Flexible attitude toward sex

� Smoking � Too much alcohol � Antihypertensive medication/drugs � Poor physical health � Heart and blood-flow problems � Diabetes

� Depression or PTSD � Lack of partner attraction � Negative attitude toward partner � Negative attitude toward sex � Focus on performance � Routine, habit � Poor self-esteem � Uncomfortable environment for sex � Rigid, narrow attitude toward sex

FIGURE 11.3 POSITIVE AND NEGATIVE FACTORS THAT AFFECT SEXUAL FUNCTIONING.

Viagra and related drugs have helped many men with erectile dysfunction.

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria326

semirigid, or continually rigid to maintain erections, but problems include awkwardness and possible damage to the penis (Trost, Patil, & Kramer, 2015). Other surgical procedures may be done as well to correct penile blood �ow problems. An alternative to surgery is a vacuum system in which a tube is placed around the penis, and a pump helps draw blood into the penis (Welliver, Mechlin, Goodwin, Alukal, & McCullough, 2014). The erection is then maintained by placing an elastic band at the base of the penis. Such a device may also be used to enhance clitoral blood �ow in women (Candy, Jones, Vickerstaff, Tookman, & King, 2016). Medications remain the primary biological intervention for erectile dif�culty, but these surgical and manual methods are also effective.

Other drugs, especially antidepressants, have been used for sexual dysfunctions such as premature ejaculation (Clayton et al., 2014). Vaginal lubricants and hormone replacement therapy may be useful for women with painful intercourse (Falk & Dizon, 2013). Medical problems that result in painful sexual

intercourse should be resolved as well. People with low sexual desire may receive testosterone, estrogen, or androgen hormonal treatment (Lowenstein, Shechter, Porst, Tripodi, & Reisman, 2016). Flibanserin, a medication that increases dopamine and norepi- nephrine and reduces serotonin, has also been used for women with hypoactive sexual desire disorder (Jaspers et al., 2016).

Psychological Treatments of Sexual Dysfunctions Medical approaches to addressing sexual dysfunctions are often accompanied by psychological approaches, or sex therapy. Sex therapy involves different techniques to enhance performance during sex. A common technique for premature ejaculation is the stop–start procedure (Jern, 2014). The penis is stimulated by the man or a partner until an erection occurs and ejaculation seems close. The top of the penis is then pinched to suppress stimulation, prevent ejaculation, and allow the erection to be maintained longer. As the man becomes more accustomed to controlling his excitement, intercourse begins slowly so ejacu- lation can be further delayed. In this way, more lengthy inter- course can occur.

For men and women with low sexual desire, sex therapy may consist of initially banning sexual contact and rebuilding a couple’s sexual repertoire. This is called sensate focus. A couple may be asked to refrain from sex and caress and massage each other only in nonsexual areas—avoiding breasts and genital areas. Both partners can thus become more relaxed and focused on pleasure, and the pressure to perform in intercourse eases. As therapy progresses, partners guide each other’s hands to dif- ferent areas of the body that give the most pleasure for that

TABLE 11.12

Female Sexual Function Index

Question Response options

Over the past 4 weeks, how often did you feel sexual desire or interest?

5 = Almost always or always

4 = Most times (more than half the time)

3 = Sometimes (about half the time)

2 = A few times (less than half the time)

1 = Almost never or never

Over the past 4 weeks, how con�- dent were you about becoming sexually aroused during sexual activity or intercourse?

0 = No sexual activity

5 = Very high con�dence

4 = High con�dence

3 = Moderate con�dence

2 = Low con�dence

1 = Very low or no con�dence

Over the past 4 weeks, when you had sexual stimu- lation or intercourse, how dif�cult was it for you to reach orgasm (climax)?

0 = No sexual activity

1 = Extremely dif�cult or impossible

2 = Very dif�cult

3 = Dif�cult

4 = Slightly dif�cult

5 = Not dif�cult

Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?

0 = Did not attempt intercourse

1 = Almost always or always

2 = Most times (more than half the time)

3 = Sometimes (about half the time)

4 = A few times (less than half the time)

5 = Almost never or never

Penile implants help the male organ become rigid for penetration during sex.

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Sexual Dysfunctions: Assessment and Treatment 327

person. Verbal communication about likes and dislikes during this process is important as well.

Intercourse is gradually reintroduced to the intimacy process as a couple becomes more experienced in relaxing and giving pleasure to a partner during sex. Fantasy trainingFantasy training and exposure to erotic material to increase the range of sexual fantasies a partner may have during sex may also be done with sensate focus (Hertlein, Weeks, & Gambescia, 2015). Douglas and Stacy were relieved by the initial ban on inter- course, and fantasy training helped start them toward a path of better sensuality.

Masturbation training may also be useful for people with orgasmic problems. A partner practices effective masturbation and stimulation so orgasm is enhanced and brought about more quickly (Frühauf, Gerger, Schmidt, Munder, & Barth, 2013).

Speci�c areas of stimulation that help produce orgasm, such as clitoral stimulation, are explored and can then be extended to intercourse with a partner to hopefully bring about orgasm at that time.

Pain during intercourse may be addressed in various ways as well. Psychological treatment generally focuses on initially prohibiting intercourse, gradually inserting dilators to increase vaginal size, practicing relaxation training, and using Kegel exer-Kegel exer-Kegel exer cises to strengthen the vaginal area (Laan & van Lunsen, 2016). Kegel exercises may involve inserting a �nger into the vagina and then systematically squeezing and releasing the vaginal muscles. Vaginal lubricants during this process may be helpful as well.

Psychological approaches for sexual problems may also tar- get related issues such as marital con�ict, exhaustion, trauma, depression, anxiety, and excessive substance use. Sex may be scheduled at relaxing and convenient times and places, such as early in the morning or at a hotel away from the demands of children. This was especially helpful for Douglas and Stacy. Increasing sexual knowledge between partners, enhancing safe- sex practices, and reducing sexual myths and avoidance are important as well (Wincze & Weisberg, 2015). Couples may ap- preciate that either partner can initiate sex, that condom use is acceptable, and that orgasm is not always the �nal product of intercourse.

What If I or Someone I Know Has a Sexual Dysfunction? If you feel you or someone you know may have a sexual dysfunc- tion, then consulting with a physician and clinical psychologist who specializes in these problems may be best. Some screening questions are listed in Table 11.13. Sexual dysfunctions are best addressed by a comprehensive medical examination and per- haps medication as well as psychological procedures to enhance sexual performance. Marital therapy may also be necessary before pursuing a sexual solution.

Various treatments for erectile disorder are pictured here, including a penile vacuum (right). It stimulates blood �ow into the penis, and the rings are used to keep the blood in.

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TABLE 11.13

Screening Questions for Sexual Dysfunction

Do you or someone you know have dif�culty in sexual relations with others?

Do you or someone you know have little or no desire for sexual intercourse?

Do you or someone you know avoid sex (or conversations about sex) because of performance worries?

Do you or someone you know have trouble achieving an orgasm during intercourse?

Do you or someone you know experience pain during intercourse?

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria328

Long-Term Outcomes for People with Sexual Dysfunctions Some sexual conditions such as erectile problems and low sexual desire often worsen over time. Other problems such as prema- ture ejaculation may get better over time, and sexual satisfaction often improves as couples mature in their relationship. Other problems, such as sexual pain, may not change much without treatment over time. In general, men tend to experience more sexual problems with age, but women do not (Angst, Hengartner, Rössler, Ajdacic-Gross, & Leeners, 2015).

Many people do, however, respond positively to medical and psychological treatment approaches for sexual dysfunctions. Some women (37.6 percent) who receive �ibanserin for low sexual de- sire improve and some effectiveness has been found for men who receive testosterone (Isidori et al., 2014; Simon et al., 2014). Men with erectile disorder using sildena�l and related oral medications achieve a positive response in 69 to 75 percent of cases (Yuan et al., 2013). Effects of medication may be enhanced by sex therapy (Schmidt, Munder, Gerger, Frühauf, & Barth, 2014).

Psychological interventions tend to be more effective for some sexual dysfunctions than others. Treatment tends to work better for female hypoactive sexual desire disorder and sexual pain, mod- erately well for erectile dysfunction and female orgasmic disorder, and less well for premature ejaculation (Frühauf et al., 2013). Psy- chotherapy alone for premature ejaculation may be effective in some cases, but its combination with medication often produces better results (Cooper et al., 2015). Many people drop out of treat- ment for sexual dysfunctions, however. Positive outcome in sex therapy may relate to good relationship quality, high partner mo- tivation for improvement, lack of serious comorbid disorders such as depression, physical attraction between partners, and treatment compliance (Segraves, 2015). Couples like Douglas and Stacy who work on problems together, and do so in a warm, supportive way, seem better destined for success during sex.

➲ Interim Summary • Interviews for sexual dysfunctions cover sexual history,

knowledge, beliefs, desires, and practices as well as relevant relationship issues.

• Self-report questionnaires are useful for assessing sexual dysfunctions and focus on sexual satisfaction, arousal, anxiety, preferences, attitudes, and knowledge.

• Self-monitoring is sometimes used as an assessment technique for sexual dysfunction.

• Physiological assessment of sexual dysfunctions includes nocturnal penile testing and other methods.

• Medical treatments for sexual dysfunctions include drugs such as Viagra, implants, vaginal lubricants, and hormone therapy.

• Psychological interventions for sexual dysfunctions concentrate on sex therapy to address premature ejacula- tion, orgasmic problems, pain, and marital relationships.

• People with sexual dysfunctions generally respond well to treatment, especially if the couple is attracted to one another, communicates well, and complies with treatment.

➲ Review Questions 1. What topics might be covered when using interviews and

self-report measures to assess sexual dysfunctions? 2. How can self-monitoring and physiological assessment help a

clinician know more about sexual dysfunctions? 3. What medications are available to treat sexual dysfunctions? 4. Describe the start-stop procedure, sensate focus, and

masturbation training. 5. What is the long-term outcome for people with sexual

dysfunctions?

11.4 Continuum of Sexual Behavior and Paraphilic Disorders

NORMAL MILD

Emotions Regular arousal and desire to have typical sexual behavior. Mild physical arousal when thinking about unusual sexual Regular arousal and desire to have typical sexual behavior. Mild physical arousal when thinking about unusual sexual Regular arousal and desire to have typical sexual behavior. Mild physical arousal when thinking about unusual sexual behavior.

Cognitions Thoughts about typical sexual behavior. Thoughts about unusual sexual behavior.Thoughts about unusual sexual behavior.

Behaviors Engaging in typical sexual behavior. Sur�ng Internet sites that cater to unusual sexual behavior.

CONTINUUM FIGURE

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

Paraphilic Disorders: Features and Epidemiology 329

Normal Sexual Desires, Paraphilias, and Paraphilic Disorders: What Are They?

Many people engage in regular sexual activity with no prob-lem but have unusual fantasies and desires during sex. These fantasies are usually harmless and do not indicate a clini- cal problem. Other people have odd sexual fantasies and �nd a consenting partner to help ful�ll the fantasies. If sexual behavior is odd but consensual and legal and causes no harm or distress, then the behavior is considered normal. Many couples mutually agree to engage in sexual “games” that may involve domina- tion, peculiar attire, tickling, videotaping, and other irregular activities (see Figure 11.4). Some of these activities can become quite frequent and fervent. Paraphilias are preferential, intense, and/or persistent sexual interests that may be odd but are not a mental disorder.

Other people experience unusual sexual fantasies and be- haviors that consume much of their time and energy. Someone might spend hours at work on Internet sex sites, spend all day at an adult bookstore, have urges to do something unusual or illegal, and constantly wonder what it would be like to have sex with different partners. These fantasies and behaviors are not necessarily abnormal but do verge on becoming a problem if work, interpersonal relationships, or �nancial or legal standing are threatened.

For other people, sexual fantasies can become quite distress- ing, central to their life, or linked to illegal or harmful behaviors that interfere with work, concentration, or regular sexual rela- tionships. Paraphilic disorders include problems arising from sexual behavior or fantasies involving highly unusual activities (APA, 2013). A person’s Internet role-playing may not necessar- ily rise to the level of a mental disorder. If he spent so much time

satisfying his urges he was arrested for an illegal activity or was distressed by obsessive fantasies, however, then he may have a paraphilic disorder.

Paraphilic Disorders: Features and Epidemiology

We next summarize major features of the most commonly diagnosed paraphilic disorders. Each paraphilia has a particular focus of sexual fantasies, urges, or behaviors, or paraphilia (Table 11.14).

MODERATE

PARAPHILIC DISORDER — LESS PARAPHILIC DISORDER — LESS

SEVERE

PARAPHILIC DISORDER — MORE PARAPHILIC DISORDER — MORE

SEVERE

Strong physical arousal when fantasizing about Strong physical arousal when fantasizing about unusual sexual behavior.unusual sexual behavior.

Intense physical arousal when fantasizing about or Intense physical arousal when fantasizing about or engaging in unusual sexual behavior.engaging in unusual sexual behavior.

Extreme physical arousal when fantasizing about or Extreme physical arousal when fantasizing about or engaging in unusual sexual behavior.engaging in unusual sexual behavior.

Sexual fantasies that lead to urges toward Sexual fantasies that lead to urges toward highly unusual sexual behaviors.highly unusual sexual behaviors.

Sexual fantasies about unusual Sexual fantasies about unusual sexual behavior that become central sexual behavior that become central to a person’s life and create distress.to a person’s life and create distress.

Obsession-like sexual fantasies about Obsession-like sexual fantasies about unusual sexual behavior that cause unusual sexual behavior that cause great distress.great distress.

Spending substantial time on the Internet or in adult bookstores, especially regarding unusual sexual behavior.

Inability to concentrate or have Inability to concentrate or have regular sexual relationships. regular sexual relationships. Engaging in some unusual sexual Engaging in some unusual sexual behavior.

Engaging in or being arrested for highly unusual sexual behavior such as inappropriate contact with a child.

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TABLE 11.14

Major Paraphilic Disorders

Paraphilic disorder Focus of arousal

Exhibitionistic Exposing genitals to strangers

Fetishistic Nonliving object or nongenital body part

Frotteuristic Physical contact with a nonconsenting person

Pedophilic Children

Sexual Masochism and Sexual Sadism

Humiliation from or to others

Transvestic Dressing as the opposite gender

Voyeuristic Secretly watching others undress or engage in sex

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria330

Exhibitionistic Disorder The particular focus of exhibitionistic disorder, or exhibition- ism or �ashing or �ashing or �ashing indecent exposure, is exposing one’s genitals to strangers who do not expect the exposure (see Table 11.15; APA, 2013). Tom exposed himself to unsuspecting teenagers in the hope of getting a strong reaction. Paraphilic disorders such as exhibitionism generally involve acting on one’s fantasies or having signi�cant distress or interpersonal problems because of the fantasies. Tom acted on his fantasies and was quite dis- tressed by them.

A person with exhibitionism will often expose himself to others and then quickly �ee the scene. Usually no actual sexual contact with others takes place. The person often leaves the scene to masturbate to fantasies that the stranger was sexually aroused by, or somehow enjoyed, the exposure. A person with exhibitionism may misinterpret the stranger’s shock or surprise as sexual arousal (Kaser-Boyd, 2015). If the person is caught, however, as Tom was, an arrest is often made. Exhibitionism may also occur with telephone scatalogia, or sexual arousal via obscene electronic communications to others (Hopkins, Green, Carnes, & Campling, 2016).

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Tom was 36 years old when he was court- referred for therapy after an arrest for indecent exposure. The incident had occurred 2 months earlier when Tom parked his car on a street near a local high school. Three female teenagers walked by Tom’s car and saw him masturbating in the front seat. One teenager grabbed her cell phone and took a picture of Tom’s license plate as he quickly drove away. The police were called and, based on the picture of the license plate, arrived at Tom’s home to make the arrest. A plea arrange- ment allowed Tom to stay out of jail but with con- siderable community service, registration as a sex offender, and court-mandated therapy.

Tom’s therapist asked him to provide a his- tory of behavior that led up to the arrest. Tom initially said he always had “kinky” sexual ideas, even from adolescence, but had never before acted on them. He often daydreamed and fan- tasized about being a powerful male �gure that was highly attractive to women, particularly adolescents and young women. His fantasies ventured into many different scenarios. One fan- tasy involved watching young women, including teenagers, undress before him or wear school- girl out�ts that made them look young. Another fantasy involved sadomasochistic interactions with young women in which he controlled their behavior and attire. Still another key fantasy in- volved his exposure to young women, who would then (in his fantasy) become very attracted to him and wish to spend time with him.

Tom said he had dominating women in his life, including his mother and teachers, and that his personality was actually shy and meek. He

thought his fantasies compensated for a deep sense of inadequacy he often felt around women, although he appeared to be socially skilled and not easily intimidated. Tom said his sex life with his wife was normal, that he had been married 8 years, that he had one child, and that neither his wife nor anyone else was aware of his secret fantasies. He reportedly had no desire to actually practice his fantasies until about 4 years ago.

When asked what changed 4 years ago, Tom said he became more involved in Internet chat rooms. He discovered various rooms that catered to his fantasies by allowing him to role- play and learn of others’ fantasies that soon became his own. He found himself daydream- ing more and more about exhibiting himself to young women, who would then be overwhelmed by his sexual prowess and become very atten- tive to him. He role-played many versions of this scenario in Internet chat rooms, found websites largely devoted to his fantasies, subscribed to services that provided pictures related to his fan- tasies, and even found other people in his area who had similar fantasies and who guided him about the best places to act out his fantasies.

Tom eventually confessed about numerous occasions where he had surreptitiously exposed himself before young women. The exposure was so covert the women did not even know what Tom had done. Tom would then go to a hid- den place and masturbate to a fantasy that the young woman had seen his genitals and that she longed to be with him.

Tom engaged in a much more risky expo- sure on the day of his arrest. He was actively seeking a reaction from one of the teenagers, after which he planned to drive home and mas- turbate to a fantasy that she was sexually aroused by his presence. Tom was now morti�ed about what happened and worried about the effect of his arrest on his marriage and career. Tom said he was deeply ashamed of what he had done and wished he could be free of his constant sexual fantasies. He sobbed and said he would do anything to make sure something like this incident would never happen again.

What Do You Think? 1. How are Tom’s fantasies and behaviors

different from a typical adult? Would any of his behaviors seem normal in a certain context or for someone of a certain age?

2. What external events and internal factors might be responsible for Tom’s fantasies and behaviors?

3. What are you curious about regarding Tom? 4. Does Tom remind you in any way of

yourself or someone you know? How so? 5. How might Tom’s fantasies and behaviors

affect his life in the future?

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Paraphilic Disorders: Features and Epidemiology 331

Fetishistic Disorder The particular focus of fetishistic disorder, or fetishism, is non- living objects or a nongenital body area to begin or enhance sexual arousal (see Table 11.16; APA, 2013). People with fetish- ism often need certain types of clothing or other objects nearby when masturbating or engaging in intercourse. The objects al- low the person to become excited during sexual activity, such as obtaining an erection, and to achieve orgasm. Many people with fetishism prefer female underclothes, stockings, high heels or boots, lingerie, or clothing fabrics such as rubber, leather, ny- lon, or silk. The fetish object is usually held or seen or smelled during masturbation to achieve excitement, or a partner may be asked to wear the fetish object (Fay, Haddadi, Seto, Wang, & Kling, 2016). Fetishism is not a mental disorder unless a person is greatly upset by the urges or behaviors or until the behavior

interferes with sexual or other areas of functioning. A nondis- tressed husband whose wife happily wears high heels to bed would not be diagnosed with fetishism. If the husband shop- lifted certain shoes for masturbation or for his wife to wear to bed, however, a diagnosis of fetishism might be warranted.

Frotteuristic Disorder The particular focus of frotteuristic disorder, or frotteurism, is physical contact with someone who has not given consent (see Table 11.17; APA, 2013). Physical contact often involves rubbing against someone in a very crowded place such as a bar, subway train, or sidewalk. A person with frotteurism may engage in light contact such as “accidentally” rubbing his genitals against an- other person, or may engage in more extensive contact such as groping a woman’s breasts and buttocks. The person may �ee

TABLE 11.15 DSM-5

Exhibitionistic Disorder

TABLE 11.16 DSM-5

Fetishistic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a noncon- senting person, or the sexual urges or fantasies cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

Specify if sexually aroused by exposing genitals to prepubertal children, mature individuals, or both. Specify if in a controlled environment or in full remission.

A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly speci�c focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices speci�cally designed for the purpose of tactile genital stimulation (e.g., vibrator).

Specify if in a controlled environment or in full remission. Specify if body part, nonliving object, or other.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.17 DSM-5

Frotteuristic Disorder A. Over a period of at least 6 months, recurrent and intense sexual

arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.

Specify if in a controlled environment or in full remission.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Paraphilic interests such as sadism and masochism are sometimes represented in �lms.

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria332

the scene quickly and masturbate to a fantasy of having a long- term relationship with the victim (Gunturu, Gonzalez, Korenis, Khadivi, & Munoz, 2015). The person will likely not see the victim again unless he is caught at the time of the incident.

Pedophilic Disorder The particular focus of pedophilic disorder, sometimes called pedophilia, is sexual attraction to a child (see Table 11.18; APA, 2013). Pedophilic disorder is not necessarily the same thing as child molestation. Someone who molests children may not be attracted to children but may have sexual contact with them because he lacks partners his age, wishes to hurt the child’s parents, is intoxicated, or has cognitive or intellectual de�cits (LeVay & Baldwin, 2012). Characteristics of those with pedo- philic disorder do overlap to some degree with characteristics of those who molest children, however; both associate child sex with feelings of power, for example. The term sex offender is a legal one that refers to someone convicted of child sexual maltreatment, whether he has pedophilic disorder or not (Seto, Harris, & Lalumiere, 2016).

Pedophilic acts involve behaviors such as observation, exposure, subtle physical contact, fondling, oral sex, and penetration. The exact age at which someone is considered to be pedophilic is controversial but is currently de�ned as someone at least 16 years old and at least 5 years older than the victim. Pedophilic disorder may not apply to someone in late adolescence who has sex with someone aged 12 to 13 years but could apply if the sexual partner is younger. This remains controversial, however, because many youths have been identi�ed as sexual offenders (Stinson & Becker, 2016). Imagine a 20-year-old who has “consensual” sex with his 15-year-old girlfriend. Some might consider this pedophilic disorder, but others might not. Age-of-consent laws vary from state to state.

TABLE 11.18 DSM-5

Pedophilic Disorder A. Over a period of at least 6 months, recurrent, intense sexually

arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal dif�culty.

C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.

Specify if exclusive to children or nonexclusive, sexually attracted to males or females or both, and limited to incest.

Specify if in a controlled environment or in full remission.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

People with frotteurism prefer crowded places such as subways to seek victims.

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Genarlow Wilson was convicted of aggravated child molestation at the age of 17 years for having consensual oral sex with his 15-year-old girlfriend. He served 2 years in prison before the Georgia Supreme Court overturned his 10-year sentence, saying his crime “does not rise to the level of adults who prey on children.”

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Paraphilic Disorders: Features and Epidemiology 333

with pedophilic disorder may rationalize their behavior by be- lieving sexual acts somehow bene�t a child educationally or sensually (Rush Burkey & ten Bensel, 2015). John Mark Karr, the man who once claimed he killed JonBenét Ramsey, also claimed he was in love with the child.

Many people with pedophilic disorder are not distressed by their behavior and concentrate on young family members, especially daughters and nieces. Those with pedophilic disorder often “groom” a child by offering extensive attention and gifts, then demanding sexual favors in return. Others may even go as far as abducting children. Children are often threatened with loss of security if they disclose maltreatment to others (Elliott, 2015).

People with pedophilic disorder may be subtyped as well along certain characteristics (Fanetti, O’Donohue, Happel, & Daly, 2015):

• Preferred victim (male, female, or both) • Relationship to victim (family member/incestuous or non-

family member/nonincestuous)

• Sexual arousal (to children only or to people of various ages)

• Sexual orientation (homosexual, heterosexual, or bisexual) • Aggressiveness (presence or absence of cruelty during an

act of pedophilic disorder)

Sexual Masochism and Sexual Sadism The particular focus of sexual masochism and sexual sadism, is a desire to be humiliated or made to suffer or to humiliate or to make suffer, respectively (see Table 11.19; APA, 2013). Sexual masochism involves desire to suffer during sexual ac- tivity, often in the form of bondage, pain, treatment as an in- fant (infantilism), extensive humiliation such as verbal abuse, or oxygen deprivation (hypoxyphilia or asphyxiophilia). Masochistic desires can be ful�lled during masturbation in

the form of self-punishment or by involving others. The physical maltreatment sought by people with masochism can be severe and quite painful. Sexual sadism involves desire to in�ict suffering on someone during sexual activity, often in the same forms of maltreatment described for masochism. Sadism is often about controlling an individual during sexual controlling an individual during sexual controlling activity, and sadistic behavior is sometimes conducted to- ward someone with masochism (Defrin, Arad, Ben‐Sasson, & Ginzburg, 2015).

Sadism and masochism can exist in one person (sado- masochism) who enjoys switching roles. Sadomasochistic acts can range in severity from mild slapping or tickling to mod- erate humiliation to severe pain or restraints to extreme rape, mutilation, or murder. Sadomasochistic acts can also involve children. Wolfgang Priklopil from Austria kidnapped 10-year-old Natascha Kampusch and held her captive for 8 years in a make- shift dungeon as she referred to him as “master.”

Transvestic Disorder The particular focus of transvestic disorder, or transvestism, is dressing as the opposite gender (see Table 11.20; APA, 2013). This disorder is often seen in males who dress as women and imagine themselves as females (autogynephilia). Transvestism differs from simple fetishism in that women’s clothes are not necessary for sexual arousal, but rather help a person engage

TABLE 11.19 DSM-5

Sexual Masochism and Sexual Sadism

Sexual Masochism Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

Sexual Sadism Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.

Specify if in a controlled environment or in full remission. Specify with asphyxiophilia.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Wolfgang Priklopil allegedly kidnapped Natascha Kampusch when she was 10 years old and engaged in pedophilic and sadomasochistic acts with her during her 8-year imprisonment.

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria334

in the fantasy of being a woman. Cross-dressing in transves- tism can be secret, such as wearing panties underneath male clothing, or obvious, such as a drag queen wearing a dress and makeup. Cross-dressing initially occurs for sexual excitement but may be done over time to reduce negative feelings such as anxiety or depression or to feel attractive (Murphy, Bradford, & Fedoroff, 2014). Some men with transvestism become more uncomfortable with their own gender and may seek to become a woman physically (see later gender dysphoria section).

Voyeuristic Disorder The particular focus of voyeuristic disorder, or voyeurism, is secretly watching others undress or engage in sexual activity without being seen (see Table 11.21; APA, 2013). People with voyeurism usually do not want sexual contact with the person(s) being watched. They become sexually aroused by the fact the

TABLE 11.21 DSM-5

Voyeuristic Disorder A. Over a period of at least 6 months, recurrent and intense sexual

arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors.

C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.

Specify if in a controlled environment or in full remission.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 11.20 DSM-5

Transvestic Disorder A. Over a period of at least 6 months, recurrent and intense sexual

arousal from cross-dressing, as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically signi�cant distress or impairment in social, occupational, or other important areas of functioning.

Specify if in a controlled environment or in full remission. Specify if with fetishism or autogynephilia.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

People with transvestism cross-dress for sexual excitement, sometimes in public.

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watched persons placed themselves in such a vulnerable posi- tion and by the fact they themselves could be caught. The risk of the situation is thus most exciting for the person (Hopkins et al., 2016). A person with voyeurism often masturbates when watch- ing others or does so later to the fantasy of having sex with the watched person(s).

Atypical Paraphilic Disorders Paraphilic disorders may also be diagnosed as other speci�ed paraphilic disorder (APA, 2013). Atypical paraphilic disorders also paraphilic disorder (APA, 2013). Atypical paraphilic disorders also paraphilic disorder involve some unusual focus of arousal during sexual activity as well as distress or impairment, but are quite rare (Beech, Miner, & Thornton, 2016). Some examples are listed in Table 11.22.

Epidemiology of Paraphilic Disorders Sexual fantasies involving various themes are common in humans (see Box 11.3). Paraphilic interests that do not rise to the level of

Paraphilic Disorders: Features and Epidemiology 335

a formal mental disorder are also prevalent in the general popu- lation, especially for voyeurism and fetishism (see Table 11.23). Rates of actual experience regarding at least one lifetime act of paraphilic behavior are also common, again primarily for voy- eurism and fetishism, but also exhibitionism and frotteurism. Intense or persistent paraphilic desires or experiences occur less than 10 percent in the general population, however (Joyal & Carpentier, 2016).

Charting the exact prevalence of formal paraphilic disorders is dif�cult because the behaviors are usually secret and rarely

TABLE 11.22

Some Atypical Paraphilic Disorders

Paraphilic disorder Focus of arousal

Acrotomophilia/ apotemnophilia

Amputees or being an amputee

Autagonistophilia Being observed, �lmed, or on stage

Autonepiophilia Pretending to be a baby in diapers

Biastophilia Surprise assault of another person

Gynemimetophilia Sex-reassigned partners

Kleptophilia Stealing from others

Klismaphilia Enemas

Narratophilia Erotic, “dirty” talk between a couple

Necrophilia Contact with corpses

Olfactophilia Odors from certain body areas

Partialism Speci�c body part, such as hair

Symphorophilia Staging an accident and then watching

Troilism Involvement of a third person in sex

Urophilia and coprophilia Urine and feces

Zoophilia Animals

(18.8 percent), strangers (14.3 percent), exhibitionism (8.9 percent), homosexual activities (8.2 percent), group sex (7.8 percent), authority �gure or celebrity (7.1 percent), and a sexual object (6.5 percent).

Among men, common fantasies surrounded themes of voyeurism (15.0 percent), fetishism (14.0 percent), threesome (12.6 percent), oral sex (11.7 percent), anal sex (11.7 percent), exotic or public places to enjoy sex (11.3 percent), homosexual activities (8.9 percent), sex with an acquaintance (8.5 percent), and group sex (8.1 percent). Interestingly, however, the most intense fantasies for people involved feeling roman- tic emotions during a sexual relationship. The authors noted that the frequency of these various fantasies indicates that they are not good indi- cators themselves of psychopathology (Joyal, Cossette, & Lapierre, 2015). Instead, as we have mentioned in this chapter, paraphilic disorders are diagnosed only when problems arise from sexual behavior or fantasies involving highly unusual activities.

Focus On

Sexual fantasies about typical and unusual themes (paraphilic interests) are obviously quite common in humans. One group of researchers sur- veyed thousands of people, including sources from universities, to glean detailed information about the kinds of sexual fantasies that men and wom- en experience. Among women, common fantasies surrounded themes of exotic or public places to enjoy sex (27.2 percent), submissive behavior

11.3

College Students Sexual Fantasies

and Paraphilic Interests

TABLE 11.23

Prevalence (%) of Men and Women Who Desire to Experience Various Paraphilic Behaviors

Men Women

Voyeurism 60.0 34.7

Fetishism 40.4 47.9

Exhibitionism (extended) 35.0 26.9

Frotteurism 34.2 20.7

Masochism 19.2 27.8

Sadism 9.5 5.1

Transvestism 7.2 5.5

Exhibitionism (strict) 5.9 3.4

Sex with child 1.1 0.2

Source: From Table 1a of Joyal, C.C., & Carpentier, J. (2016). The prevalence of paraphilic interests and behaviors in the general population: A provincial survey. Journal of Sex Research, 2016, 1-11.

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria336

brought to a therapist’s attention. Harsh societal stigma against unusual sexual practices often forces people with paraphilic dis- orders to online activities (Wurtele, Simons, & Moreno, 2014). Survey data about fantasies are often not helpful because people may answer questions in a socially desirable way and because simple fantasies are not enough to diagnose someone with a paraphilic disorder. The presence of a paraphilic disorder is thus

usually determined when a person is arrested or seeks medical or psychological help (Krueger & Kaplan, 2016).

Paraphilic disorders are much more common in men than women. This is especially true for voyeuristic disorder (12 percent of men; 4 percent of women), exhibitionistic dis- order (2–4 percent of men; rare in women), sexual masoch- ism disorder (2.2 percent of men; 1.3 percent of women), sexual sadism disorder (2–3 percent, mostly in men), pedo- philic disorder (3–5 percent in men; rarer in women), and transvestic disorder (3 percent of men; rare in women). Frot- teuristic, fetishistic, and atypical paraphilic acts are likely more common among males, but the general prevalence of disorders associated with these behaviors is not known (Beech et al., 2016). Case reports from around the globe sug- gest that paraphilic disorders are not culture-speci�c. Para- philic activity, especially among males, may be universally common (Gross, 2014).

Paraphilic disorders generally develop during adolescence and the early 20s, and most people with the problems, like Tom, are married and either heterosexual or bisexual. Another key characteristic of paraphilic disorders is that several may be present in a given individual (Krueger & Kaplan, 2016). Tom had exhibitionism but also fantasies about watching teenagers and young women undress before him without their knowledge. Pedophilic disorder is also comorbid with other mental disorders such as anxiety-related, depressive, sub- stance use, and personality disorders (Stinson & Becker, 2016). Paraphilic disorders are sometimes associated with violent be- havior. Acts of child molestation and pedophilic disorder can obviously involve serious damage or death to a child. Rape is sometimes considered sadistic as well, particularly if in�icting pain is sexually arousing for the rapist (Zinik & Padilla, 2016; see Box 11.4).

Some researchers claim paraphilic disorders are deviations from common courtship practices.

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Rape can occur within marital or dating relationships. Acquaintance or date rape affects many female college students and often involves male acdate rape affects many female college students and often involves male acdate rape - ceptance of violence, heavy alcohol or other drug use, isolated situations, and miscommunication. Drugs such as �unitrazepam (Rohypnol or “roof�unitrazepam (Rohypnol or “roof�unitrazepam - ies”) may also be secretly passed on to women to induce a near state of unconsciousness and vulnerability to rape (see Chapter 9). Some males who engage in this kind of coercive sexual activity may eventually victimize people they do not know.

Only a fraction of all rapes are reported to police. Sometimes a woman is unsure a crime took place, as in the case of marital or date rape. Other women may take some responsibility for the attack (even though it was clearly not her fault) or be afraid of the consequences of reporting the at- tack. Whether a rape is reported or not, however, the psychological after- effects are devastating and can include depression, posttraumatic stress and anxiety disorders, sleep dif�culties, and various sexual and interper- sonal problems.

Focus On

Acts of sadism can involve severe violence. One such behavior is rape, and rapists tend to fall into certain categories. Rape is not a mental dis- order, but some rapists are motivated by anger toward women or anger in general and may have aspects of narcissism or antisocial personality disorder. About 5 to 10 percent of rapists enjoy the suffering they cause to their victims, and this may be categorized as sadistic rape. Many rapists are aroused by stimuli that suggest sexual force and control (Zinik & Padilla, 2016).

Violence Rape

11.4

Paraphilic Disorders: Causes and Prevention 337

➲ Interim Summary • People with paraphilic disorders experience sexual urges,

fantasies, and behaviors that involve unusual stimuli and cause signi�cant distress or impairment.

• Paraphilic disorders include exhibitionism, fetishism, frotteurism, pedophilic disorder, sexual masochism and sexual sadism, transvestism, and voyeurism.

• Paraphilic disorders are more common in men and typically begin in adolescence or young adulthood.

• Paraphilic disorders can be linked to other mental disor- ders and violence.

➲ Review Questions 1. What are major features of a paraphilia? 2. What are major targets of sexual arousal in people with

different paraphilic disorders? 3. How might pedophilic disorder differ from child molestation? 4. What are possible subtypes of pedophilic disorder? 5. What are common demographic and clinical features of

paraphilic disorders?

Paraphilic Disorders: Causes and Prevention

The exact cause of paraphilic disorders is not known, but some biological predispositions and environmental risk factors may exist. We next dis- cuss these causal factors.

Biological Risk Factors for Paraphilic Disorders Moderate to strong relationships have been found between certain paraphilic behaviors (exhibition- ism, masochism, sadism, and voyeurism) and sexual coercion in twins (Baur et al., 2016). In addition, genetics potentially affect the reward de�ciency syndrome sometimes implicated in peo- ple with pedophilic disorder. Reward de�ciency syndrome is a spectrum of impulsive, compulsive, or addictive behaviors such as intense sexual urges (Blum et al., 2014). Men with an extra Y chromo- some have also been found to display sexual devi- ancy (Re & Birkhoff, 2015).

Neuropsychological problems such as dementia may also lead to less inhibited and more compulsive and abnormal sexual behaviors (see Chapter 14). This may be due to damage in temporal-limbic brain areas that in�uence sex drive and in frontal lobe brain areas that in�uence sexual inhibition (see Figure 11.5; Mendez & Shapira, 2013). Hormonal changes may

also exist in some people with paraphilic disorders, but consistent evidence remains elusive (Holoyda & Kellaher, 2016).

Some personality characteristics seem common to people with paraphilic disorders. Examples include low empathy as well as poor social, intimacy, self-regulation, and problem- solving skills (especially around women). Other traits include impulsivity, psychopathy, dependency, sense of inferiority and inadequacy, anger, neuroticism, sensation-seeking, and narcis- sism (Gabbard, 2014; Hoberman, 2016; Kafka, 2015). Antisocial characteristics and antisocial personality disorder (Chapter 10) also characterize some people with sexual interest in children (Beech et al., 2016). One speci�c personality pro�le does not �t most people with pedophilic disorder or other paraphilic disor- ders, however.

Environmental Risk Factors for Paraphilic Disorders Environmental risk factors for paraphilic disorders may include family contributions, learning experiences, cognitive distortions, and cultural and evolutionary factors. These risk factors are discussed next.

Family Contributions Dif�cult family circumstances may contribute to paraphilic disorder development. People with paraphilic disorders often

FIGURE 11.5 MAJOR BRAIN AREAS IMPLICATED IN THE PARAPHILIC DISORDERS.

Frontal lobe

Hypothalamus

Amygdala

Hippocampus

Cingulate gyrus

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria338

describe their early home lives as emotionally abusive, unsta- ble, or violent (Ricks & DiClemente, 2015). Such early problems could lead to poorly developed social, sexual, and intimacy skills because appropriate parental feedback was not given. Family factors also contribute to pedophilic disorder, and poor attachment and frequent and aggressive sexual activity within a family may predispose some toward sexual offenses (diGiacomo & Clerici, 2013). Indeed, having a father or brother convicted of a sexual offense greatly increases one’s risk for the same result compared to the general population (Långström, Babchishin, Fazel, Lichtenstein, & Frisell, 2015).

Learning Experiences Many paraphilic disorders begin with a learning experience in which a person associates sexual arousal or orgasm with an unusual object or situation or person. A teenager may have inadvertently and secretly noticed someone undressing and then became sexually aroused. His sexual arousal was classically conditioned with the voyeuristic act, and this association was later reinforced by masturbation and orgasm. Learning theory is likely a good explanation for some paraphilic disorder devel- opment, especially because paraphilic disorders occur more in males (who masturbate more). But learning theory cannot be the sole explanation for paraphilic disorders; if it were, then most people would have paraphilic disorders (Brom, Both, Laan, Everaerd, & Spinhoven, 2014). Paraphilic behaviors may also be reinforced by family members or others or the behaviors were learned as a way to reduce anxiety or escape from dif�cult life circumstances. Paraphilic disorders may become a problem sim- ilar to obsessive-compulsive disorder in some cases (Chapter 5; Real, Montejo, Alonso, & Menchón, 2013).

Paraphilic disorders may also result when courtship behav- iors are not properly learned or expressed (Cantor & Sutton, 2015). Courtship among two people generally involves the following stages:

• Finding and evaluating a potential partner • Communicating with the partner in a nonphysical way,

such as smiling or talking

• Physical contact without sexual intercourse, such as kissing or petting

• Sexual intercourse Voyeurism, exhibitionism, frotteurism, and preferential rape

(when a man prefers rape more than a consenting partner) may link to disruptions in each of these four stages, respectively. A person with voyeurism may have dif�culty �nding potential sexual partners and resorts to secretive peeping. Such disrup- tions could be caused by faulty learning patterns or biological variables, but no de�nitive conclusions have been made.

Cognitive Distortions Many people with paraphilic disorders or those who commit sexual offenses have strong cognitive distortions or irrational beliefs about their peculiar sexual behavior (Rush Burkey & ten Bensel, 2015). These beliefs allow a person to justify his

behavior. Tom believed the surprised reactions of others to his genital exposure represented sexual arousal on their part or a desire to be with him. People who view explicit and illegal im- ages online often justify their actions by claiming distance from speci�c acts or that the images simply appeared in front of them (Winder, Gough, & Seymour-Smith, 2015). In addition, those with paraphilia often rationalize their behavior by believing that no one is harmed. People with pedophilic disorder may believe that they have little control or responsibility for their acts, that sexual acts somehow bene�t a child, that a child victim is more interested in sexual acts than is actually so, and that a child is a sexual being (Vito & Maahs, 2017).

Cultural and Evolutionary Factors Paraphilic disorders are present in different areas of the globe, but some paraphilias may be more prevalent in certain cultures that practice greater tolerance for such behavior. Substantial cul- tural differences exist with respect to the age of consent for sex, age differences between brides and grooms, touching of noncon- senting women, sexualization of inanimate objects, and mas- ochism (Ayonrinde & Bhugra, 2015). In addition, cross-dressing has been prominently displayed in Filipino and American �lms, suggesting some level of cultural acceptance. Sweeping general- izations regarding culture and paraphilic disorders cannot yet be made, however.

From an evolutionary standpoint, paraphilic disorders may be understood by considering parental investment in offspring. Females are generally more invested in type of offspring they bear, so they may be more discriminating in their sexual inter- actions and less promiscuous. Men, on the other hand, may be less invested in type of offspring they bear. Men may choose more variable mating strategies and tend toward promiscuity. A minority of men would thus be expected to engage in very deviant sexual behavior. A related evolutionary theory is that humans evolved from strict mating practices seen in animals by becoming more diverse in ways that males try to attract females (Quinsey, 2012).

Causes of Paraphilic Disorders Integrated causal models for general paraphilic disorders have not been highly developed, although speci�c models for pedo- philic disorder have been presented. Some researchers focus on neurodevelopmental models of pedophilic disorder in which early risk factors set the stage for other risk factors that then lead to pedophilic disorder. One important early risk factor is ab- normal cortical development that leads to sexual hyperarousal and dif�culty limiting sexual arousal to adults. Other early risk factors include sexual maltreatment as a child and poor attach- ment with parents.

These early risk factors could interact with later risk fac- tors such as poor social and sexual skill development, learning experiences leading to deviant sexual arousal toward children, and cognitive distortions and maladaptive personality pat- terns. The latter may include antisocial tendencies that prevent stoppage of pedophilic acts. These risk factors collectively

Paraphilic Disorders: Causes and Prevention 339

could help produce pedophilic disorder (Mohnke et al., 2014; Stephens & Seto, 2016).

Biological predisposition toward sexual hyperarousal and poor self-regulation may be evident in other paraphilic disorders (Cantor & Sutton, 2015; Cheng, Burke, Fedoroff, & Dwyer, 2015). This predisposition likely interacts with key environmental vari- ables such as unusual sexual learning experiences, cognitive distortions, social skill de�cits, paraphilic fantasies reinforced by masturbation, and attempts to suppress paraphilic fantasies, which ironically leads to more fantasies (see Figure 11.6). Tom was aroused by various stimuli and had several “successful” exposures without being caught. His acts were reinforced by subsequent masturbation and orgasm, and his attempts to stop his fantasies and behavior were unsuccessful. Much more re- search is needed regarding the development of speci�c para- philic disorders like Tom’s.

Prevention of Paraphilic Disorders Information is scarce regarding prevention of paraphilic disor- ders despite the importance of this goal. Part of the reason for this is that people with paraphilic disorders often have multiple targets for their sexual desire and because sexual behaviors are usually secretive. Some have proposed guidelines for develop- ing paraphilic disorder prevention programs, however. Preven- tion programs could focus on developing appropriate social and

sexual skills in childhood and adolescence (Townsend, 2015). Youth might thus be better able to engage in prosocial same- gender and cross-gender interactions, understand sexual desire and adaptive sexual activities, and avoid sexism and violence. Interventions to improve family communication and problem- solving skills might be helpful as well.

Prevention of paraphilic disorders often comes in the form of relapse prevention after a person has been arrested or seeks help for his problem. Relapse prevention has primarily applied to people with pedophilic disorder or sexual offenders. A key aspect of relapse prevention training is to help a person identify situations that place him at high risk for committing a paraphilic act. Examples of places to avoid might include high schools (pedophilic disorder), college dormitories (voyeurism), empty parking lots (exhibitionism), crowded bars (frotteurism), and isolated settings with computers (Proulx, 2014). Spouses or po- lice of�cers can also keep track of a person and remind him to stay away from or escape certain places.

Relapse prevention of paraphilic disorders can also involve identifying emotional and cognitive triggers to paraphilic acts, including anxiety, anger, depression, boredom, and intense sexual thoughts (Seto & Ahmed, 2014). The person is taught skills to man- age these emotions and thoughts and to develop appropriate social and intimacy interactions with others. Other treatment procedures mentioned later in this chapter, such as cognitive therapy or em- pathy training, may be helpful during relapse prevention as well.

➲ Interim Summary • Paraphilic disorders may relate to certain biological risk

factors such as genetics, neuropsychological problems, and hormonal changes.

• Those with paraphilic disorders may have poor social and intimacy skills as well as certain personality traits.

• Family variables may contribute to paraphilic disorders, including hostile family behaviors, poor attachment, and aggressive sexual activity within the home.

• Paraphilic disorders may be affected as well by learning experiences and courtship problems.

• People with paraphilic disorders often have cognitive distortions to justify or rationalize their sexual behavior.

• The cause of paraphilic disorders may involve hypersexu- ality, deviant sexual arousal, learning experiences, social skills de�cits, and other important variables.

• Preventing paraphilic disorders may involve teaching appropriate social and sexual skills as well as relapse prevention after one has been arrested or seeks treatment.

➲ Review Questions 1. What are major biological risk factors for paraphilic disorders? 2. What personality and family characteristics are evident in

people with paraphilic disorders? 3. How might learning experiences and cognitive distortions

contribute to paraphilic disorders? FIGURE 11.6 SAMPLE DEVELOPMENTAL PATHWAY OF A PARAPHILIC DISORDER.

Possible paraphilic disorder

Biological predisposition toward hypersexuality

Inadequate attachment, maltreatment, poor development of social and sexual skills

Aberrant learning experiences regarding sexuality

Classical conditioning with odd sexual stimuli, deviant attachment and arousal to children,

unusual fantasies reinforced by masturbation

Maladaptive cognitive and personality patterns

Rationalizations for odd sexual behavior, inability to suppress paraphilic thoughts, antisocial tendencies

Problematic family environment

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria340

4. What is an integrated theory for the cause of pedophilic disorder?

5. What strategies might be used to prevent paraphilic behavior?

Paraphilic Disorders: Assessment and Treatment Assessment of Paraphilic Disorders Sexual desire and arousal can be subjective, so assessing para- philic disorders often depends on a person’s self-report as well as questionnaires that focus on sexual interests. Physiological measurement has also been used as an assessment tool.

Interviews When interviewing someone with a possible paraphilic disor- der, a clinician would likely focus on past and present sexual interests and activities, paraphilic acts, legal problems or sexual offenses, interactions with sexual partners, family and medical history, and comorbid problems like anxiety, depression, and substance use. Other important issues include sense of empathy and responsibility to victims, impulsive and aggressive behav- ior, and level of insight about the wrongfulness of one’s behav- ior. Interviews must be conducted with care given the delicate nature of the material being covered and the sometimes-hostile nature of an interviewee who is in legal trouble, such as a sex offender. Information from interviews often needs to be sup- ported by legal of�cials, sexual partners, written documenta- tion, or polygraph testing (Seto, Kingston, & Bourget, 2014).

Questionnaires Questionnaires and screening instruments may be useful for as- sessing people with paraphilic disorders, but this method may be problematic if someone fears legal consequences or wants to appear socially desirable. Still, some inventories assess sex- ual history and unusual interests, hypersexuality, and sexually aggressive and pedophilic behavior. Common examples include the Bradford Sexual History Inventory, Clarke Sex History Ques- tionnaire, Multidimensional Inventory of Development, Sex, and Aggression, Multiphasic Sex Inventory, and Sex Offender Treatment Intervention and Progress Scale (McGrath, Lasher, & Treatment Intervention and Progress Scale (McGrath, Lasher, & Treatment Intervention and Progress Scale Cumming, 2012; Seto et al., 2014)

Other screening instruments focus on sexual offense histo- ries. The Screening Scale for Pedophilic Interests (SSPI) is based on prior pedophilic behavior. The SSPI is useful for identifying people with pedophilic disorder who are likely to harm addi- tional children (Seto et al., 2014). Sample items from the SSPI are listed in Table 11.24.

Physiological Assessment Physiological assessment of paraphilic disorders is often called phallometric testing. A person is usually presented with slides or other stimuli such as audiotapes that represent different sex- ual acts or activities. Subsequent arousal in males is evaluated via penile plethysmograph or strain gauge, a rubber ring that

measures circumference of the penis. Sexual response in females is measured by examining blood volume in the vaginal area via a vaginal photoplethysmograph or perineal (vaginal/anal) mus- cle function via a myograph or perineometer. Sexual interest can also be examined by showing erotic slides or �lms and measur- ing how long a person attends to the material (Knack, Murphy, Ranger, Meston, & Fedoroff, 2015).

Plethysmography can distinguish child sex offenders from nonoffenders and possibly rapists from nonoffenders. Problems with physiological assessment include �nding the best stimuli for a particular person and a person’s ability to fake respond- ing by suppressing arousal or not paying attention to a sexual stimulus. Test–retest reliability of plethysmography also remains under scrutiny (Murphy et al., 2015).

Biological Treatment of Paraphilic Disorders A key treatment of paraphilic disorders is pharmacotherapy to reduce testosterone levels in men and, thus, sexual desire,

TABLE 11.24

Items from the Screening Scale for Pedophilic Interests (SSPI)

Offender has male victim (Yes = 2; No, female victims only = 0)

Offender has more than one victim (Yes = 1; No, single victim only = 0)

Offender has a victim aged 11 or younger (Yes = 1; No, child victims were 12 or 13 years old = 0)

Offender has an unrelated victim (Yes = 1; No, related victims only = 0)

Note. Higher scores indicate greater risk of harming additional children. Source: Seto, M.C., & Lalumiere, M.L. (2001). A brief screening scale to identify pedophilic interests among child molesters. Sexual Abuse: A Journal of Research and Treatment, 13, 15-25.

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Paraphilic Disorders: Assessment and Treatment 341

arousal, and unusual behavior. The main drugs to do so include medroxyprogesterone acetate (Depo-Provera), medroxyprogesterone acetate (Depo-Provera), medroxyprogesterone acetate leuprolide acetate (Lupron), and cyproterone acetate (Cyproterone). These drugs cyproterone acetate (Cyproterone). These drugs cyproterone acetate reduce unusual sexual desires or dangerous sexual activity, but severe side effects and noncompliance to taking the medications are common (Holoyda & Kellaher, 2016).

Antidepressant medications, especially selective serotonin reuptake inhibitors (Chapter 7), may reduce sexual urges and di- minish performance or relieve depression or compulsive behav- iors that trigger paraphilic acts (Holoyda & Kellaher, 2016). Side effects and noncompliance can be problematic. Chemical castra- tion by injecting certain drugs to eliminate production of testos- terone has been advocated by some to treat people with violent sexual behavior, and the procedure does seem to reduce but not eliminate the rate of new offenses (Nair, 2016). The procedure is obviously a drastic one, however, and may not completely “cure” a person of all unusual sexual desires and behaviors. Programs to monitor sexual predators have thus become more common (see Box 11.5).

Psychological Treatments of Paraphilic Disorders Behavior therapy has also been explored to reduce paraphilic activities. Relevant forms of behavior therapy include aversion treatment, covert sensitization, and orgasmic reconditioning. Aversion treatment initially involves having a person view slides or stimuli most central to his paraphilic focus, such as a fetish object or pictures of children. The person then obtains an erection and masturbates, but this behavior is then pun- ished via electric shock, foul odors, or something otherwise distasteful (Maggi, 2012). Sexual arousal toward the unusual stimulus may eventually decline but results in outcome studies are mixed. Treatment may also take the form of shame aver-shame aver-shame aver sion whereby a person, usually one with exhibitionism, engages

in the paraphilic act before clinic staff members who offer no response or who laugh (Carroll, 2016).

Related to aversion treatment is covert sensitization, which may involve having a person imagine grotesque scenes that re- mind him of possible negative consequences of his actions and that punish the paraphilic urge (Fisher & Maggi, 2014). A male with exhibitionism could imagine exposing himself to others from a car as well as subsequent scenes in which his car would not start, where people began to laugh and call the police, and where he felt utterly humiliated. Tom engaged in this technique with some success. A problem with covert sensitization, how- ever, is that the procedure requires someone to imagine vivid scenes and be motivated enough to comply with a therapist’s instructions. Positive scenes of successful control of urges, such as a person imagining staying at work to avoid high schools in the afternoon, may thus be introduced as well.

Orgasmic reconditioning or masturbatory reconditioning also involves initial masturbation to an unusual sexual stimulus or imaginal scenes, but the person switches to more appropriate stimuli or scenes such as intercourse with his partner immedi- ately before orgasm. The pleasurable orgasm is thus associated with appropriate sexual content. Later in therapy, the person can switch to more appropriate scenes much earlier and further away from orgasm. More complete arousal to appropriate stimuli is thus achieved. Orgasmic reconditioning may also link to mastur-mastur-mastur batory satiation in which a person continues to masturbate after orgasm to paraphilic stimuli. The irritating and boring nature of this activity is therefore associated with the paraphilic stimulus, which serves as a mild punishment (Fisher & Maggi, 2014).

Therapists may also use cognitive therapy to help a person with paraphilic disorder change irrational thoughts. The illogi- cal reasons a person may have to justify illicit sexual behavior can be challenged and modi�ed. A person’s belief that a sex act was for a child’s bene�t can be confronted. Therapy can

website. These laws raise important ethical dilemmas surrounding the con�ict between an individual’s right to privacy and societal rights to be protected from dangerous felons. The laws imply that government agen- cies such as prisons and mental health centers have not successfully curbed pedophilic behavior, essentially leaving supervision of convicted sex offenders in the hands of community groups (Burch�eld, Sample, & Lytle, 2014).

Another controversial practice regarding sexual offenders surrounds committing people to a mental hospital after their full prison term has exafter their full prison term has exafter - pired. Several states allow authorities to transfer a convicted sexual offender to an inpatient mental health facility, even against the person’s will, for an inde�nite period. The sex offender is kept involuntarily in some setting (often one connected to a prison) until such time that he is determined not to be dangerous to the community. Such laws raise an important ethical dilemma—who has more rights, the person who paid a full debt to society for his crimes or community members who wish to be protected against a potentially violent offender (Harris, 2015)?

Focus On

A 7-year-old New Jersey girl, Megan Kanka, was raped and murdered in 1994 by a previously convicted sex offender who lived across the street from her family; they were unaware of his past history. After her death, several states and the federal government passed laws that “sexual pred- ators,” or those with histories of sexual crimes against children, would have to register with police (so-called Megan’s laws). Many of these laws gave communities the right to be noti�ed as to who these people were, even after they served long prison sentences. You may be able to �nd registered sex offenders in your location listed on a police department

Law and Ethics Sex Offender Noti�cation and Incarceration

11.5

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria342

also involve educating a person to identify and avoid high-risk situations such as playgrounds, teaching social and other skills to control impulses and reduce anxiety and depression, and in- creasing empathy by having a person identify with the victim and understand the harm he caused. These therapy components may be useful in individual and group settings and in Twelve Step programs (similar to the ones for substance use disor- ders discussed in Chapter 9) for people with sexual addictions (Garcia et al., 2016; Grant & Raymond, 2016).

What If I or Someone I Know Has a Paraphilic Disorder? If you feel you or someone you know may have a paraphilic disorder, then consulting with a clinical psychologist or other mental health professional who understands these problems may be best. Some screening questions are listed in Table 11.25. Paraphilic disorders are best addressed by cognitive-behavioral procedures to enhance appropriate behavior. Medical conditions should be explored as well.

Long-Term Outcomes for People with Paraphilic Disorders The long-term prognosis for people with paraphilic disorders is largely unknown, partly because many such people are never identi�ed or they drop out of treatment. Treatments for different paraphilic disorders remain in development, although cognitive behavioral therapies may be most useful for people with exhibi- tionism, fetishism, or masochism (Beech et al., 2016). Long-term outcome for many people with paraphilic disorders may simply improve, however, because of reduced sexual arousal with age and regular contact with a therapist (Marshall & Marshall, 2015). Tom’s extended therapy and the humiliation of being arrested resulted in successful abstinence from exhibitionistic exposures.

Much of the long-term outcome data for paraphilic disor- ders has centered on people with pedophilic disorder or those who have committed sexual offenses against children. Recidi- vism rates, or number of people arrested a second time for a pedophilic act, are typically examined. Recidivism rates for pedophilic disorder are 5 to 42 percent. Those who recidivate or

show poor treatment response are more likely to display strong sexual arousal to children, violence in their sexual offenses, poor mood and anger regulation, less cooperation with super- vision, and more paraphilic interests and antisocial personality traits (Seto, Sandler, & Freeman, 2015; Stinson & Becker, 2016).

➲ Interim Summary • Interviews with people with paraphilic disorder often focus

on paraphilic thoughts and behaviors as well as personality characteristics and comorbid problems.

• Self-report questionnaires may be used to assess sexual history and unusual interests, hypersexuality, and sexually aggressive and pedophilic behavior.

• Physiological assessment for paraphilic disorders includes penile plethysmograph, vaginal blood volume, and mea- suring how long a person views erotic material.

• Drug treatment for paraphilic disorders aims to reduce testosterone and sex drive and to improve depression and compulsive behaviors.

• Psychological treatments for paraphilic disorders concentrate on aversive techniques to quell behavior, masturbatory procedures to reorient arousal to more appropriate stimuli, and cognitive therapy to change irrational thoughts.

• People with paraphilic disorders can respond positively to treatment and tend not to be rearrested, though this may be due to reduced sex drive with age.

➲ Review Questions 1. What topics might a clinician cover when interviewing some-

one with a paraphilic disorder? 2. What self-report questionnaires and physiological procedures

might be useful for assessing someone with a paraphilic disorder?

3. What medications are used to treat paraphilic disorders? 4. What psychological interventions are used to treat paraphilic

disorders? 5. What long-term outcomes have been suggested for people

with paraphilic disorders?

Normal Gender Development and Gender Dysphoria: What Are They?

Other problems have less to do with sex and more to do with gender. Most children and adolescents develop a strong sense of who they are and to what gender they belong. Think about an elementary school playground—boys often group themselves together when playing and exclude girls. Likewise, girls congregate with one another and away from boys. This is normal developmental behavior because it prevents premature sexual contact and helps children learn certain gender roles.

TABLE 11.25

Screening Questions for Paraphilic Disorder

Do you know someone whose sexual behavior constantly surrounds unusual urges or possibly illegal activities?

Do you know someone who has trouble concentrating or completing daily tasks because of their sexual desires and urges?

Do you know someone attracted sexually to children?

Do you know someone who has been arrested for unusual sexual activity?

Gender Dysphoria: Features and Epidemiology 343

Sometimes the gender-learning process goes awry. Gender dysphoria involves strong desire to be the opposite gender and strong dislike of one’s current sexual anatomy. The problem is more a gender issue than a sexual one because many people with gender issue than a sexual one because many people with gender gender dysphoria enjoy normal sexual relations. A person with gender dysphoria wants to be the opposite gender and a diagno- sis requires that the person experience considerable distress or problems in daily life functioning (see Table 11.26; APA, 2013). A boy with gender dysphoria may act like a girl, be ridiculed by his peers, and subsequently refuse to attend school. Gender dysphoria was previously called gender identity disorder.

Gender Dysphoria: Features and Epidemiology

Austin may have features of gender dysphoria, sometimes called transsexualism, which is marked by strong desire to be

case Austin was a 7-year-old boy referred for treatment by his parents, who were concerned about some of Austin’s ongoing behavior. Their son had been insisting for months that he was actually a girl. Austin’s parents were not initially concerned by the behavior because many children like to act like someone else, such as a favorite superhero. Over the past few months, how- ever, Austin’s insistence he was a girl had not changed and had led to other odd behaviors. Austin persistently entered his mother’s closet and drawers to try on her clothes and makeup, often wanted to be “mommy” or other female �gures when playing, and generally preferred to be around girls rather than boys at school. He was greatly teased at school for being around girls and for not playing sports. Austin was also somewhat effeminate in his behavior and often tried to act like other girls with respect to walking and toileting. His parents sought treatment after Austin’s recent statement that he wished he could “cut off my penis.”

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TABLE 11.26 DSM-5

Gender Dysphoria

Gender Dysphoria in Children

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).

2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.

3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble

play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

B. The condition is associated with clinically signi�cant distress or impairment in social, school, or other important areas of functioning.

Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/ expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s

assigned gender).

Specify with a disorder of sex development and/or posttransition to desired gender.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria344

of the opposite gender and identifying oneself as a person of the opposite gender (APA, 2013). Austin insisted he was a girl and was not simply role-playing. Gender dysphoria is often marked by cross-dressing, but not for sexual excitement as in transves- tism. People with gender dysphoria often prefer to be around people of the opposite gender, to act like them, and insist others treat them as someone of the opposite gender.

People with gender dysphoria are also uncomfortable with their own gender, believe they were born as the wrong gender, and may even try to change their gender as adolescents or adults. Peo- ple with gender dysphoria may be heterosexual or homosexual, and the disorder can be associated with severe stress, depression, and social isolation (Zucker, Lawrence, & Kreukels, 2016). Gender dysphoria could be but is usually not diagnosed if a person was born with unclear genitalia that forced parents at that time to choose the gender of their child (APA, 2013).

The diagnostic category of gender dysphoria is controver- sial, however. The diagnosis in children may reinforce stereo- types of masculinity and femininity by tacitly assuming which toys and clothes are appropriate for each gender. Transsexual persons also experience signi�cant discrimination and stigma (Hughto, Reisner, & Pachankis, 2015). Researchers contend, however, that many youths with gender dysphoria suffer great distress and remain unhappy with their gender into adolescence and adulthood (Fuss, Auer, & Briken, 2015).

Gender dysphoria is quite rare, affecting 0.005 to 0.014 per- cent of men and 0.002 to 0.003 percent of women (APA, 2013). Prevalence rates are often based on referrals for treatment and not the general population, however. Approximately 0.9 to 1.7 percent of young children wish to be the opposite gender, although these numbers may not re�ect true gender dysphoria and seem to decline with age (Becker & Perkins, 2014). In addi- tion, some adolescents and adults, 4.0 percent of females and 5.7 percent of males, do not experience themselves as clearly one gender. Age of onset for gender dysphoria can be in child- hood or adolescence, but earlier onset is usually associated with greater intensity (Cohen-Kettenis, & Klink, 2015).

Gender Dysphoria: Causes and Prevention

Data are scarce regarding risk factors for gender dysphoria. No strong biological risk factors, including genetics, fam- ily history, and physical problems, have been supported. Some point to prenatal sex hormones as somehow related to the dis- order. Exposure to opposite-gender hormones such as testoster- one sometimes relates to cross-gender behavior. Possible genetic predisposition has been identi�ed as well. Hormonal and ge- netic in�uences can help create many brain changes associated with gender identity (Zucker et al., 2016). Biological risk factors for gender dysphoria are not well established, however.

Psychological risk factors also remain unclear. Children with gender dysphoria often have relationship dif�culties with parents (57 percent) and peers (52 percent) and family mental health prob- lems (38 percent). These children also experience considerable

harassment or persecution from others (33 percent; Di Ceglie, 2014). Parenting variables might thus be important, such as par- ent depression or tolerance of social isolation and cross-gender behavior in children. In addition, parents of children with gender dysphoria are often described as rejecting, less warm, and more overprotective than control children (Zucker et al., 2016).

Gender dysphoria is a formal diagnostic condition, but changes in gender are commonplace in many parts of the world. A fa’afa�ne is a Polynesian boy voluntarily raised as a girl in a fa’afa�ne is a Polynesian boy voluntarily raised as a girl in a fa’afa�ne family with too many male children. Many of these boys con- tinue to view themselves, and are viewed by others, as female even into adulthood. A fakaletti is a boy from Tonga who dresses and lives as a girl to help with chores and who may choose to continue to live as a woman in adulthood. Males adopt charac- teristics of females in androgynous and socially acceptable ways in many other cultures as well. Examples include kathoey male- to-female dancers in Thailand, mukhannathun Islamic males who adopt female appearance and other characteristics, and

Young boys and girls typically play apart, but children with gender dysphoria may identify more with the opposite gender.

In Polynesia, boys are sometimes raised as girls, even into adulthood, if a family has too many male children. Here, Ta� Toleafa, who was born as a boy and raised as a girl, helps serve food at a family party.

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Gender Dysphoria: Assessment and Treatment 345

evening people of India who purposely assume colorful, effemievening people of India who purposely assume colorful, effemievening people - nate clothing in a transgender manner. These examples represent culturally normal or accepted practices, which calls into question the universal validity of a diagnosis of gender dysphoria.

The cause of gender dysphoria remains unknown, but early biological predispositions and certain parenting factors may be in�uential (Zucker et al., 2016). Austin’s parents tolerated his odd behaviors for some time. Other variables such as attach- ment to a speci�c parent (e.g., to mothers in boys), child and parent insecurity, and responses from peers and siblings may be important as well. The lack of knowledge about the cause of gender dysphoria leaves little information about preventing the disorder other than addressing symptoms early in life (see treatment section).

Gender Dysphoria: Assessment and Treatment Assessment of Gender Dysphoria The assessment of youths with gender dysphoria includes in- terviews, observations of cross-gender behavior, and drawings of oneself and others. Important interview questions include current and future beliefs about one’s gender (e.g., are you a boy or girl and what will you be when you grow up?), posi- tive and negative beliefs about the two genders, fantasies about being the opposite gender, and whether one is confused about being a boy or girl. Observations of cross-gender behavior are also important, including cross-dressing, preference for cross- gender toys (and rejection of same-gender toys), and state- ments about wanting to be the opposite gender. Youths may also be asked to draw pictures of people because children with gender dysphoria may draw someone of the opposite gender �rst (Di Ceglie, 2014).

Adults with gender dysphoria, especially those considering sex reassignment surgery (see next section), are typically evalu- ated along personality, projective, intelligence, and other psy- chological tests to rule out severe problems such as personality disorders (Chapter 10) and ensure a person is truly ready for such a life-changing experience. Information should also be ob- tained about history of the person’s gender dysphoria and peer relationships, medical status, family functioning, and sexual interests (Wylie et al., 2014).

Biological Treatment of Gender Dysphoria The primary biological treatment for adults with gender dys- phoria is sex reassignment surgery. For men, external genitalia and facial hair are removed, a vagina is created, and hormones are given to develop breasts and soften more rugged, masculine features. For women, an external phallus is created, internal sexual organs and possibly breasts are removed, and hormones are given to develop more traditionally masculine features. Sex reassignment surgery is done only after an extensive period, perhaps several years, of psychotherapy or actual living in the role of the opposite gender (Wylie et al., 2014).

Psychological Treatment of Gender Dysphoria Psychological approaches to treating gender dysphoria may fo- cus on behavioral techniques to reduce cross-gender behaviors in children and adolescents and encourage same-gender identi�ca- tion. Parents may reward same-gender behavior, such as wearing traditional gender clothing, or discourage cross-gender behavior. Parents may also tell a child they value him or her as a boy or girl and help the child develop same-gender friendships and social ac- tivities (Becker & Perkins, 2014). Conversely, some parent-focused interventions are designed to provide education and support re- garding children with gender dysphoria, reduce stigma, and help parents accept their child’s af�rmed gender. Psychological treat- ment of adolescents and young adults may consist of videotaping behaviors and providing feedback about how cross-gender behav- iors can be changed. For example, a male may be given feedback about his effeminate voice. However, many believe that this ap- proach is less desirable once a person with strong gender dyspho- ria reaches adolescence (Vance, Ehrensaft, & Rosenthal, 2014).

What If I or Someone I Know Has Questions About Gender or Gender Dysphoria? You or someone you know may have questions about the play, dress, and gender-related behavior of a child, or you may have

Caitlyn Jenner has made headlines with her recent gender transition.

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CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria346

V THE CONTINUUM VIDEO PROJECT

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“The more I tried to be a girl, it just wasn’t right.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

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I’m Sam, and there’s nothing abnormal about me. There is, however, something incredibly disturbing and sick about a society that wants to hurt and annihilate me simply because I don’t �t into its rigid gender binary. I am a transsexual, and I am in the process of being �red from my current job. This is the third job that I have lost due to the discomfort people feel about my gender presentation and my particular em- bodied journey through life. I have had men in pickup trucks pull up alongside me and shout “Freak!” and follow me home, making threaten- ing gestures. I have had people walking by me shout that I’m going to burn in hell. In this, I am actually one of the lucky ones. Last night I attended the Transgender Day of Remembrance vigil on my campus to light candles and hear the stories of the transgender people who were murdered in the last year. There is, on average, one transgender person per month who is killed somewhere in the United States, and this sta- tistic drastically underrepresents the staggering violence against transgender people, because it only documents those individuals whose mur- ders were reported as transgender murders. This does not account for those bodies that were never recovered, nor does it count those transgender people who end up taking their own

lives because they could no longer stand to face the kind of scorn and contempt that is part of living as transgen- der. These murders are not just clean and simple killings. The transgender women spoken about at the vigil last night were shot in the chest 10 times each. This is typical of such murders—multiple stab wounds, dismember- ment. They are crimes of intense hatred and frenzy—signs of a very insecure and disturbed society. And yet it is transgender people who are labeled as mentally disordered.

Transgender people do not possess au- thority over our own bodies. We are not treat- ed as trustworthy informants about our own experience. For instance, when I decided that I wanted to go on male hormones to effect particular changes in my body—after living as openly transgendered for 13 years, completing a Ph.D. in Gender Studies, and doing extensive research both abroad and within the United States on transgender issues/communities—I was required to obtain a letter from a therapist before I could schedule my appointment with

the endocrinologist. This thera- pist knew far less about trans- gender issues than I did and I had only been seeing him for a couple of months, but

his credentials were required before I could pursue changes

to my body. When I met with the endocrinologist, he consulted with his

young intern, not with me, about whether he would consent to writing me a prescription for testosterone. His ultimate decision was determined by asking my partner whether she thought it was a good idea. I was 40 years old at the time and was treated as though I were 5—though without the lollypop afterward. This is extremely insulting to transgender people— folks who usually have done extensive personal research and often know more about the rel- evant medical interventions than the doctors themselves (especially those of us, like myself, who live in small towns). This is especially out- rageous given the fact that “gender-normative” people can seek body modi�cations to enhance their gender performance (for instance, breast implants or penile enhancements) without needing permission from a therapist or being diagnosed with a mental disorder.

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concerns a child may have gender dysphoria. Two important screening questions in this regard are the following: (1) Does the child engage in a great deal of cross-gender behavior? and (2) Is the child dissatis�ed with his or her gender? If you feel a child does have strong gender distress, then consulting a clinical psychologist or other mental health professional who

understands these issues is important. Keep in mind, however, that cross-gender behavior is common and that gender dyspho- ria is rare.

Long-Term Outcomes for People with Gender Dysphoria Children with gender dysphoria are thought to respond to be- havior therapy better than adolescents with the disorder because their sense of gender orientation as youngsters is more �exible. Adolescents and adults with gender dysphoria may be more suc- cessfully treated via sex reassignment surgery. Approximately 80 percent of people who undergo sex reassignment are generally satis�ed, but the remainder do not experience substantial ben- e�t, and some express regret (Zucker et al., 2016). Satisfaction with the process may relate to good surgical results, reduced anx- iety and depression, and strong support from family and friends (De Vries et al., 2014).

Youths who continue to show intense cross-gender behav- ior throughout their childhood may be more likely to develop

Gender Dysphoria: Assessment and Treatment 347

Society feels compelled to study and try to understand transgender experience because it seems to be so different from the “normal” ex- perience of gender. However, there is nothing remotely normal about gender development in the contemporary United States. Gender socialization is entirely compulsory and usu- ally begins before we are even born. We are given gendered names and pronouns, directed toward certain colors, toys, and hobbies while discouraged away from others, encouraged to express certain aspects of our personalities but warned against expressing others. My students constantly remind me of the often severe pen- alties of breaking these mandatory rules—be- ing called a “sissy” or “fag,” getting beat up, being punished by parents and other authority �gures, being a social outcast. It requires an awful lot of policing on the part of society to create something that is supposedly “natural” and inevitable.

Contrary to what we are taught, gender is a spectrum, not a binary—a rainbow of colors, not the limited choices of black and white. Even biologically, research has demonstrated that there is immense variation in our bodies and approximately one in every thousand of us (and this is a very conservative estimate) comes

an ordained minister, I’ve been in two 10-year relationships, and I’m currently married. Despite all of these social accomplishments, people constantly look down on me and regard me with suspicion because I am a transsexual. The only thing that is different about my journey is that I sought to look in- wardly for my answers about myself, some- thing that I continually recommend to my students. Despite living in a “free country” that prides itself on individualism, we are expected to conform most aspects of our- selves and our life journeys to extremely limited and proscribed paths and we are constantly bombarded with relentless media images telling us how we should look, what we should buy, how much we should weigh, what we should wear, what we should think, continually reinforced by admonitions from our families, religious organizations, educa- tional institutions, and the state. I attempted for several decades to live in this manner and ended up miserable, as many others are cur- rently. My path to happiness and ultimately freedom came from listening to my own heart above the din of all of the other voices trying to de�ne my experience. I highly recommend it to anyone.

into the world with a body that doesn’t neatly �t into the two available choices of “male” and “female.” Our gender identities are even more complicated and individualized. Very few of us actually comfortably �t into the masculine men/ feminine women poles—many have to commit considerable life energy to meet these expecta- tions and such gender requirements harm all of us, not just transgender people. They inhibit our full range as human beings—from men who have health or family problems because the only emotion they were taught to express was anger, to women who can’t access their full power, con�dence, and potential because they were socialized to prioritize pleasing oth- ers and making their bodies attractive. Trans- genderism is part of the beautiful diversity of human life. It is only pathological in a society whose resources are fundamentally allocated on the basis of what genitalia you were born with. If we did not live in a society in which there were so many social advantages to being male over female, it would not matter to which category you were assigned or whether you moved between them—or created your own new categories.

Again, my name is Sam, and there is noth- ing abnormal about me. I have a Ph.D., I’m

personal narrative

gender dysphoria, especially for girls (Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013). Others with gender dysphoria experience a remission of symptoms by ado- lescence and pursue later same-sex relationships or engage in substantial cross-gender and cross-dressing behavior but without a surgical change (Cantor & Sutton, 2015). Austin’s treatment focused on changing some of his effeminate behav- iors, which seemed to be successful. His long-term function- ing, including sexual behaviors and any mental disorder, is unclear.

➲ Interim Summary • Gender dysphoria refers to strong desire to be of the

opposite gender and identifying oneself as a person of the opposite gender.

• Risk factors for gender dysphoria are still being inves- tigated, although some have pointed to early hormonal changes and parenting practices.

• The assessment of gender dysphoria may involve asking questions about current and future beliefs about one’s gender, positive and negative beliefs about the two genders, fantasies, and confusion about one’s gender.

• The primary biological intervention for gender dysphoria, particularly in adults, is sex reassignment surgery in which external genitalia and bodily features are modi�ed to �t the characteristics of the opposite gender.

• Psychological interventions for gender dysphoria may focus on changing cross-gender behaviors or af�rming one’s gender choice.

➲ Review Questions 1. What are features of gender dysphoria? 2. What biological risk factors may relate to gender dysphoria? 3. What psychological risk factors may relate to gender dysphoria? 4. What methods are used to assess gender dysphoria? 5. What methods are used to treat gender dysphoria?

CHAPTER 11 Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria348

Key Terms sexual dysfunctions 314 male hypoactive sexual desire

disorder 315 female sexual interest/arousal

disorder 315 erectile disorder 316 female orgasmic disorder 316 delayed ejaculation 317 premature (early) ejaculation 317 genito-pelvic pain/penetration

disorder 318

spectator role 322 stop–start procedure 326 sensate focus 326 masturbation training 327 paraphilias 329 paraphilic disorders 329 exhibitionistic disorder 330 fetishistic disorder 331 frotteuristic disorder 331 pedophilic disorder 332 sexual masochism 333

sexual sadism 333 transvestic disorder 333 voyeuristic disorder 334 aversion treatment 341 covert sensitization 341 orgasmic reconditioning 341 gender dysphoria 343 sex reassignment surgery 345

Final Comments People with sexual dysfunctions, paraphilic disorders, or gender dysphoria suffer enormous daily distress because sexual and gender-related behaviors are so central to human existence. Furthermore, these prob- lems are much more common than previously thought, as evidenced by high demands for sexual therapy and related medications. Sexual problems are sometimes embarrassing to admit, but acknowledging a problem and addressing it appropriately can have an enormous positive impact on quality of life. Openly discussing problems with sexual response and unusual sexual desires with one’s partner, and improving communication in general, is critical as well. Open communication and thought about a child’s gender and play preferences is also important.

Thought Questions 1. Are there unusual sexual behaviors you feel should not be classi�ed as a mental disorder, if any?

Which unusual sexual behaviors do you feel should de�nitely be classi�ed as a mental disorder, if any? Why or why not?

2. What is the impact of the Internet on sexual fantasies and behaviors?

3. What guidelines would you recommend for de�ning pedophilic disorder? Would two young adoles- cents engaging in sexual activity qualify for the diagnosis?

4. How do you think Viagra and other drugs for sexual activity will affect sexual practices in the United States and elsewhere?

5. What separates “normal” sexual activity from “abnormal” sexual activity? Do you think sexuality has more to do with biological, family, or other factors? Why?

6. What cross-gender behaviors might you tolerate in your child? How far would you allow cross- gender behavior to go in your child before you became worried?

351

Special Features

CONTINUUM FIGURE 12.1 Continuum of Unusual Emotions, Cognitions, and Behaviors and Psychotic Disorder 354–355

Personal Narrative 12.1 John Cadigan 360–361

• 12.1 FOCUS ON DIVERSITY: Ethnicity and Income Level in Schizophrenia 364

• 12.2 FOCUS ON COLLEGE STUDENTS: Psychotic Symptoms 365

• 12.3 FOCUS ON VIOLENCE: Are People with Schizophrenia More Violent? 366

V THE CONTINUUM VIDEO PROJECT Andre / Schizophrenia 373

• 12.4 FOCUS ON LAW AND ETHICS: Making the Choice of Antipsychotic Medication 376

C James / What Do You Think?

Unusual Emotions, Thoughts, and Behaviors and Psychotic Disorders: What Are They?

Psychotic Disorders: Features and Epidemiology

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Stigma Associated with Schizophrenia

Psychotic Disorders: Causes and Prevention

Psychotic Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Schizophrenia and Other Psychotic Disorders 12

CHAPTER 12 Schizophrenia and Other Psychotic Disorders352

C / James

James was 29 years old when he was referred to an inpatient psychiatric ward at a city hospital. He was brought to the emergency room the night before by police, who initially found him trying to gain illegal access to a downtown FBI building. James �ed hysterically down the street, running and screaming loudly, when �rst confronted by two police of�cers. He then darted into traf�c, nearly causing an accident, before entering a convenience store. The police of�cers entered the store and found James curled up in a corner and sobbing. They tried to speak to James but said he was unresponsive and frightened. James was eventually led into a patrol car after some coaxing. James told the of�cers he knew they were going to kill him and asked that they do so quickly. The of�cers told James they had no intention of hurt- ing him, but James was unconvinced.

James was taken to the hospital for evalu- ation. This was done because he engaged in self-destructive behavior by running into traf�c and because he seemed intoxicated or greatly confused. A physician examined James’s physi- cal state in the emergency room. James seemed unhurt and had no signs of external injury. Later, toxicology tests revealed James had been drink- ing alcohol, but not enough to justify his bizarre behavior. A psychiatrist from the inpatient unit was thus consulted.

The psychiatrist found James terri�ed of his immediate environment and others around him. James became more receptive to the idea he would not be harmed after considerable dis- cussion and extensive sedative medication. The psychiatrist asked James if he could remember his earlier behavior and piece together what hap- pened that day. James did not recall his entire day but did convey some important bits of information.

James said he was overwhelmed lately with feelings of apprehension and fear that he and someone important were about to be harmed. He could not specify why he felt this way, but he was sure he had special information that the president of the United States was going to be harmed soon and that he, James, would also be harmed be- cause he knew of the plot. These feelings eventu- ally became so strong that James felt he had to leave his apartment and warn someone at the FBI of�ce. James said he thought the police were go- ing to kill him because they were agents respon- sible for the plot against the president. James was still agitated and worried for his own life despite heavy sedation. Nonetheless, he did provide the psychiatrist with names of people close to him.

James was transferred to the inpatient psy- chiatric unit and held for observation and medi- cation. The psychiatrist spoke to James again the next morning and conveyed that his wife and parents were to visit him that day. Following their visit, the psychiatrist spoke to each fam- ily member to piece together James’s personal history. They said James had always been an unusual child and adolescent and that things greatly worsened once he entered college in his early 20s. James would often become sullen,

withdrawn, morbid, and focused on what might happen if he or family members or important people were harmed. These behaviors escalated whenever James was particularly stressed dur- ing college, and he barely completed require- ments for his degree.

James worked intermittently as an assistant to a �nancial advisor the past 4 years but was hospitalized twice for severe depression and unusual behaviors. The last hospitalization oc- curred a year ago when James was reprimanded at work for trying to persuade an important client that her life was in danger. The reprimand trig- gered bizarre responses in James ranging from agitation to hiding in the basement of his house. James was placed on different medications that eased his agitation, but his wife said he “did not always take his pills.” His wife said James was upset over a conversation he overheard at work, one in which a client was bragging about hav- ing met the president of the United States. Per- haps James misinterpreted this statement as one of threat toward the president, which triggered his current behavior. James was committed to the inpatient unit for further assessment and treatment.

What Do You Think? 1. Why do you think James was so agitated

and scared? 2. What external events and internal factors

might be responsible for James’s feelings? 3. What are you curious about regarding

James and his family? 4. Does James remind you of a character you

have seen in the movies? How so? 5. How might James’s behavior affect him in

the future?

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Unusual Emotions, Thoughts, and Behaviors and Psychotic Disorders: What Are They?

We have discussed throughout this textbook mental dis-orders that affect speci�c areas of functioning. Anxiety-speci�c areas of functioning. Anxiety-speci�c related and depressive disorders, for example, affect limited areas of functioning and are sometimes called neurotic disorders or

neuroses. Someone with social anxiety disorder might have trouble functioning effectively in social situations but can function well in other tasks like caring for oneself or working independently.

Many people also experience odd emotions, thoughts, and behaviors during the course of obsessive-compulsive disorder, illness anxiety disorder, or schizotypal personality disorder. People with these disorders often have odd thoughts, but the thoughts are usually somewhat plausible or believable. A person

Psychotic Disorders: Features and Epidemiology 353

with psychotic disorders like James are haunted every day by horrendous and irrational fears, images, thoughts, and beliefs that do not seem like their own.

Schizophrenia You may have seen behavior like James’s depicted in �lms such as A Beautiful Mind, The Shining, or Spider. Symptoms of schizophrenia are evident in these �lms and in people like James. Schizophrenia generally consists of two main groups of symptoms: positive and negative. Positive symptoms of schizo- phrenia represent excessive or overt symptoms; negative symp- toms of schizophrenia represent de�cit or covert symptoms (see Table 12.2). Positive symptoms of schizophrenia include delusions and hallucinations as well as disorganized speech and behavior. Negative symptoms of schizophrenia include lack of speech or emotion and failure to care for oneself (American Psychiatric Association [APA], 2013). We next describe different positive and negative symptoms in more detail.

Delusions A key positive symptom of schizophrenia is a delusion. A delusion is an irrational belief involving a misperception of life experiences. Delusions are usually very �xed beliefs, meaning they are highly resistant to others’ attempts to persuade the person otherwise, and are often incomprehensible and simply untrue. James’s strong but strange belief that the conversation he overheard at work meant the president of the United States was about to be harmed is a delusion. In the �lm A Beautiful Mind, the lead character John Nash believed he could �nd secret Soviet codes in magazines and newspapers. Delusions can come in several forms, including persecutory, control, grandiose, ref- erential, and somatic, among others.

with obsessive-compulsive disorder may obsess about bacteria growing on his hands, but this is something that could occur. People with illness anxiety disorder worry about having a seri- ous disease, which may be a plausible though untrue explanation for their physical symptoms. Emotional states often associated with these conditions, such as anxiety and depression, are un- derstandable as well. Behaviors associated with these thoughts and emotions, such as excessive hand washing and medical doc- tor visits, are also unusual but largely an extension of normal things that many people do.

Other mental disorders affect many areas of functioning and involve emotions, thoughts, and behaviors so bizarre a person cannot function in most areas of her life. Some of these disorders are psychotic disorders or psychoses (Figure 12.1). People with psychotic disorders may have unusual emotional states or affect. Flat affect refers to lack of emotion even in situations that call for great joy or sadness. Inappropriate affect refers to a mood that does not match the context of a given situation. A person may laugh hysterically as someone describes a sad story, become enraged for little reason, or break down crying after watching a reality television show. Clearly these kinds of emotional reac- tions prevent a person from interacting well with others.

People with psychotic disorders also have extremely rigid or bizarre thoughts called delusions. James’s unyielding belief that others wanted to harm him is an example of a delusion. People with psychotic disorders also have trouble organizing their thoughts to form clear sentences or communicate well with others.

People with psychotic disorders also show highly unusual behaviors. Some hear voices no one else does that tell them to do something. These voices are auditory examples of hallucinations, or sensory experiences without a real environ- mental stimulus. People with psychotic disorders can also dis- play catatonic positions by remaining in a near immovable state for hours. Those with psychotic disorders often have trouble going to work or engaging in daily self-care such as washing or getting dressed. This is known as avolition.

Psychotic disorders affect a tiny minority of people, but their overall effect on those with the disorders is devastating. People with psychoses, especially those in the active phase of the disorders, cannot work, communicate with others, think rationally, or care for themselves. James’s symptoms progressed to the point where he was unable to work, was convinced others wanted to harm him, and was engaged in potentially severe self- destructive behavior.

Psychotic Disorders: Features and Epidemiology

The most well known of the psychoses, and the one we devote the most attention to in this chapter, is schizo- phrenia. We also cover other psychotic disorders related to schizophrenia, including schizophreniform, schizoaffective, delusional, and brief psychotic disorders (see Table 12.1). Com- mon to each disorder is a debilitating and tragic mental condi- tion that can rob people of their basic personality. Many people

TABLE 12.1

Types of Psychotic Disorders

Disorder Key features

Schizophrenia Positive symptoms such as delusions and hallucinations and negative symp- toms such as lack of speech or emotion and failure to care for oneself

Schizophreniform disorder

Features of schizophrenia for 1 to 6 months but not necessarily with great impairment in daily functioning

Schizoaffective disorder Characteristic features of schizophrenia and a depressive or manic episodeand a depressive or manic episodeand

Delusional disorder No psychotic symptoms except for one or more delusions

Brief psychotic disorder Several key features of schizophrenia for 1 day to 1 month

CHAPTER 12 Schizophrenia and Other Psychotic Disorders354

may intersect with control delusions, in which a person may believe others are deliberately:

• Placing thoughts in her mind without permission (thought insertion)

• Transmitting his thoughts so everyone can know them (thought broadcasting)thought broadcasting)thought broadcasting

• Stealing her thoughts and creating memory loss (thought withdrawal; Frith, 2015)

Grandiose delusions represent irrational beliefs that one is an especially powerful or important person, when actually this is not so (Boyden, Knowles, Corcoran, Hamilton, & Rowse, 2015). Delusions of grandiosity are more peculiar than simple beliefs about grandiosity in people with bipolar disorder or narcissistic personality disorder (Chapters 7 and 10). A per- son with bipolar disorder or narcissistic personality disorder may truly but wrongly believe he is a great writer, but a person with a grandiose delusion may truly but wrongly believe he is a top government of�cial, a company’s chief executive of�cer, or Napoleon! Charles Cullen, a nurse sentenced to 11 consecutive life terms for killing up to 40 patients, may have suffered from a grandiose delusion in claiming at one time he was an “angel of mercy.”

Referential delusions (or delusions of reference) are irratio- nal beliefs that events in everyday life have something special to do with oneself. A person may be watching local television news and believe each story is based on some aspect of her life from that day (Menon, Addington, & Remington, 2013). Somatic delusions represent irrational beliefs that one’s physical body is affected, usually in a negative way and often by an outside source (Spalletta, Prias, Rubino, Caltagirone, & Fagioli, 2013). A person may believe an inability to sleep is caused by excessive microwave radiation outside the house.

Persecutory delusions are the type of delusion most com- monly seen in people with schizophrenia; these delusions rep- resent irrational beliefs that one is being harmed or harassed in some way (Freeman & Garety, 2014). A person with a persecu- tory delusion may believe secret government of�cials are follow- ing him and about to do something dire. Persecutory delusions

12.1 Continuum of Unusual Emotions, Cognitions, and Behaviors and Psychotic Disorder

NORMAL MILD

Emotions Laughing at a joke or crying at a funeral. Slightly restricted range of emotions, such as not responding Slightly restricted range of emotions, such as not responding to a joke or sad story.

Cognitions Ability to organize thoughts and sentences and communicate well.

Slight oddities of thinking, such as belief that a dead relative Slight oddities of thinking, such as belief that a dead relative is in the room.

Behaviors Working and interacting with others appropriately. Working and interacting with others appropriately. Slightly peculiar behaviors such as failing to wash or brush Slightly peculiar behaviors such as failing to wash or brush one’s teeth for a couple of days. one’s teeth for a couple of days.

TABLE 12.2

Positive and Negative Symptoms of Schizophrenia

Positive symptoms Negative symptoms

• Delusions (rigid, bizarre, irrational beliefs)

• Alogia (speaking very little to others)

• Hallucinations (sensory experi- ences in the absence of actual stimuli)

• Avolition (inability or unwillingness to engage in goal- directed activities)

• Disorganized speech (jumbled speech or speech conveys little information)

• Anhedonia (lack of pleasure or interest in life activities)

• Inappropriate affect (showing emotions that do not suit a given situation)

• Flat affect (showing little emotion in different situations)

• Catatonia (unusual symptoms marked partly by severe restriction of movement or extreme excitability)

• Lack of insight (poor awareness of one’s mental condition)

CONTINUUM FIGURE

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

Psychotic Disorders: Features and Epidemiology 355

Hallucinations Hallucinations are sensory experiences a person believes to be true, when actually they are not. The most common hallucina- tion in schizophrenia is auditory, in which a person may hear voices that repeat her thoughts, comment on her appearance or behavior, argue, or command her to do something (Docherty et al., 2015). Unlike many media portrayals, however, the voices the person hears are not always threatening or demanding of violent behavior. The voice or voices may be recognizable and

MODERATE

PSYCHOTIC DISORDER — LESS PSYCHOTIC DISORDER — LESS

SEVERE

PSYCHOTIC DISORDER — MORE PSYCHOTIC DISORDER — MORE

SEVERE

Greater restrictions in emotions or odd Greater restrictions in emotions or odd emotional content for a situation, such as emotional content for a situation, such as getting upset for little reason. getting upset for little reason.

Intense restrictions in mood or intense anger at Intense restrictions in mood or intense anger at a coworker for innocuous behaviors such as not a coworker for innocuous behaviors such as not responding immediately to an e-mail. responding immediately to an e-mail.

No mood changes whatsoever or extreme No mood changes whatsoever or extreme inappropriate affect such as laughing for no inappropriate affect such as laughing for no reason or sobbing loudly during a happy story. reason or sobbing loudly during a happy story.

Greater oddities of thinking, such as a belief Greater oddities of thinking, such as a belief that one’s life resembles segments on a that one’s life resembles segments on a television news program, or some dif�culty forming clear thoughts.

Delusional or very odd beliefs that seem possible, Delusional or very odd beliefs that seem possible, such as belief that a coworker is deliberately such as belief that a coworker is deliberately poisoning one’s lunch, or greater dif�culty forming poisoning one’s lunch, or greater dif�culty forming clear thoughts. clear thoughts.

Delusional or extremely odd beliefs that seem Delusional or extremely odd beliefs that seem impossible, such as a belief that one is being impossible, such as a belief that one is being abducted by aliens, or complete inability to form abducted by aliens, or complete inability to form clear thoughts. clear thoughts.

Greater peculiarity of behavior, such avoiding all television shows because of possible resemblance to one’s life or failing to wash for 1-2 weeks.

Intense peculiarity of behavior, Intense peculiarity of behavior, such as refusing to go to work for such as refusing to go to work for several weeks due to fear of being several weeks due to fear of being harmed or great dif�culty caring harmed or great dif�culty caring for oneself. for oneself.

Extremely peculiar behavior such as hearing Extremely peculiar behavior such as hearing voices, running wild down a street, not moving voices, running wild down a street, not moving at all for hours, or loss of interest in caring for at all for hours, or loss of interest in caring for oneself. oneself.

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comforting to the person, or it may be the person’s own voice. The latter may relate to a thought broadcasting delusion, where a person hears his thoughts repeated aloud and assumes others can hear them as well. Imagine how distressing that can be!

Hallucinations can also be visual or tactile, as when a per- son sees images or visions not seen by others or feels bizarre sensations on his skin. In the �lm A Beautiful Mind, John Nash was portrayed as seeing a roommate who was not actually there. Sometimes visual and tactile hallucinations are linked

CHAPTER 12 Schizophrenia and Other Psychotic Disorders356

Patient: Smell of the chocolate cake. Psychiatrist: Do you see or smell something? Patient: (after more silence) No, I can do it. Psychiatrist: What can you do? Patient: Time to relax.

Disorganized or Catatonic Behavior Many people with schizophrenia are disorganized not only in their speech but also in their behavior. A person may be un- able to care for herself and not engage in appropriate hygiene, dress, or even eating. The person may be highly agitated as well (like James) or show inappropriate affect or emotions in inappropriate affect or emotions in inappropriate affect a given situation (Marder & Kirkpatrick, 2014). He may laugh during a sad story. Such behavior is often unpredictable and frightening to others, as was James’s behavior when chased by police.

Even more bizarre is catatonic behavior, which may include unusual motor symptoms (Hirjak et al., 2015). A person with schizophrenia may not react to environmental events such as someone saying hello or may seem completely unaware of his surroundings (catatonic stupor). A person’s body part, such as an arm, can be moved to a different pos- ture and that posture is maintained for long periods. This is waxy flexibility or catalepsy. Other people with schizophre- nia may:

• Show wild or uncontrolled motor activity (stereotypy or agitation)stereotypy or agitation)stereotypy or agitation • Repeat others’ words (echolalia) or actions (echopraxia) • Adopt a rigid posture that is dif�cult to change

Negative Symptoms Delusions, hallucinations, and disorganized speech and behav- ior are positive symptoms of schizophrenia. Negative symptoms of schizophrenia refer to pathological de�cits in behavior, or showing too little of a certain behavior. Common negative symp- toms in schizophrenia include:

• Flat affect, or showing very little emotion even in situations that seem to demand much emotion, such as a wedding or funeral. A person often speaks in monotone and shows few changes in her facial expression.

• Alogia, or speaking very little to other people and appear- ing withdrawn. Even when a person with schizophrenia does speak, his language is often very basic and brief.

• Avolition, or inability or unwillingness to engage in goal- directed activities such as caring for oneself, working, or speaking to others. A person with these negative symptoms may appear depressed.

• Anhedonia, or lack of pleasure or interest in life activities. Lack of insight or poor awareness of one’s mental condiLack of insight or poor awareness of one’s mental condiLack of insight -

tion, a common occurrence in schizophrenia, sometimes links to negative symptoms as well (McCormack, Tierney, Brennan, Lawlor, & Clarke, 2014). Negative symptoms are not as dramatic or obvious as positive symptoms such as delusions and hal- lucinations but are nevertheless crucial and damaging aspects

in an especially distressing way, as when a person “sees” and “feels” large bugs and snakes crawling up her arms (Ford et al., 2015). Hallucinations can obviously be extremely upsetting and interfere with ability to interact with others.

Hallucinations can even be olfactory. Following is a brief transcript of a woman seen in an inpatient psychiatric ward by one of your authors:

Therapist: Can you describe what changes have been happening to you?

Patient: I’ve been having very strange smells coming to me lately. Just awful.

Therapist: What kind of smells? Can you describe them? Patient: Well . . . I know it sounds weird, I know . . . I

guess I’m . . . maybe crazy or something, but everything smells to me like . . . garbage.

Therapist: Garbage? Really? Patient: Yeah, my food, my clothes . . . even you! Therapist: (retrieving and then presenting a sweet-smelling

piece of heated apple pie) Okay, let’s test this out a bit. How does this smell to you?

Patient: (moving head away quickly) Ewwww, awful, like rotten eggs or something. I can’t even eat lately . . . ich . . . that’s so disgusting!

Disorganized Speech Many people with schizophrenia also show disorganized speech. Speech patterns can be so disorganized a person can- not maintain a regular conversation. Verbalizations may be disconnected, jumbled, interrupted, forgotten in midsentence, or mixed in their phrasing (loose association). A person might say “store I go to the have to” instead of “I have to go to the store.” A person may also simply make up words that do not make sense to anyone (neologism), repeat the same words over and over, say words together because they rhyme (clang asso- ciation), or not speak at all (alogia; Roche, Creed, MacMahon, Brennan, & Clarke, 2015). A woman with schizophrenia once called one of your authors a “bifalugel,” which seemed to have some angry meaning to her but had little meaning to the listener.

Other people with schizophrenia speak quite clearly, stop without warning, and then talk about a completely different topic. This phenomenon, known as tangentiality, requires the listener to constantly steer the speaker back to the original topic of conversation. You might guess that interviews with people with schizophrenia can sometimes last hours and may produce only bits of useful information. Consider this interview with someone just committed to an inpatient unit:

Psychiatrist: Do you know where you are? Patient: In a room that is in the . . . (voice trails off) Psychiatrist: Yes, go ahead, continue. Patient: (after considerable silence) The room to the park

area . . . I see it. Psychiatrist: What are you seeing?

Psychotic Disorders: Features and Epidemiology 357

of schizophrenia and often more dif�cult to treat (Millan, Fone, Steckler, & Horan, 2014). Positive symptoms of schizophrenia may relate to neurochemical changes amenable to medication, but negative symptoms may relate to structural brain changes not largely affected by medication (we discuss this further in later sections).

Other Criteria Other criteria must also be present for a diagnosis of schizo- phrenia. Symptoms of schizophrenia must interfere signi�- cantly with one’s ability to function on an everyday basis. James became unable to work or appropriately interact with others. A person’s symptoms must not be due to a substance or medical condition (see Table 12.3; APA, 2013). Schizo- phrenia must not be diagnosed with schizoaffective disor- der (see later section), depressive or bipolar disorder with psychotic features (Chapter 7), or autism spectrum disorder (Chapter 13) unless prominent delusions and hallucinations are present.

Phases of Schizophrenia People with schizophrenia often, but not always, progress through stages of symptoms (Figure 12.2). Many begin with a prodromal phase that can last days, weeks, months, or even years. This phase is often marked by peculiar behaviors such as minor disturbances in speech and thought processes, odd or withdrawn social interactions, perceptual distortions, attention and memory problems, and symptoms of depres- sion and anxiety (Modinos & McGuire, 2015). The prodromal

Pictures drawn by artist Louis Wain. Cats were the subject matter of Wain’s art even as he experienced intense periods of psychosis.

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CHAPTER 12 Schizophrenia and Other Psychotic Disorders358

phase is often marked by negative symptoms that make it dif- �cult to determine exactly what problem a person has. This phase may resemble severe depression. Positive symptoms in attenuated or lesser form, such as unusual perceptual ex- periences or beliefs, may be present in the prodromal phase as well.

Following the prodromal phase, a person may enter a psychotic prephase marked by the �rst “full-blown” posi- tive symptom of schizophrenia such as a hallucination. A particular stressor may trigger the psychotic prephase, such as James’s overheard conversation, and the prephase often lasts less than 2 months. Positive symptoms usually increase at this point and a person is often admitted for treatment. Positive or negative symptoms must last at least 6 months for a diagnosis of schizophrenia, which may constitute the prodromal phase and psychotic prephase (Rajji, Miranda, & Mulsant, 2014).

This 6-month (or longer) period must include a 1-month phase in which the symptoms are especially acute, or an active phase (APA, 2013). A person in the active phase usually ex- periences many “full-blown” positive and negative symptoms, as James did, and needs hospitalization to protect himself and others. Following treatment, many people with schizophrenia advance to a residual phase that usually involves symptoms very similar to the prodromal phase (Schennach et al., 2015). Many people with schizophrenia remain in this residual phase for much of their life.

Many people with schizophrenia show heterogeneous behavior, meaning their symptoms are present in differ- ent combinations and severity. The Diagnostic and Statisti- cal Manual of Mental Disorders (5th edition; DSM-5) thus provides a rating scale for dimensions of schizophrenia that are �uid and that may apply better to people with mixed symptoms of schizophrenia (APA, 2013). These dimensions represent a continuum of different symptoms a person may have, ranging from not present and equivocal to mild, mod- erate, and severe. These dimensions include hallucinations, delusions, disorganized speech, abnormal psychomotor be- havior (e.g., catatonia), negative symptoms, impaired cogni- tion, depression, and mania (Figure 12.3).

Another possible dimension of schizophrenia relates to social disturbance (Hooley, 2015). All of these dimen- sions allow a therapist to describe someone with a psychotic

TABLE 12.3 DSM-5

Schizophrenia A. Two (or more) of the following, each present for a signi�cant portion

of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or

avolition).

B. For a signi�cant portion of the time since the onset of the distur- bance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in child- hood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symp- toms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred dur- ing active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

F. If there is a history of autism spectrum disorder or a communica- tion disorder of childhood onset, the additional diagnosis of schizo- phrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Specify if �rst episode, multiple episodes, continuous, or unspeci�ed; if with catatonia; and severity.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Psychotic prephase

First positive symptom such as a

hallucination

Active

Many positive

and negative

symptoms

Residual

Low-grade symptoms similar to

prodromal phase

Prodromal

Peculiar behaviors

and negative

symptoms

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FIGURE 12.2 PHASES OF SCHIZOPHRENIA. PHASES OF SCHIZOPHRENIA.

Psychotic Disorders: Features and Epidemiology 359

Schizophreniform Disorder What about people who experience psychotic symptoms for less than 6 months? People who show features of schizophrenia for 1 to 6 months, and whose daily life functioning may not yet be greatly impaired, may have schizo- phreniform disorder (see Table 12.4; APA, 2013). This disorder is sometimes studied within the context of a �rst-episode psychosis (Drake et al., 2016).

James experienced times in his life, as in college, when he had psychotic features for less than 6 months and was able to function at a basic level. If a person with schizophreni- form disorder has psychotic symptoms that last longer than 6 months, then the diagnosis could be changed to schizophrenia. People with schizophreniform disorder may be those with or without good prognostic features (APA, 2013). Those with good prognostic features, like James, have adequate daily function- ing before the onset of psychotic symptoms, confusion during the most active psychotic symptoms, no �at affect, and quick onset of psychotic symptoms after their behavior be- comes noticeably different (Compton, Berez, & Walker, 2014).

Schizoaffective Disorder You may have noticed that people with schizophrenia often have symptoms that resemble depression, such as loss of interest in

disorder more speci�cally. James showed a moderate to severe degree of delusions and milder degrees of disorganized speech and negative symptoms. Someone with schizophrenia could have any combination of these problems to any degree in this dimensional approach.

TABLE 12.4 DSM-5

Schizophreniform Disorder A. Two (or more) of the following, each present for a signi�cant portion of time during a 1-month period (or less if successfully treated). At least one

of these must be (1), (2), or (3):

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be quali�ed as “provisional.”

C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symp- toms, they have been present for a minority of the total duration of the active and residual periods of the illness.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Specify if with or without good prognostic features; if with catatonia; and severity.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

Hallucinations

Degree of pressure to respond to voices or

being bothered by voices

Delusions

Degree of pressure to

act on beliefs or being

bothered by beliefs

Disorganized speech

Degree of difficulty following person’s speech

Negative symptoms Degree of

decrease in facial

expression or gestures

or self-initiated behavior

Impaired cognition Degree of reduction

in cognitive function

Depression Degree of sadness or

hopelessness or guilt

Mania Degree of elevated, expansive, or irritable mood or

restlessness

Abnormal psychomotor

behavior

Degree of bizarre motor

behavior or catatonia

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FIGURE 12.3 DSM-5 DIMENSIONS OF SCHIZOPHRENIA.

CHAPTER 12 Schizophrenia and Other Psychotic Disorders360

things and decreased movement and talking. A person who meets many of the diagnostic criteria for schizophrenia may also meet diagnostic criteria for depression. She may thus qualify for a diagnosis of schizoaffective disorder (see Table 12.5; APA, 2013).

Schizoaffective disorder includes characteristic fea- tures of schizophrenia and a depressive or manic episode (Chapter 7). Symptoms of schizophrenia, however, are considered primary—delusions or hallucinations must last at least 2 weeks without prominent symptoms of a mood disorder. A person often develops schizophrenia and later develops depression, which may happen when she experi- ences negative consequences such as a job loss due to odd behavior. Two subtypes of schizoaffective disorder include depressive type and bipolar type, the latter meaning the co-occurrence of main features of schizophrenia with manic episodes. Recall from Chapter 7 that people with depressive and bipolar disorders can also have psychotic symptoms, but in these cases, the depressive or bipolar disorder is most prominent (Rink, Pagel, Franklin, & Baethge, 2016).

John Cadigan described living with schizophre- nia in a �lm he made for HBO/Cinemax called People Say I’m Crazy (www.peoplesayimcrazy. org). His woodcuts have been exhibited at museums and galleries nationwide.

My worst symptom is paranoia. A lot of times my paranoia comes in the form of thinking people hate me, thinking people don’t like me just be- cause of the way they look at me or because of what they do with their hands or what they say or what they don’t say. At my boarding house, I can tell whether they like me or they don’t like me by the way they make my bed. If the sheets are not slick and they are old sheets, with little bumps on them—that means they’re sending me a message that they don’t like what I’m doing. They’re trying to get rid of me, they don’t like me. If the sheets are all new and slick—that means I’m doing OK.

My disorder hit when I was in college at Carnegie Mellon. I had my �rst psychotic break 6 months before graduating, and I’ve been struggling with a form of schizophrenia ever since. Growing up, sports and art were the most important things in my life. I sometimes fanta- sized about being a professional soccer player. When I was in �fth grade I was voted most pop- ular, most athletic, and most artistic. My senior year I was voted most quiet, which was pretty

much true. I was. I think that was the beginning of my symptoms.

The �rst 3 years of my disorder I was sick all the time. I tried every antipsychotic, mood stabi- lizer and antidepressant on the market. But nothing worked. I couldn’t read for a few years. Schizophrenia affects logic and comprehension. I literally could not understand the words. It was even hard to watch television. Basically, what I did all day was pace and drink coffee. And I eventually turned to alcohol and was getting drunk every day.

Finally the new generation of medication be- came available—the �rst new drugs for schizo- phrenia in decades. And I began taking one of them. Very very slowly, it started working. And, I got a new doctor, who is wonderful.

When my family realized that my schizophrenia was not going to go away, my mother moved out to California (where I live) from Boston. My disorder brought everyone in my family together. Since my parents’ divorce, my family had been very frac- tured. But they all united to try and help me.

I’m really close with my oldest sister Katie, who’s a �lmmaker. I usually go to Katie

or my Mom when I’m having a bout of paranoia or de- pression. In the beginning of my disorder, when we really didn’t know what was go-

ing on, Katie and her husband let me live with them. I was very

sick then, so I wasn’t the easiest person to live with. Now I hang out at

Mom’s house a lot and watch TV. There I can be alone. I can be safe. I’m lucky to have such a supportive family.

A lot of other families don’t understand that schizophrenia is a brain disease. One of my best friends, Ann, was disowned by her family. Her children don’t talk to her because they think she’s crazy and don’t want anything to do with her. She doesn’t get to see her grandchildren. My mom and I have adopted her into our family. She calls me her adopted son and calls my mom her sister.

Here’s what some of my family said when I asked what the hardest part of my disorder was for them:

MY MOM: “The hardest part? To single out one I couldn’t do it. There were a hundred hardest parts. Just to watch the amount of suffering. . . . Once I understood how much having this brain disease was hurting you, how much you

12.1 / John Cadigan

John Cadigan lizer and antidepressant on sick then, so I wasn’t the easiest Katie

Ca dig

TABLE 12.5 DSM-5

Schizoaffective Disorder A. An uninterrupted period of illness during which there is a major

mood episode (major depressive or manic) concurrent with criterion A of schizophrenia.

Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

Psychotic Disorders: Features and Epidemiology 361

struggled with it and how much pain you were in—it felt unbearable to me and that I couldn’t do anything, really, to help you.”

MY BROTHER STEVE: “There was a time when we went to see you in the hospital and you couldn’t speak. Your eyes had this look of entrapment—that you were trapped inside yourself. And there was just sheer terror in your eyes. That was hard. Really hard.”

MY SISTER KATIE: “The very hardest part was when you started getting suicidal. It was about 2 years into your disorder. It was hor- rible. I didn’t want you to die.”

People think that schizophrenia means split personality or multiple personality, but they’re making a big mistake. The “schizo-” pre�x doesn’t mean personality split—it means a break with reality. I don’t know what reality is. I can’t trust my own perceptions. The hardest struggle is to know what’s real and what’s not real. And that’s a daily struggle for me.

I have a hard time being around people. Sometimes I feel restless and I feel like I’ve got to pace. I guess it’s my constant fear that people are out to purposely drive me crazy or mess with my mind. Like there’s a secret agenda. As if everybody is interconnected and they are slowly and subtly dropping clues. A glance here, and

his �rst time going and I just decided to go along and help. Clients are allowed two visits a week. They have a little computer there and Patrick checks them in. They move about a ton of food a week. So many people helped me and I get so much support from other people. I think it’s good for my own soul to help others. It makes me feel good doing it. I enjoy it. I really enjoy doing it.

At the food closet, everything was �ne for a while. Until the paranoia crept in. It all revolved around nametags. My friend Patrick had a nametag and this woman Shelly did and this guy Morris did and so did Gloria. They all had nametags and I didn’t. And I thought it was a secret message telling me: “We hate you, John. We don’t want you around, John. We think you are an awful person, John.” It sounds so stupid when I say it but it really devastates me. This kind of thing happens to me all the time.

I wonder if I am ever going to get better. I know I’ve gotten better. But I wonder if I’m ever going to get a lot better. Totally better. I’m 30 years old now and have been struggling with this disorder for close to 9 years. Nine years. I remember one thing my friend Ed said to me. He said something like, “when you get to around 50 the symptoms kind of ease up a bit.” That’s another 20 years for me.

a glance there. It is evil and the evil is after me. It makes it really dif�cult to communicate to others and to get up the courage to reach out to others and make friends.

These thoughts—they just get in my head and fester in there. Then I tell myself, “It’s not true. It’s not true. It’s not true. It’s not true. It’s not true. It’s not true.” And, I try to just say that over and over again. “It’s not true. It’s not true. It’s not true.”

My doctor helped me learn how to do reality checks. When I’m having a hard time with ter-checks. When I’m having a hard time with ter-checks. When I’m having a hard time with ter rible thoughts, and I think it might be paranoia, I try to get up my courage to go to a safe person. It might be one of my sisters or my mom, or even my doctor. And I tell them what I’m thinking. And every single time, they tell me, “John, you’re wrong. Your perceptions and your thoughts aren’t based in reality.” It doesn’t take away the paranoia, but it helps lessen the intensity.

There are times when I can work and there are times when I can’t work. When my thoughts are racing or when I’m incredibly paranoid, those are times when I can’t work. It feels aw- ful. It’s just a terrible feeling. I don’t have much hope. I don’t. But I try to keep telling myself that it will pass. It will pass.

I’ve been volunteering at a food closet with my friend Patrick. He was signed up and it was

personal narrative

Schizoaffective disorder is sometimes considered part of a schizophrenia spectrum that includes depression, bipolar dis- order, and schizotypal personality disorder (MacDonald, 2015). Clinicians often have a dif�cult task distinguishing symptoms of severe depressive or bipolar disorder from symptoms of schizophrenia. Imagine someone who is intensely withdrawn, who fails to move for hours at a time, and who has distorted thoughts—this could be someone with severe depression, symp- toms of schizophrenia, or both.

Delusional Disorder People with schizophrenia or schizophreniform or schizoaffective disorder have psychotic symptoms such as delusions, hallucina- tions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Other people with a psychotic disorder, such as those with delusional disorder, however, have no psy- chotic symptoms except for one or more delusions (see Table 12.6; APA, 2013). A delusion could be nonbizarre or bizarre, the latter meaning it is not plausible. In the Case on page 362, Jody’s belief

that a coworker poisoned her lunch is plausible, although not true, and thus nonbizarre. People with delusional disorder do not expe- rience signi�cant impairments in daily functioning apart from the impact of the delusion but may be quite distressed.

A person with delusional disorder may have one or more of the following delusions:

• Erotomanic, such as the mistaken belief a special person, such as a celebrity, loves the person from a distance

• Grandiose, such as the mistaken belief one is an especially powerful, famous, or knowledgeable person

• Jealous, such as the mistaken belief a spouse is having an affair

• Persecutory, such as Jody’s mistaken belief another person aimed to harm her

• Somatic, or a mistaken belief about one’s body, such as having some serious medical disease (Hui et al., 2015).

Some people develop a delusion because of their close relationship with another person who also has a delusion.

CHAPTER 12 Schizophrenia and Other Psychotic Disorders362

second person when she is separated from the more dominant, delusional partner.

Brief Psychotic Disorder What happens when a person has psychotic symptoms for less than 1 month? A person with such symptoms may qualify for a diagnosis of brief psychotic disorder, which involves several key features of schizophrenia occurring for 1 day to 1 month (see Table 12.7; APA, 2013). These features include delusions, hallucinations, disorganized speech, and disorganized

This is sometimes called folie à deux. The two people often share similar ideas with respect to the irrational be- lief. This process could explain why Wanda Barzee, the wife of the man who kidnapped Elizabeth Smart in Utah, con- sented to and participated in this terrible crime. She appeared to believe, as her husband Brian Mitchell did, that kidnap- ping Smart was a “revelation from God” and that polygamy (multiple spouses) was acceptable. This process is also sometimes evident in cases of child maltreatment in which both parents believe their maladaptive behavior bene�ts the child (Erickson, 2014). The delusion may weaken in the

TABLE 12.6 DSM-5

Delusional Disorder A. The presence of one (or more) delusions with a duration of 1 month

or longer.

B. Criterion A for schizophrenia has never been met.

C. Apart from the impact of the delusion(s) or its rami�cations, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

Specify if erotomanic, grandiose, jealous, persecutory, somatic, mixed, or unspeci�ed type; if �rst episode, multiple episodes, continuous, or unspeci�ed; if with bizarre content; and severity.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 12.7 DSM-5

Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms. At least one

of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or

incoherence). 4. Grossly disorganized or catatonic behavior.

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.

C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

C / Jody

Jody was a 38-year-old of�ce manager who worked for a large law �rm. She interacted with lawyers and their private secretaries to conduct �nancial and other business necessary for the �rm to function ef�ciently. The �rm was a com- petitive environment that involved substantial turnover and jockeying for better positions and of�ces. Jody was a competent manager, but she consistently wondered if her coworkers deliber- ately tried to sabotage her to gain her position.

Jody was involved in many discussions with the law partners over the years about these

concerns, few of which were substantiated. Problems intensi�ed recently, however, when one of the lawyers was promoted to partner, and his personal secretary was appointed as Jody’s assistant. Jody felt threatened by this organiza- tional move and became suspicious of Rachel, her new assistant. These suspicions deepened when Rachel moved her desk near Jody’s and when Rachel took initiative to help Jody with daily tasks.

Jody’s suspicions became more unusual— she believed Rachel was deliberately poisoning

her lunch in an effort to make her sick. Jody thought this was an effort on Rachel’s part to eventually secure Jody’s position. Jody accused Rachel on several occasions of stealing, inserting substances into, and spitting on her lunch. Rachel vehemently denied all of this, but Jody enlisted the help of others in the of�ce to spy on Rachel and even asked one of the lawyers to represent her in a lawsuit against Rachel. The law partners eventu- ally had to intervene and told Jody she would lose her job if she continued these accusations and that she needed professional help.

case

Psychotic Disorders: Features and Epidemiology 363

any age), and schizophrenia is somewhat more frequent among males than females (Chong et al., 2016; MacDonald, 2015). Males with schizophrenia tend to have symptoms at a younger age than females with schizophrenia. This means men usually have more severe symptoms as well (Eranti, MacCabe, Bundy, & Murray, 2013).

One possible reason why men have more severe schizophre- nia symptoms than women may be that women have certain biological factors, such as protective hormones or less severe brain changes, that help prevent the development of very severe symptoms. Another possibility is that women function better than men in work and social settings, which delays onset of schizophrenia symptoms until later in life (Falkenburg & Tracy, 2014). Ethnicity and income level may relate to schizophrenia as well (see Box 12.1 and later section on cultural in�uences). Symptoms of psychotic disorders are also sometimes evident in college students (see Box 12.2).

Schizophrenia can be associated with many other mental disorders because of its complex and devastating symptoms. Recall that schizophrenia can be, for some people, the final phase of a psychotic spectrum that initially includes brief psychotic disorder (less than 1 month) and schizophreni- form disorder (1–6 months). The odd behaviors associated with schizophrenia, such as unusual perceptual experiences and persecutory thoughts, may also mean schizophrenia is part of a spectrum of disorders that includes schizotypal, schizoid, and paranoid personality disorders (Chapter 10; Figure 12.4; Bolinskey et al., 2015). These disorders gener- ally involve bizarre and suspicious behaviors and thought- related problems that greatly interfere with many aspects of a person’s life.

The most common mental disorders otherwise associated with schizophrenia are anxiety-related, depressive, bipolar, and substance use disorders (Castle & Buckley, 2015). Depression could develop before schizophrenia and help trigger psychotic symptoms, or the development of psychotic symptoms could lead to a downward spiral involving dif�cult events such as job

or catatonic behavior. Symptoms of brief psychotic disorder often occur after an environmental stressor or traumatic event (Sher, 2015).

Psychotic symptoms may occur in women after giving birth—postpartum psychosis (O’Hara & McCabe, 2013). Recall from Chapter 7 that some women have postpartum depression; some women experience postpartum depres- sion and psychosis. Andrea Yates, a woman from Texas who drowned her �ve children in a bathtub in her house, appeared to have delusional and depressive symptoms following the birth of her most recent child and the death of her father. Her condition underscores the need for greater knowledge and prevention of postpartum psychosis and depression. Symptoms of brief psychotic disorder often dissipate as a person becomes better able to cope with the stressor, if one exists. The symptoms persist and can lead to disastrous con- sequences or schizophreniform disorder or schizophrenia in other cases, however.

Epidemiology of Psychotic Disorders Schizophrenia occurs in 0.40 to 1 percent of the general popu- lation. Median age of onset is 20 to 24 years for men and 25 to 29 years for women (although the disorder could occur at

Andrea Yates, a Texas woman who drowned her �ve children (four pictured), may have suffered from a postpartum psychosis.

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CHAPTER 12 Schizophrenia and Other Psychotic Disorders364

(Popovic et al., 2014). Violence toward others is sometimes but not usually a feature of schizophrenia (see Box 12.3).

Schizophreniform disorder is quite similar to schizo- phrenia, especially the prodromal phase of schizophrenia. Most people with the disorder have thus not yet presented for treatment, so prevalence rates for schizophreniform dis- order are likely much lower than for schizophrenia. As many as one half to two thirds of people with schizophreniform disorder may eventually receive a diagnosis of schizophrenia or schizoaffective disorder (Hill et al., 2012; Pope, Joober, & Malla, 2013).

The prevalence of schizoaffective disorder is also likely lower than schizophrenia (0.32 percent). Those with schizo- phrenia and bipolar disorder tend to display symptoms at a younger age than those with schizophrenia and depression. Schizoaffective disorder tends to be more prevalent among women than men. This is likely due to frequent presence of depression in schizoaffective disorder (Lawrence, First, & Lieberman, 2015).

Unusual beliefs about people or events are common in the general population, but formal delusional disorder is rare. Many people with delusional disorder have persecutory (59.3 percent), jealous (22.1 percent), erotomanic (4.7 percent), and grandiose (4.7 percent) delusions. Delusional disorder may be slightly more common in women than men, but men with the disorder tend to have more severe symptoms and worse functioning (de Portugal et al., 2013).

Little is known about brief psychotic disorder because the problem is often limited in duration and scope and because many people recover quickly. Brief psychotic disorder is thus considered to be an acute transient psychosis. Acute transient psychoses differ from schizophrenia in that they involve more females, a later age of onset, greater anxiety and �uctuation

loss that causes someone to later become depressed (Fusar-Poli, Nelson, Valmaggia, Yung, & McGuire, 2014).

Suicide is also much more common among people with schizophrenia (4–6 percent) than the general population (0.01–0.03 percent). Suicide in people with schizophrenia closely relates to onset of the disorder, depression, excessive substance use, recent loss, agitation, and poor adherence to treatment. People with schizophrenia most at risk for suicide tend to be male, younger, single, unemployed, and socially isolated

Possible reasons for these �ndings include exposure to more pollution and noise, higher rates of excessive substance use, increased risk of infec- tious diseases and malnutrition, stress from poverty conditions and unem- ployment, racism, social isolation, poor availability of treatment services, and the interaction of these conditions with genetic predispositions for psychotic disorder (Mura, Petretto, Bhat, & Carta, 2012). One single factor does not seem responsible, however, for possible ethnic differences in schizophrenia.

Schizophrenia also relates to lower income level. Knowing the direction of this relationship is not easy, however. Some people may develop schizo- phrenia following the stressors of poverty, but some people may �rst develop schizophrenia and then drift into lower socioeconomic levels as their disor-schizophrenia and then drift into lower socioeconomic levels as their disor-schizophrenia and then drift into lower socioeconomic levels as their disor der progresses and their income declines, such as after job loss. People with more income may also have access to earlier treatment and display less posi- tive symptoms of schizophrenia. People with less income are also more likely to believe their disorder will result in stigma and discrimination from others (Brooke-Sumner et al., 2015; Broussard, Goulding, Talley, & Compton, 2012).

Focus On

A controversial issue is whether ethnicity and income level have an impact on schizophrenia. An analysis of different countries gener- ally indicates no large variation in prevalence rates for schizophrenia (MacDonald, 2015). Certain groups of people may be at increased risk for psychotic disorder, however. Schizophrenia is more common in cer- tain immigrant populations of ethnic minority status. People in urban settings may also be at higher risk for schizophrenia than those in rural settings (Vilain et al., 2013).

Diversity Ethnicity and Income Level in Schizophrenia

12.1

“Social withdrawal”

Schizoid

Negative symptoms of

schizophrenia

Aloof Aloof Uninterested in others

Solitary, socially withdrawn Unaffected by praise

and criticism

“Delusional/paranoid”

Paranoid

Paranoia Paranoia Distrustful nature

Doubts loyalty Keeps grudges Easily offended

“Distorted reality”

Schizotypal

Odd ideas Odd ideas Eccentricity

Unusual experiences Superstition

Suspiciousness Reclusiveness

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FIGURE 12.4 SCHIZOPHRENIA SPECTRUM DISORDERS.

Stigma Associated with Schizophrenia 365

suf�cient number of friends (Corrigan, Sokol, & Rusch, 2013). This may especially be the case if supportive friends and family members have knowledge about the psychotic disorder (Smith, Reddy, Foster, Asbury, & Brooks, 2011).

Stigma associated with schizophrenia and other psy- chotic disorders is important because it affects symptoms and treatment. Greater self-stigma relates to more depression and social anxiety and withdrawal, as well as poorer treatment outcome, among people with schizophrenia spectrum disorders (Gerlinger et al., 2013). Conversely, less self-stigma and more insight into one’s symptoms are related to better alliance with one’s therapist among people with schizophrenia or schizo- affective disorder (Kvrgic et al., 2013). Others have found that helping people with schizophrenia actively resist stigma can be an important component of treatment (Campellone, Caponigro, & Kring, 2014). Stigma can be a powerful force in the lives of people with psychotic disorders, so addressing the problem directly is important.

➲ Interim Summary • People with psychotic disorders have bizarre emotions,

thoughts, and behaviors that greatly interfere with many different areas of daily functioning.

• Positive or excessive symptoms of schizophrenia include delusions, hallucinations, and disorganized speech and behavior.

• Negative or de�cit symptoms of schizophrenia include �at affect, alogia, avolition, and anhedonia.

of symptoms, and less social withdrawal (Castagnini, Laursen, Mortensen, & Bertelsen, 2013). Postpartum psychosis occurs in 1 or 2 of 1,000 births and is often linked to social isolation, confusion, disorganized behavior, sleep deprivation, and severe symptoms of depression and bipolar disorder (Blackmore et al., 2013; Essali, Alabed, Guul, & Essali, 2013). Suicide or harm to a newborn, as was the case with Andrea Yates, can occur in extreme cases as well.

Stigma Associated with Schizophrenia

Schizophrenia is a severe and debilitating disorder, so stigma associated with the problem is clearly a concern. One group of researchers surveyed hundreds of people with schizophrenia about their perceptions of discrimination and stigma. Almost three quarters (72 percent) said they felt the need to conceal their diagnosis because of dif�culties they anticipated with family members or possible coworkers. In addition, 64 per- cent said they had stopped applying for work or educational opportunities, and 58 percent said they had stopped looking for a close relationship. The latter was especially true if those with schizophrenia felt disrespected by mental health staff members. Others reported ceasing travel, social activities, ap- plying for mortgages, and having children, often due to per- ceived discrimination from others (Üçok et al., 2012). People with schizophrenia with more social support may experience less self-stigma, however. Stigma resistance, or one’s capacity to counteract stigma, is associated with a social network with a

symptoms as well and thus did not seek support from friends about the symptoms (Denenny, Thompson, Pitts, Dixon, & Schiffman, 2015). Others have similarly found that vignettes about schizophrenia elicit more social distance and less willingness to help among college students than vignettes about other mental disorders (Yang et al., 2013).

Others have looked at attenuated psychotic symptoms in college stu- dents in greater detail. A key �nding has been that these symptoms are often linked to a prior traumatic event in a person’s life, which is a theme we have seen for other mental problems in college students. In particular, researchers have found that stress sensitivity relates closely to the associa- tion between traumatic life events and attenuated psychotic symptoms. Stress sensitivity refers to perceived threat to one’s physical or psychologi- cal health (Gibson et al., 2014). Others have found as well that attenuated psychotic symptoms in college students relate to depression and suicidal ideation (Chen et al., 2014; DeVylder, Thompson, Reeves, & Schiffman, 2015). These data indicate that, despite the substantial stigma often attached to the symptoms described in this chapter, seeking help must be a priority.

Focus On

You might think that the disorders described in this chapter do not apply much to college students, but researchers have focused on what is called attenuated psychotic symptoms. Attenuated symptoms refer to mild or subtle signs of a psychotic episode to the point that they cause distress for a person. Examples include perceptual abnormalities, delusional ideas, or a negative symptom. One group of researchers assessed college students for attenuated signs of psychosis. A large majority of the students (84 percent) endorsed one or more early psychotic symptoms, and 57 percent said at least one of the symptoms worried them or caused problems. Many of the students experienced self-stigma about the

12.2

College Students Psychotic Symptoms

CHAPTER 12 Schizophrenia and Other Psychotic Disorders366

spectrum of disorders and is associated with depression and suicide and substance use.

• Stigma associated with schizophrenia can be severe and affects symptoms and treatment.

➲ Review Questions 1. What are key positive and negative symptoms of schizophrenia? 2. Describe the main dimensions of schizophrenia that can be

rated. 3. Describe the main features of schizophreniform, schizoaffec-

tive, and brief psychotic disorder. 4. What types of delusions are common to people with psychotic

disorders? 5. Who most commonly has schizophrenia and what conditions

relate to the disorder?

• Schizophrenia may also be rated by severity across dimensions that include positive and negative symptoms as well as impaired cognition, depression, and mania.

• Schizophreniform disorder is very similar to schizophre- nia but lasts 1 to 6 months and may not involve serious impairment in daily functioning.

• Schizoaffective disorder applies to those who have features of schizophrenia and a depressive or manic episode.

• Delusional disorder involves one or more delusions that may or may not have bizarre content.

• Brief psychotic disorder involves features of schizophre- nia that last 1 day to 1 month and can be triggered by a traumatic event.

• Schizophrenia is a rare disorder but is more commonly seen in males. The disorder is often viewed along a

Consider other evidence regarding violence and schizophrenia, however. First, the great majority of people in prison do not have psychotic disorders and more have depression than psychotic disorder (Fazel & Seewald, 2012). Second, less than 2 percent of those arrested for a crime have schizophre- nia, a number not much different from the general prevalence rate for the disorder (1 percent; Morgan et al., 2013). Third, after people with psychotic disorders begin treatment, rates of violence are close to those of the gen- eral population (Langeveld et al., 2014). Fourth, people at risk for psychotic disorders are much more likely to be victimized by, rather than commit, victimized by, rather than commit, victimized a violent crime (Purcell, Harrigan, Glozier, Amminger, & Yung, 2015). Finally, people with a �rst episode of psychosis are much more likely to harm themselves than others (Nielssen, Malhi, McGorry, & Large, 2012). Some people with schizophrenia are at risk for committing violent crimes, but the vast majority do not do so and, as just noted, are more likely to be harmed themselves.

Focus On

Media portrayals of people with psychotic disorders such as schizophre- nia are often skewed toward images of voices commanding a person to commit violent acts. A serial killer in 1970s New York City was murder- ing women and young lovers with a .44 caliber handgun. The murderer claimed in a letter that “Papa Sam” was commanding him to go out and kill—the murderer was later dubbed the “Son of Sam.” David Berkowitz, a man with psychotic delusions about demons telling him to hunt for blood, was eventually arrested for these terrible crimes. Newspaper headlines screamed almost daily about the hunt for Berkowitz and later about his mental state. The widespread and intensive coverage gave people the impression that those with psychoses must necessarily be dangerous. Many voices heard by people with schizophrenia do not com- mand them to kill, but intense media coverage of certain cases such as Berkowitz’s does raise the question about whether this population is particularly violent.

People with schizophrenia are arrested for violent acts much more frequently than are members of the general population (Nederlof, Muris, & Hovens, 2013). Strong risk factors for violence in this popula- tion include hostile behavior, poor impulse control, excessive substance use, and nonadherence with medication (Witt, van Dorn, & Fazel, 2013). Furthermore, 3.6 percent of men and 3.9 percent of women imprisoned in various countries have a psychotic disorder, which is substantially greater than in the general population (less than 1 percent; Fazel & Seewald, 2012).

Violence Are People with Schizophrenia More Violent?

12.3

The violent crimes of “Son of Sam” David Berkowitz were prominently displayed in newspaper headlines, which may have skewed the public’s perception of people with schizophrenia as overly dangerous.

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Psychotic Disorders: Causes and Prevention 367

general population to develop schizophrenia. Data also indicate increased risk for close relatives for schizophreniform, schizo- affective, and aspects of schizotypal and avoidant personality disorders (Bolinskey et al., 2015; Ettinger, Meyhofer, Steffens, & Wagner, 2014; Rasic, Hajek, Alda, & Uher, 2013).

Twin studies also indicate that schizophrenia has a genetic component. Concordance rates for schizophrenia among identi- cal twins (50 percent) are generally much higher than for fra- ternal twins (6–17 percent; MacDonald, 2015). Adoption studies reveal a similar �nding. Children born to mothers with schizo- phrenia but raised by parents without schizophrenia still show a higher likelihood of developing schizophrenia (5.6–9.1 percent) than control groups (0.9–1.1 percent). This appears to be espe- cially true if parents have problems communicating with their adoptive children whose biological mothers had schizophrenia (Lawrence, First, & Lieberman, 2015). Heritability for schizo- phrenia is estimated to be 0.70 to 0.90 (Mulle, 2012).

Several researchers have found linkages to schizophrenia on different chromosomes but especially for chromosomes 1, 2, 3, 7, 15, 16, 17, and 22 (Kotlar, Mercer, Zwick, & Mulle, 2015). The data are not consistent, however, because many people with schizophrenia do not show these genetic markers. Current research has thus begun to focus on new genetic mutations, especially on chromosome 22, that could lead to schizophrenia (Malherbe, Roos, Ehlers, Karayiorgou, & Roos, 2015).

Many people with schizophrenia may also have multiple genes that work together to help produce the disorder. This is known as a polygenic or polygenic or polygenic multilocus model (Hatzimanolis et al., 2015). Some people with schizophrenia may have individual genes strong enough to help produce schizophrenia, and thus to be recognized by researchers, but even these genes most likely work with others to help produce the disorder.

Genetic data do not paint the whole picture as to why peo- ple develop schizophrenia, however. Most relatives of people with schizophrenia, even identical twins of parents with schizo- phrenia, do not develop the disorder themselves. People with do not develop the disorder themselves. People with do not schizophrenia also do not usually have children themselves, which raises questions about genetic transmission. Perhaps genetic predispositions are stronger for some types of schizo- phrenia or speci�c behaviors related to the disorder, and per- haps many other biological and environmental variables are responsible as well (Seidman et al., 2015).

Brain Features Some people with schizophrenia have certain brain features that may help produce the disorder. One key feature is enlarged ven- tricles, or spaces or gaps in the brain (Figure 12.6). This �nding is not speci�c to schizophrenia, because some people with neu- rocognitive disorders (Chapter 14) also have enlarged ventricles. This brain feature is a highly replicated biological �nding in people with schizophrenia, however (del Re et al., 2015).

How might enlarged ventricles lead to schizophrenia? One possibility is that enlarged ventricles mean a general failure in normal brain development or disruption of pathways from one area of the brain to the next. An important disruption may involve neural connections between areas of the brain that

Psychotic Disorders: Causes and Prevention

Why would someone like James have such bizarre thoughts and behaviors? Recall that many mental disorders are thought to result from a combination of biological and envi- ronmental variables. Many people are born with a genetic or biological predisposition toward certain personality characteris- tics and mental conditions. These biological predispositions are sometimes strong and sometimes weak, but they appear to be quite strong in schizophrenia. We thus concentrate mostly on biological risk factors for schizophrenia but cover environmen- tal factors that may have some impact as well.

Biological Risk Factors for Psychotic Disorders Biological predispositions in people with psychotic disorders may involve genetics, brain and neurochemical features, and cognitive de�cits.

Genetics Family, twin, and adoption studies indicate that schizophre- nia has a strong genetic basis. Figure 12.5 summarizes studies of the prevalence of schizophrenia in relatives of people with schizophrenia. Recall that schizophrenia is present in less than 1 percent of the general population. Children of people with schizophrenia, however, are about 12 times more likely than the general population to develop schizophrenia. The risk factor is high even among more distant relatives. Grandchildren of peo- ple with schizophrenia are about 3 times more likely than the

FIGURE 12.5 LIFETIME PREVALENCE OF SCHIZOPHRENIA BY DEGREE OF RELATIONSHIP TO A PERSON WITH SCHIZOPHRENIA. From Faraone, S.V., Tsuang, M.T., & Tsuang, D.W. (1999). Genetics of mental disorders: A guide for students, clinicians, and researchers. New York: Guilford. Copyright © 1999 by Guilford Publications, Inc. Reprinted by permission.

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CHAPTER 12 Schizophrenia and Other Psychotic Disorders368

Schizophrenia researchers have paid par- ticular attention to poor development of the temporal lobe of the brain, which is partially re- sponsible for auditory processing and language (Figure 12.7). People with schizophrenia often have key problems in auditory processing and language, so these problems may be due to dif- ferences in temporal lobe areas. The medial temporal lobe, especially the amygdala and hippocampus, is smaller in people with schizo- phrenia than in control participants (Seidman et al., 2014). These areas are partially respon- sible for verbal and spatial memory processing and emotion, which are also problematic for people with schizophrenia. Reduced size in the superior and middle temporal gyri, which can affect auditory memory and language process- ing, has also been linked to schizophrenia (van Tol et al., 2014).

Other researchers have found reductions in total brain size and gray matter, which affect the size of different brain lobes and thus cogni- tion (Figure 12.8; Lee et al., 2015). Some have pointed to more speci�c de�cits with respect to the frontal lobe, which is heavily involved in complex information processing and orga-

nization of functioning and may contribute to auditory halluci- nations (Watanabe, Urakami, Hongo, & Ohtsubo, 2015). Other speci�c brain differences implicated in schizophrenia, which also often involve smaller size, include the following:

• Thalamus and parietal/occipital lobes, differences in which may affect the integration of sensory information and visual attention (Buchmann et al., 2014)

• Basal ganglia and Basal ganglia and Basal ganglia cerebellum, differences in which may affect motor behavior and output to higher-order brain areas (Hirjak et al., 2015)

• Corpus callosum, differences in which may affect language and communication between the brain hemispheres (del Re et al., 2015)

Enlarged ventricles and reduced brain size in certain areas such as the frontal lobe may help explain negative symptoms of schizophrenia (Bijanki, Hodis, Magnotta, Zeien, & Andreasen, 2015). Differences in other areas, such as the temporal lobe, may help explain positive symptoms of schizophrenia. Loss of gray matter may start in the parietal lobe, perhaps even dur- ing adolescence, and later spread to the frontal and temporal lobes (Haut et al., 2015). How this loss spreads and the degree to which it does may help determine a person’s speci�c symp- toms of schizophrenia.

The other major �nding with respect to brain changes and schizophrenia is lack of asymmetry in certain areas. Some people with schizophrenia may have differences in the hetero- modal association cortex, which includes two key brain areas for language processing: Broca’s area and planum temporale.

in�uence cognition and language. Schizophrenia is increas- ingly seen as a disorder of cortical connectivity (Jiang et al., 2015). Another possibility is that added space means critical brain areas are less well developed than they should be. This leads us to the next major �nding in this area: differences in lobes of the brain.

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FIGURE 12.6 COMPARISON OF BRAINS OF PEOPLE WITHOUT (LEFT) AND WITH (RIGHT) SCHIZOPHRENIA. NOTE THE INCREASED VENTRICULAR SIZE IN THE AFFECTED BRAIN. From “Regional de�cits in brain volume in schizophrenia: A meta-analysis of voxel based morphometry studies,” by R. Honea, T.J. Crow, D. Passingham, and C.E. Mackay, American Journal of Psychiatry, 162, 2005. Reprinted with permission from the American Journal of Psychiatry, Copyright (2005) American Psychiatric Association.

The Genain quadruplets were identical siblings, all female, who developed schizophrenia. Researchers at the National Institute for Mental Health studied them closely to learn more about genetic contributions to psychosis.

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Psychotic Disorders: Causes and Prevention 369

Studies of brain features represent fas- cinating advances in the �eld, but bear in mind that �ndings are often less than con- clusive. How these brain changes might lead to speci�c symptoms of schizophre- nia is not completely known either. These brain changes could be due to genetic predispositions, simple anatomical differ- ences in the general population, degenera- tion in the brain over time, environmental factors, or other variables. Not everyone with schizophrenia shows measurable brain differences, which means that other causes, such as the neurochemical fea- tures we discuss next, are likely present.

Neurochemical Features One of the most prominent theories of schizophrenia is that symptoms are caused by an excess of certain neu- rotransmitters in the brain, especially dopamine (Figure 12.9). The excess do- pamine hypothesis has been popular largely because:

• Many people with positive symptoms of schizophrenia are successfully treated with drugs that lower dopa- mine levels (discussed later in the treatment section).

• Antipsychotic drugs may actually produce very low levels of dopamine and create side effects similar to Parkinson’s disease, which is caused by de�cient levels of dopamine (Chapter 14).

• Excess levels of dopamine, from methamphetamine intoxi- cation for example, can lead to motor problems and psy- chotic symptoms.

Lack of asymmetry in the planum temporale is a possible risk factor for learning disorder (Chapter 13), and a similar �nding has been found for people with schizophrenia (Atagun et al., 2015). Lack of asymmetry in other brain areas has also been implicated in schizophrenia, including the anterior cingulate cortex (Salgado-Pineda et al., 2014), which is partially respon- sible for types of decision making.

FIGURE 12.7 BRAIN AREAS MOST IMPLICATED IN SCHIZOPHRENIA.

Frontal lobe

Amygdala

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FIGURE 12.9 METHAMPHETAMINE USE, WHICH INCREASES DOPAMINE, CAN LEAD TO PSYCHOTIC SYMPTOMS.

5 YEARS LATER (SAME PARTICIPANTS)

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CHAPTER 12 Schizophrenia and Other Psychotic Disorders370

cognitive clusters in people with schizophrenia may include the following:

• Less verbal �uency (ability to form and express words) • Poor verbal memory and motor control • Slower information processing • Diminished intellectual function

Each of these clusters may be linked to a speci�c brain change (Geisler et al., 2015). Severity levels and symptoms of schizophrenia are incredibly diverse and not easily subject to such classi�cation, however (Gilbert et al., 2014). Still, cognitive distinctions may be important for assessment and treatment.

Environmental Risk Factors for Psychotic Disorders Early and later environmental factors also in�uence the devel- opment of psychotic disorders. These environmental factors in- clude prenatal complications, adverse life events and excessive substance use, and cultural and evolutionary in�uences.

Prenatal Complications People with schizophrenia, if they had some developmental delay, tend to have had more prenatal complications than the general population (Walder, Faraone, Glatt, Tsuang, & Seidman, 2014). One prenatal complication that seems closely involved in psychotic disorders is hypoxic ischemia, or low blood �ow and oxygen to the brain. This can lead to enlarged ventricles (see earlier brain features section). Lower birth weight and smaller head circumference are also common to this population (Fineberg, Ellman, Buka, Yolken, & Cannon, 2013).

Prenatal complications can also come in the form of viruses and infections. People with schizophrenia are born dispropor- tionately in late winter or spring months; therefore, the fetus has developed in times involving higher risk for in�uenza and other diseases (Figure 12.10). This risk may be even more so if a child is born in a large urban setting or if his family recently migrated to another country. Schizophrenia may also be more frequent during times of famine (Miller, Culpepper, Rapaport, & Buckley, 2013). Exposure to rubella, viral encephalitis, or severe malnutrition could place a fetus at increased risk for schizophre- nia and other disorders (Fraile, Ruiz, & Peinado, 2015).

Adverse Life Events and Excessive Substance Use Maternal stress during the prenatal period may lead to impor- tant brain changes and later mental disorders, including schizo- phrenia (Fineberg et al., 2016). Later environmental factors such as adverse life events and excessive substance use could also in�uence the development of psychotic disorders. Many people with schizophrenia experience stressful life events in weeks and months before the onset of psychotic symptoms, especially if they are emotionally reactive (Barrantes-Vidal, Dominguez, Cristobal-Narvaez, & Kwapil, 2014). Such was the case with James. Traumatic life events, such as physical maltreatment, are also common to people with schizophrenia (O’Hare, Shen, & Sherrer, 2013). What remains unclear, however, is whether

• L-dopa, a drug that boosts levels of dopamine in people with Parkinson’s disease, can produce psychotic symp- toms if taken in excess and can aggravate symptoms of schizophrenia.

• Dopamine receptors, especially D2 receptors, may be dens- er in the brains of some people with schizophrenia (Howes & Murray, 2014; Larulle, 2014).

A revised theory regarding dopamine is that the neu- rotransmitter itself is less important than is its role in helping to control information processing in the cortex (Belujon, Patton, & Grace, 2014). Recall that changes in brain lobes have been im- plicated in schizophrenia and many of these areas involve large amounts of dopamine receptors. Areas of the brain that link to the cortex, such as the basal ganglia or amygdala, also have large amounts of dopamine receptors. Changes in dopamine and key areas of the brain may interact to help produce symp- toms of schizophrenia, but the precise nature of this possibility remains under study.

Other neurotransmitters have been implicated in schizo- phrenia as well, including serotonin, gamma-aminobutyric acid, and glutamate (Tamminga & Ivleva, 2013). Perhaps these other neurotransmitters, especially serotonin, interact with dopamine and de�cits in key brain areas to help produce symptoms of schizophrenia. Less serotonin in the frontal cortex may lead to more activity in this brain area and thus more dopamine activity (Selvaraj, Arnone, Cappai, & Howes, 2014).

Cognitive De�cits Brain changes and other biological factors may help explain why many people with schizophrenia have several key cognitive de�- cits. Key de�cits include memory, attention, learning, language, and executive functions such as problem-solving and decision- making abilities. Memory and attention in particular are prob- lematic for many people with schizophrenia. With respect to memory, many people with schizophrenia have great dif�culty recalling information and retaining information over time (Lett, Voineskos, Kennedy, Levine, & Daskalakis, 2014).

Many people with schizophrenia also experience sustained attention problems that may begin in childhood or adolescence. Many close relatives of people with schizophrenia have atten- tion problems as well (Larsson et al., 2013). Also, many people with schizophrenia have problems processing rapid visual in- formation, tracking objects with their eyes, and concentrating on one subject (Tibber et al., 2015). Dif�culty processing in- formation may lead to sensory overload, and this may help ex- plain positive symptoms such as hallucinations and delusions. Negative symptoms might be the result of withdrawal from this sensory overload. Dif�culty processing information may also be central to the disorganized speech found in many people with psychotic disorders (Holshausen, Harvey, Elvevåg, Foltz, & Bowie, 2014).

Some researchers believe schizophrenia subtypes could be based on cognitive functioning. Many people with schizophre- nia have little cognitive impairment, but others have severe and generalized impairment similar to dementia (Chapter 14). Main

Psychotic Disorders: Causes and Prevention 371

common risk factors, such as increased mesolimbic dopaminer- gic activity (Thoma & Daum, 2013).

Cultural and Evolutionary In�uences Other factors related to schizophrenia may include culture and evolutionary in�uences. Schizophrenia does seem more com- mon in people in developing countries and in immigrants and migrant workers than in people in developed countries and native populations. Increased rates of schizophrenia are re- ported among African Caribbean samples in England compared with native samples (Tortelli et al., 2015). Social isolation and lack of social support among migrant workers may be a key risk factor for schizophrenia.

Sociocultural models of schizophrenia also focus on the issue of labeling or assigning someone with a diagnosis of labeling or assigning someone with a diagnosis of labeling severe mental disorder. The process of labeling someone with a diagnosis like schizophrenia may indeed predispose the per- son to display symptoms that could be construed as consistent with the disorder. A person just diagnosed with schizophrenia may withdraw from others to avoid discrimination, experience lowered self-esteem and quality of life, become enraged or depressed, and act oddly (Imhoff, 2015).

Labeling can also affect how others view someone. Rosen- han (1973) conducted a famous study in which people without mental disorder went to various hospitals and falsely claimed to hear voices. All of these “pseudo-patients” were hospitalized and kept on an inpatient unit despite the fact that they purpose- fully displayed normal behavior on the unit. Hospital records indicated that staff members often judged normal behavior such as note-taking as pathological, simply on the basis that the per- son was admitted to an inpatient unit. The study underscored the fact that stigma can be quite strong and hard to challenge once a diagnosis of severe mental disorder is given.

The issue of social functioning has also been raised with respect to evolutionary hypotheses about schizophrenia. One theory is that humans tolerate greater deviation from normal functioning the more they develop complex social lives further removed from the basic “hunter-gatherer” status of our distant ancestors. Early groups of humans could not tolerate people incapable of protecting and nourishing the group because of psychotic symptoms, but people with these symptoms today can more easily be assimilated into, and contribute to, society. Another evolutionary hypothesis is that a genetic mutation oc- curred in some humans as they split from other primates eons ago. This genetic mutation might affect areas of functioning that separate us from other primates—most notably language. De�cits in language, of course, are often central to psychotic disorders (van Dongen & Boomsma, 2013).

Causes of Psychotic Disorders How do all of these risk factors interact to produce a psychotic disorder? A popular integrative model for how schizophrenia and other psychotic disorders might develop is the neurodevel- opmental hypothesis (Howes & Murray, 2014). Proponents of this model essentially state that a subtle disease process affects

stressful life events trigger psychotic symptoms or whether psy- chotic symptoms place people in vulnerable positions in which they may be exploited by others.

People with psychotic disorders are also much more likely to use marijuana excessively than the general population (Solowij et al., 2013). Other drugs could lead to psychotic symptoms as well. Excessive substance use among people with schizophrenia symptoms is common (see Table 12.8). Whether stressful life events and excessive substance use trigger psychotic symptoms or whether they develop afterward is not clear. Some people may use alcohol or other drugs to cope with psychotic symp- toms, but substance use disorder and schizophrenia also share

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FIGURE 12.10 RATES OF FIRST ADMISSIONS AND READMISSIONS OF SCHIZOPHRENIA BY BIRTH MONTH. Note the generally higher rates of �rst admissions among people born in spring and summer months. Source: Clarke, M., Moran, P., Keogh, F., Morris, M., Kinsella, A., Larkin, C., Walsh, D., & O’Callaghan, E. (1999). Seasonal in�uences on admissions for affective disorder and schizophrenia in Ireland: A comparison of �rst and readmissions. European Psychiatry, 14, 253.

TABLE 12.8

Comorbidity of Substance Use Disorder and Schizophrenia

Substance Substance use disorder and schizophrenia

Cannabis 27.0%

Alcohol 20.6%

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Amphetamine 8.9%

Opioid 4.1%

Diagnostic distributions of people with a lifetime or cumulative prevalence of substance use disorder and schizophrenia. Some people may have had more than one substance use disorder. From Kivimies et al. (2015) and Thoma & Daum (2013).

CHAPTER 12 Schizophrenia and Other Psychotic Disorders372

the ears, head, face, tongue, palate, and hands and feet (Gassab, Aissi, Slama, Gaha, & Mechri, 2013). Some irregularities have been linked to brain ventricle size in schizophrenia (Tenyi et al., 2015). Many people with schizophrenia do not have these irregularities, however, and many people with these irregulari- ties do not have schizophrenia.

Stronger evidence for the neurodevelopmental hypothesis comes from strange motor behaviors often seen in children of parents with schizophrenia or children who eventually de- velop schizophrenia. Some of these strange motor behaviors have been identi�ed in home movies and videotapes of children whose parents had schizophrenia. These strange motor behav- iors may be the result of prenatal complications or genetics that affect brain development, or may have to do with excess lev- els of dopamine. Many of these children display the following characteristics:

• Irregularities or lags in motor development, such as delayed walking

• Slow head and body growth • Poor �ne and gross motor coordination and perception • Overactivity • Odd hand movements and other involuntary movements • Twitching and grimacing

Keep in mind, however, that these odd motor behaviors sometimes predict other disorders such as depressive and bipo- lar disorders. Not all people with schizophrenia necessarily had these symptoms in childhood either, and these symptoms do not necessarily mean someone will go on to develop schizophrenia (Laurens et al., 2015).

Other childhood changes that may provide support for the neurodevelopmental hypothesis include changes in cognitive and social behaviors. Children at risk for developing schizo- phrenia tend to show a decline in intelligence over time, lower tested intelligence, and more repeated grades and trouble pay- ing attention than controls (Laurens et al., 2015). Some children who eventually develop schizophrenia also show schizotypy (odd behavior and speech) and unusual perceptual experiences (Nelson, Seal, Pantelis, & Phillips, 2013). People with schizo- phrenia often develop poor social cognition and theory of mind, or an understanding of the thoughts and beliefs of others (Ventura et al., 2015). James did not always fully appreciate or understand the perspectives of other people. These cognitive and social changes are quite inconsistent and not always pre- dictive of schizophrenia, however.

As a child develops further, environmental events certainly have an impact on his development and may speed or even prevent the onset of full-blown symptoms of a later psychotic disorder. We mentioned that stressful life events and excessive substance use have been linked to schizophrenia. A child who displays problematic behavior as a youngster may experience stress from loss of family members, academic demands, family con�ict, and peer pressures. This may lead to various outcomes such as depression, excessive substance use to cope, or triggered psychotic symptoms. Conversely, environmental support from

brain areas early in life, perhaps as early as the second trimester of the prenatal period, and progresses gradually to the point where full-blown symptoms are produced (Figure 12.11; Miller et al., 2013). Early brain changes could come from disease, fam- ine, and low birth weight, among other variables. Genetic pre- dispositions could also affect fetal and child brain development that may contribute to later symptoms of schizophrenia.

Some theorists believe these early brain changes become especially pertinent when the adolescent brain goes through signi�cant reorganization and increased use. One possibility is that neurons are insuf�ciently pruned at this time, which means old synaptic connections are not discarded as they are in most people. This can lead to a “packing” of useless neurons in key areas of the brain such as the hippocampus. Such abnormalities can help lead to full-blown symptoms of schizophrenia (Cocchi, Drago, & Serretti, 2015). Another possibility is that a less well- developed brain can no longer handle the increased complexi- ties of life during adolescence and adulthood.

If the neurodevelopmental hypothesis is true, then one might expect signs of early problems and brain changes to emerge as a child develops. Some evidence indicates this to be so. People with schizophrenia often have other physical problems that probably developed about the same time as key brain changes, and some of these problems may be evident in children and adolescents. These physical problems include irregularities of

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FIGURE 12.11 SAMPLE DEVELOPMENTAL PATHWAY OF PSYCHOTIC PATHWAY OF PSYCHOTIC PA DISORDER.

Psychotic Disorders: Causes and Prevention 373

This model may be useful for implementing prevention efforts. At-risk children could be identi�ed by evaluating family history, early environmental stressors, minor physical anoma- lies, and early problematic behaviors. “First hits” are dif�cult to prevent, but “second hits” could be targeted. Possible ideas to address second hits include the following:

• Use of foster care homes instead of institutions for residen- tial placement

• Family therapy to address problem-solving and communica- tion skills

• Academic skills training to boost sustained attention, verbal skills, and intelligence

• Social skills training to improve abilities to interact with others

• Motor skills training to improve coordination • Instruction about psychotic disorders and recognizing their

symptoms

• Psychosocial therapy to help a child cope with daily stressors • Early use of neuroleptic medications (see treatment section)

Large-scale prevention studies focused on these ideas remain necessary. Some researchers, however, have provided intervention to adolescents and young adults at high risk of having a �rst psychotic episode. This often involves a supportive approach that focuses on helping participants ad- dress social, vocational, and family problems in addition to cognitive-behavioral therapy and medication (see treatment sections). These procedures can delay the onset of a full- blown psychotic disorder (Piskulic, Nelson, Alvarez-Jimenez, & McGorry, 2015).

Another target of prevention in general and relapse preven- tion in particular is expressed emotion. Recall from Chapter 7 that expressed emotion refers to emotional overinvolvement and hostility on the part of family members toward one another as well as inability to cope with a person’s mental disorder, in this case schizophrenia. A person with schizophrenia is often blamed for his mental disorder and harshly criticized by families with high expressed emotion (Cechnicki, Bielanska, Hanuszkiewicz, & Daren, 2013).

High levels of expressed emotion produce greater relapse in people with schizophrenia and so expressed emotion may be a good target for relapse prevention (Bogojevic, Ziravac, & Zigmund, 2015). Expressed emotion relates to medication com- pliance and may interact with culture. Some claim family mem- bers communicate poorly to someone with a psychotic disorder if the person deviates much from core cultural values and norms (Wiguna et al., 2015). The area of family dynamics and how they relate to further psychotic episodes remains a fascinating area of study.

➲ Interim Summary • Biological risk factors for psychotic disorders include

genetics, brain and neurochemical differences, and cognitive de�cits.

others and early intervention may help prevent serious symp- toms from occurring. We discuss this in the prevention section.

Once full-blown symptoms of schizophrenia begin, levels of functioning tend to remain stable (Miles et al., 2014). This pro- vides even more support for the neurodevelopmental hypoth- esis, which predicts that early brain changes will outline a fairly consistent course of behavior for a person. Many people with schizophrenia eventually show remission or some improvement in their symptoms over time, meaning early and stable brain changes are more likely a cause for schizophrenia than ongoing brain deterioration (Rabanea-Souza et al., 2016).

Whatever the actual cause of schizophrenia and other psy- chotic disorders, these problems are clearly among the most complex mental disorders. We will likely �nd over time that many different types of schizophrenia exist and that each has its own developmental pathway. Charting these pathways will require substantial research effort and collaboration among mental health professionals. In the meantime, efforts to prevent these disorders must be a priority.

Prevention of Psychotic Disorders Given what we know about risk factors for psychotic disorders, what could be done to prevent them? Early symptoms of psy- chotic disorders may emerge in adolescence or early adulthood, so it makes sense to think of prevention in the childhood and ad- olescent years. We know genetics play a large role in schizophre- nia, so it might be useful to focus on children whose parents had schizophrenia and look for early signs of stressful life events and motor, cognitive, and social problems. Children identi�ed as at risk could then be taught ways to improve their functioning and perhaps blunt the onset of schizophrenia symptoms.

Some researchers discuss a two-hit model of schizophrenia that may help guide prevention efforts (Selemon & Zecevic, 2015). A child is deemed to be at particular risk for schizophre- nia if his close relatives had schizophrenia (the �rst hit) and if he experienced a severe environmental stressor such as prena- tal complications, residence in an institution, or family con�ict, among others (the second hit). A special kind of “second hit” involves problems in early child rearing. Children at risk for schizophrenia often experience negative life events, maltreat- ment, and loss of a parent (Davis et al., 2016).

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CHAPTER 12 Schizophrenia and Other Psychotic Disorders374

may be conducted to get as much useful information as possible. Information about the following areas should be a priority:

• Current level of functioning and speci�c problem behaviors and de�cits

• Recent life events and personal history • Medication and treatment history and degree of compliance • Comorbid medical and psychological conditions • Financial resources and support from signi�cant others

A semistructured interview often used for people with se- vere mental disorder is the Schedule for Affective Disorders and Schizophrenia. This interview concentrates on background and demographic characteristics as well as past and present symp- toms of various disorders including psychoses. The interview, and other similar ones, can take a long time to administer, re- quires much expertise to give, and may not be useful for some- one with highly disorganized thoughts. Other interviews thus focus more on current level of functioning, such as living inde- pendently, employment, friendships, and romantic partnerships (Joseph et al., 2015).

Brief rating scales used as semistructured interviews are thus sometimes used. These scales focus mainly on negative and positive symptoms of schizophrenia as well as impaired thinking. The scales are usually completed by mental health professionals who obtain information from chart reviews, obser- vations, or discussions with a person with schizophrenia, sig- ni�cant others, and other professionals. An individual may also be asked to complete certain scales if possible. The Psychotic Symptoms Rating Scales, for example, measure frequency of and distress associated with delusions and auditory hallucinations (Woodward et al., 2014). Table 12.9 includes simulated items from a psychoticism subscale.

Behavioral Observations Behavioral observations of people with psychotic disorders are useful to evaluate social and self-care skills. Important skills to observe include starting and maintaining a conversation, solving problems, managing stress and one’s symptoms, tak- ing medications, engaging in basic hygiene, working well with others, and maintaining appropriate facial expressions and affect, among others. Side effects of medications should also be observed closely. One could also evaluate “neurological soft signs” that may indicate some brain change (Bachmann, Degen, Geider, & Schroder, 2014). These signs include poor balance and coordination, awkward movements and re�exes, tremors, and speech and sleep problems.

The most common method for evaluating these behav- iors is to carefully monitor a person with a psychotic disor- der and get information from family and friends. Behavioral observations are most useful if they occur in multiple settings, especially at home, work, and during recreational activities. Role-play or scales that measure social and self-care skills may be helpful with observations in these areas as well (Kurtz, Mueser, Thime, Corbera, & Wexler, 2015). Consider

• Environmental risk factors for psychotic disorders include prenatal complications, disease, famine, stressful life events, and excessive substance use.

• Biological and environmental risk factors can make a per- son vulnerable to having a psychotic disorder. These risk factors may produce early brain changes that, over time, do not allow a person to fully address life’s stressful and complex tasks.

• One causal theory for psychosis is a neurodevelopmental model in which an early disease state leads to key brain changes and stable psychotic symptoms.

• Preventing psychosis may involve assessing for markers early in life, enhancing skills that deteriorate in one’s lifetime, and reducing expressed emotion in families.

➲ Review Questions 1. Describe data supporting a genetic contribution to psychotic

disorders. 2. What key brain changes and environmental factors relate to

psychotic disorders? 3. Explain the neurodevelopmental model of schizophrenia. 4. What factors might be important for a program to prevent

psychotic disorders? 5. What is expressed emotion?

Psychotic Disorders: Assessment and Treatment

Psychotic disorders often involve multiple and severe de�-cits, so assessment can be quite dif�cult. Information often comes from spouses, children, family members, and friends to piece together a history of symptoms and behavior patterns. Such was true for James. Clinical observations by mental health professionals who have experience with this population are invaluable as well. We discuss each of these methods in the following sections.

A full medical examination should always precede a psy- chological assessment of schizophrenia because certain medi- cal conditions could produce psychotic symptoms. Examples include epilepsy, brain trauma such as stroke, central nervous system infections such as AIDS, endocrine and metabolic disorders, vitamin de�ciency, and autoimmune disorders. Substances such as amphetamines, marijuana, phencycli- dine (PCP), and LSD could produce psychotic symptoms as well. Alcohol and sedative withdrawal can also lead to psychotic-like symptoms (Jordaan & Emsley, 2014; Oldham & Desan, 2015).

Interviews Interviews are dif�cult for many people with psychotic disor- ders because of delusions, hallucinations, suspicion, and disor- ganized thoughts and behaviors. Still, unstructured interviews

Psychotic Disorders: Assessment and Treatment 375

be used as a premorbid (before disorder) level of functioning. These scores can then be compared with WAIS-IV verbal subtest scores, which indicate current functioning, to see what changes have taken place. This assessment strategy may be less help- ful, however, for someone with severely disorganized symptoms or intense reading problems. Attention or concentration de�cits may be evaluated using the Conners Continuous Performance Test 3, which requires a person to react to a long series of stimuli presented at regular intervals (Conners, 2014).

Other neuropsychological tasks such as sorting objects into categories like color are also used to assess frontal cortex prob- lems in schizophrenia, especially problems in decision making, problem solving, and verbal memory. People with psychotic dis- orders often have motor problems, so speci�c subtests of neu- ropsychological measures that evaluate �nger tapping and grip strength in dominant and nondominant hands may be useful as well. Other subtests may be used to evaluate sensory perceptual problems in vision, hearing, or touch. An example is the Fingertip Number Writing subtest of the Halstead-Reitan test where a per- son closes his eyes and identi�es what number is written on his �ngertip by the examiner. This test can differentiate people with and without brain dysfunction. Other neuropsychological tests for people with schizophrenia measure concepts such as verbal learning, memory, and sorting (Agnew-Blais & Seidman, 2013).

Physiological Assessment People with psychotic disorders often have intense symptoms that may have a strong biological basis, so competing medical explanations should be ruled out �rst. Laboratory tests such as urine and blood analyses may also be done to examine excess levels of neurotransmitters and legal and illegal drugs. Such tests are often done to monitor a person’s compliance with prescribed

the following role-play between a therapist and a person with residual schizophrenia:

Therapist: How are you doing today? Patient: (saying something in a mumbled voice, head down) Therapist: Can you look at me when you say that? And I

need to hear you a bit better. Patient: (more clearly) I said �ne . . . (voice trailing off a bit). Therapist: Great! I could hear you much better that time. Patient: (silence) Therapist: How about responding to what I just said?

What could you say in reply? Patient: Um, well . . . ah . . . thanks? Therapist: Yes, great! You’re welcome! Let’s keep this

conversation going.

Cognitive Assessment Many people with schizophrenia and other psychotic disorders have dif�culties with language and verbal ability, attention and concentration, memory, problem solving, decision making, and sensory-perceptual functioning. Tests to evaluate these areas of cognitive function in this population are thus often crucial.

Tests of language and verbal ability are often derived from certain subtests of intelligence and achievement tests. These include verbal subtests from the Wechsler Adult Intelligence Test (4th edition; WAIS-IV) and reading subtests from the Test (4th edition; WAIS-IV) and reading subtests from the Test Wide Range Achievement Test (4th edition; WRAT-4; Wechsler, 2008; Range Achievement Test (4th edition; WRAT-4; Wechsler, 2008; Range Achievement Test Wilkinson & Robertson, 2006). One should look for problems in language �uency, perception, production, and syntax as well as differences in scores on these tests. Reading scores on the WRAT-4 may not deteriorate even after development of a se- vere mental disorder or brain dysfunction, so these scores may

TABLE 12.9

Simulated Items from a Psychoticism Subscale

How much were you distressed by: N ot

a t

al l (

0 )

A li

tt le

b it

( 1

)

M od

er at

el y

(2 )

Q ui

te a

b it

( 3

)

E xt

re m

el y

(4 )

The idea that someone else can control your thoughts

Hearing voices that other people do not hear

Other people being aware of your private thoughts

Having thoughts that are not your own

The idea that you should be punished for your sins

The idea that something serious is wrong with your body

The idea that something is wrong with your mind

CHAPTER 12 Schizophrenia and Other Psychotic Disorders376

address depressive and negative symptoms, and minimize side effects. These newer drugs affect various dopamine receptors as well as other neurotransmitter systems such as serotonin (Meltzer, 2013).

Typical and atypical antipsychotic drugs do work better than no drug treatment. Typical and atypical antipsychotic drugs are similar in effectiveness with respect to rehospi- talization rates, but atypical antipsychotics appear more ef- fective for severe cases of schizophrenia (Stan & Tamminga, 2014). Other data indicate the long-term effectiveness of atypical antipsychotics is better than typical antipsychotics (Meltzer, 2013).

medication as well as potentially dangerous interactions with other drugs. These tests are not foolproof, however, so behav- ioral observations and rating scales may be used with laboratory testing. Magnetic resonance imaging is becoming increasingly common for people with psychotic conditions as well (Fusar-Poli et al., 2013).

Biological Treatments of Psychotic Disorders Someone like James with a severe psychotic disorder clearly needs intense treatment for bizarre and complex symptoms. Schizophrenia and other psychotic disorders have a strong bio- logical component, so treatment often begins with medication (see Box 12.4). Medication for psychotic symptoms is some- times called antipsychotic or antipsychotic or antipsychotic neuroleptic medication. These med- ications are typically divided into typical antipsychotics and atypical antipsychotics (see Table 12.10; Meltzer, 2013).

Typical antipsychotics such as phenothiazines are tradi- tionally used for this population and focus primarily on reduc- ing excess levels of dopamine in the brain. These drugs were introduced in the 1950s and led to a widespread decline in people hospitalized for severe mental disorders such as schizo- phrenia (Figure 12.12). Typical antipsychotics are helpful but have several problems:

• Many people with psychotic disorders do not respond well to these drugs.

• The drugs are useful for treating positive symptoms of psy- chotic disorders such as delusions and hallucinations but not negative symptoms.

• Side effects may be extremely unpleasant or irreversible in some cases (discussed later).

Atypical antipsychotic drugs are newer (or second-generation) agents developed to treat more people with psychotic disorders,

Most jurisdictions allow physicians to administer antipsychotic medication without consent of the individual in situations that involve emergencies, obvious incompetence of the individual, and/or dangerousness to self or others (as with James). Even in these cases, however, every attempt should be made to include the person in the consent process as soon and as much as possible, to consult with family members about treatment options, and to provide only enough treat- ment to help the person make competent decisions about further treatment.

A more serious issue is forced medication. Should the government man- date that someone arrested for a crime and who is acutely psychotic re- ceive antipsychotic medication against his will for the purpose of increasing legal competence and the possibility of imprisonment? This issue has been raised in several court cases and has deep rami�cations for other practices. Could government agencies eventually mandate medications for children and adults with certain other mental disorders? How would the line be drawn for other kinds of treatments as well? For now, these questions are answered only on a case-by-case basis by the courts.

Focus On

Making the independent choice to take medication is a crucial step to- ward recovery for many people with mental disorders. Controversy arises, however, with respect to antipsychotic medication and what to do if a person is legally incapable of making choices about treatment. Imag- ine someone referred by police to an inpatient psychiatric unit who has acute delusions and hallucinations. If his ability to understand reality is impaired, and he cannot give consent about antipsychotic medication, then what?

Law and Ethics Making the Choice of Antipsychotic Medication

12.4

TABLE 12.10

Antipsychotic Agents Available in the United States

Typical antipsychotics Atypical antipsychotics

Chlorpromazine (Thorazine) Aripiprazole (Abilify)

Fluphenazine (Prolixin) Asenapine (Saphris)

Haloperidol (Haldol) Clozapine (Clozaril)

Loxapine (Loxitane) Iloperidone (Fanapt)

Perphenazine (Trilafon) Lurasidone (Latuda)

Thioridazine (Mellaril) Olanzapine (Zyprexa)

Thiothixene (Navane) Paliperidone (Invega)

Tri�uoperazine (Stelazine) Quetiapine (Seroquel)

Risperidone (Risperdal)

Ziprasidone (Geodon)

Psychotic Disorders: Assessment and Treatment 377

psychological approaches. Psychological approaches usually aim to improve medication compliance, social and self-care skills, employment duration, support from relevant others, mood, and cognitive abilities. Psycho- logical approaches for this population are designed to enhance a person’s quality of life and help prevent relapse.

Milieu Therapy and Token Economy Two psychological techniques adopted on inpatient psychiatric units for people with acute psychotic symptoms are milieu therapy and token economy. Milieu therapy involves establishing an environment in which prosocial and self-care skills are encouraged. Mental health professionals, physicians, nurses, and other staff continually praise and encourage a person with psychotic symptoms to dress, eat, groom, attend therapy services, interact appropriately with others, and engage in other positive behaviors (Borge, Angel, & Rossberg, 2013).

Milieu therapy is sometimes linked to a token econ- omy in which prosocial and self-care skills are tangibly

rewarded via points (or other items) later exchanged for privi- leges such as day trips outside the hospital. A token economy might involve rewards for teeth brushing and eating dinner with others. James was allowed more time outside the hospital as he attended inpatient group therapy sessions. These inpatient strategies help reduce symptoms, improve social behavior, and facilitate earlier discharge (Kokaridas et al., 2013).

Cognitive-Behavioral and Supportive Psychotherapies You might think psychotherapy for someone with strong psy- chotic symptoms would not be useful, but think again! Cogni- tive-behavioral and supportive psychotherapies do help prevent relapse (Jones, Hacker, Cormac, Meaden, & Irving, 2012). Cog- nitive-behavioral therapy is typically better than routine care for people with schizophrenia and aims to achieve the following:

• Create a strong therapeutic alliance with a client built on acceptance, support, and collaboration

• Educate a client about his psychosis and reduce stigma associated with symptoms

• Reduce stress associated with psychotic symptoms • Decrease delusions and hallucinations and change errone-

ous expectancies and thoughts about them

• Address comorbid conditions such as excessive substance use, anxiety, and depression

• Lower chances of relapse by identifying and eliminating triggers such as stress, family con�ict, and forgotten medi- cation (Kurtz, 2015).

Recall that Jody had delusions about her coworkers harm- ing her and that her employers asked her to seek professional help. Her therapist helped Jody separate more realistic from less realistic thoughts and reduce life stress to help prevent

Antipsychotic medication is useful for people with schizo- phrenia and is often necessary for someone to complete even basic self-care tasks. Still, key problems remain. First, the drugs are not effective for all people with psychotic disorders. Second, many people experience signi�cant side effects from antipsy- chotic medication. Common side effects of typical antipsychotics include muscle spasms and rigidity, restlessness, pacing, �xed facial expression, sedation, and seizures. Involuntary move- ments of the body, or extrapyramidal effects, are also common. Another side effect of typical antipsychotics, tardive dyskinesia, is a potentially irreversible condition marked by involuntary tics of the face, mouth, tongue, and upper body (Kim, MacMaster, & Schwartz, 2014). Side effects of atypical antipsychotics tend to be less severe but may include low blood pressure, diabetes, sedation, weight gain, concentration problems, and seizures, among others (Owens, 2014).

Another problem with medication is that one must take the drug for it to work. Compliance rates for taking medication are not always strong for people with psychotic disorders (Haddad, Brain, & Scott, 2014). People often struggle with multiple medica- tions, memory and thought dif�culties, stressful life events, side effects, excessive substance use, and transportation to pharma- cies and doctors’ of�ces. The cost of atypical antipsychotic drugs is also much higher than typical antipsychotic drugs (Meltzer, 2013). A person with a psychotic disorder has a high chance of relapse if she delays or stops taking prescribed medication (Higashi et al., 2013). Methods of increasing compliance are part of the psychological treatment approach for psychotic disorders.

Psychological Treatments of Psychotic Disorders Medications are a mainstay ingredient of many treatment plans for psychotic disorders, but they are typically supplemented with

FIGURE 12.12 THE POPULATIONATIONA IN STATEATEA AND COUNTY HOSPITALS. The number of people hospitalized for severe mental disorders such as schizophrenia declined greatly after 1960 partly because of the introduction of antipsychotic drugs. Source: Manderscheid, R. W., Atay, J. E., & Crider, R. A. (2009). Changing trends in state psychiatric hospital use from 2002 to 2005. Psychiatric Services, 60, 29-34. Reprinted by permission.

100

300

200

600

500

400

T h

o u

sa n

d s

19 40

19 20

20 00 20

05 19

60 19

80 19

00 18

70 18

31 18

Residents Admissions

CHAPTER 12 Schizophrenia and Other Psychotic Disorders378

settings with different people, be rewarded for her efforts, and later advance to more dif�cult tasks such as introducing herself and participating in long conversations. Social skills training could be done individually but is quite effective when done with a group of people. Such training is useful in therapy settings, but good generalization of skills to more natural settings requires extensive and ongoing practice (Rus-Calafell et al., 2013).

Cognitive and Vocational Rehabilitation Psychotherapy for people with psychotic disorders also in- volves rehabilitation of cognitive and vocational de�cits. Many people with schizophrenia have great problems in attention, memory, and decision-making and problem-solving skills. The main goal of cognitive rehabilitation is to improve performance in these areas and integrate performance into social interactions. Examples of cognitive rehabilitation tech- niques include repeated instruction and practice on neuropsy- chological tests, computer exercises, use of self-instructions to maintain focus and guide performance in social situations, careful listening to others’ statements, training in speci�c tasks that require attention and memory, and ongoing vigi- lance and encoding of important information. Reinforcement of these tasks is important as well. These techniques are gen- erally effective for improving cognitive skills, but questions remain about whether they can lead to long-lasting and broad changes (Kluwe-Schiavon, Sanvicente-Vieira, Kristensen, & Grassi-Oliveira, 2013).

Vocational rehabilitation aims to reintegrate a person with a psychotic disorder into a productive occupational environment. Vocational rehabilitation concentrates mainly on job training, support, and employment in an area a person is motivated to work. Other areas of vocational rehabilitation include practicing language and cognitive skills in a work setting, detailed work performance feedback, and resolution of job-related dif�culties. These efforts successfully increase job performance for this pop- ulation (Tsang & Man, 2013).

her suspiciousness. Jody learned to examine evidence for and against her thoughts, talk to others about her concerns in a socially appropriate way, and pursue enjoyable activities out- side of work.

Medication Compliance People with schizophrenia and other psychotic disorders of- ten need to stay on medication to function on a daily basis, so helping them comply with medication is important. Behavioral strategies to do so could include discussions about bene�ts of taking medication and disadvantages of not taking medication, education about medications and their main and side effects, pairing medication use with an essential part of a daily routine such as eating dinner, putting medication in obvious places so it is remembered, and rewarding appropriate medication use, per- haps using a token economy. Signi�cant others or an electronic device may also monitor a person closely and even count pills, especially after her hospitalization or during times of high stress (Stauffer, Baygani, Kinon, & Krikke-Workel, 2014).

Social Skills Training Many people with schizophrenia have great dif�culty interact- ing with others, either because of their developmental history or current symptoms. They are thus at risk for social withdrawal, depression, and other problems. Social skills training has been used to enhance contact with others, decrease distress, and pre- vent relapse. Social skills training usually consists of repeated modeling and practice and feedback regarding small behaviors �rst. A person with schizophrenia could watch two people have a short conversation and then try the same task with her thera- pist. The therapist closely watches for key behaviors such as lack of eye contact, inaudible or incoherent speech, interrup- tions, poor emotional control, and other important problems.

Feedback to educate a client about these de�ciencies is cru- cial, and a person should continue to practice until the skill is well developed. The person should practice her skills in natural

People with schizophrenia on an inpatient unit are often encouraged, via milieu therapy, to be together to build social skills and support and reduce isolation.

Bu rli

ng ha

m /F

ot ol

ia L

Family therapy is often a key treatment for people with schizophrenia to improve communication and medication compliance and to solve problems effectively.

Sy da

P ro

du ct

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/F ot

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L LC

Psychotic Disorders: Assessment and Treatment 379

persons with severe mental disorder. This approach involves case managers to assist and supervise a person, mental health services, help with work and money management and self-care skills, efforts to improve social and verbal skills, and family therapy (Drake, Strickler, & Bond, 2015). The eventual goal for the person is often to return to the care of family mem- bers or perhaps live more independently. James was eventually discharged from the hospital once his mental condition was stable. He was placed in a group home with 5 other individuals with severe mental disorder and staff members who served as case managers.

Another model of community care is assertive community treatment. A person with schizophrenia may live independently but receive frequent (assertive) contact from psychiatrists and other mental health professionals. Treatment often occurs at a person’s home or nearby area such as a park. Emphasis is placed on community integration, family support, employment, and long-term physical and mental health services. Assertive community treatment is effective for maintaining patient contact and for reducing hospitalizations and homelessness (Meuser, Deavers, Penn, & Cassisi, 2013).

What If I or Someone I Know Has a Psychotic Disorder? Knowing if someone is developing a psychotic disorder can be hard, but some telltale signs may suggest that further evalua- tion or treatment is warranted. Some screening questions are

listed in Table 12.11. If you �nd the answer to most of these questions is yes, then you or the person you know may wish to consult a clinical psychologist, psychiatrist, or other mental health pro- fessional (Chapter 15). You may wish to contact mental health profession- als af�liated with local inpatient psy- chiatric units and/or community care settings for people with severe mental disorder. Provide detailed information about the person’s thought patterns, behaviors, and positive symptoms such as delusions and hallucinations. Signs of depression and excessive substance use should be monitored closely as well. Talk to family and friends about your concerns. Early symptom recogni- tion and intervention is often the best approach to prevent potentially life- threatening behaviors. Additional pro- fessional information is available from the National Alliance for Research on Schizophrenia and Depression (www. narsad.org) and the National Institute of Mental Health (www.nimh.nih.gov/ health/publications/schizophrenia/ complete-index.shtml).

Family Therapy Recall that expressed emotion, or family hostility and criticism and overinvolvement, is a risk factor for psychotic disorders and re- lapse. Many people with schizophrenia also return to their spouses or families for care. Family therapy is thus an important compo- nent of treatment for this population. Therapy usually concen- trates on educating family members about a psychotic disorder, providing support, decreasing highly emotional communications within the family, decreasing stress and depression, helping family members cope with caring for a relative with a psychotic disorder, managing crises, and improving problem-solving skills.

Family therapy may be conducted for a single family or done within a support group of many people. Family therapy may also be done in early or later stages of a person’s psychotic disorder. Family therapy at any stage should be coordinated closely with other psychological and drug treatments. Family therapy does contribute to lower relapse rates for people with schizophrenia (Caqueo-Urízar, Rus-Calafell, Urzúa, Escudero, & Gutiérrez-Maldonado, 2015).

Community Care A person with a psychotic disorder is often treated for acute symptoms in a hospital setting, but simple discharge after- ward is not a suitable care strategy. This is especially true if families are initially overwhelmed with the task of caring for the person. Extensive support is thus offered to a person via community or residential treatment (Figure 12.13). A person may live in a group home or another living arrangement for

1800 18501750 1900 1950

Hospitals

Community-based interventions for schizophrenia

First alternative-farm of St. Anne

Illinois cottage plan

Massachusetts boarding out

Aftercare

Outpatient

Traveling clinics

Crisis intervention

Satellite clinics

Day hospitals

Home care Halfway houses

Vocational rehabilitation

Social rehabilitation

FIGURE 12.13 ALTERNATIVES TO PSYCHIATRIC HOSPITALS. Community-based alternatives to hospital care for people with psychotic disorders have been developed historically to help prevent relapse and rehospitalization. From A. Kales et al., Recent Advances in Schizophrenia, New York: Springer-Verlag, 1990, Figure 1. Reprinted by permission of Springer Science and Business Media.

CHAPTER 12 Schizophrenia and Other Psychotic Disorders380

suicidal ideation, and frequent need for additional hospital- izations (Juola, Miettunen, Veijola, Isohanni, & Jääskeläinen, 2013; Lang, Kosters, Lang, Becker, & Jager, 2013). Cognitive as- pects are important for long-term outcome as well. A person’s ability to return to work or school after a psychotic episode, for example, often depends on working memory, attention, and processing speed (Nuechterlein et al., 2011). Higher intel- ligence before a psychotic episode also appears to be a protec- tive factor in long-term outcome (Khandaker, Clarke, Cannon, & Jones, 2014).

James’s long-term prognosis was thought to be fair be- cause he did receive treatment soon after each of his episodes of strange behavior, because he had extensive social support, because his cognitive functioning was still relatively good (if bizarre), and because each of his episodes was triggered by a speci�c event such as an overheard conversation. Jody’s long- term prognosis is good because she was intelligent, had good cognitive functioning, and pursued effective therapy. The best approach for addressing psychotic disorders at any age is early and complete treatment.

➲ Interim Summary • Assessing people with psychotic disorders is important be-

cause of their complicated symptoms and is often based on family discussions and observations.

• Interviews have been created for people with psychotic disorders, although brief rating scales in the form of inter- views are often used.

• Behavioral observations of people with psychotic disorders often focus on social and self-care skills.

• Cognitive assessment of people with psychotic disorders involves intelligence, neurological, and attention-based tests that can be linked to physiological assessment.

• Treating psychotic disorders often involves a biological approach �rst, and many typical and atypical neuroleptic drugs are available. Side effects, compliance, and relapse are common problems, however.

• Psychological treatments for people with psychotic dis- orders aim to improve quality of life and focus on milieu therapy, token economy, cognitive-behavioral and support- ive psychotherapies, compliance with medication, social skills training, cognitive and vocational rehabilitation, and family therapy.

• Long-term outcome for people with psychotic disorders is variable and often depends on age of onset, negative symptoms, cognitive abilities, family functioning, and medication adherence.

➲ Review Questions 1. Outline major assessment techniques for psychotic disorders,

including interviews, brief rating scales, observations, and cognitive and physiological measurements.

Long-Term Outcome for People with Psychotic Disorders What is the long-term picture, or prognosis, for people like James and Jody with psychotic disorders? Many people once believed that the long-term outcome for people with schizophrenia was generally bleak, but recent evidence suggests a much more vari- able course. About 45 to 67 percent of people with schizophre- nia show signi�cant improvement over time, and 7 to 52 percent achieve complete remission (Lawrence et al., 2015). Factors that predict better outcome include less brain volume reduction and substance use, shorter length of untreated symptoms, preserved cognitive function, good social and work skills, supportive fam- ily, good response to antipsychotic drugs, treatment adherence, and female gender (Penttilä, Jääskeläinen, Hirvonen, Isohanni, & Miettunen, 2014; Schennach, Musil, Moller, & Riedel, 2012; Spellman et al., 2012).

Others have found that people with schizophrenia display several paths over time. Most (57 percent) develop the disor- der in early adulthood and deteriorate for a few years before seeking treatment and experiencing relief from major symp- toms. Others develop the disorder in adolescence (16 percent) or early adulthood (15 percent) and experience a chronic but stable course over time. Still others (12 percent) develop the disorder in adolescence and remain hospitalized for long pe- riods of time (Levine, Lurie, Kohn, & Levav, 2011). Those who experience a more chronic course often have family dif�cul- ties, poorer medication compliance, more negative symptoms,

TABLE 12.11

Screening Questions for Psychotic Disorder

Do you �nd that any of the psychotic symptoms described in this chapter apply to someone you know much more so than most people your age?

Does someone you know show very peculiar behaviors that impair his ability to function in daily life (e.g., go to work, do well in school)?

Does someone you know have great suspicions or paranoia about others?

Is someone you know greatly troubled by symptoms of impaired attention, concentration, or other higher-order thought processes?

Does someone you know have greater problems organizing and expressing thoughts?

Does someone you know seem very socially withdrawn for the �rst time?

Has someone you know recently experienced a traumatic event that seems to have triggered very bizarre behaviors?

Does the person you are concerned about have a family history of severe mental disorders?

Psychotic Disorders: Assessment and Treatment 381

4. What psychological strategies could a mental health profes- sional use to help someone with a psychotic disorder in an outpatient clinical or residential setting?

5. What is the long-term outcome for people with psychotic disorders?

2. What biological methods may be used to manage symptoms of psychoses, and what are some problems associated with these methods?

3. What psychological strategies could a mental health pro- fessional use to help someone with a psychotic disorder on an inpatient unit?

Final Comments People with psychotic disorders suffer substantial distress and impairment from their symptoms. Imagine hearing voices, believing others can hear your personal thoughts, having trouble forming sentences, and being unable to work or go to school. These problems are devastating, so be as compassionate and help- ful as possible when addressing someone with a psychotic disorder. Try to consider the person �rst and his disorder second—a person with schizophrenia, not a schizophrenic. Try also to get help for someone you may come across in your life who begins to have these symptoms.

Thought Questions 1. Think about television shows or �lms with characters with psychotic symptoms in them. Do you

think these characters display realistic or unrealistic symptoms of psychosis? Do you think the entertainment industry has skewed the public’s view of psychotic disorders?

2. What symptoms of psychotic disorders do you think many people experience to a lesser degree at different times of their lives?

3. What would you now say to a friend who might be developing symptoms of a psychosis? Has what you have learned here helped you understand these symptoms and become more compassionate?

4. What separates “normal” thought patterns from “abnormal” thought patterns? How can you tell if someone’s thinking processes are affected?

5. What do you think could be done socially to reduce psychotic experiences in people?

Key Terms psychotic disorders 353 �at affect 353 inappropriate affect 353 delusions 353 hallucinations 353 catatonic 353 schizophrenia 353 positive symptoms 353 negative symptoms 353 disorganized speech 356

catatonic behavior 356 alogia 356 avolition 356 anhedonia 356 prodromal phase 357 psychotic prephase 358 active phase 358 residual phase 358 schizophreniform disorder 359 schizoaffective disorder 360

delusional disorder 361 brief psychotic disorder 362 postpartum psychosis 363 neurodevelopmental hypothesis 371 theory of mind 372 typical antipsychotics 376 atypical antipsychotics 376 extrapyramidal effects 377 milieu therapy 377 token economy 377

383

Special Features

CONTINUUM FIGURE 13.1 Continuum of Normal Development and Developmental Disorder 384–385

• 13.1 FOCUS ON COLLEGE STUDENTS: Autism 392

• 13.2 FOCUS ON LAW AND ETHICS: Key Ethical Issues and Developmental Disorders 394

• 13.3 FOCUS ON DIVERSITY: Testing for People with Developmental Disorders 399

V THE CONTINUUM VIDEO PROJECT Whitney / Autism Spectrum Disorder 401

CONTINUUM FIGURE 13.4 Continuum of Disruptive Behavior and Disruptive Behavior Disorder 406–407

• 13.4 FOCUS ON COLLEGE STUDENTS: ADHD 410

• 13.5 FOCUS ON VIOLENCE: Juvenile Arrests and “Diversion” 417

Personal Narrative 13.1 Toni Wood 418–419

Developmental and Disruptive Behavior Disorders

C Robert / What Do You Think?

Normal Development and Developmental Disorders: What Are They?

Developmental Disorders: Features and Epidemiology

C Alison

Stigma Associated with Developmental Disorders

Developmental Disorders: Causes and Prevention

Developmental Disorders: Assessment and Treatment

Normal Rambunctious Behavior and Disruptive Behavior Disorders: What Are They?

C Will / What Do You Think?

Disruptive Behavior Disorders: Features and Epidemiology

Stigma Associated with Disruptive Behavior Disorders

Disruptive Behavior Disorders: Causes and Prevention

Disruptive Behavior Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Developmental and Disruptive Behavior Disorders 13

CHAPTER 13 Developmental and Disruptive Behavior Disorders384

Developmental and Disruptive Behavior Disorders

We have discussed many disorders in this textbook that ap-ply largely to adults, such as somatic symptom, personal- ity, and psychotic disorders. Other mental disorders, however, apply more to children and adolescents than adults, although the disorders often persist into adulthood. Examples include devel- opmental disorders (or developmental disabilities) and disruptive behavior disorders. We focus on these disorders in this chapter.

Developmental disorders involve delay in normal matu- rity, especially with respect to intellect, cognition, learning, and methods of self-care (Figure 13.1). Examples of developmental disorders include intellectual disability, autism, and learning disorder. Disruptive behavior disorders involve externalizing or externalizing or externalizing obvious behavior problems that include overactivity, impulsivity, inattention, aggression, noncompliance, and other disturbances. Examples of disruptive behavior disorders include attention- de�cit/hyperactivity disorder and oppositional de�ant and con- duct disorders.

C / R/ R/ obert

Robert was a 17-year-old male recently transferred Robert was a 17-year-old male recently transferred Robert to a small residential facility (group home) for peo- ple with severe developmental disorders. He was transferred to the facility after several years of liv- ing with his family at home or with peers in a large developmental center. He was often placed in the developmental center when he was overly aggres- sive or emotional and when his parents feared he might hurt himself or others. His behavior gener-might hurt himself or others. His behavior gener-might hurt himself or others. His behavior gener ally improved over the past year, but Robert’s par-ally improved over the past year, but Robert’s par-ally improved over the past year, but Robert’s par ents said they were no longer able to physically care for their son. They approved his transfer to the group home where trained staff members could supervise and help him.

Robert had several developmental delays in language, social and motor skills, and cognitive

ability during childhood. He rarely interacted with others and preferred to play by himself. He had enormous dif�culty in school and was placed in special education after being diagnosed with autism. Robert assaulted other people as an adolescent and was on medication to control an explosive temper. His transfer to the smaller group home was designed to simulate family-type living but in an environment where his behavior toward others could be monitored frequently.

What Do You Think? 1. How are Robert’s behaviors different from

a typical child or young adult? Which of his behaviors might seem normal for a child or adolescent?

2. What external events and internal factors might be responsible for Robert’s behaviors?

3. What are you curious about regarding Robert?

4. Does Robert remind you in any way of someone you know? How so?

5. How might Robert’s behaviors affect his life in the future?

case

13.1 Continuum of Normal Development and Developmental Disorder

NORMAL MILD

Emotions Good control of emotions and appropriate emotional experiences.

Mild delays in impulse, anger, or other emotional control. Mild delays in impulse, anger, or other emotional control.

Cognitions Normal intelligence and thinking. and thinking.

Below average intelligence but little interference in daily Below average intelligence but little interference in daily functioning. functioning.

Behaviors Good self-care skills and academic achievement.

Low academic achievement and perhaps delay in some self-care skills.

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CONTINUUM FIGURE

Emotions

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Developmental Disorders: Features and Epidemiology 385

Developmental and disruptive behavior disorders may be comorbid, occurring together in a particular child. Youths with autism are sometimes aggressive and impulsive and fail to pay close attention to others. Youths with attention-de�cit/ hyperactivity disorder commonly have learning problems such as dif�culty reading. Researchers generally study these sets of disorders—developmental and disruptive—as separate entities, however, so we describe them separately here. We will occasion- ally identify in this chapter instances in which developmental and disruptive behavior disorders intersect. Consider, for exam- ple, Robert’s case, which opened this chapter.

Normal Development and Developmental Disorders: What Are They?

We develop many skills during childhood necessary for us to become independent and function well in various situ- ations. We learn how to speak clearly, dress and feed ourselves, interact with others, tell time, read, use complex arithmetic, drive a car, and balance a checking account. Many of these skills we now take for granted because we learned them at an early age and practiced them repeatedly during our life. Think about all the basic things you did this morning to get ready for the day. You generally do these things automatically or with little thought.

Some children, however, become “stuck” in a particular area of development. These children may be slower than peers to learn to speak in a grammatically correct way or to read. These children may have limited developmental disorders be- cause one area but not many areas of functioning are affected. A learning disorder is one example (see later in this chapter). A child with trouble learning to read is often of normal intel- ligence, has friends, and performs �ne in other school subjects. People with limited developmental disorders can often function independently and care for themselves adequately as adults.

For other children, many areas of normal development are delayed. These areas include intellect and cognition, language, social interactions, and even physical growth. Skills may fail to develop or may develop much more slowly compared with peers. These delays are often so severe a youth cannot care for himself. Robert was unable to learn to read and his language development was very slow for many years. His ability to interact with others was also severely impaired and he was sometimes aggressive to himself and others.

Robert had a pervasive developmental disorder. His delays were evident in many areas and interfered with his abil- ity to communicate with, or function independently of, others. Robert was thus unable to live on his own. People with per- vasive developmental disorders often have unique talents, but almost all have de�cient cognitive ability or intelligence. Exam- ples of pervasive developmental disorders include severe forms of intellectual disability as well as autism. We discuss these per- vasive and limited developmental disorders in the next section.

Developmental Disorders: Features and Epidemiology

This section summarizes the major features of the most com-monly diagnosed developmental disorders. Various symp- toms of intellectual disability, autism, and learning disorder are discussed.

Intellectual Disability Have you ever known someone unable to attend regular class- room settings or learn things like tying a shoe or putting on a jacket? Perhaps you have seen television shows or �lms that de- pict people who have trouble understanding basic aspects of life. People with these problems are often diagnosed with a pervasive developmental disorder known as intellectual disability (pre- viously called mental retardation). Intellectual disability can be

MODERATE

DEVELOPMENTAL DISORDER—LESS DEVELOPMENTAL DISORDER—LESS

SEVERE

DEVELOPMENTAL DISORDER—MORE DEVELOPMENTAL DISORDER—MORE

SEVERE

Moderate delays in impulse, anger, or other Moderate delays in impulse, anger, or other emotional control.

Substantial delays in emotional control that may lead Substantial delays in emotional control that may lead to instances of aggression or self-injury. to instances of aggression or self-injury.

Extremely poor emotional control that may lead to Extremely poor emotional control that may lead to frequent aggression or self-injury. frequent aggression or self-injury.

Below average intelligence and some dif�culty Below average intelligence and some dif�culty with language. with language.

Severely impaired intelligence with considerable Severely impaired intelligence with considerable dif�culty forming and expressing thoughts. dif�culty forming and expressing thoughts. dif�culty forming and expressing thoughts. dif�culty forming and expressing thoughts.

Profoundly impaired intelligence with extreme Profoundly impaired intelligence with extreme dif�culty forming and expressing thoughts. dif�culty forming and expressing thoughts. dif�culty forming and expressing thoughts.

Failing subjects at school and greater dif�culty caring for oneself.

Inability to function in a normal classroom and in Inability to function in a normal classroom and in need of considerable assistance in daily living. need of considerable assistance in daily living.

Extreme delays in functioning and inability to eat, dress, and wash, requiring complete assistance in daily living.

CHAPTER 13 Developmental and Disruptive Behavior Disorders386

the sole diagnosis given to a child, although the disorder is often part of other pervasive developmental disorders such as autism. We thus �rst cover major features of intel- lectual disability.

Intellectual disability consists of three main features (see Table 13.1; American Psychiatric Association [APA], 2013). The �rst main feature is poor cognitive (thinking) develop- ment, sometimes de�ned as a score of less than 70 on an intelligence test. Clinical judgment or alternative testing may be used to assess cog- nitive delay, however. The second main feature of intellectual disabil- ity is de�cits in adaptive function- ing, which refers to the ability to complete everyday tasks that allow one to be independent (Tasse et al., 2012). Consider these important areas of adaptive functioning and think how hard your life might be if you were unable to do them:

• Language: stating one’s desires, understanding others, and asking for help

• Social interaction: conversing, initiating activities, and being assertive

TABLE 13.1 DSM-5

Intellectual Disability Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intel- lectual and adaptive functioning de�cits in conceptual, social, and practical domains. The following three criteria must be met:

A. De�cits in intellectual functions, such as reasoning, problem solv- ing, planning, abstract thinking, judgment, academic learning and learning from experience, con�rmed by both clinical assessment and individualized, standardized intelligence testing.

B. De�cits in adaptive functioning that result in failure to meet develop- mental and socio-cultural standards for personal independence and social responsibility. Without ongoing support, the adaptive de�cits limit functioning in one or more activities of daily life, such as com- munication, social participation, and independent living, across mul- tiple environments, such as home, school, work, and community.

C. Onset of intellectual and adaptive de�cits during the developmental period.

Specify mild, moderate, severe, or profound severity.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Many of us take for granted social and work skills that are often a struggle for people with developmental disorders.

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• Academic: studying, taking tests, reading, and using numbers • Self-care: eating, washing, dressing, toileting, driving, and

telling time

• Home living: paying bills, doing yard work, cleaning the house, and caring for a child

• Community: shopping, taking a bus, and using mail or money

• Self-direction: deciding on a career, marriage, or whether to have children

• Leisure: seeing a movie or playing a sport, game, or musical instrument

• Health: knowing when to see a doctor, take medications, and apply �rst aid

• Safety: preventing �re and theft and knowing what to do in an emergency

• Work: �ling an application, cashing a paycheck, and delegat- ing tasks

The third main feature of intellectual disability is that the disorder must begin during the developmental period, usually be- fore age 18 years, which excludes certain people. A person who suffers a head injury at age 30 years and now has trouble thinking and dressing would not be diagnosed with intellectual disability. A 65-year-old with Alzheimer’s disease (Chapter 14), who may have cognitive and adaptive functioning problems for the �rst time, also would not be diagnosed with intellectual disability.

Intellectual delay, de�cits in adaptive functioning, and on- set during the developmental period must occur together for a together for a together diagnosis of intellectual disability. This is important because a

Developmental Disorders: Features and Epidemiology 387

low score on an intelligence test does not necessarily mean a person has intellectual disability. A person may score low on an intelligence test but still be able to earn a living by working in- dependently at a lower-paying job and managing a place to live. A diagnosis of intellectual disability would thus not apply. Intel- lectual disability is a diagnosis that should be given only after a thorough assessment of cognitive and adaptive functioning.

Intellectual disability can be subtyped by mild, moderate, severe, and profound severity. These subtypes were previously based on intelligence test scores but such groupings are not always helpful; someone who scores a 52 on an intelligence test could have better adaptive functioning than someone who scores a 60. Grouping people with intellectual disability based on how much help they need in daily living is preferable to IQ scores; the following categories have been de�ned (APA, 2013; Luckasson & Schalock, 2013):

• Intermittent or mild: support when needed, such as mov- ing, shopping for groceries, or seeking a new job

• Limited or moderate: consistent support, such as transpor- tation, employment training, or help paying bills

• Extensive or severe: regular, daily support, such as preparing food, getting dressed, or bathing

• Pervasive or profound: constant, intense support, such as ongoing medical attention or complete care

Autism Spectrum Disorder Have you worked with people with developmental disorders? Perhaps you noticed a certain group who always seem by them- selves and who show strange behaviors, like Robert. Perhaps you have seen certain �lms such as Rain Man or Fly Away that show people with these strange behaviors. These people have another pervasive developmental disorder associated with mul- tiple cognitive and social de�cits: autism spectrum disorder (sometimes called autism, autistic disorder, or infantile autism). People with autism often have intellectual disability, but autism is a distinctly different disorder in certain key ways.

Autism is marked by three main sets of symptoms (see Table 13.2; APA, 2013). The �rst set involves severe impairment in social interaction. People with autism do not generally in- teract with others, preferring instead to be by themselves (the pre�x “auto” meaning “self”). Robert often squirmed away from others and failed to develop good relationships. This is an im- portant difference between people with autism and people with

People with intellectual disability often appreciate and enjoy relationships as much as anyone else.

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Autism is a devastating developmental disorder, but some people with the disorder, like Jason McElwain, who scored six 3-pointers in his high school basketball game, offer heartwarming stories of accomplishment.

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CHAPTER 13 Developmental and Disruptive Behavior Disorders388

intellectual disability—the latter do enjoy playful social interac- tions (Boddy, Downs, Knowles, & Fairclough, 2015).

People with autism generally avoid eye contact, show few facial expressions and bodily gestures, and fail to develop friend- ships (Gordon, Pierce, Bartlett, & Tanaka, 2014). People with autism do not share their experiences with others or reciprocate emotions like joy. A child with autism would not typically show her parents a new �nger-painting (as many children would) or react strongly to praise or criticism. Social interaction is a pain- ful process for many people with autism.

The second set of autistic symptoms is severe impairment in communication with others. This problem overlaps to some extent with intellectual disability, though language de�cits are often more extreme and bizarre in people with autism (Benítez- Burraco & Murphy, 2016). Many people with autism like Robert are mute or show a long delay in language. Even if a person with autism does have some speech, the speech is often unusual.

Some people with autism have echolalia, or repeating what one has just heard (Neely, Gerow, Rispoli, Lang, & Pullen, 2016). One of your authors who worked with children with autism would greet them at the bus before escorting them to class. One 7-year-old girl named Hope would get off the bus each day and be greeted with “Hi, Hope!” to which she replied “Hi, Hope!” This immediate echolalia occurred for several months despite immediate echolalia occurred for several months despite immediate daily efforts to correct her response. Echolalia can also be de- layed as a person suddenly blurts out something recalled from several days earlier. Other strange speech patterns include pro- noun reversal, such as switching “I” for “you,” and incoherent sentences, such as jumbling words together in a nonsensical way (Gernsbacher, Morson, & Grace, 2016).

The third main set of autistic symptoms is bizarre behavior patterns. Many children with autism do not engage in pretend play, and they often fail to imitate others, as most young children do. Their play is instead marked by withdrawal and preoccupa- tion with parts of objects, such as spinning a wheel on a toy truck for hours (Paul, McKechanie, Johnstone, Owens, & Stan�eld, 2015). People with autism also tend to be routine-oriented, and disruptions in their routine can lead to tantrums or aggression. Many people with autism also show socially inappropriate self- stimulatory behavior, such as excessive rocking, hand �apping, or walking on their toes (Chebli, Martin, & Lanovaz, 2016).

People with autism are sometimes aggressive toward them- selves or others. Self-injurious behavior can include biting or Self-injurious behavior can include biting or Self-injurious behavior hitting oneself or banging one’s head against a wall (Adler et al., 2015). About 31 percent of children with autism have in- tellectual disability and another 23 percent have below average intellectual ability (Centers for Disease Control and Prevention, 2014). However, autism is marked in some cases by special savant skills, such as superior memory, calendar, mathematical, savant skills, such as superior memory, calendar, mathematical, savant or artistic abilities (De Marco, Iavarone, Santoro, & Carlomagno, 2016). Such skills were apparent in Dustin Hoffman’s character in Rain Man. Savant skills appear to be linked to well-developed memory systems in the brain that lead to narrow but very deep abilities (Bouvet et al., 2014).

TABLE 13.2 DSM-5

Autism Spectrum Disorder A. Persistent de�cits in social communication and social interaction

across multiple contexts, as manifested by the following, currently or by history:

1. De�cits in social-emotional reciprocity. 2. De�cits in nonverbal communicative behaviors used for social

interaction. 3. De�cits in developing, maintaining, and understanding

relationships.

Severity is based on social communication impairments and restricted, repetitive patterns of behavior.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:

1. Stereotyped or repetitive motor movements, use of objects, or speech.

2. Insistence on sameness, in�exible adherence to routines, or ritualized patterns of verbal or nonverbal behavior.

3. Highly restricted, �xated interests that are abnormal in intensity or focus.

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

Severity is based on social communication impairments and restricted, repetitive patterns of behavior.

C. Symptoms must be present in the early developmental period.

D. Symptoms cause clinically signi�cant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability or global developmental delay.

Specify if with intellectual impairment, language disturbance, catatonia, or medical factor or mental disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Many children with autism engage in strange, repetitive motor behaviors known as self-stimulation.

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Developmental Disorders: Features and Epidemiology 389

The severity of autism spectrum disorder depends on the level of de�cits in social communication and restricted, repetitive behaviors (see Table 13.3; APA, 2013). A previously diagnosed condition, Asperger’s disorder, involved impairment in social interaction with some unusual behavior patterns but not major de�cits in language, cognitive development, or adaptive func- tioning. People previously diagnosed with Asperger’s disorder would now likely be diagnosed with autism spectrum disorder at Level 1 (Table 13.3; APA, 2013). People with Asperger’s disor- der or those at Level 1 autism spectrum disorder may be able to function more independently later in life than people with severe intellectual disability or autism (Magiati, Tay, & Howlin, 2014).

Learning Disorder The developmental disorders we discussed so far involve delays or problems in multiple areas of functioning. Developmental dismultiple areas of functioning. Developmental dismultiple - orders can also be limited in scope, however, affecting just one or two areas of functioning. People with limited developmental disorders usually function much better than people with perva- sive developmental disorders but still struggle in key areas. One type of limited developmental disorder is learning disorder.

TABLE 13.3 DSM-5

Severity Levels for Autism Spectrum Disorder

Severity level Social communication Restricted, repetitive behaviors

Level 3

“Requiring very substantial support”

Severe de�cits in verbal and nonverbal social communica- tion skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interac- tion and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.

In�exibility of behavior, extreme dif�culty coping with change, or other restricted/ repetitive behaviors markedly interfere with functioning in all spheres. Great distress/dif�culty changing focus or action.

Level 2

“Requiring substantial support”

Marked de�cits in verbal and nonverbal social communica- tion skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication.

In�exibility of behavior, dif�culty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or dif�culty changing focus or action.

Level 1

“Requiring support”

Without supports in place, de�cits in social communica- tion cause noticeable impairments. Dif�culty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversation with oth- ers fails, and whose attempts to make friends are odd and typically unsuccessful.

In�exibility of behavior causes signi�cant interference with functioning in one or more contexts. Dif�culty switching be- tween activities. Problems of organization and planning hamper independence.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

case Alison was an 8-year-old girl experiencing great trouble in school. She con- sistently failed reading and spelling assignments despite enormous effort. Her teacher said Alison’s work was barely legible and often contained basic errors of writing, such as misspelled words and incomplete letters. These errors were beginning to affect her arithmetic work as well because many of the math problems contained stories and symbols. Alison was still working at a �rst-grade level by the middle of third grade.

Alison regularly struggled when asked to read a story in a group setting. She read very slowly, paused often, and had trouble answering basic questions about the story afterward. Her teacher was particu- larly confused by Alison’s performance because the girl seemed bright, capable, motivated, and alert. Alison performed well in other subjects such as science, music, art, and physical education. She also had no problem with basic self-care skills and showed no behavior problems in class. Alison’s teacher did notice, however, that her student was becoming quite frustrated with her homework and was turning in fewer assignments on time.

C / A/ A/ lison

CHAPTER 13 Developmental and Disruptive Behavior Disorders390

Have you or someone you know ever struggled in a par- ticular subject at school such as reading, spelling, or math? For some people like Alison, learning a certain academic skill can be a trying and fruitless experience. Many youth cannot read or spell words correctly, solve basic arithmetic problems, or write a paragraph even though their intelligence is normal. These chil- dren may have a learning disorder.

A learning disorder (or speci�c learning disorder) is marked speci�c learning disorder) is marked speci�c learning disorder by dif�culties in reading, spelling, math, or written expression, which could mean a student is failing that particular subject (see Table 13.4; APA, 2013). A learning disorder cannot be explained by intellectual disability, however, because the person’s intelli- gence is usually normal (Moll, Kunze, Neuhoff, Bruder, & Schulte- Körne, 2014). A large discrepancy may exist between the person’s discrepancy may exist between the person’s discrepancy

actual school achieve- ment (below normal) and their potential to learn (normal).

A learning disor- der is not due to sen- sory problems such as visual or hearing impairments, although a child with these problems could still be diagnosed with learn- ing disorder. Learning disorder is not a result of simple lack of motivation in school or environmental disad- vantage such as poor teaching. A true learn- ing disorder is likely related to changes in the person’s brain (Boros et al., 2016).

Dyslexia is sometimes used to refer to learning problems in Dyslexia is sometimes used to refer to learning problems in Dyslexia reading and spelling. Some people with dyslexia reverse letters when seeing them, but not all do. Dyslexia is instead a broader term that includes trouble with reading or spelling (Peterson & Pennington, 2015). Dyscalculia is sometimes used to refer to Dyscalculia is sometimes used to refer to Dyscalculia problems learning mathematics and can relate to dyslexia be- cause a person may have trouble reading mathematical sym- bols or story problems (Rubinsten, 2015). Other terms related to learning disorder include the following:

• Dysgraphia: problems of written expression, such as writing very slowly or off a page

• Dysnomia: problems naming or recalling objects, such as saying “fork” when seeing a “spoon”

• Dysphasia: problems comprehending or expressing words in proper sequence, such as failing to understand what others say or trouble speaking logically to others

• Dyspraxia: problems of �ne motor movements, such as trouble buttoning a shirt

• Dyslalia: problems of articulation or trouble saying words clearly and understandably

Epidemiology of Developmental Disorders Intellectual disability occurs in 1.04 percent of the population (Tomlinson et al., 2014). The disorder is much more common in boys than girls and is typically diagnosed in preschool and

Dustin Hoffman’s character in Rain Man (left) illustrates someone with savant skills. Kim Peek (right) is the basis for the character in Rain Man.

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Stigma Associated with Developmental Disorders 391

elementary school-age years when a child is compared academi- cally with peers (Moeschler et al., 2014). Intellectual disability can be comorbid with autism and is commonly associated with anxiety, depression, dementia, and psychotic disorders (Matson & Cervantes, 2013). The onset of intellectual disability is usually gradual because early developmental delays are sometimes hard to spot or are confused with other possible problems such as hearing impairment.

Intellectual disability appears more common in less devel- oped nations than wealthier ones and among people of low socioeconomic status (Tomlinson et al., 2014). Intellectual dis- ability is also more common among African Americans than other racial groups. Some speculate that this may be due to racial segregation, economic disadvantage, culturally inappro- priate testing, or higher rates of diabetes and other disease in mothers (Bershadsky, Hiersteiner, Fay, & Bradley, 2014; Jasper & Bouck, 2013).

Autism spectrum disorder occurs in 14.7 per 1000 or about 1 in 68 children aged 8 years. The prevalence of autism appears to be increasing and is about 4 times more common in boys than girls. The problem is 30 percent more prevalent among European American than African American children and 50 per- cent more prevalent among European American children than Hispanic children (Centers for Disease Control and Prevention, 2014). Boys with autism tend to show more repetitive and ste- reotypical behaviors than girls with autism, but no gender differ- ences emerge with respect to social behavior or communication problems (Van Wijngaarden-Cremers et al., 2014).

People with autism are not often diagnosed with comorbid psychiatric disorders, perhaps because of restricted emotions, but symptoms of anxiety and depression are common (Ozsivad- jian, Hibberd, & Hollocks, 2014). Autism is associated with med- ical problems such as seizures and hearing and visual problems, however (van Dooren, McPherson, & Lennox, 2016). The onset of autism tends to be more sudden than intellectual disability as tendencies such as self-stimulatory behavior and social with- drawal are more apparent in toddlerhood.

Learning disorder affects about 5 percent of students, al- though problems in speci�c areas, such as reading or math, may be more common. Another 15 percent of students may have unidenti�ed or untreated learning problems. Learning disorder is more common among boys than girls, especially if processing de�cits are severe. African American and Hispanic students tend to be diagnosed more with learning disorder than European American and Asian American students (National Center for Learning Disabilities, 2014). Learning disorder may be comorbid with any other disorder but is linked in many cases (45.1 percent) with attention-de�cit/hyperactivity dis- order (DuPaul, Gormley, & Laracy, 2013; see later section on disruptive behavior disorders). Problems with social skills, ag- gression, and substance use are also common to youths with learning disorder. Onset of learning disorder is gradual and of- ten marked by early language delays and medical conditions (Leonard, 2014).

Stigma Associated with Developmental Disorders

Children are especially susceptible to stigma because they are more vulnerable and powerless than adults. This applies es- pecially to children with developmental disorders and their par- ents. Parents of children with autism often report feeling blamed for their child’s behavior, isolated from family and friends, and distressed about others’ anger and pity. Part of this may be be- cause children with autism appear normal physically but can display severe behavior problems. Self-stigma can occur as well, as some parents blame themselves or their parenting style for their child’s autism (DePape & Lindsay, 2015; Kinnear, Link, Ballan, & Fischbach, 2016). Some teachers may also be less empathetic toward children with autism and some may see such children as de�cient (Lalvani, 2015). Stigma may affect college students with autism as well (see Box 13.1). These perceptions

TABLE 13.4 DSM-5

Speci�c Learning Disorder A. Dif�culties learning and using academic skills, as indicated by

the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interven- tions that target those dif�culties:

1. Inaccurate or slow and effortful word reading. 2. Dif�culty understanding the meaning of what is read. 3. Dif�culties with spelling. 4. Dif�culties with written expression. 5. Dif�culties mastering number sense, number facts, or calculation. 6. Dif�culties with mathematical reasoning.

B. The affected academic skills are substantially and quanti�ably below those expected for the individual’s chronological age, and cause signi�cant interference with academic or occupational performance, or with activities of daily living, as con�rmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 years and older, a documented history of impairing learning dif�culties may be substituted for the standardized assessment.

C. The learning dif�culties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).

D. The learning dif�culties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of pro�ciency in the language of academic instruction, or inadequate educational assessment.

Specify if impairment in reading, written expression, or mathematics and severity as mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

CHAPTER 13 Developmental and Disruptive Behavior Disorders392

illustrate the importance of educating the public about pervasive developmental disorders.

➲ Interim Summary • People with pervasive or limited developmental disorders

experience delays in key areas of functioning and impaired cognitive ability or intelligence.

• Intellectual disability is a pervasive developmental disor- der involving early de�cits in cognitive ability and adaptive functioning.

• Autism is a pervasive developmental disorder involving severe impairments in social interaction and communica- tion as well as bizarre behavior patterns.

• Asperger’s disorder is now part of autism spectrum dis- order and involves impairment in social interaction with some unusual behavior patterns but not major de�cits in language, cognitive development, or adaptive functioning.

• Learning disorder is a limited developmental disorder involving de�cits in a subject like reading, math, spelling, or writing.

• Stigma is an important part of developmental disorders and can affect others’ view of a child.

➲ Review Questions 1. What are major features and subtypes of intellectual disability? 2. What are major symptoms of autism? 3. Outline differences between pervasive and limited develop-

mental disorders. 4. Describe major features of learning disorder and its related

terms. 5. Describe the epidemiology of pervasive and limited develop-

mental disorders.

Developmental Disorders: Causes and Prevention

We turn our attention next to factors that cause develop-mental disorders. We also discuss how understanding these factors might help prevent developmental disorders.

Biological Risk Factors for Developmental Disorders Many mental disorders are caused by a combination of biologi- cal and environmental variables. This is also true for develop- mental disorders, although biological predispositions tend to be very strong. These predispositions include genetic in�uences, chromosomal aberrations, and prenatal and perinatal problems that lead to brain changes.

Genetic In�uences: Gene Damage Genes represent individual units on a chromosome that conchromosome that conchromosome - tain important information about a person’s traits and charac- teristics. Thousands of genes are part of each of the typically 46 chromosomes in a human. Genes predispose us to become whoever we are but may also become damaged and lead to developmental disorders. Many cases of severe intellectual disability relate to genetic and other organic defects.

Fragile X syndrome is a condition that results when the FMR1 gene of the X chromosome narrows, breaks, or otherwise becomes mutated. Fragile X syndrome affects 1.4 in 10,000 males but is less common in females (0.9 in 10,000) because they have another X chromosome to help compensate for damage. Females may, however, suffer from effects of fragile X syndrome or be carriers of the problem—they may have the genetic mutation but not the full-blown syndrome. The genetic mutation leads to certain brain changes (see brain changes section). People with

Some researchers have thus attempted to address conceptions of autism among college students. In one study, hundreds of college students watched an online presentation that introduced them to current research about autism at different stages of development. Participants were initially educated about the de�nition and prevalence of autism, autism as a spectrum disorder, and major causes of the disorder. Later components focused on the challenges faced by adults with autism, such as dif�culties in relationships, mood, and indepen- dence, as well as impaired empathy. Results indicated that desire for social distance from people with autism decreased signi�cantly fol- lowing the presentation, although stigma related to having a romantic relationship with someone with autism remained high (Gillespie-Lynch et al., 2015). The �ndings support the point made several times in this textbook that proper education about a mental disorder often reduces stigma, which can be especially important for someone with as severe a disorder as autism.

Focus On

An increasing number of young adults with autism are entering college, but this population has been understudied for some time. Recent �ndings, howev- er, indicate that adolescents with autism who do enroll in college often struggle with its less structured and more complicated learning environment and may be less likely to graduate as a result. College students with autism must often deal with fear and misunderstanding from others regarding their condition and even bullying and social exclusion by classmates. As such, college students with autism feel considerable stigma on campus (Gillespie-Lynch et al., 2015).

13.1

College Students Autism

Developmental Disorders: Causes and Prevention 393

fragile X syndrome show hyperactivity, self-stimulatory and self- injurious behavior, aggression, poor social skills, perseveration (doing the same thing over and over), and bizarre language. Most have intellectual disability (Hunter et al., 2014).

Another example of how genetics in�uence intellectual disability is phenylketonuria (PKU). PKU is also caused by a genetic mutation, this time on chromosome 12. PKU is an au- tosomal recessive disorder, meaning the defective gene must be inherited from both parents for problems to occur. The defective gene leads to the body’s inability to break down phenylalanine, an amino acid. Excess phenylalanine in the body can damage the liver and brain. Check out a diet soda can—it warns the product contains phenylalanine.

Untreated PKU may create physical problems such as awkward gait and spasms and cognitive problems such as severe language delay, learning disorder, and in- tellectual disability. Fortunately, however, early screening can de- tect newborns with PKU, and a special diet limiting phenylalanine intake can prevent many of these problems. People on this special diet must usually refrain from meat, �sh, eggs, dairy products, nuts, and corn, among other items. PKU occurs in 1 in 10,000 births, although many more people may be carriers. Carriers have the defec- tive gene from only one parent, so no symptoms develop (Al Ha�d & Christodoulou, 2015).

Genetic in�uences can lead to intellectual disability in other ways as well. People with sickle cell disease, which affects 1 of 600

live births, especially African Americans, experience damaged red blood cells, slow blood movement, and less oxygenation to the body. The problem has been linked to a genetic mutation (HbS) and could lead to severe brain damage and intellectual disability, especially early in life (Steinberg, 2016). People with Tay-Sachs disease, which affects 1 in 300,000 births, especially Ashkenazi Jews, experience severe motor and sensory impair- ments, intellectual disability, and death at age 2 to 4 years. Sev- eral genetic mutations have been linked to this disorder as well (Bodamer, 2016) (see also Box 13.2).

Genetic In�uences: Concordance A genetic component seems at least partially responsible for causing autism. Concordance rates of autism are 82 to 92 per- cent in identical twins but 1 to 10 percent in fraternal twins. Autism also runs in families—siblings of a child with autism have an up to 20 percent chance of having autism themselves. Abnormalities on chromosomes 2, 7, 15, 16, and 22 have been implicated in autism (Huguet, Ey, & Bourgeron, 2013). Parents of children with autism are not more likely than the general population to have autism themselves, however. Because identi- cal twin concordance rates for autism are not 100 percent, in�u- ences other than genetic must be contributing as well.

A genetic component also accounts for about 40 to 80 percent of the cause of learning disorder, especially reading problems (dyslexia). Twin studies reveal concordance rates of 68 percent or higher for monozygotic twins and 20 to 38 per- cent for dizygotic twins. These data supplement other studies that show dyslexia to run in families. About 35 to 45 percent of children with dyslexia may have a �rst-degree relative with dyslexia. Genetic defects responsible for learning disorder,

People with fragile X syndrome often experience narrowing or breakage in the X chromosome.

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especially reading problems, may be on chromosomes 2, 3, 6, 15, and 18 (Frank, 2014).

Chromosomal Aberrations Changes in sections of a chromosome or an entire chromo- some also in�uence about 22 percent of severe developmental problems (Battaglia et al., 2013). Almost all (95 percent) cases of Down syndrome are due to an extra chromosome 21. Most people with Down syndrome thus have 47 chromosomes in their cells. This “extra” genetic information leads to several distinct characteristics, especially physical ones such as a large tongue, upward-slanting eyes, short �ngers, brittle blond hair, and visual, hearing, and cardiac problems (Jorde, 2017).

People with Down syndrome often develop symptoms of Alzheimer’s disease after age 40 to 50 years (see Chapter 14). Down syndrome affects 1 in 600 live births, but the chances of having a child with the condition increase greatly with maternal age. A 25-year-old mother has a 1 in 1,350 chance of giving birth to a child with Down syndrome, but a 35-year-old mother has a 1 in 350 chance and a 44-year-old mother has a 1 in 40 chance. This is likely due to problems in chromosome separation at con- ception (Ward, Hisley, & Kennedy, 2016). Other syndromes and chromosomal aberrations linked to intellectual disability are in Table 13.5.

Prenatal and Perinatal Problems Genetic and chromosomal changes are obviously very impor- tant, but other biological phenomena can also lead to devel- opmental disorders. Teratogens are conditions that negatively impact physical development of a child during prenatal (before birth) or perinatal (during birth) periods. Teratogens that occur

Another key issue for this population surrounds quality of life and level of control and choice that should be made available to someone with a per- vasive developmental disorder (Kåhlin, Kjellberg, & Hagberg, 2015). How much choice should Robert have in his living environment, and could too much freedom lead to harm toward others or lack of progress toward his educational goals? All people have the right to available and effective treat- ment that causes the least amount of restriction on freedom (Chapter 15). For Robert, this meant placement in a group home that simulated family living as opposed to a more impersonal developmental center.

Ethical considerations for people with developmental disorders also concern medication and punishment, which are often used without a per- son’s explicit consent (and usually with the consent of others). Is it fair to medicate, restrain, or severely punish someone for misbehavior when they have not given consent? What if a behavior such as head-banging is life-threatening? An ethical dilemma such as this involves juxtaposing an individual’s right to expression with societal right to prevent harm. What might you do in this situation?

Focus On

People with developmental disorders are often children or those who have trouble speaking for themselves, so many ethical dilemmas arise with this population. One dilemma that arises almost immediately is the question of what parents should do if they discover, through genetic testing, that their fetus has a severe and potentially fatal developmental disorder. A related question surrounds the decision to have children if a person knows a developmental disorder will likely be genetically trans- mitted. What would you do in these situations, and why?

Law and Ethics Key Ethical Issues and

Developmental Disorders

13.2

TABLE 13.5

Other Syndromes and Chromosomal Aberrations That May Lead to Intellectual Disability

Syndrome Possible cause Prevalence

Prader–Willi syndrome

Deletion on chromosome 15

1/10,000–25,000 births

Klinefelter syndrome

Males with extra X chromosome(s)

1/500-1,000 male births

Turner syndrome Females with one X chromosome

1/2,000–3,000 female births

Noonan syndrome May be similar to Turner syndrome

1/1,000–2,500 births

Neuro�bromatosis Deletion on chromosomes 17 or 22

1/3,000 births

Williams syndrome Deletion on chromosome 7

1/7,500-20,000 births

Smith–Magenis syndrome

Deletion on chromosome 17

1/25,000 births

Angelman syndrome

Deletion on chromosome 15

1/10,000-20,000 births

Rett’s disorder Mutation on MECP2 gene on X chromosome

1/10,000-15,000 births

Sources: Dulac, Lassonde, & Sarnat (2013); Kelly (2013); Nelson & Trussler (2016).

Developmental Disorders: Causes and Prevention 395

early in pregnancy can lead to many structural changes because this is a key time for organ development. Teratogens that occur later in pregnancy, or even during birth, can also affect brain development and may produce a developmental disorder in conjunction with genetic/chromosomal problems (Ellison, Rosenfeld, & Shaffer, 2013).

A key teratogen is maternal use of alcohol and other drugs during pregnancy. A child exposed to alcohol prenatally may develop fetal alcohol syndrome (FAS; see Chapter 9) or broader fetal alcohol effects (Williams & Smith, 2015). Children with fetal alcohol effects tend to have a small head size, facial and heart defects, and lower intelligence, the latter of which may last for years. These children also show problems in learning, memory, hyperactivity, impulsivity, and communication and social skills (Lewis et al., 2015; Popova et al., 2016). Maternal use of other drugs such as nicotine, narcotics, and stimulants can also lead to lower birth weight, premature birth, behavioral problems,

inattention, and developmental disorders (Behnke et al., 2013). Other important teratogens include diseases such as HIV and toxins such as lead and mercury.

Excessive maternal stress can increase adrenaline and thus limit oxygen to a fetus. Malnourished fetuses are especially likely to perish or have malformations, low birth weight, or premature birth. Some children also experience a lack of oxygen, termed anoxia or anoxia or anoxia hypoxia, during birth from delays in the birth canal or choking by the umbilical cord (Smith, Alexander, Rosenkrantz, Sadek, & Fitch, 2014). All of these experiences could lead to brain damage and thus severe developmental delay. We next discuss speci�c brain areas affected by genetic, chromosomal, and teratogenic in�uences.

Brain Features Researchers have focused on key brain changes with respect to intellectual disability, including gross malformations and subtle markers of brain damage. Gross malformations include induction and migration defects. Induction defects are prob- lems in closure of the neural tube (linking the spinal cord to the brain), proper development of the forebrain, and comple- tion of the corpus callosum, the part of the brain linking left and right hemispheres (Figure 13.2). Migration defects refer to problems in cell growth and distribution in the second to �fth month of pregnancy, which can lead to underdeveloped brain areas (Maeda, 2015).

Subtle markers of brain damage usually involve minor changes in size and shape of certain brain areas. A larger than normal cerebellum has been found in youth with developmen- tal delays, and a smaller cerebellum has been found in adults with fragile X syndrome (Nguyen et al., 2016; Schneider, Ligsay, & Hagerman, 2013). Developmental disorders have also been linked to enlarged ventricles, a phenomenon we discussed for schizophrenia in Chapter 12 (Williams et al., 2015).

Other developmental disorders have even more speci�c types of brain changes. Autism seems associated in some cases with en- largement of the overall brain, especially with respect to the mid- sagittal area, limbic system, amygdala, and occipital, parietal, and temporal lobes. Increased brain size relates to less well-connected neurons (Lainhart, 2015). This may help explain unusual emo- tional and social behaviors seen in people like Robert.

People with autism tend to have a smaller corpus callosum, which may affect motor coordination and emotion regulation (Wolff et al., 2015). Those with autism also may have fewer Purkinje cells, which relate to behavioral inhibition (Chen, Peñagarikano, Belgard, Swarup, & Geschwind, 2015). Autism has also been linked to high levels of serotonin, a neurotrans- mitter involved in motor activity (Muller, Anacker, & Veenstra- VanderWeele, 2016). These latter changes may be related to self-stimulatory behavior and perseveration. People with autism may have changes in the amygdala-prefrontal cortex pathway that affect facial expressions of emotion (Tottenham et al., 2014).

Children with learning disorder often show brain symme- try, in which opposing sides of a brain area are nearly equal in size. Most people have asymmetry, where one side is larger than the other. Brain areas most implicated in learning disorder,

Children with Down syndrome often have an extra chromosome 21 and intellectual disability but can still participate in and enjoy many typical childhood activities.

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CHAPTER 13 Developmental and Disruptive Behavior Disorders396

especially reading and language problems, are the planum tem- porale and porale and porale parietal lobe (Guadalupe et al., 2015; Norton, Beach, & Gabrieli, 2015). These areas may not be as well developed as they are for people without learning disorder. Disruptions of the posterior (rear) areas of the left hemisphere closely link to learn- ing disorder (Xia, Hoeft, Zhang, & Shu, 2016).

Environmental Risk Factors for Developmental Disorders Environmental and cultural factors can also be important for shaping developmental disorders. This pertains most to mild forms of intellectual disability, which can result from family variables such as poor language stimulation, neglect of a child’s educational needs, or inconsistent parenting. This is sometimes referred to as cultural–familial intellectual disability and may account for up to 50 percent of cases of intellectual disability. Children in this group tend to live in poverty and have parents lower in intelligence (Hodapp, Grif�n, Burke, & Fisher, 2011). Lack of attention to education can also prolong other develop- mental problems such as learning disorder. Autism is largely unrelated to culture, but some have noted a higher prevalence among immigrant populations (Crafa & Warfa, 2015). Recall this same kind of �nding for people with schizophrenia (Chapter 12).

Developmental disorders can also result from accidents or other traumas that lead to brain damage. About 15 to 29 of

100,000 infants are severely shaken each year, which can lead to death or permanent brain damage (Nadarasa, Deck, Meyer, Willinger, & Raul, 2014). Many of those who shake babies are fathers, some of whom are frustrated by a child’s crying or toileting problems (Scribano, Makoroff, Feldman, & Berger, 2013). Other forms of physical child maltreatment could cause brain damage as well. Brain injury can also result from hit- ting one’s head on the sidewalk after a fall from a bike, a near-drowning experience, a car accident, poisoning from lead or clean- ers, or being punched in the face. Neurolog- ical damage could also come from diseases such as meningitis (Khandaker, Stochl, Zammit, Lewis, & Jones, 2015). Most of these problems are preventable, and edu- cation about ways to protect children from brain injury is crucial.

Causes of Developmental Disorders How do these risk factors interact to pro- duce a developmental disorder? Strong bi- ological factors clearly predispose certain people to have intellectual disability and/ or autism. These biological factors lead to brain changes that cause problems or delays

in thinking, reasoning, decision making, judgment, and other higher-order cognitive processes. These problems then lead to severe de�cits in self-care, academic, communication, and other crucial skills. Environmental factors could also help cause critical brain changes or maintain a developmental disorder over time.

You may �nd it dif�cult to sort out all the biological in- �uences related to developmental disorders. Consider a model called the �nal common pathway (Tye, Varcin, Bolton, & Jeste, 2016; Figure 13.3). In this model, various biological factors con- spire or interact in different ways for children with different dis- orders. One child may have a certain genetic predisposition in addition to a key neurotransmitter change, such as increased se- rotonin, that leads to autism. Another child may have a certain chromosomal aberration in addition to anoxia at birth that leads to moderate intellectual disability. Another child may have been exposed to alcohol prenatally and was born prematurely, which may lead to learning disorder. In the �nal common pathway model, various combinations of biological factors could lead to certain key brain changes that then lead to a speci�c type of developmental disorder.

Prevention of Developmental Disorders Developmental disorders begin early in life, so it makes sense to think of prevention before and immediately after birth. Preven- tion may thus involve genetic testing and counseling, fetal care,

FIGURE 13.2 MAJOR BRAIN AREAS IMPLICATED IN DEVELOPMENTAL DISORDERS.

Forebrain

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Developmental Disorders: Causes and Prevention 397

screening of newborns, and early medi- cal care for babies. Preventing accidents and other factors that could lead to brain damage is also imperative. Delivering educational services to at-risk children may be helpful as well.

Prenatal genetic testing can occur in different ways, most commonly through chorionic villus sampling or chorionic villus sampling or chorionic villus sampling amniocente- sis. These methods involve DNA extrac- tion as a fetus develops. DNA testing can be easily done after birth as well by examining hair, skin, or blood. These methods are done to check number of chromosomes or conduct a more thor- ough DNA assessment to �nd missing or defective genes. Genetic testing is often done for adolescent and older mothers, when a family history exists of a certain problem, or when a child shows signs of a genetically based disorder (Vissers, Gilissen, & Veltman, 2015). If a fetus has a genetic disorder or chromosomal aberration, then genetic counseling would follow to explore all options with the parents.

Prenatal care of the fetus is also crucial for prevention of developmental disorders, and this can involve proper diet, especially folic acid, regular visits to a medical doctor, and avoidance of drugs, high stress, toxins, and diseases. Proper diet includes limits on caffeine and plenty of grains, fruits, veg- etables, water, and sources of protein such as nuts and beans. Vitamin supplements are also important. Pregnant women should also consult a physician before taking medications or exercising vigorously (Richards, Brady, & Taylor, 2015).

Screening newborns is another important preven- tion technique, and not just for PKU. Many diseases potentially related to developmental disorders, such as HIV, can be identi�ed after birth. Early medical care for babies and insurance coverage for minimum hospital stays after birth are also important. Adherence to immu- nization schedules, proper diet, and ongoing checkups is critical as well (Richards et al., 2015).

Accident prevention is a large part of pediatric psy- chology as well. This includes preventing head injury, such as wearing helmets when bike riding, using proper car seats and cribs, and providing safe toys. Prevention must also include denying access to poisons, eliminating items that could choke a child, locking cabinets and toilets and pools, placing gates before stairs, and ensur- ing a small child cannot reach a stove, topple a televi- sion, enter a refrigerator, or place a �nger in an electrical socket (Cusimano & Parker, 2016).

Educating children at risk for developmental disor- ders may help prevent their onset or severity. Services include preschool interventions for children predisposed to learning and other developmental disorders. Parents

Children with reading problems often show symmetry of a key brain area known as the planum temporale. The upper images illustrate the location of the planum temporale and the lower image illustrates graphically the similarity or symmetry of the size of the planum temporale in a child with learning disorder.

FIGURE 13.3 SAMPLE FINAL COMMON PATHWAY OF PERVASIVE DEVELOPMENTAL DISORDER.

Pervasive developmental disorder

Contributing environmental factors

Key neurochemical and brain changes such as induction

and migration defects

Chromosomal aberrations Teratogens

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CHAPTER 13 Developmental and Disruptive Behavior Disorders398

can also learn about the importance of developing language in their children, monitoring early delays, and refraining from shaking a baby or hitting a child in the head. Early screening is critical as well. The earlier a child with a developmental disorder is identi�ed, the earlier appropriate services can be provided and the better a child’s long-term outcome may be (Catts, Nielsen, Bridges, Liu, & Bontempo, 2015).

➲ Interim Summary • Biological risk factors for developmental disorders include

genetic contributions, chromosomal aberrations, prenatal teratogens, perinatal problems, and induction and migra- tion brain defects.

• Environmental risk factors for developmental disorders include family variables and traumatic brain injury.

• Biological and environmental risk factors can create brain changes that impair cognition and ability to live an inde- pendent life.

• Preventing developmental disorders often involves genetic testing and counseling, prenatal care, newborn screen- ing, early medical care for babies, accident prevention, and delivering educational services to at-risk children and parents.

➲ Review Questions 1. Explain how genetic and chromosomal problems can lead to

developmental disorder. 2. De�ne teratogens and indicate how they can lead to develop-

mental disorder. 3. Outline brain changes associated with different developmental

disorders. 4. What could happen in the environment to create a develop-

mental disorder? 5. How might biological predispositions and environmental

factors work together to cause a developmental disorder? 6. How might developmental disorder be prevented?

Developmental Disorders: Assessment and Treatment

Mental health professionals use various methods to exam-ine people with developmental disorders. These methods include cognitive, achievement, and other tests as well as inter- views, rating scales, and behavioral observation.

Cognitive Tests People with developmental disorders often experience severe cognitive and intellectual de�cits, so a basic assessment strategy is to use tests that assess for overall intellectual and problem- solving functioning. We described commonly used intelligence

Preventing accidents that could lead to head and brain injury is key for reducing instances of developmental disorder.

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Developmental Disorders: Assessment and Treatment 399

tests in Chapter 4. Intelligence tests generally assess two types of cognitive ability: verbal and performance. Verbal tasks that intelligence tests address include knowledge of general infor- mation and vocabulary, comprehension of verbal material, and drawing comparisons. Performance tasks include sequenc- ing items, arranging designs, putting pieces together to form a whole, identifying missing parts, and recalling information. Collectively, these tasks are used to assess for attention, con- centration, anxiety, short-term and long-term memory, practical knowledge, social judgment, motivation and persistence, visual discrimination, mental processing speed, distractibility, visual association, conceptual thinking, ordering and planning ability, and perceptual and spatial ability.

Many intelligence tests are norm-referenced, which means test scores are compared with those from thousands of people who previously took the test. The norms are age-based, so Rob- ert’s performance could be compared with people his age. Most intelligence tests are based on a mean of 100 and a standard deviation of 15. Recall that intellectual disability may partly in- volve a score less than 70 (or 2 standard deviations below the mean) on a standardized intelligence test. Robert’s early score on one of these tests was 55.

Intelligence tests are highly useful for gathering infor- mation about cognitive ability and potential for future scho- lastic achievement. They are not a measure of how “smart” one is, however. The tests measure global problem-solving ability, not what speci�c information a person knows (Sattler, Dumont, & Coalson, 2016). Intelligence tests must be used carefully (see Box 13.3). One should never diag- nose a developmental disorder based only on an intelligence test score. Test results should be combined with other information (described below) to determine diagnosis and functioning level.

Neuropsychological testing may also be used if brain damNeuropsychological testing may also be used if brain damNeuropsychological testing - age is suspected in a person with developmental disorder. These tests are more speci�c than intelligence tests and assess for sen- sation, motor speed and strength, perceptual ability, memory, language, attention, abstract and �exible thought processes, and orientation or knowledge of time, people, and places. We described common neuropsychological tests in Chapter 4.

Some children may be too young to be formally tested. An examiner could thus rely on developmental tests such as the Bayley Scales of Infant and Toddler Development—Third Edi- tion (Bayley, 2005). The Bayley assesses youngsters aged 1 to 42 months by comparing performance on certain tasks to normal developmental milestones. For example, children commonly recognize themselves at age 12 months (a cognitive ability) and can walk up stairs alone at age 21 to 25 months (a motor abil- ity). The test covers cognitive, language, motor, adaptive, and social-emotional abilities.

Developmental tests are also available for newborns, such as the Neonatal Intensive Care Unit Network Neurobehavioral Scale; these tests assess muscle tone, motor activity, and stress (Pineda et al., 2014). Developmental test scores relate to intel- ligence test scores but are not exactly the same. Performance on these tests, however, may help identify developmental delay and predict how well a child may function over time.

Achievement Tests Intelligence tests measure general problem-solving ability, but achievement tests measure more speci�c types of knowl- edge. Achievement tests are often criterion-referenced, meaning they measure a child against a level of performance. Children are assessed on reading, spelling, and arithmetic tasks to de- termine their grade level on the Wide Range Achievement Test 4

According to the American Educational Research Association and American Psychological Association (2014) testing and ethical guidelines, those who use tests must recognize situations in which assessment tech- niques may not apply to certain people based on their gender, age, ethnic- ity, religion, sexual orientation, disability, language, socioeconomic status, and other key distinctions. Examiners must always be aware that certain tests may not be the best method of gathering information about a particular child. Many children have parents who speak only Spanish at home, for example, and these children may be penalized on an intelligence test that assumes good English-speaking ability.

The best approach to evaluating people with developmental disorders is to rely on a multimethod, multisource assessment approach. This means, in addition to testing, that one should rely on other assessment methods such as rating scales, interviews, and observation. One should also speak to parents, siblings, peers, teachers, and other sources who know a person well. A more complete picture can thus be gathered about a person’s functioning in his envi- ronment and whether a diagnosis of developmental disorder is truly necessary.

Focus On

Many cognitive, achievement, and other tests are available for assess- ing people with developmental disorders. These tests are standardized on thousands of people and have shown excellent reliability and validity. Still, questions remain about how applicable these tests are to minorities and people from disadvantaged backgrounds. Concerns have arisen that the tests unfairly predispose certain groups toward diagnoses of developmental disorder and placement in special educa- tion settings.

Diversity Testing for People with

Developmental Disorders

13.3

CHAPTER 13 Developmental and Disruptive Behavior Disorders400

(Wilkinson & Robertson, 2006). A fourth-grader who scores at the 2.5 grade level would thus be considered low achieving. Achievement tests are popular for assessing children with learn- ing disorder, but scores do not always correspond well with school performance.

Interviews Interviews are also used to assess people with developmental disorders, although the measures are obviously limited if some- one cannot or will not communicate. Some interviews have been designed speci�cally for people with developmental disorders using pictures (Stancliffe, Tichá, Larson, Hewitt, & Nord, 2015). Interviews speci�c to autism have also been designed, such as the Autism Diagnostic Interview—Revised (de Bildt et al., 2015). Questions when interviewing people with developmental disor- ders often surround mental status, concerns about one’s envi- ronment, individual choice and quality of life, communication ability, relationships with others, anxiety and depression, and needed support.

Interviews can also shed light on a person’s abilities to func- tion independently and adaptively. A common instrument is the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3; Sparrow, Cicchetti, & Saulnier, 2016). The Vineland-3 covers four primary domains of adaptive functioning: communication, daily living skills, socialization, and motor skills. Like intelli- gence tests, the measure is based on a mean of 100 and a stan- dard deviation of 15. People who know a person well, such as parents and siblings, can also be interviewed regarding a person with a developmental disorder.

Rating Scales Rating scales are also available to assess people with a devel- opmental disorder and can be very useful when testing and in- terviewing is not possible. Many scales focus on adaptive and problem behaviors and are completed by mental health pro- fessionals or caregivers. An example is the Adaptive Behavior Assessment System, Third Edition (Harrison & Oakland, 2015). Other rating scales are more speci�c to a certain disorder, like autism, to help diagnose the problem. A common example is the Childhood Autism Rating Scale, Second Edition (CARS2; Schopler, Van Bourgondien, Wellman, & Love, 2010), sample items of which are listed in Table 13.6. Rating scales have the advantage of providing fast information but should generally be supplemented with behavioral observations.

Behavioral Observation Direct behavioral observation of a person with a developmen- tal disorder is very important when examining speci�c behavior problems. Direct observation is often used to gauge the frequency and severity of self-injurious and self-stimulatory behaviors, aggression, and tantrums. One could also observe adaptive behaviors regarding social interactions and language (Neal, Matson, & Belva, 2013).

For children with learning disorder, direct observation is used to measure inattention, motivation, out-of-seat behavior, and actual schoolwork behaviors such as on-task and test- taking behavior and organization and study skills. Reviewing a child’s schoolwork and home behavior is also important (Frank, 2014). Behavioral observations can be formally structured but more often involve a rater who simply watches a person and records the presence and severity of certain behaviors in short time intervals.

Biological Treatment for Developmental Disorders Medications may be used to treat speci�c aspects of develop- mental disorders. Seizures are quite common in people with autism, so anticonvulsant medications are often prescribed. Sedative and neuroleptic medications may be used to con- trol agitation or dangerous behaviors such as aggression and self-injury (Buck et al., 2014). Fen�uramine leads to decreased Fen�uramine leads to decreased Fen�uramine serotonin levels and has been used with limited success to treat dangerous motor behaviors in people with autism (Farmer, Thurm, & Grant, 2013). Medications may also be used to ease comorbid symptoms of attention-de�cit/hyperactivity, anxiety- related, depressive, bipolar, and sleep disorders (Spencer et al., 2013). Medication use in this population must be considered carefully because many who take the drugs cannot give consent or accurately report side effects.

TABLE 13.6

Sample Items from Childhood Autism Rating Scale, Second Edition (CARS2) Rating Sheet for “Relating to People”

Relating to people

1—No evidence of dif�culty or abnormality in relating to people (The child’s behavior is appropriate for his or her age. Some shyness, fussiness, or annoyance at being told what to do may be observed, but not to an atypical degree.) 1.5-2—Mildly abnormal relationships (The child may avoid looking the adult in the eye, avoid the adult or become fussy if interaction is forced, be excessively shy, not be as responsive to the adult as is typical, or cling to parents somewhat more than most children of the same age.) 2.5-3—Moderately abnormal relationships (The child shows aloof- ness [seems unaware of adult at times]. Persistent and forceful at- tempts are necessary to get the child’s attention at times. Minimal contact is initiated by the child.) 3.5-4—Severely abnormal relationships (The child is consistently aloof or unaware of what the adult is doing. He or she almost never responds or initiates contact with the adult. Only the most persistent attempts to get the child’s attention have any effect.)

Sample items from the CARS2-ST “Standard Version Rating Booklet” copyright © 2010 by Western Psychological Services. Reprinted by permission of the publisher, Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, California, 90025, USA (www.wpspublish.com). Not to be reprinted in whole or in part for any additional purpose without the expressed, written permission of the publisher. All rights reserved.

Developmental Disorders: Assessment and Treatment 401

Gene therapy may also be a key biological treatment in the future for people with developmental disorders (Chapter 14). Examples include replacing fragile X and other genetic muta- tions with healthy genes to reverse or stem developmental delay. Early work with mice is promising, but gene therapy for humans is still a distant hope (Vissers et al., 2015).

Psychological Treatments for Developmental Disorders Psychological treatments for people with developmental disor- ders, like Robert, often target individual areas of functioning. We next cover treatments to improve language, social relation- ships, self-care and academic skills, and problem behaviors. These treatments are based largely on behavioral principles and models of learning (Chapter 2) and have been found to be quite effective for people with developmental disorders.

Language Training Many developmental disorders involve language problems, and language skills are an excellent predictor of long-term function- ing in this population. A child must �rst pay attention, however, to learn language and other skills. This is especially important for children with autism, many of whom vigorously avoid social and eye contact with others. Discrete-trial training may be used to increase eye contact. A teacher issues a command (“Look at me”) and rewards the child if he complies. If not, the teacher holds a desirable item such as a cookie near her own eye to entice the child to make eye contact. Such training must eventually elimi- nate use of the cookie, but the training successfully increases eye contact and attention (Shillingsburg, Bowen, & Shapiro, 2014).

Language training can begin once good attention is estab- lished. Such training often focuses �rst on building receptive labeling ability for various objects. A child may be shown four pictures, one of which is a chair, and told to “Point to the chair.” Rewards are given for correct answers; incorrect answers are met with prompts toward the correct response. Pictures usually include items commonly used by the child or that are important for daily functioning such as eating utensils, types of food or drink, the toilet, or clothing. A main goal is to enhance later expressive speech and give a child a way to communicate his

wants. This is also important for reducing problem behaviors—a child pointing to a toilet to indicate a need to go is less likely to be as aggressive in communicating that desire as a child with no language (Eikeseth, Smith, & Klintwall, 2014).

Language training then involves more expressive speech. Early expressive language programs often focus on shaping, or rewarding approximations of talking. A child might �rst be given a reward every time he makes a vocalization, even babbling, yelling, or crying. As the child vocalizes more, these sounds are shaped into basic speech sounds. A child’s lips could be pressed together to make the “m” sound. Easier sounds are trained �rst, then more dif�cult ones such as “j” and “q.” These sounds may be shaped eventually into words and sentences. Unfortunately, such training can last years and is often incomplete (Tek, Mesite, Fein, & Naigles, 2014).

Language training can also involve speech imitation in which a teacher places an object before a child, names it, and asks a child to repeat the name. The child may eventually be asked to name the object without help. The child will hopefully learn to make requests of different items independently and gen- eralize his language to request other items. Natural incidental training is used as a person’s language develops further. Extentraining is used as a person’s language develops further. Extentraining - sive language is taught in a more natural way (Lane, Lieberman- Betz, & Gast, 2015). A teacher may look at a child and wait a few seconds for a request for an item. Appropriate requests are then rewarded with the item or the teacher prompts the request by telling the child he needs to communicate what he wants.

Language training is best if a child has some language before age 5 years, even echolalia, and if the intervention is intensive. If formal language training is not working, then sign language may be taught (Eikeseth et al., 2014). Sign language language may be taught (Eikeseth et al., 2014). Sign language language is an especially desirable option for children with autism who often have excellent motor skills but who resist language train- ing. Robert learned signs for 15 objects. Sign language is useful but has limitations because many other people do not recognize the signs. Technological assistance to help with communication may thus be useful (Lo�and, 2016).

Socialization Training Another key aspect of treating people with developmental dis- orders is socialization training. A person is taught to perform and use social skills such as making eye contact, conversing ap- propriately, playing and cooperating with others, and expressing affection. Basic socialization training consists of imitation and observational learning. A teacher will model certain social be- haviors as a child watches, then prompt imitation on the child’s part. Initial social behaviors often include basic play actions such as stacking blocks, group activities such as rolling a ball to oth- ers, and manipulating objects such as opening a door. Advanced training involves generalization to other settings and behaviors, use of language, and quicker imitation of others (Otero, Schatz, Merrill, & Bellini, 2015). Parent involvement is also important.

Another socialization training method involves social play- groups where children are rewarded for play with peers instead of solitary play. Children may also be taught to act out different imaginary scenes to build pretend play, use appropriate facial

V THE CONTINUUM VIDEO PROJECT

Whitney / Autism Spectrum Disorder

“I don’t know why I can’t read people’s expressions.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

CHAPTER 13 Developmental and Disruptive Behavior Disorders402

expressions and verbalizations to express affection, and coop- erate with others (Wolfberg, DeWitt, Young, & Nguyen, 2015). Another socialization training method is peer-mediated interven- tions in which children without developmental disorders teach different social skills to children with developmental disorders (Kasari et al., 2016). Peers or siblings could ask a child with autism to share an object, join a group activity, give a hug, carry on a short conversation, or make eye contact. Teaching children to initiate social contacts on their own and learn social cogni- tive abilities such as understanding others’ emotions is also an important part of socialization training (Russo-Ponsaran, Evans- Smith, Johnson, Russo, & McKown, 2016).

Self-Care Skills Training For people with severe developmental disorders, improving self-care skills is often necessary. These skills lie at the heart of adaptive functioning and one’s ability to be independent, so developing these skills is usually a top priority. Self-care skills training programs are most effective for toileting, eating, dress- ing, and grooming.

Self-care skills training programs typically involve task anal- ysis, chaining, and feedback and reinforcement. A skill is divided into steps in task analysis. If a person wants to put on a jacket, steps might include picking up the jacket, placing one arm in the correct sleeve, placing the other arm in the other sleeve, pull- ing the jacket over the shoulders, and zippering the jacket. In a forward chaining process like this one, a person is taught each step from beginning to end. Frequent feedback and rewards for completing the step correctly are given (Allen & Cowdery, 2015).

In a backward chaining process, a person is taught each step from end to beginning. A teacher could help a person put on a jacket using all steps except �nal zippering, which the per- son would do herself. As that step was mastered, the teacher would work backward until each step was accomplished in- dependently. Some adaptive behaviors can only be done in a forward way, of course—you cannot brush your teeth or apply deodorant backward!

Academic Skills Training Academic skills training programs are most pertinent for chil- dren with learning disorder, though they can certainly apply to people with pervasive developmental disorders. Academic skills can include readiness skills such as holding a pencil, using scis- sors, staying in a seat, and raising a hand to talk. For people with learning disorder, however, academic skills training must also include detailed educational programs that target and improve speci�c de�cits in reading, spelling, writing, and math- ematical ability (Lerner & Johns, 2015).

Educational programs for reading generally center on help- ing children recognize and decode words that delay reading. This often involves a phonetic approach to reading that rephonetic approach to reading that rephonetic - quires children to “break down” the sounds of dif�cult words. A teacher may present a child with a book passage and ask a child to note words that might be dif�cult. The child then sounds out a word, writes it several times, and perhaps looks it up in the dictionary. The teacher then reads the passage to the child as she follows along. The child is then asked to read the passage, with special attention to the dif�cult words. Reading programs for children with learning disorder focus on being aware of basic speech sounds, understanding the relationship between sounds and symbols, blending speech sounds together, and reading and writing certain texts (Lovett, Barron, & Frijters, 2013).

Teachers who address writing problems focus on handling a pencil correctly, tracing and saying letters, writing from mem- ory, and having a child describe what she is writing, such as a circle and tail for “Q.” A focus is made as well on organizing writing tasks and producing coherent written products. Comput- ers may also be used to increase writing ef�ciency (Berninger, Nagy, Tanimoto, Thompson, & Abbott, 2015).

Programs for spelling problems can include the cover, copy, and compare method, which involves asking a child to look at a written spelling word, cover and then copy the word, and then compare the word with the original and make corrections as needed (McLaughlin, Weber, & Derby, 2013). Teachers who address

A key treatment for children with developmental disorders, especially autism, is socialization training.

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mathematical problems concentrate on a student’s ability to read symbols, count ef�ciently without using �ngers, recall basic arith- metic facts and words such as “divide,” and follow logical steps to solve a problem (Fuchs, Fuchs, Schumacher, & Seethaler, 2013).

Addressing Problem Behaviors Recall that people with developmental disorders often show problem behaviors such as self-stimulation, self-injury, aggres- sion, tantrums, and noncompliance. Several behavioral proce- dures are thus used to reduce these misbehaviors:

• Time-out, or isolating a person to extinguish attention- seeking misbehavior.

• Token economy, or establishing a set system of points or tokens for appropriate behavior later exchanged for rewards such as special food or playtime. This may also include response cost, or losing points for misbehavior.

• Differential reinforcement of incompatible behavior, or reward- ing behaviors that cannot be done at the same time as the misbehavior. One could write on a piece of paper, a behavior incompatible with slapping someone. Differential reinforce- ment of other behavior involves rewarding the absence of a ment of other behavior involves rewarding the absence of a ment of other behavior certain misbehavior after a time interval such as 5 minutes.

• Restitution and practice positive overcorrection, or requiring a person to practice appropriate behavior after some disrup- tive behavior, such as cleaning one’s deliberate spill as well as others’ messes.

• Punishment, or using restraint or other aversive procedures after misbehavior. Punishment is often used with other proce- dures because it may suppress but not eliminate misbehavior.

What If I Think Someone Has a Developmental Disorder? Children are often screened for developmental disorders in school, especially learning disorder. If you feel a child you know is struggling in school or having dif�culty with language or

social skills, then you may wish to consult a clinical or school psychologist, special education teacher, or other mental health professional (Chapter 15).

Long-Term Outcome for People with Developmental Disorders What is the long-term picture for people like Robert? Those with severe developmental disorders such as profound intel- lectual disability or autism generally have a poor prognosis. Nearly all of those with autism spectrum disorder continue to show at least several symptoms of the disorder into adult- hood. Intelligence levels remain fairly stable or decrease over time, but improvements in daily living and communication skills are sometimes seen. Language skills may also improve, but social communication and socialization skills remain poor. Even in less severe autism, social awkwardness, thought disturbance, and desire to be left alone are often present (Magiati, Tay, & Howlin, 2014; Robinson, Curwen, & Ryan, 2012). For many people with autism, lifelong care in a super- vised setting is necessary.

Other people with developmental disorders show substan- tial improvement and function fairly independently. People with Down syndrome often live and work independently with some assistance, although many experience later dementia (McCarron, McCallion, Reilly, & Mulryan, 2014). Good prognosis for people with pervasive developmental disorders relates to language before age 5 years, early and intensive intervention, higher intel- ligence, better adaptive skills, attention to others, less delay in major developmental milestones, less neurological impairment and epilepsy, and fewer genetic/chromosomal problems (Bresnahan, Brugha, & Susser, 2014; Eapen, Cmcec, & Walter, 2013). Chil- dren with learning disorder continue to experience several dif- �culties into adolescence and adulthood. Children with reading problems often have continued trouble naming words quickly, recognizing basic speech sounds, spelling, and reading symbols. Many eventually have anxiety and antisocial behavior problems and few enroll in college (Gregg, 2013). Many schools are better equipped now to assist students with learning disorder, however, often providing arrangements such as longer test-taking sessions and computer facilities for writing. Positive long-term outcome for this population generally relates to higher intelligence, good parent reading ability, early diagnosis and intervention, early language ability, fewer comorbid diagnoses such as ADHD, and less severe disorder (Bonifacci, Montuschi, Lami, & Snowling, 2014; Helland & Morken, 2016; Lyytinen, Erskine, Hämäläinen, Torppa, & Ronimus, 2015).

➲ Interim Summary • Cognitive assessment for people with developmental

disorders includes intelligence, neuropsychological, and achievement tests.

• Interviews and rating scales for people with developmental disorders cover current functioning as well as needs, support systems, and behavior problems.

Technology is often used to help children with learning disorder develop better reading, spelling, mathematical, and writing skills.

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• Direct observation is often used to assess frequency and severity of problem behaviors but can also be used to examine adaptive and academic behaviors.

• Medications for people with developmental disorders are sometimes used for explosive behaviors, seizures, and symptoms of comorbid problems.

• Psychological treatment for people with developmental disorders includes attention and language training, socialization training, self-care skills training, and academic tutoring.

• Treatments for problem behaviors in people with devel- opmental disorders include time-out, token economy, differential reinforcement of incompatible or other behav- ior, restitution and practice positive overcorrection, and punishment.

• Long-term functioning of many people with developmental disorders is dif�cult, but good prognostic signs include early language and intervention, higher intelligence, and less severe disorder and neurological impairment.

➲ Review Questions 1. Describe methods of cognitive assessment for people with

developmental disorders. 2. What are primary aspects of achievement and other tests for

people with developmental disorders? 3. Outline main features of attention, language, socialization,

and self-care skills training for those with severe develop- mental disorders.

4. Describe strategies for treating youth with learning disorder. 5. Describe interventions to address problem behaviors in

people with developmental disorders. 6. What is the long-term functioning for most people with

developmental disorders?

Developmental disorders are not the only kind of mental disorders that occur mostly in children and adolescents. Recall from our discussion at the beginning of the chapter that youth may also have disruptive behavior disorders involving inatten- tion, impulsivity, overactivity, noncompliance, or aggression.

Normal Rambunctious Behavior and Disruptive Behavior Disorders: What Are They?

Have you ever baby-sat a highly active preschooler? Or per-haps you have small children that constantly test your pa- tience. Watching and raising young children can be an arduous and exhausting task, so much so that many parents look for- ward to work on Monday morning! Many children are naturally curious about their environment and are egocentric, meaning they have trouble understanding the needs of others. They focus much more on what they want and usually interrupt, throw a tantrum, or even hit someone to get what they want. Young children eventually learn to better control emotions, delay im- pulses, and act in socially appropriate ways to get what they want. A child may learn that he �rst needs to pick up some toys or eat dinner using good manners to watch a favorite television program (Figure 13.4).

Other children take longer to control their emotions and impulses and might be described as rambunctious. They con- stantly test limits placed on them by parents and teachers. They may continue, even into the school-age years, to throw tantrums or become upset when something happens they do not like. Or they may continue to be very physically active, always climbing on the furniture or running about. Many of these children are dif�cult to control but can pay attention and comply with oth- ers when they absolutely have to, such as dinnertime or when at church. These children eventually learn appropriate ways to channel their excess energy, such as playing soccer or running as hard as possible during recess.

For other children like Will, severe problems of impulsiv- ity, overactivity, and inattention continue for lengthy periods of time. These problems greatly interfere with their ability to Many people with developmental disorders go on to live productive lives.

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function in daily situations that require behavior control and concentration. Many children are able to adjust their behavior from recess (wild horseplay) to a classroom (sitting at a desk quietly) within a few minutes. Other children, such as Will, however, cannot do so and continue to be disruptive. They thus have trouble following class rules and concentrating on academic tasks. These children may have attention-de�cit/hyperactivity disorder (ADHD).

Other children continue to show noncompliance and ag- gression during and after elementary school. Severe problems of noncompliance comprise oppositional de�ant disorder, and se- vere problems of aggression comprise conduct disorder. ADHD and oppositional de�ant and conduct disorders are disruptive behavior disorders. The disorders can occur separately but sometimes occur together in a child like Will. We next discuss major features of disruptive behavior disorders.

Disruptive Behavior Disorders: Features and Epidemiology Attention-De�cit/Hyperactivity Disorder Children with attention-de�cit/hyperactivity disorder (ADHD) have three key behavior problems: inattention, overactivity, and impulsivity (see Table 13.7; APA, 2013). Inattention means a child has ongoing problems listening to others, attending to

details in schoolwork and other tasks such as chores, and organizing work. Such children are constantly distracted by irrelevant stimuli—they may suddenly run to a window to look outside as a teacher is speaking. Children with ADHD, especially those with inattention, are also forgetful, reluctant to complete schoolwork, sloppy, and somewhat absentminded, meaning they always seem to be losing things and unaware of what is happening around them. Such children may be diag- nosed with ADHD that is predominantly inattentive (APA, 2013).

Children may also be diagnosed with ADHD that is predom- inantly hyperactive-impulsive. Hyperactive means a particular child always seems to be �dgeting, leaving his seat at school or the dinner table, climbing excessively on furniture or desks, and talking too much. These children are often described as “hav- ing no ‘off’ switch,” meaning they are always moving from the time they wake up to the time they go to bed. They also have trouble playing quietly. Impulsive means a particular child often interrupts others, tries to answer questions before a questioner is �nished, and has trouble waiting his turn, such as when play- ing a game.

Children with ADHD may have problems with all three symptoms—inattention, hyperactivity, and impulsivity; this is ADHD with a combined presentation. Will had all these char- acteristics. A diagnosis of ADHD is made only when a child’s behaviors impair his abilities to function in at least two settings, such as home and school. This excludes children who act �ne in school but not at home. To be diagnosed as such, symptoms of

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Will was an 8-year-old boy referred to a psy- chologist and psychiatrist for severe disruptive behavior. His behavior problems began in pre- school and consisted of running about the class- room, failing to comply with parent and teacher requests, and being aggressive to other children. The problems became so dif�cult that Will was expelled from two preschools. Will’s problems were stable during kindergarten, but his entry into �rst grade was highly problematic. He ran about his classroom, often disturbing his class- mates, and was regularly sent to the principal’s of�ce. Will threw a metal object at a child’s head on one occasion and was suspended for 3 school

days. His teacher described him as a highly im- pulsive child who did not have control over his behavior. Will seemed to do as he pleased, rarely completed class assignments, and was disorga- nized. He had great trouble comprehending what others were saying to him, perhaps because he was not paying much attention.

Will’s entry into second grade was marked by severe escalation of his disruptive behaviors. His teacher said Will was dif�cult to control, especially because he was physically strong for his age. Repeated attempts by the teacher and principal to engage Will’s parents to address their son’s behavior were fruitless. Will’s parents seemed unfazed by the school’s complaints and attributed his behavior to lack of school disci- pline. They said they were “tired” of their son’s misbehavior and learned it was best to just “give him what he wants.”

Will’s impulsive, hyperactive, and noncom- pliant behavior became so bad he was failing

school at the end of second grade. He also be- came more brazen in his aggressiveness toward others, often using obscene language and bully- ing tactics to get what he wanted. The �nal straw came when Will was caught with a razor blade at school. He was suspended inde�nitely and his parents were told he would be allowed to return to class only after they sought professional help for their son’s misbehavior.

What Do You Think? 1. How do Will’s behaviors differ from a typical

child? Which of his behaviors might seem normal for a child?

2. What external events and internal factors might be responsible for Will’s behaviors?

3. What are you curious about regarding Will? 4. Does Will remind you in any way of

someone you know? How so? 5. How might Will’s behaviors affect his life in

the future?

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ADHD must also be present before age 12 years, as was true for Will (APA, 2013). The diagnosis of ADHD is somewhat contro- versial because many children with true ADHD are often misdi- agnosed with oppositional de�ant or conduct disorder (see next section). At the same time, however, medications for ADHD may be overprescribed. ADHD may thus be both an underdiagnosed and an overdiagnosed disorder (Thomas, Sanders, Doust, Beller, & Glasziou, 2015).

Oppositional De�ant Disorder and Conduct Disorder Children with oppositional de�ant disorder often refuse to com- ply with others’ commands (see Table 13.8; APA, 2013). They often seem hostile and angry toward others, argumentative, bul- lying, spiteful, and overly sensitive. They lose their tempers eas- ily, and these behaviors cause substantial impairment in daily functioning. Will’s mean-spirited attitude toward others meant few children wanted to be near him, much less play with him.

Oppositional de�ant disorder may continue over time and eventually evolve into a more severe condition: conduct dis- order. Conduct disorder, sometimes equated with juvenile de- linquency, involves a consistent pattern of violating the rights of others (see Table 13.9; APA, 2013). Symptoms of conduct disorder may be divided into four main categories. First, these youths may be aggressive toward other people or animals, often displaying cruel behavior such as using a weapon or torturing someone (or an animal), assaulting and stealing from someone, or engaging in rape (Lahey & Waldman, 2012). Second, these youths may destroy property, such as setting �res or vandalizing a school building. Third, many youths with conduct disorder lie to others to get something or to avoid punishment. They may also steal from others in a secretive way, such as shoplifting, and forcibly break into someone’s house or car. Finally, many youths with conduct disorder violate laws or rules for their age group, such as missing school or curfew or running away from home. Collectively, these behaviors must cause serious impairment in

13.4 Continuum of Disruptive Behavior and Disruptive Behavior Disorder

NORMAL MILD

Emotions Good control of emotions and appropriate emotional Good control of emotions and appropriate emotional experiences.

Mild problems in impulse, anger, or other emotional control. Mild problems in impulse, anger, or other emotional control.

Cognitions Rational thoughts about social situations and interactions Rational thoughts about social situations and interactions with parents.

Occasional thoughts of noncompliance or aggression. Occasional thoughts of noncompliance or aggression.

Behaviors Good self-control of behavior and compliance toward Good self-control of behavior and compliance toward authority �gures.

Occasional rambunctiousness and noncompliance to authority �gures.

CONTINUUM FIGURE

Many children are occasionally disruptive in public, but some show such frequent and intense misbehaviors that they have a disruptive behavior disorder.

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functioning, such as being expelled from school or being ar- rested for a crime. Conduct disorder may begin in childhood or adolescence and its symptoms can range from mild to moderate to severe (APA, 2013).

Epidemiology of Disruptive Behavior Disorders ADHD occurs in 3.4 to 7.2 percent of youth and 3.6 percent of adults. Many general problems are associated with ADHD, including academic and social skill de�cits, school failure, low self-esteem, and excessive substance use (see also Box 13.4). Speci�c mental disorders associated with ADHD include oppo- sitional de�ant and conduct disorder, anxiety-related and de- pressive disorders, and learning disorder. ADHD is much more prevalent among boys than girls. Girls with ADHD tend to have less disruptive behavior problems but greater internalizing prob- lems such as depression than boys with ADHD. ADHD appears to be a worldwide phenomenon not generally linked to cultural factors (Matte et al., 2015; Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015; Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014; Thomas, Sanders, Doust, Beller, & Glasziou, 2015).

Oppositional de�ant disorder affects 7.8 to 8.3 percent of youth and is much more common in boys than girls. The dis- order is commonly associated with other disruptive behavior and learning problems. Oppositional de�ant disorder often evolves into conduct disorder when a child shows severe dis- ruptive behavior at an early age. Only about 25 percent of youth with oppositional de�ant disorder go on to develop conduct disorder, however (Barkley & Robin, 2014; Kessler et al., 2012; Merikangas & He, 2014).

Conduct disorder affects 5.4 to 11.2 percent of youth and is much more common in boys than girls. Girls with conduct disorder usually show more covert and less aggressive behav- iors than boys with conduct disorder and are often diagnosed later in adolescence. Conduct disorder is often comorbid with other mental conditions, especially anxiety-related, depressive,

learning, and substance use disorders (Kessler et al., 2012; Merikangas & He, 2014).

Symptoms of conduct disorder are present in youth world- wide. American youths in juvenile detention facilities meet crite- ria for conduct disorder in 38 percent of cases (Washburn et al., 2015). Minority youth comprise 62 percent of those charged in juvenile court. African American youth are 5 times more likely to be detained than European American youth, and Hispanic youth are 2.5 times more likely to be detained than European American youth. This is especially true for youth in disadvan- taged neighborhoods who lack access to mental health treat- ment, but factors related to judicial decisions regarding arrest and con�nement may explain some of this effect (Desai, Falzer, Chapman, & Borum, 2012). ADHD and conduct and oppositional disorders affect less than 17 percent of children, but the disorders account for 71 to 74 percent of referrals to mental health agencies (Costello, He, Sampson, Kessler, & Merikangas, 2014). This is

MODERATE

DISRUPTIVE BEHAVIOR DISORDER—DISRUPTIVE BEHAVIOR DISORDER—

LESS SEVERE

DISRUPTIVE BEHAVIOR DISORDER—DISRUPTIVE BEHAVIOR DISORDER—

MORE SEVEREMORE SEVERE

Moderate problems in impulse, anger, or other Moderate problems in impulse, anger, or other emotional control.

Substantial problems regulating one’s impulses and Substantial problems regulating one’s impulses and emotions that create trouble functioning in a classroom. emotions that create trouble functioning in a classroom.

Extremely poor emotional control or lack of Extremely poor emotional control or lack of emotion that leads to aggression or explosiveness. emotion that leads to aggression or explosiveness.

Frequent irritation toward Frequent irritation toward others and thoughts of others and thoughts of de�ance or aggression. de�ance or aggression. de�ance or aggression.

Intense thoughts that others are Intense thoughts that others are actively hostile to the person, even actively hostile to the person, even in ambiguous situations. in ambiguous situations. in ambiguous situations. in ambiguous situations.

Frequent thoughts of aggression, hostility toward Frequent thoughts of aggression, hostility toward others, and rule-breaking. others, and rule-breaking.

Signi�cant rambunctiousness and noncompliance at home or school.

Highly disruptive behavior at home Highly disruptive behavior at home and school and/or property destruction and school and/or property destruction and severe noncompliance. and severe noncompliance.

Extreme disruptive behavior and/or aggression to people and animals.

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because symptoms of these disorders are usually quite disturbing to parents and teachers.

Stigma Associated with Disruptive Behavior Disorders

Stigma can affect children with disruptive behavior disorders. Studies indicate that adults often have negative views of chil- dren with ADHD. Childhood ADHD symptoms are often labeled by adults as serious, less likely to constitute a mental disorder, and less likely to be seen as a condition that requires treatment. In addition, the symptoms are sometimes seen as dangerous,

violent, and harmful. Other studies indicate that some adults favor coercive measures to force a child with ADHD symptoms to see a clinician, take medication, or be hospitalized. A sub- stantial number of parents say they do not want a child with ADHD to live next door, have their friend befriend a child with ADHD, spend an evening with a child with ADHD or his or her family, or have a child with ADHD in their child’s classroom. Teachers also tend to perceive children with ADHD as less suc- cessful academically (Lebowitz, 2016).

Stigma can also apply to youths with conduct disorder, especially those with a juvenile record. Youths given a label as “delinquent” often face restricted academic and vocational op- portunities (Ray & Childs, 2015). In addition, many juveniles

TABLE 13.7 DSM-5

Attention-De�cit/Hyperactivity Disorder A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, de�ance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least �ve symptoms are required. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities. b. Often has dif�culty sustaining attention in tasks or play activities. c. Often does not seem to listen when spoken to directly. d. Often does not follow through on instructions and fails to �nish schoolwork, chores, or duties in the workplace. e. Often has dif�culty organizing tasks and activities. f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort. g. Often loses things necessary for tasks or activities. h. Is often easily distracted by extraneous stimuli. i. Is often forgetful in daily activities.

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, de�ance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least �ve symptoms are required. a. Often �dgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected. c. Often runs about or climbs in situations where it is inappropriate. d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor”. f. Often talks excessively. g. Often blurts out an answer before a question has been completed. h. Often has dif�culty waiting his or her turn. i. Often interrupts or intrudes on others.

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.

Specify if combined, predominantly inattentive, or predominantly hyperactive/impulsive presentation; if in partial remission; severity as mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

Stigma Associated with Disruptive Behavior Disorders 409

feel stigmatized after involvement with the justice system and shun mental health treatment (Samuel, 2015). This may be es- pecially so for youths who experienced traumatic experiences before or during detention (Ford & Blaustein, 2013). Some thus contend that legal and other professionals should move away from viewing status offenses as criminal and toward an under- standing that many juveniles have unaddressed mental disor- ders (Taylor & Fritsch, 2015).

➲ Interim Summary • Many children may be described as rambunctious, but some

have disruptive behavior disorders involving inattention, impulsivity, overactivity, aggression, and noncompliance.

• Attention-de�cit hyperactivity/disorder refers to intense problems of inattention, impulsivity, and/or overactivity.

• Oppositional de�ant disorder refers to noncompliance, hostility and anger toward others, argumentativeness, and bullying behavior, among other symptoms.

• Conduct disorder refers to intense problems of aggression, property destruction, lying and stealing, and status violations.

• Disruptive behavior disorders are common and seen more in boys than girls. The problems seem universal and are often comorbid with one another.

• Stigma is an important part of disruptive behavior disorders and can affect others’ view of a child.

TABLE 13.8 DSM-5

Oppositional De�ant Disorder

TABLE 13.9 DSM-5

Conduct Disorder A. A pattern of angry/irritable mood, argumentative/de�ant behavior,

or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful.

Argumentative/De�ant Behavior 4. Often argues with authority �gures or, for children and adoles-

cents, with adults. 5. Often actively de�es or refuses to comply with requests from

authority �gures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness 8. Has been spiteful or vindictive at least twice within the past

6 months.

B. The disturbance in behavior is associated with distress in the indi- vidual or others in his or her immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Specify if mild (symptoms in one setting), moderate (symptoms in two settings), or severe (symptoms in three or more settings).

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the catego- ries below, with at least one criterion present in the past 6 months:

Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical �ghts. 3. Has used a weapon that can cause serious physical harm to

others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim. 7. Has forced someone into sexual activity.

Destruction of Property 8. Has deliberately engaged in �re setting with the intention of

causing serious damage. 9. Has deliberately destroyed others’ property (other than by �re

setting).

Deceitfulness or Theft 10. Has broken into someone else’s house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations. 12. Has stolen items of nontrivial value without confronting a victim.

Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning

before age 13 years. 14. Has run away from home overnight at least twice while living

in the parental or parental surrogate home, or once without returning for a lengthy period.

15. Is often truant from school, beginning before age 13 years.

B. The disturbance in behavior causes clinically signi�cant impair- ment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specify if childhood, adolescent, or unspeci�ed onset; if with limited prosocial emotions, lack of remorse or guilt, callous-lack of empathy, unconcerned about performance, shallow or de�cient affect; mild, moderate, or severe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 13 Developmental and Disruptive Behavior Disorders410

➲ Review Questions 1. How do disruptive behavior disorders differ from normal ram-

bunctious behavior? 2. De�ne major symptoms and subtypes of attention-de�cit/

hyperactivity disorder. 3. Outline main symptoms of oppositional de�ant disorder. 4. What are main categories of symptoms of conduct disorder? 5. Describe the epidemiology of the disruptive behavior disorders.

Disruptive Behavior Disorders: Causes and Prevention

Disruptive behavior disorders involve biological and environ-mental risk factors. ADHD relates especially to biological risk factors and oppositional and conduct disorders clearly relate to many environmental risk factors.

Biological Risk Factors for Disruptive Behavior Disorders Genetic In�uences Strong evidence supports a genetic basis for ADHD. First, the disorder runs in families: �rst-degree relatives of children with ADHD are 2 to 6 times more likely than the general population to have ADHD. Second, twin studies worldwide indicate that ge- netic factors account for about 75 percent of the variance when explaining ADHD onset. Third, �ndings from adoption studies reveal biological relatives of children with ADHD to have an elevated rate of ADHD compared with the general population (Franke et al., 2012; Schachar, 2014).

Studies of the biology of conduct disorder indicate that the problem has moderate to strong genetic in�uences. Much of the

explanation for this, however, may be due to genetic overlap with ADHD and oppositional de�ant disorder (Lahey & Waldman, 2012). In addition, some genetic basis may be more pertinent to certain aspects of conduct disorder, such as aggression, emo- tionality, and impulsivity. Proactive aggression in children tends to have a stronger genetic basis than reactive aggression (Waltes, Chiocchetti, & Freitag, 2015). In addition, callous-unemotional traits (see later section on personality factors), which are often part of severe conduct disorder, appear to have a strong genetic basis (Hawes, Price, & Dadds, 2014). Negative emotionality refers to persistent experiences of nervousness, sadness, and anger and is often associated with conduct disorder. Negative emotionality also has some genetic basis (Mikolajewski, Allan, Hart, Lonigan, & Taylor, 2013). Impulsive antisocial behavior and the neurochemical features associated with this (see next section) are in�uenced by genetics as well (Blair, 2013).

Neurochemical Features Neurochemical changes implicated for children with ADHD in- clude de�ciencies or imbalances in dopamine and norepineph- rine, especially in prefrontal brain areas. Such changes may help explain problems of motor control, behavior inhibition, and cognition. ADHD may be an inability to regulate one’s own behavior, so medications to help improve symptoms of ADHD focus on increasing these neurotransmitter levels (Sharma & Couture, 2014).

Serotonin levels have been found to be low among youths with aggression and conduct disorder. Lower levels of cortisol and higher levels of testosterone also appear among youths with disruptive behavior disorders, which is consistent with �ndings that these youths have lower heart rates and less physiological arousal. Some of these youths may thus lack anxious inhibition to engage in aggressive or other antisocial acts (Matthys, Vanderschuren, & Schutter, 2013; Portnoy & Farrington, 2015).

students with ADHD also report more dif�culties with respect to social skills and adjustment, self-esteem, mood symptoms, substance use, and relationships with parents and peers (Weyandt et al., 2013).

Some have examined these problems in greater depth. College stu- dents with ADHD have been found to report more obsessive-compulsive behaviors, depression, anxiety, and hostility compared with controls. College students with ADHD also reported lower grades on speci�c course assignments, less well-developed organizational skills, and more prob- lems related to social adjustment as students. Finally, those with ADHD reported speci�c cognitive problems related to emotional control, working memory, and task management much more so than control participants. The authors contended that students with ADHD should be assessed for impairment as well as symptoms and that treatment should be broad in scope and include problems in academic, cognitive, and social functioning (Weyandt et al., 2013).

Focus On

Many adolescents with ADHD are entering college, and approximately 2 to 5 percent of college students report ADHD or signi�cant levels of ADHD symptoms. In addition, about 25 percent of students who receive disability services on college campuses do so for ADHD symptoms. On average, college students with ADHD or signi�cant ADHD symptoms tend to have lower grade point averages, are more likely to be on academic probation, and are less likely to graduate than their classmates without ADHD. College

13.4

College Students ADHD

Disruptive Behavior Disorders: Causes and Prevention 411

Brain Features Children with disruptive behavior disorders have characteristic brain changes, some of which may relate to genetic predisposi- tions and that may interact with neurochemical changes. Youths with ADHD have smaller or different volumes of key brain areas, especially the prefrontal cortex, anterior cingulate cortex, basal ganglia, caudate, putamen, pallidum, corpus callosum, and cere- bellum. Less blood �ow and poor connectivity in key frontostriatal areas is often seen as well. Such changes help explain problems of inattention, overactivity, and impulsivity in this population (Jun & Castellanos, 2015; Weyandt, Swentosky, & Gudmundsdottir, 2013).

Neuroimaging studies of youths with oppositional de�ant or conduct disorder are sparse, though some work has focused on aggression and antisocial behavior. The most reliable �nding is less volume in the prefrontal cortex, a result that overlaps with ADHD (Figure 13.5). Others have implicated changes in the amygdala, basal ganglia, and brain stem. De�cits in these brain areas may help explain trouble controlling excess emo- tions and aggressive behaviors (Fairchild et al., 2015; Noorder- meer, Luman, & Oosterlaan, 2016).

Personality Factors Personality factors also come into play in youths with disrup- tive behavior disorders, particularly oppositional de�ant or

conduct disorder. These personality factors could relate to tem- perament issues raised earlier and involve callous-unemotional traits. Youths with these traits often lack guilt or remorse for their hurtful acts toward others, show little emotion, are unem- pathetic to others, and manipulate others for their own grati�ca- tion. A teenager with this personality pattern might resemble someone with antisocial personality disorder (Chapter 10). He will use others for personal grati�cation, such as sexually or to obtain goods or services, and do so with little regard for others. This personality pattern seems particularly relevant to youths with severe conduct disorder (Ray, Thornton, Frick, Steinberg, & Cauffman, 2015).

Environmental Risk Factors for Disruptive Behavior Disorders Teratogens Recall that teratogens refer to prenatal risk factors such as maternal drug use and exposure to toxins. Youths with disrup- tive behavior disorders may have been exposed to various pre- natal teratogens more than occurs in the general population. Key teratogens related to later disruptive behavior disorders, espe- cially ADHD, include maternal smoking and alcohol use, which closely relate to problems of attention, cognition, and learning.

Increased stress during pregnancy, pregnancy and delivery complications, premature birth, and lower birth weight are signi�cant risk factors as well (Doyle & Mattson, 2015; Gard, Owens, & Hinshaw, 2015; Graham, Glass, & Mattson, 2016).

Family Con�ict and Parenting Practices Con�ict in a marriage and among family members closely relates to disruptive behavior problems in youth. Fright associated with watching parents �ght may cause attachment problems and contribute to a child’s inability to control his emotions. Young- sters could also model parental aggression as a way to solve problems. Other youths may be rewarded for aggression or overactivity by a parent’s unwill- ingness to address the behavior (Karriker-Jaffe, Foshee, Ennett, & Suchindran, 2013; Martel, Nikolas, Jernigan, Friderici, & Nigg, 2012).

Poor parenting practices closely relate to dis- ruptive behavior problems. Examples include re- warding child misbehavior by providing positive consequences or removing negative ones. A child could become aggressive and overactive so parents will bribe him to stop the behaviors. Or a child could misbehave in response to parent commands to avoid a chore. Patterns of coercion begin early in life, can escalate to extreme forms of misbehavior, and can be accelerated by ineffective parent disci- pline (Snyder, 2016; Smith et al., 2014).

Other parenting problems associated with dis- ruptive behavior disorders include poor monitoring FIGURE 13.5 MAJOR BRAIN AREAS IMPLICATED IN DISRUPTIVE BEHAVIOR DISORDERS.

AmygdalaAmygdala

Cingular cortex

PrefrontalPrefrontal cortexcortex

CorpusCorpus callosumcallosum

Basal ganglia CaudateCaudate Putamen Pallidum

CerebellumCerebellum

Brain stemBrain stem

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CHAPTER 13 Developmental and Disruptive Behavior Disorders412

of a child’s behavior, harsh and uncaring communications, overcontrol, excessive physical punishment, and use of unclear commands. Some parents phrase commands in the form of a question (“Will you please just go to school?”), interrupt or lecture their children when giving a command, or issue vague commands that leave room for interpretation (“Go clean your room”). This often leads to child noncompliance or de�ance (Eisenberg, Taylor, Widaman, & Spinrad, 2015; Tolan, Dodge, & Rutter, 2013).

Deviant Peers Youths with disruptive behavior disorders, especially those with conduct disorder, associate more with deviant peers, are rejected by nondeviant peers, and have hostile interper- sonal relationships. Many of these youths also have poor social and verbal skills, which contribute to their inability to form positive friendships. Oftentimes such rejection from others leads a child to associate with others who have also been rejected because of aggression. Hostile and aggressive behavior may thus be rewarded by peers (Vitaro, Brendgen, & Lacourse, 2015).

Association with deviant peers is sometimes linked to bul- lying behavior. Bullying refers to victimizing someone through aggression and other hostile behavior such as yelling or ver- bal threats. Bullying appears to be a stable behavior—many children who bully continue to do so during adolescence. Factors associated with ongoing bullying include disruptive behavior problems, poor social competence, and male gender (Camodeca, Caravita, & Coppola, 2015; Fergusson, Boden, & Horwood, 2014).

Cognitive Factors Older children and adolescents with disruptive behavior disorders, particularly those with conduct disorder, have key information- processing differences. Many of these youth misinterpret actions of others as hostile or threatening when no real threat exists. A teen- ager may be accidentally bumped by someone in a school hallway and immediately assume the per- son committed the act intention- ally and with intent to harm. Such assumptions could help trigger thoughts and behaviors of ven- geance or spitefulness.

Youths with conduct disorder also favor aggressive solutions for problems, fail to fully understand the negative consequences of ag- gression, de�ne problems in hostile ways, and perceive their self-worth as low. A child who hits another child may have done so as a �rst

resort to get something and might have trouble appreciating negative consequences of this act (Dodge, Godwin, & Conduct Problems Prevention Research Group, 2013; Dodge et al., 2015).

Maltreatment Early sexual and physical maltreatment toward a child also relates to disruptive behavior problems. If a child is maltreated during the infancy, toddler, or preschool phases of life, various externalizing behavior problems during later childhood and adolescence are much more likely to occur than if the child was not maltreated. Of course, maltreatment may also occur in response to a child’s misbehavior. Why might maltreatment help produce disruptive behaviors? Possibilities include poor attachment to parents, dif- �culty controlling emotions, and development of cognitive distor- tions and low self-esteem (Narayan, Cicchetti, Rogosch, & Toth, 2015; VanZomeren-Dohm, Xu, Thibodeau, & Cicchetti, 2016).

Poverty Poverty and low socioeconomic status strongly relate to disruptive behavior disorders in youth. This is partly due to problematic parenting practices and general neighborhood disorganization and violence. Whether neighborhood violence helps trigger aggressive behavior or whether youths are ones who provoke the neighborhood problems remains unclear, however (Evans & Cassels, 2014; Jennings & Fox, 2016).

Cultural Factors Ethnicity does play some role in disruptive behavior disor- ders. European American children are more likely to receive a diagnosis of ADHD than children who are African American,

Marital con�ict is a key risk factor for children with behavior problems.

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Disruptive Behavior Disorders: Causes and Prevention 413

Hispanic, or of other ethnicities (Collins & Cleary, 2016). This difference is not present in 4- to 5-year old children but becomes appar- ent after age 5 years (Pastor, Reuben, Duran, & Hawkins, 2015). African American mothers, however, often endorse more inattentive and hyperactive-impulsive symptoms in children than European American mothers (Barrett & DuPaul, 2015). These discrepancies have led some to claim that ADHD may be overdiag- nosed in some groups and underdiagnosed in other groups, but much research remains nec- essary in this regard (Morgan, Staff, Hillemeier, Farkas, & Maczuga, 2013).

Juvenile arrest records are generally higher for African American youth than European American and Native American youth and lowest for Asian American youth (Of�ce of Juvenile Justice and Delinquency Prevention, 2015). This difference is some- times attributed to the more frequent presence of certain risk factors such as prenatal prob- lems. This overall pattern masks some more nuanced �ndings, however. Arrests for liquor law violations, for example, are much higher among Native American and European American youth than African American and Asian American youth. In addition, rates of running away from home differ little by ethnicity. Communi- ties with higher numbers of immigrant populations also tend to have lower crime rates. Much more research is needed with respect to disentangling the relationships among race, ethnicity, and criminal or antisocial behavior (Leiber & Peck, 2015).

Causes of Disruptive Behavior Disorders Researchers have focused on multifactorial or biopsychosocial models of disruptive behavior disorders that combine many risk factors. A multifactorial model of ADHD includes biological and environmental factors that interact to help produce the disorder. Many risk factors have been suggested, with others still to be discovered; therefore, some suggest that multiple pathways to ADHD exist. Some of these pathways could be largely genetic, some largely due to pregnancy and delivery complications, some largely due to stress and other teratogens, and some largely due to a combination of these factors. The latter pathway is the most likely early scenario. These pathways may then lead to key brain and neurochemical changes, especially changes that affect abil- ity to self-regulate behavior. When combined with certain en- vironmental factors such as ineffective parenting, these brain changes help trigger symptoms of inattention, impulsivity, and overactivity (Molina & Pelham, 2014; Pham, 2015; Figure 13.6).

A multifactorial approach may also apply to oppositional de�ant disorder and conduct disorder, although the pathways to these disorders likely rely more heavily on environmental factors. General biological predispositions can set the stage for certain dif�cult and hostile temperaments as well as tendencies

toward aggression and impulsivity. Such predispositions seem strong in children with ADHD but weaker in those with conduct problems. Irritable temperaments and tendencies toward anti- social behavior can, however, set the stage for poor attachment with parents, ineffective parenting, and social and academic problems. A child who inherits a fussy and irritable tempera- ment from parents could be dif�cult to care for and may be re- jected by parents with the same irritable temperament (Pardini & Frick, 2013; Tolan et al., 2013; Figure 13.7).

Some of these problems can be resolved early in a child’s life if parents provide effective supervision and appropriate con- sequences for behavior. Some children may resist such efforts or these efforts may break down, however, which can lead to harsh parenting, family con�ict, peer rejection, and school fail- ure. Association with deviant peers, exposure to neighborhood violence, and other factors such as excessive substance use or depression can aggravate the situation as well (Brook, Lee, Finch, & Brook, 2015; Kaltiala-Heino, Fröjd, & Marttunen, 2015).

Prevention of Disruptive Behavior Disorders Prevention programs for disruptive behavior disorders are largely school-based to help youths improve social and academic com- petence. One of the most comprehensive prevention programs for these disorders involved classroom-based behavior manage- ment. This strategy focused on developing class rules with stu- dents, placing students in teams of disruptive and nondisruptive members, and providing group reinforcement so children were encouraged to manage their own and group members’ behavior.

If a classroom rule was violated, a teacher would take away a card from several cards at the beginning of class. If at least

Attention-deficit/hyperactivity disorder

Contributing environmental factors

Key neurochemical and brain changes such as frontostriatal

alterations

Genetic contributions and

temperament

Pregnancy and delivery

complications Teratogens

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FIGURE 13.6 SAMPLE MULTIFACTORIAL MOULTIFACTORIAL MOUL DEL OF ATTENTION ATTENTION A -DEFICIT/HYPERACTIVITY DISORDER.

CHAPTER 13 Developmental and Disruptive Behavior Disorders414

one card remained after a set period of time, then some reward was given. The frequency of assembling these teams was gradu- ally increased over time to three 1-hour time periods per week. Later phases of prevention involved attention toward prosocial behavior. The procedure helped prevent disruptive behaviors in general, especially for youths with moderate disruptive prob- lems (Spilt, Koot, & van Lier, 2013).

Given the severe nature of many disruptive behavior dis- orders, however, effective prevention programs will likely have to involve developing appropriate parenting skills, improv- ing social-cognitive skills in children, and providing academic skills training, group interventions, and classroom management (Sandler et al., 2014; Villodas, P�ffner, & McBurnett, 2012). An example is the Fast Track model for young children at high risk for conduct problems. This model includes social skill and anger control training, tutoring for academic problems, parent train- ing, and home visits. In one study, 37 percent of the intervention group was free of conduct problems after third grade compared with 27 percent of a control group. Prevention efforts over 10 years generally result in less use of professional services and less harsh parental discipline, but prevention of antisocial outcomes in adolescence does not occur (Pasalich, Witkiewitz, McMahon, Pinderhughes, & Conduct Problems Prevention Research Group, 2016). These results are encouraging but also indicate great dif- �culty modifying severe behavior problems. How do you think Will might have responded to such a prevention program?

➲ Interim Summary • Evidence strongly supports a genetic basis

for ADHD but less so for conduct disorder.

• Imbalances of dopamine and norepi- nephrine have been noted in ADHD and low serotonin has been noted in conduct disorder.

• Youth with disruptive behavior disorders may have smaller brain areas as well as key differences in the prefrontal cortex and other areas.

• Prenatal teratogens implicated in disrup- tive behavior disorders include maternal drug use.

• Family con�ict, poor parenting practices, and association with deviant peers seem especially related to conduct disorder but may also apply to cases of ADHD.

• Youth with disruptive behavior disorders Youth with disruptive behavior disorders Y often interpret actions of others as hostile, have other social-cognitive de�cits, and have callous-unemotional personality traits.

• Causal theories for disruptive behavior disorders focus on multifactorial models that include biological predispositions and environmental risk factors as well as various pathways that can lead to ADHD or conduct disorder.

• Preventing disruptive behavior disorders may involve a thorough approach targeting skills de�cits, parenting, and classroom behavior management.

➲ Review Questions 1. What genetic predispositions exist for disruptive behavior

disorders? 2. What other biological risk factors exist for disruptive behavior

disorders? 3. Describe child-based, parent-based, and community-based

factors that may cause disruptive behavior disorders. 4. Outline a multifactorial model for the cause of ADHD and

conduct disorder. 5. What methods have been used to prevent disruptive behavior

disorders?

Disruptive Behavior Disorders: Assessment and Treatment

Mental health professionals use various methods to examine children with disruptive behavior disorders. These meth- ods primarily include interviews, rating scales, and behavioral observation.

Key cognitive and personality

factors

Social and academic problems

Ineffective parenting

Poor attachment

Genetic and other biological influences

Contributing poverty, maltreatment, neighborhood disorganization, depression,

association with deviant peers

Oppositional defiant and/or conduct disorder

Hostile temperament

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FIGURE 13.7 SAMPLE MULTIFACTORIAL MODEL OF OPPOSITIONAL DEFIANT DISORDER AND SAMPLE MULTIFACTORIAL MODEL OF OPPOSITIONAL DEFIANT DISORDER AND SAMPLE MULTIFACTORIAL MODEL OF OPPOSITIONAL DEFIANT DISORDER AND CONDUCT DISORDER.

Disruptive Behavior Disorders: Assessment and Treatment 415

Interviews Interviews of a child and his parents and school of�cials are essential when assessing a child with a possible disruptive be- havior disorder. Questions should surround various aspects of a child’s cognitive, emotional, and social development. The pres- ence of risk factors mentioned in this chapter should also be determined. Ongoing risk factors in a child’s daily environment should be assessed as well, including parent-child interactions, parenting style and discipline, marital and family interactions, and school-based interactions with peers and teachers. Medi- cal conditions and school performance should also be evaluated (Sparrow & Erhardt, 2014).

A thorough history of a child’s symptoms must also be obtained, especially the frequency, intensity, and duration of overactivity, impulsivity, inattention, noncompliance, and ag- gression. Interviews to assess these problems can be unstruc- tured or structured. Commonly used structured interviews for youths with disruptive behavior disorders include the National Institute of Mental Health Diagnostic Interview Schedule for Chil- dren and Structured Clinical Interview for Childhood Diagnoses (Roelofs, Muris, Braet, Arntz, & Beelen, 2015).

Rating Scales Parent and teacher rating scales are also available for assessing disruptive behavior in youths. Scales commonly used to assess global levels of disruptive behavior include the Child Behavior Checklist, Teacher Report Form, Conners Rating Scales (Conners 3), and Behavior Assessment System for Children, Third Edition (Achenbach & Rescorla, 2001; Conners, 2008; Reynolds & Kamphaus, 2015). For youth with ADHD, a common measure is the ADHD Rating Scale—5 (DuPaul, Power, Anastopoulos, & Reid, 2016). For conduct disorder, a commonly used rating scale is the Home and School Situations Questionnaire (Barkley, 2013). Home and School Situations Questionnaire (Barkley, 2013). Home and School Situations Questionnaire Sample items from this questionnaire are listed in Table 13.10.

Behavioral Observation Observing the behavior of children with disruptive behavior in their natural environments, such as school and home, is an essential part of assessment. Behavioral observations help add information and clarify discrepancies from interview and rat- ing scale data and are useful for examining speci�c aspects of behavior (DuPaul & Stoner, 2014). Behavioral observations are also conducted to determine why a child misbehaves over time. Possible reasons include attention from parents, desire to escape situations such as classrooms, or to obtain tangible rewards such as toys. Therapists sometimes link behavioral observations to speci�c tests for ADHD symptoms. The Continuous Perfor-Continuous Perfor-Continuous Perfor mance Test measures a child’s ability to sustain attention and mance Test measures a child’s ability to sustain attention and mance Test limit impulsivity on various tasks (Conners, 2014).

Biological Treatments for Disruptive Behavior Disorders The primary biological treatment for youths with disruptive be- havior disorders is stimulant medication. This might seem odd when considering ADHD and excessive aggressive behavior— why stimulate those symptoms?! Recall, however, that a major problem in disruptive behavior disorders is trouble regulating one’s behavior. Self-regulation de�cits may be due to low levels of neurotransmitters such as dopamine and norepinephrine in key brain areas such as the prefrontal and cingulate cortexes (Arnsten & Berridge, 2015; Bedard et al., 2015). Stimulating in- hibitory centers of the brain may actually help children regulate their behavior and become less overactive and impulsive.

The main stimulant medication for ADHD is methylpheni- date (Ritalin or Concerta). About 55 to 75 percent of youths date (Ritalin or Concerta). About 55 to 75 percent of youths date with ADHD bene�t from the drug, as do many adults. The drugs help children reduce overactivity and impulsivity, although less strong effects are evident for attention and academic perfor- mance (Kass, Posner, & Greenhill, 2015; Storebo et al., 2015). One problem with stimulant medication is side effects that in- clude headaches, stomachaches, tics, restlessness, weight loss, reduced appetite, and insomnia (Craig, Davies, Schibuk, Weiss, & Hechtman, 2015). For those with severe side effects, who do not respond to stimulant medication, or who have tic disorders, a nonstimulant medication, atomoxetine (Strattera), is also helpatomoxetine (Strattera), is also helpatomoxetine - ful for increasing norepinephrine levels and improving ADHD symptoms (Clemow et al., 2015). Another problem with respect to stimulant medications is illicit use by college students to im- prove concentration, stay awake, control appetite, or change mood (Bavarian, Flay, Ketcham, & Smit, 2015).

Stimulant medications have also been used for youths with conduct disorder, but the drugs tend to be more effective if a youth has comorbid ADHD symptoms. These medications help reduce classroom disruption, aggression, property destruction, and other conduct problems. Other drugs such as antianxiety, mood stabilizing, and antipsychotic medications are sometimes used as well to help control explosive symptoms such as intense anger outbursts. Psychological treatments for oppositional de�- ant and conduct disorders are typically recommended as a �rst

TABLE 13.10

Sample Items from the Home and School Situations Questionnaire

Does your child present any problems with compliance to instruc- tions, commands, or rules for you in any of these situations?

Playing with other children

Mealtimes

When you are on the telephone

In public places

While in the car

Note. Items are scored as yes/no and then on a 1 to 9 scale where 1 = mild and 9 = severe.

CHAPTER 13 Developmental and Disruptive Behavior Disorders416

resort, however (Kass et al., 2015; Pringsheim, Hirsch, Gardner, & Gorman, 2015).

Psychological Treatments for Disruptive Behavior Disorders Psychological treatments for disruptive behavior disorders pri- marily focus on home-, school-, and community-based programs to reduce problematic symptoms and develop academic, social, and self-regulation skills. We describe these treatments next.

Parent Training Ineffective parenting is a key risk factor for disruptive behav- ior disorders and home-based misbehaviors likely have to be addressed by parents. Parent training programs are thus a key treatment element for this population. Many parent training pro- grams have been proposed, and their effectiveness with youth with disruptive behavior disorders is well documented. Parent training programs typically include the following components:

• Educate parents about a child’s behavior problems and how best to address them.

• Teach parents to identify and speci�cally de�ne problem behaviors, such as “My son will not wash the dishes when told,” and establish clear rules for behavior.

• Provide appropriate attention and tangible rewards when a child engages in prosocial behaviors such as completing homework, �nishing chores, and eating dinner quietly.

• Ignore minor inappropriate behaviors such as whining. • Provide appropriate and consistent disciplinary procedures

such as time-out or loss of privileges when a child engages in serious misbehaviors.

• Give effective commands that are clear, short, and linked to consequences.

• Use a token economy for prosocial and antisocial behaviors. • Increase daily monitoring and supervision of a child. • Teach parents to solve problems effectively and refrain from

con�ict.

• Increase daily contact with school of�cials to coordinate treatment and consequences for behavior, such as asking teachers to send home a daily behavior report card (Barkley & Robin, 2014; Jones et al., 2013).

School-Based Behavior Management Children with disruptive behavior disorders pose a challenge to teachers trying to maintain classroom order, so school-based be- havior management is also a key treatment for this population. School-based treatment does overlap with parent-based training and the two procedures are often coordinated so a child always faces clear guidelines and consequences regarding his behavior (Schultz & Evans, 2015). Will’s transgressions at school should have been met with school- and home-based consequences such as loss of privileges. School-based strategies for children with ADHD can also include rotating rewards to maintain novelty and

interest in them, providing frequent feedback about rules and self-regulation, developing social skills, and encouraging peers to help a child modify his behavior (DuPaul, Eckert, & Vilardo, 2012; Evans et al., 2016).

Social and Academic Skills Training Because children with disruptive behavior disorders have social and academic problems that can lead to further aggression and other misbehaviors, training programs to en- hance skills in these key areas are important and effective. These programs focus on helping youth control impulses and anger, develop social and problem-solving skills, cooperate better with others, and enhance academic competence. This may be done by challenging and modifying irrational thoughts, recognizing and addressing early warning signs of anger and impulsivity such as muscle tension, considering alternative explanations for another’s behavior, rewarding appropri- ate participation in prosocial group activities, and receiving extra tutoring and educational support for academic de�cits (Fabiano, Schatz, & Pelham, 2014; Villodas, McBurnett, Kaiser, Rooney, & P�ffner, 2014).

Residential Treatment A teenager may have to temporarily leave his family and be placed in residential or community-based treatment if disruptive behavior is severe. Such programs include camps, group homes, or other facilities where adolescents live until they can be re- integrated to their regular home. Residential treatment often consists of group therapy to develop social and self-care skills, anger management, family therapy to reduce con�ict and build problem-solving strategies, supervised chores and other work, and systematic consequences for prosocial and inappropriate behavior. Residential treatment programs have been shown to produce short-term improvements in disruptive behavior, but their long-term effectiveness is not strong. Many youth who at- tend these programs eventually commit more crimes or require additional community placement (Lee et al., 2014; Lockwood & Harris, 2015).

The Freestate Challenge Academy is a residential program for at-risk high school students who have past issues with disruptive behavior.

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Disruptive Behavior Disorders: Assessment and Treatment 417

Multisystemic Treatment A new way to address severe disruptive behavior in children and adolescents is to provide extensive family services that include many psychological treatments. Multisystemic treat- ment is a family-based approach that includes procedures we described here as well as the following: therapy for parent psychopathology and substance use problems, in- volvement with appropriate peers, social support, school and vocational achievement, and linkage to agencies that can provide �nancial, housing, and employment support. This approach is effective in the long-term for reducing aggres- sive criminal activity, although ongoing access to treatment is likely necessary. This approach is sometimes used as a diversion program for adolescents arrested for a crime (see Box 13.5; Henggeler, 2015).

What If I Think a Child Has a Disruptive Behavior Disorder? If you suspect your child or someone you know has ADHD or another disruptive behavior disorder, consider the screen- ing questions in Table 13.11. If the answer to most of these questions is yes, a good idea would be to consult a clinical child psychologist and a psychiatrist who specialize in these issues. Consulting both professionals is especially important for ADHD because medication in conjunction with behavior management may be the best treatment approach. Many adults with ADHD symptoms may be helped with these therapies as well. If the answers to these questions are mostly no but you still believe considerable family con�ict is resulting from a child’s misbehavior, then seeking the help of a family therapist is a good idea.

Long-Term Outcome for Children with Disruptive Behavior Disorders Children with disruptive behavior disorders are at serious risk for later aggression and other mental disorders. Severe symp- toms of hyperactivity and impulsivity in young children often predict later onset of oppositional de�ant disorder. Oppositional

Some states have since reevaluated this practice and instituted “diversion” programs allowing �rst-time offenders to avoid incarceration (Vries, Hoeve, Assink, Stams, & Asscher, 2015). Examples include wil- derness and boot camps, court-based mediation and con�ict resolution, and referral to counseling services or group homes. Diversion programs typically focus on detailed assessment of a particular youth, expunging arrest and conviction records, family-based treatment, and linkage to community-based agencies.

A prominent example is the Miami-Dade Juvenile Assessment Center Post-Arrest Diversion Program. This program evaluates and addresses �rst-time youth offenders by providing treatment services as an alternative to incarceration. Charges against a youth may be dismissed after intense supervision and completion of treatment, often for substance use and family-related problems. This practice helps reduce stigma associated with “delinquency” and allows youths to experience a second chance at entering adulthood without the detriment of an arrest record.

Focus On

Adolescents with disruptive behavior disorders sometimes display ag- gression toward others as well as antisocial behavior such as property destruction or stealing. Arrest rates for juveniles remain high. The issue of juvenile violence and other antisocial behavior was widely debated in the 1990s, and many states lowered the age at which juveniles could be arrested and tried as adults for various crimes. Many of these youth were incarcerated with adult prisoners and were at risk for severe exploitation because of their youth and inexperience.

Violence Juvenile Arrests and “Diversion”

13.5

TABLE 13.11

Screening Questions for Disruptive Behavior Disorders

Does a particular child always seem to be in trouble both at home and school?

Does a particular child always seem to be “on the go” even at mealtime and bedtime?

Does a particular child seem much more inattentive, hyperactive, or impulsive than most kids his age?

Can the child in question concentrate well on her homework or chores?

Is a particular child often noncompliant with adult requests, much more so than most kids his age?

Does a particular child frequently engage in aggression, theft, deceitfulness, and rule-breaking behavior much more so than most kids her age?

Has the child in question been arrested?

Does a particular child often seem hostile, argumentative, and overly sensitive?

CHAPTER 13 Developmental and Disruptive Behavior Disorders418

de�ant disorder is also an excellent predictor of later conduct disorder. The eventual comorbidity of all three disorders is especially likely if strong genetic contributions exist (Danforth, Connor, & Doer�er, 2016).

Children with ADHD generally experience stable symptoms over time, although these symptoms can change. Preschoolers with ADHD sometimes have sleep disturbances and can be dif- �cult to control, overactive, inattentive, and noncompliant. Full- blown symptoms of inattention, overactivity, and impulsivity are seen as these children enter elementary school. Many children with ADHD then experience social and academic problems such as rejection by others, poor social skill development, and school failure. Will was having many of these problems (Cherkasova, Sulla, Dalena, Ponde, & Hechtman, 2013; Holbrook et al., 2016).

Severe levels of overactivity and impulsivity improve some- what as children with ADHD reach adolescence. Still, about two-thirds continue to experience inattention, restlessness, and dif�culty with impulse control. These adolescents are also at se- rious risk for conduct disorder, excessive substance use, depres- sion, and school dropout. Parental inattention, family history of ADHD, intense family con�ict, and social disadvantage of- ten predict persistence of symptoms. Approximately 15 percent of those with ADHD in adolescence continue to have the full disorder in adulthood (Agnew-Blais & Seidman, 2014; Holbrook et al., 2016). For most adults, however, ADHD symptoms such as inattention and impulsivity often remain in the form of poor

concentration or underachievement at work, constant forget- fulness and working memory problems, low frustration toler- ance, loss of temper, and dif�culty completing a college degree (Mof�tt et al., 2015; Shaw, Stringaris, Nigg, & Leibenluft, 2014; Williamson & Johnston, 2015).

Three developmental pathways may mark youths with op- positional de�ant or conduct disorder. Two pathways begin in childhood and one in adolescence. The �rst childhood pathway is largely associated with symptoms of ADHD, especially im- pulsivity and severe family dysfunction. Such a pathway might apply best to Will. The second childhood pathway is associated with a callous-unemotional personality and dif�cult tempera- ment. About half of youth whose conduct problems begin with these early pathways show enduring antisocial behavior into ad- olescence and adulthood. Finally, an adolescent-onset pattern is marked by general rebelliousness and association with deviant peers normally associated with adolescence, and usually does not lead to severe adjustment problems in adulthood (Jaffe & Odgers, 2014; Pardini & Frick, 2013).

Persistent ADHD and oppositional de�ant/conduct symp- toms seem best predicted by severity and complexity. This means that particularly severe symptoms, greater impairment, and substantial comorbidity predict problems throughout ado- lescence and adulthood. Other high-risk factors include early age of onset and aggression, depression, behavior problems in multiple settings, lower intelligence, excessive substance

As I sat among piles of unfolded laundry, sorted through junk mail and unpaid bills, and walked through the clutter in the house, my newly re- ceived diagnosis of ADHD did not surprise me. What did surprise me was not being diagnosed did surprise me was not being diagnosed did until I was 38 years old. My two boys had already been diagnosed years earlier, the oldest with ADHD inattentive and the youngest with ADHD combined. Both were diagnosed by �rst see- ing a developmental pediatrician and ruling out physical ailments that could mimic symptoms of ADHD. From there they went to a health care practitioner for psychoeducational testing through the local children’s hospital. They received com- prehensive evaluations, but as an adult I could not utilize the same resources they used.

I started talking to other adults about this once-thought childhood disorder to gauge their reactions and seek referrals. I was mostly met with cynicism and doubt. Adult ADHD was just coming onto the scene as a plausible occurrence.

Surprisingly, my search led to a friend who had recently been diag- nosed. I say surprisingly because at the time, ADHD was not some- thing people talked about openly. In a lot of ways, it still isn’t.

Formally receiving the diagno- sis did a number of things for me. It lifted a big weight off my shoulders by providing an answer to so many “why’s?” in my past. But then it opened a bigger chasm by asking another ques- tion: “If I’m not who I thought I was, then who am I . . . really?” The diagnosis threw me into confusion as I tried to deal with these questions.

I soon found myself at the door of a thera- pist’s of�ce, certain I would be deemed “crazy.” I wasn’t. I was diagnosed as depressed, though: was diagnosed as depressed, though: was a common occurrence among adults diagnosed

with ADHD. My treatment now included an antidepressant with the stimulant medication for ADHD while in therapy to learn how to integrate this new

“person” into my view of myself. During a period of 4 years or

so, I rode the roller-coaster of de- pression. It took me in and out of valleys,

through tunnels, up over mountains where things looked stunning only to plunge back to the valley by way of a long, dark tunnel. I with- drew from life, not trusting what it had to offer. I recall times when my children would walk past and see the glazed look in the general direction of the television, and hear them announce that “Mom’s depressed again.”

I can’t recall that last journey out of the val- ley, how it was different from the others. I just knew it was. Life began again. The piles seemed to have taken on a life of their own and the bills

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Disruptive Behavior Disorders: Assessment and Treatment 419

use, parental psychopathology, and low socioeconomic status (Agnew-Blais & Seidman, 2014; Jaffe & Odgers, 2014).

➲ Interim Summary • Methods to assess youths with disruptive behavior dis-

orders include interviews, rating scales, and behavioral observations.

• Biological treatment of disruptive behavior disorders includes stimulant medication to address de�cits or imbalances in dopamine and norepinephrine.

• Parent training for treating disruptive behavior disorders involves de�ning behavior problems, providing appropriate consequences for child behavior, giving effective com- mands, and increasing supervision of a child and contact with school of�cials.

• School-based behavior management of disruptive behavior problems is often done in coordination with parent train- ing and focuses on methods of helping children enhance control over their behavior.

• Social and academic skills training is used to help youth control impulses and anger and develop better social and academic skills.

• Residential treatment is sometimes used for severe cases of adolescent disruptive behavior disorder and includes

placement in community-based settings with an eventual goal of returning a child to his home.

• Multisystemic treatment is a strategy for addressing severe disruptive behavior problems by providing treatment at different levels: family, school, and agency.

• Children with disruptive behavior disorders often have stable symptoms, especially in cases of early age of onset and aggression, more intense severity and complexity of symptoms, excessive substance use, family dysfunction, and parental inattention.

➲ Review Questions 1. What are the primary methods of assessing youths with

disruptive behavior? 2. What are the main medications for children with ADHD, and

what are their side effects? 3. Outline major goals of parent training and school-based

behavior management for youths with disruptive behavior. 4. Describe social and academic skills training and residential

and multisystemic treatments. How might these strategies be combined to address a child with severe disruptive behavior?

5. What is the long-term outcome for youths with ADHD and/or oppositional de�ant and conduct disorder?

were all merged into one heap, as the phone rang off the hook with bill collectors on the other end. Taking the medication and armed with knowledge about myself, I started on the trek out of the abyss, tackling one issue at a time and creating systems that worked with my processing styles. My family looked on with guarded optimism wondering if they could trust what they were seeing.

The biggest change that came about was my desire to help others. Since my youngest son was diagnosed, I advocated for him at his school, getting accommodations, trying to keep his playing �eld level. I learned what his challenges were, found his strengths, and then went to work getting approval for him to use those strengths to overcome the challenges. I had learned a lot about myself and what I could do for others. The medica- tion allowed me to focus and follow through on projects. I wanted to put those new skills

determined it was not going to control me; I was going to control it. Once I made that deter- mination, my life changed.

I learned what I believe to be one of the critical concepts that everyone needs to learn: experiences don’t make or mold the person . . . it’s what the person does with the experiences that de�nes who they are. I went back to col- lege, using general education credits from my �rst degree to apply toward my second bach- elor of science degree. With the help of the Disabilities Services of�ce at the university, I graduated 18 months later, feeling much more successful than my �rst time through college. From there I went on to another challenge, tak- ing an 11-month teleclass to become a coach to ful�ll my goal of helping others. There was no Disabilities Services of�ce but I knew enough that I managed just �ne, and today I am now a certi�ed coach working out of my home . . . helping others with ADHD.

to work helping others go through their dif�cult times.

Although I wanted to get to work instantly, I was able to recognize I needed further education. As I looked back, I saw that school had not been easy for me, despite the embossed gold sticker on the diploma. I remembered the long hours reading texts, and then rereading them, taking copious notes in class, feeling like every teacher talked too fast and I wrote too slow, then copy- ing the notes later using different colors to set things apart. Remembering the anxiety around tests brought about its own anxiety; how was I going to survive another go-round? (It had been so long, I thought, since I had been to school.)

And the house—how would I be able to keep up with the bills, feed the kids, do the laundry . . . all the “normal” things others seemed to do so naturally? I didn’t have an- swers to those questions; I just had the answer to how I was going to use my experience. I had

personal narrative

CHAPTER 13 Developmental and Disruptive Behavior Disorders420

Final Comments People with developmental disorders suffer many problems functioning on a daily basis. They often rely on others for help and are frustrated with their inability to be fully independent. This is important to remember the next time you see someone struggle to get the right change in line at a store or someone with trouble talking articulately or reading a story quickly. Of course, many of us need help from other people in our daily lives. If you know someone who seems to need a lot of extra help, however, then talking to someone about it or contacting a quali�ed mental health professional is a good idea. Think about a child who acts up in a supermarket, movie theater, or airplane. Your �rst response is likely annoyance, and your second response might be to wonder what is wrong with the parents. Why don’t they control their child? Many kids who act up can and should be managed better by parents, but consider the possibility that a parent is trying to address a child with a severe disruptive behavior dis- order. Children with ADHD, oppositional de�ant disorder, or conduct disorder are enormously dif�cult to live with, both at home and out in public. When you next see a child being disruptive in public, ask yourself what might be causing the child’s misbehavior.

Thought Questions 1. When you notice people with developmental disorders portrayed in television shows and �lms,

what strikes you most? How realistic are the portrayals, given what you have learned here?

2. Who should make decisions for adults with developmental disorders? If you had a relative with mild intellectual disability, how much supervision would you want to provide?

3. If a friend of yours was pregnant with a child who had a major chromosomal aberration, what would you tell her?

4. How do you think children with learning disorder should be addressed in schools? Is separation with a special education teacher the best option? Should girls have as many opportunities for arithmetic tutoring as boys have for reading tutoring?

5. Do you think people with pervasive developmental disorders should have children? Why or why not?

6. Why do you think disruptive behavior disorders are much more common in boys than girls? How might parents and teachers deal differently with boys and girls?

7. What are advantages and disadvantages of teaching children with ADHD in regular classroom settings?

8. What is the difference between normal adolescent rebelliousness and conduct disorder?

9. What are risks of medicating youths with ADHD?

421Key Terms

Key Terms developmental disorders 384 limited developmental disorders 385 pervasive developmental disorder 385 intellectual disability 385 adaptive functioning 386 autism spectrum disorder 387 learning disorder 390 fragile X syndrome 392 phenylketonuria (PKU) 393

sickle cell disease 393 Tay-Sachs disease 393 Down syndrome 394 teratogens 394 induction defects 395 migration defects 395 cultural–familial intellectual

disability 396 gene therapy 401

discrete-trial training 401 attention-de�cit/hyperactivity

disorder 405 oppositional de�ant disorder 405 conduct disorder 405 disruptive behavior disorders 405 multisystemic treatment 417

423

Special Features

CONTINUUM FIGURE 14.1 Continuum of Thinking and Memory Problems and Neurocognitive Disorder 426–427

• 14.1 FOCUS ON COLLEGE STUDENTS: Delirium 434

• 14.2 FOCUS ON VIOLENCE: Maltreatment of the Elderly 436

V THE CONTINUUM VIDEO PROJECT Myriam / Alzheimer’s Disease 437

• 14.3 FOCUS ON GENDER: Grief in the Spouse Caregiver 448

• 14.4 FOCUS ON LAW AND ETHICS: Ethical Issues and Dementia 449

C William and Laura / What Do You Think?

Normal Changes During Aging and Neurocognitive Disorders: What Are They?

Neurocognitive Disorders: Features and Epidemiology

Stigma Associated with Neurocognitive Disorders

Neurocognitive Disorders: Causes and Prevention

Neurocognitive Disorders: Assessment and Treatment

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

Neurocognitive Disorders 14

CHAPTER 14 Neurocognitive Disorders424

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William Ponder and his wife, Laura, were both 83 years old. They had been married 58 years and lived in a rural area much of their lives. The Ponders were arrested after an incident in which their checking account was grossly overdrawn. The bank manager said the couple had written more than $22,000 worth of bad checks during the previous several months. Detectives sought help from the Ponders’ two grown sons and discovered that Mr. Ponder simply added zeroes to his checkbook balance whenever he needed to pay bills—he would change a $100 balance to $1,000 as necessary. No actual funds had been placed into the checking account for some time, however.

Detectives found the couple to be agi- tated, argumentative, and confused. The Pon- ders insisted no problem existed with their checking account and that they should not be hassled because “we’re old and you just want our money.” They could not recall their ad- dress at times, but other times seemed lucid. Mr. Ponder’s memory of events was worse than his wife’s memory, and he could no longer drive because of poor motor skills and forget- fulness about where he was. The couple thus depended on Mrs. Ponder’s driving and on their two sons, who would check on their par- ents from time to time.

The presiding judge at a court hearing about the bad checks asked the couple to submit to a neuropsychological examination. The examination was to determine the extent to which Mr. and Mrs. Ponder were impaired and could no longer care for each other or manage their �nances. Mrs. Ponder had mod- erate memory problems and seemed some- what withdrawn and occasionally confused, and her scores on the test were in the low normal range. Mr. Ponder, however, struggled mightily on many of the items, especially those related to sensory-motor functioning and memory. He struggled to such an extent he

began yelling at the examiner and refused to �nish the examination.

The neuropsychologist also interviewed the couple’s two sons, who said they were stunned at the recent turn of events. They did reveal their parents were not as “sharp” as in years past and that their parents had become more withdrawn from others. Both sons were particularly con- cerned about their father, who displayed major personality changes over the past 2 years. They described their father as typically mellow and easygoing who was transforming into a belliger- ent, short-tempered, and tense man. The sons once approached their parents about the pos- sibility of living in an assisted care facility, but their father verbally threatened them for even mentioning the subject.

Mr. Ponder refused a second interview with the neuropsychologist, but Mrs. Ponder agreed. She con�rmed her sons’ reports and admitted she was sometimes afraid to live with her husband. He was becoming more aggres- sive and even struck her on two occasions, although he had never done so earlier in their marriage. He spent much of his day consum- ing alcohol, watching television, and sleeping. She also worried he might wander about and get lost.

Mrs. Ponder conceded she was feeling overwhelmed by having to care for her hus- band as well as the house. She continued to allow Mr. Ponder to control the couple’s �nances and worried that “something awful” was going to happen to their retirement ac- count. Mrs. Ponder was reportedly becoming more depressed and confused and was hav- ing trouble eating and sleeping. Her mood was somber as she realized her husband was changing, that he was not the same loving man he used to be, and that they could be in severe legal trouble or be forced to sell their home. Mrs. Ponder knew her future must involve enormous change. She worried about where

she would live and how much money was left, but mostly she worried about her husband’s fading physical and mental health.

The neuropsychologist concluded that Mr. Ponder was likely in middle stages of a neurocognitive disorder, perhaps due to Alzheimer’s disease. Mrs. Ponder displayed normal memory changes for someone her age, but she was also depressed and occasionally confused, which may have led to mild thought and memory problems. The neuropsychologist reported to the court his �ndings and the Pon- ders were allowed to make proper restitution to various businesses without additional legal trouble. The state department of aging was noti�ed, however, and the Ponders’ life as they had known it for decades was about to change dramatically.

What Do You Think? 1. Which of Mr. and Mrs. Ponder’s symptoms

seem typical of someone in later stages of life and which seem very different?

2. What external events and internal factors might be responsible for Mr. Ponder’s dramatic changes in thoughts and behaviors?

3. What are you curious about regarding Mr. and Mrs. Ponder?

4. Do the Ponders remind you in any way of someone you know? How so?

5. How might the Ponders’ memory problems affect their lives in the future?

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Normal Changes During Aging and Neurocognitive Disorders: What Are They? 425

Normal Changes During Aging and Neurocognitive Disorders: What Are They?

Most of us experience subtle changes in memory and other thinking processes as we age. As we enter our 30s and 40s, slightly greater problems start to occur with respect to short-term memory. Middle-aged adults may start to wonder more why they went upstairs (what was I looking for?), where they misplaced something (what did I do with those keys?), or the name of someone they met last night (who was that guy?). Other people experience changes in long-term memory, such as forgetting who won the World Series 5 years ago. Still others experience more problems with episodic memory, or ability to recall personal experiences from further in the past, such as the name of their �fth-grade teacher (El Haj et al., 2016).

These normal changes may relate to alterations in brain areas most responsible for memory. The hippocampus and fron- tal lobes may lose brain cells or be affected by neurochemical changes such as loss of dopamine over time (Rolls & Deco, 2015). These alterations, however, are often slow to develop, only mildly annoying, and do not signi�cantly interfere with daily functioning. Once a person is reminded of something (you went upstairs to look for keys), the sought-after memory is usually retrieved quickly. Still, one can usually tell he is not as “quick” to remember things as in the past. He may experience more of what is known as the tip-of-the-tongue phenomenon, or feeling he knows something he cannot immediately remember.

Normal changes occur in the frontal lobe and other brain areas over time, so one might also experience subtle dif�culties in other cognitive areas. Such dif�culties often involve process- ing and reasoning speed, decision making, planning for events, paying attention, and exercising good judgment (Resnick & Boltz, 2016). A person may �nd it takes more time than usual to decide which car to buy, has trouble keeping straight all the details of organizing a wedding or concentrating on a long lecture, or cannot navigate a complex driving trip in a strange city. Subtle changes may also occur with respect to computing mathematical problems, sorting objects, and discriminating patterns. A person may begin to have more trouble reading complex music. What makes all of these changes normal, however, is the fact that most everyone experiences them to some extent and that these experiences do not interfere signi�cantly with daily functioning.

General memory, learning, or concentration problems do increase over time. The percentage of people experiencing mild cognitive impairment is 4.5 percent at age 60 to 69 years, 5.8 percent at age 70 to 79 years, and 7.1 percent at age 80 to 89 years (Sachdev et al., 2015). These �gures are signi�cant but also tell us that the large majority of older people do not have do not have do not substantial cognitive problems. People aged 65 years and older tend to be married, living in a household, and owners of their own home (U.S. Department of Health and Human Services, 2014). These facts dispel the notion that most elderly people must depend on others for their livelihood.

For some people, however, memory and thinking changes do become much more severe under certain circumstances (Figure 14.1). Someone’s ability to remember information and pay close attention to others is likely impaired when she has been drinking heavily, has just come out of surgery under general anesthesia, or has a high fever. People in these states are often confused and have trouble staying awake. Such impairments in cognition, which are usually temporary and reversible, are often referred to as delirium.

For other people, memory and thinking changes become much more severe as they age. Someone’s ability to recall in- formation may still be impaired even after a reminder is given, or a person’s forgetfulness may become very frequent. A person may start to forget how to do simple things like tying a shoelace or using a microwave oven. She may also have trouble learn- ing new tasks, especially complicated ones, and struggle to have conversations with others. Other problems might include the need to repeat oneself or to constantly ask the same question to get information and remember it. A person in this situation, like Mr. Ponder, might also experience personality changes, loss of

For some older people, memory and thinking changes can be severe.

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CHAPTER 14 Neurocognitive Disorders426

social skills, loss of interest in daily activities, and psychological issues such as worry and sadness about cognitive changes. These cognitive changes are massive, often irreversible, and do signi�- cantly interfere with daily functioning. People undergoing such dramatic changes in memory and cognition experience demen- tia. In the following sections, we review features of these two major sets of neurocognitive disorders: delirium and dementia.

Neurocognitive Disorders: Features and Epidemiology Delirium Have you ever been in a state of mind where things around you seemed fuzzy or confusing? Perhaps you were just coming out of surgery with general anesthesia, were extremely tired, or stayed a little too long at happy hour. Your ability to think clearly or even to stay awake may have been affected. Delirium exists when someone’s normal state of thinking or conscious- ness is impaired (see Table 14.1; American Psychiatric Asso- ciation [APA], 2013). Impairment due to delirium is typically short-lived, and a person usually recovers fully. Examples in- clude fading of general anesthesia or another drug, becoming rehydrated, recovering from a high fever, or reducing stress or exhaustion.

A person in a state of delirium often has trouble interact- ing with others and is not clearly aware of surrounding events. She may have great trouble maintaining attention in a conversa- tion or moving attention from one person to another. Focused attention or concentration is dif�cult in these situations as well. Other higher-order cognitive processes are also impaired, including ability to remember information, speak clearly, or integrate information such as assembling a puzzle. Delirium is sometimes associated with disorientation, meaning a person has dif�culty remembering personal information, where he is, or even what time it is (Fong, Davis, Growdon, Albuquerque, & Inouye, 2015). A person may have been in a car accident that caused temporary inability to identify oneself, realize she is in a hospital, or recognize day or night. Mrs. Ponder sometimes showed symptoms of delirium when she appeared confused or unsure around others. These symptoms may have been due to sleep deprivation or stress.

14.1 Continuum of Thinking and Memory Problems and Neurocognitive Disorder

NORMAL MILD

Emotions Stable emotions during thinking and recall. Mild frustration and concern following memory lapses. Mild frustration and concern following memory lapses.

Cognitions Good thinking and memory processes. Occasional lapses of attention or memory or tip-of-the-Occasional lapses of attention or memory or tip-of-the- tongue phenomenon. tongue phenomenon. tongue phenomenon.

Behaviors Engaging in good work and social behavior. Engaging in good work and social behavior. Slight delays in work or requests to repeat something Slight delays in work or requests to repeat something someone has said. someone has said.

CONTINUUM FIGURE

Emotions

Cognitions

Behaviors

Emotions

Cognitions

Behaviors

People with delirium often have trouble understanding time and location.

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Neurocognitive Disorders: Features and Epidemiology 427

Another key aspect of delirium is �uctuation of the problem over hours and days. A person may be lucid and can maintain a conversation at times but seem confused and sleepy at other times (Bush & Lawlor, 2015). Many people in a state of delirium slip in and out of sleep or conscious awareness. A person’s mood may also shift quickly, perhaps from anger to apathy to giddiness

within a short time. Motor behavior can change quickly as well, as when someone becomes agitated and then slows down con- siderably or sleeps (Fitzgerald et al., 2015). Psychotic-like symp- toms of delusions and hallucinations can occur as well, which make states of delirium potentially dangerous. Someone in this state should never drive a car or be left unsupervised.

Delirium is usually caused by general medical conditions or substance intoxication or withdrawal, but many other fac- tors can lead to the problem as well (see Table 14.2). Speci�c medical evidence is usually necessary to assign a diagnosis of delirium, but direct observation can sometimes be enough. If delirium might be due to an electrolyte imbalance, then a medi- cal assessment is likely necessary. If delirium might be due to recent alcohol intake, however, then simply observing the per- son or interviewing signi�cant others may be suf�cient. States of delirium should not be assumed when a person may actually be in a state of dementia, aspects of which we discuss next.

MODERATE

NEUROCOGNITIVE DISORDER—LESS NEUROCOGNITIVE DISORDER—LESS

SEVERE

NEUROCOGNITIVE DISORDER—MORE NEUROCOGNITIVE DISORDER—MORE

SEVERE

Increasing frustration at loss of attention and Increasing frustration at loss of attention and memory or irritability with others. memory or irritability with others.

Intense anxiety and concern about attention and Intense anxiety and concern about attention and memory loss.

Dramatically decreased emotional behavior, Dramatically decreased emotional behavior, including apathy about one’s condition. including apathy about one’s condition.

Ongoing and regular lapses of Ongoing and regular lapses of attention or memory, especially attention or memory, especially attention or memory, especially short-term memory.

Intense decreases in attention, Intense decreases in attention, memory, processing speed, memory, processing speed, memory, processing speed, planning ability, and judgment.

Extreme loss of attention and memory, such that Extreme loss of attention and memory, such that long-term memories become lost. long-term memories become lost. long-term memories become lost.

Greater dif�culties organizing and completing work and engaging in conversations.

Ongoing inability to converse well with others; getting lost frequently and wandering.

Dramatically decreased physical behavior; little verbal activity and sleeping much.

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TABLE 14.1 DSM-5

Delirium A. A disturbance in attention and awareness (reduced orientation to

the environment).

B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to �uctuate in severity during the course of a day.

C. An additional disturbance in cognition.

D. The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disor- der and do not occur in the context of a severely reduced level of arousal, such as coma.

E. There is evidence from the history, physical examination, or labora- tory �ndings that the disturbance is a direct physiological conse- quence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

Specify if due to substance intoxication, substance withdrawal, medi- cation, another medical condition, or multiple etiologies; if acute or persistent; if hyperactive, hypoactive, or mixed level of activity.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 14 Neurocognitive Disorders428

Dementia and Major and Mild Neurocognitive Disorder Delirium involves cognitive de�cits that are acute, develop quickly, �uctuate, and are typically reversible. Dementia, on the other hand, involves cognitive de�cits that:

• are chronic, meaning the de�cits last for long periods • develop slowly, meaning gradual onset of the de�cits • show a progressive course, meaning little �uctuation in the progressive course, meaning little �uctuation in the progressive

de�cits

• are usually irreversible, meaning the de�cits do not improve with time

Cognitive de�cits in dementia also involve problems with learning, memory, attention, language, recognition, planning, decision making, problem solving, concentration, judgment, and perceptual-motor ability (such as driving). Mr. Ponder had many problems with mathematical ability, memory, and focused attention. Delirium and dementia often occur together and

share common etiologies such as general medical conditions, substance use, or some combination of these, and symptoms of each also commonly resemble those of depression and schizo- phrenia (see Table 14.3; Fong et al., 2015). Delirium is usually reversible, however, so we concentrate in this chapter on dementia or delirium with dementia.

Dementias may be characterized as a neurocognitive dis- order that can differ in severity (see Table 14.4; APA, 2013). A major neurocognitive disorder involves signi�cant cogni- tive decline and interference with daily activities such as paying bills. This was the case for Mr. Ponder. A mild neurocognitive disorder involves modest cognitive decline but without interfer- ence in daily activities. This was the case for Mrs. Ponder. A mild neurocognitive disorder may eventually progress to a major neurocognitive disorder. The terms dementia and major neu- rocognitive disorder remain generally synonymous, although dementia sometimes speci�cally refers to older persons with multiple cognitive problems.

Dementias can also be characterized as presenile or senile. You may have heard the term “senile” sometimes applied to older people. This term is not a clinical one but refers only to some loss of mental ability with age. Presenile dementia, how- ever, commonly refers to onset of dementia symptoms before age 65 years, whereas senile dementia is a term that commonly senile dementia is a term that commonly senile dementia refers to onset of dementia symptoms after age 65 years (Vieira et al., 2013). People with presenile (or early onset) dementias typically show more severe symptoms and often die from the disorders much sooner than people with senile dementias. Pre- senile dementias may have a more aggressive course due to stronger genetic or other biological links than senile dementias (Shrestha, Wuerz, & Appleby, 2015).

We describe the most common types of neurocognitive disorder in this chapter. You should be aware that many other types exist, however. Examples include neurocognitive disorder brought on by HIV disease, Prion disease, Huntington’s disease, brain tumor, thyroid problems, malnutrition, blood that collects on the surface of the brain (subdural hematoma), infections, metabolic disorders, and advanced stages of multiple sclerosis (APA, 2013). Creutzfeldt-Jakob disease, a condition that leads to rapid neurological impairment, can also produce neurocognitive disorder and death (Song & Zhang, 2015). Various substances or toxins can also lead to neurocognitive disorder if ingested for prolonged periods. Examples include carbon monoxide, inhal- ants, lead, and mercury (Caito & Aschner, 2015).

Alzheimer’s Disease One of the most tragic and severe mental problems we discuss in this textbook is Alzheimer’s disease (see Table 14.5; APA, 2013). Some of you may already be familiar with this disorder by reading about famous people who had the disorder, such as Ronald Reagan or Charlton Heston, or by knowing older family members with the disorder. Alzheimer’s disease involves slow and irreversible progression of dementia. Alzheimer’s disease necessarily involves multiple cognitive de�cits, but especially those related to memory. The disorder accounts for about 60 to

TABLE 14.2

Possible Causes of Delirium

Substance intoxication

Substance withdrawal

Metabolic/endocrine disturbance

Traumatic brain injury

Seizures

Neoplastic disease

Intracranial infection

Systemic infection

Cerebrovascular disorder

Organ insuf�ciency

Other central nervous system etiologies

Other systemic etiologies:

Heat stroke

Hypothermia

Radiation

Electrocution

Postoperative state

Immunosuppression

Fractures

Neurocognitive Disorders: Features and Epidemiology 429

78 percent of all cases of dementia (Mielke, Vemuri, & Rocca, 2014; Tom et al., 2015).

The following cognitive de�cits are likely to occur in some- one with Alzheimer’s disease:

• Aphasia, or impaired ability to use or comprehend spoken language, as when a person has dif�culty speaking or can- not understand what is being said to him

• Apraxia, or impaired voluntary movement despite adequate sensory and muscle functioning, as when a person can no longer tie her shoes

• Agnosia, or impaired ability to recognize people or common objects, as when a person fails to recognize loved ones or basic items such as a spoon

• Executive functioning de�cits, which include impaired abil- ity to plan or organize daily activities, engage in abstract thinking, or understand the sequence of events, such as ma- neuvering driving turns to get to and from a grocery store

These cognitive problems develop slowly and worsen over a period of 5 to 9 years. People with Alzheimer’s disease in early stages of the disorder may appear simply forgetful or distracted when speaking to others. They may become confused about where they are, take less initiative in daily activities, and have trouble with logical thought. These subtle impairments eventu- ally worsen, however, as people with Alzheimer’s disease will often take longer time to complete simple tasks such as making a sandwich or will have greater dif�culty with more complicated

tasks (Leoutsakos et al., 2015). Mr. Ponder could no longer drive himself places or compute complex mathematical problems.

As Alzheimer’s disease progresses further, personality changes are seen, and problems start to develop with skills prac- ticed for many years, such as reading and writing (Chertkow, Feldman, Jacova, & Massoud, 2013). Mr. Ponder was becom- ing more belligerent and tense and clearly had trouble with his

TABLE 14.3

Differential Diagnosis of Delirium, Dementia, Depression, and Schizophrenia

Delirium Dementia Depression Schizophrenia

Onset Acute Insidiousa Variable Variable

Course Fluctuating Often progressive Diurnal variation Variable

Reversibility Usuallyb Not usually Usually but can be recurrent

No, but has exacerbations

Level of consciousness Impaired Unimpaired until late stages

Generally unimpaired Unimpaired (perplexity in acute stage)

Attention and memory Inattention is primary with poor memory

Poor memory without marked inattention

Mild attention problems, inconsistent pattern, memory intact

Poor attention, memory intact

Hallucinations Usually visual; can be auditory, tactile, gustatory, olfactory

Can be visual or auditory

Usually auditory Usually auditory

Delusions Fleeting, fragmented, usually persecutory

Paranoid, often �xed Complex and mood congruent

Frequent, complex, system- atized, often paranoid

aExcept for large strokes. bCan be chronic (paraneoplastic syndrome, central nervous system adverse events of medications, severe brain damage). From Essentials of Neuropsychiatry and Behavioral Neurosciences (2nd ed.), by Stuart C. Yudofsky, M.D, and Robert E.Hales, M.D., M.B.A., Table 5.3 p. 154. Copyright © 2010 American Psychiatric Publishing, Inc.

Herb Winokur, 83, is suffering from dementia and Parkinson’s disease. His daughter must decide how to provide the best care for him because his condition makes it virtually impossible for him to complete sentences and maintain his independent lifestyle.

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CHAPTER 14 Neurocognitive Disorders430

checkbook. People with Alzheimer’s disease also begin to have enormous problems interacting with others and completing basic motor tasks such as tying shoelaces. Long-term memory and other cognitive areas of functioning eventually become much more impaired, even to the point where a person cannot recognize others or care for himself (Bortolon, Louche, Gely- Nargeot, & Raffard, 2015). Mr. Ponder needed assistance doing everyday activities such as getting dressed and may get to the point where he will not recognize his wife of nearly 60 years. Basic abilities such as speech, walking, feeding, and toileting are severely impaired in �nal stages of Alzheimer’s disease.

Someone with the disorder is often placed under supervised care and usually dies from pneumonia or other diseases (Weuve, Hebert, Scherr, & Evans, 2014).

Lewy Bodies Another neurocognitive disorder that is similar to Alzheimer’s disease involves Lewy bodies (see Table 14.6; APA, 2013). This disorder, sometimes called Lewy body disease, includes most of the key features of Alzheimer’s disease, but may also include visual hallucinations, muscle tremors, and a more �uctuating course of symptoms (Urwyler et al., 2015). A person with ad- vanced Lewy body disease may speak normally at one time of day and later experience great dif�culty interacting with oth- ers. The problem is linked mostly to Lewy bodies in the cortex,

TABLE 14.4 DSM-5

Major and Mild Neurocognitive Disorder

TABLE 14.5 DSM-5

Major or Mild Neurocognitive Disorder Due to Alzheimer’s DiseaseMajor Neurocognitive Disorder

A. Evidence of signi�cant cognitive decline from a previous level of performance in one or more cognitive domains based on:

1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a signi�cant decline in cognitive function; and

2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quanti�ed clinical assessment.

B. The cognitive de�cits interfere with independence in everyday activities.

C. The cognitive de�cits do not occur exclusively in the context of a delirium.

D. The cognitive de�cits are not better explained by another mental disorder.

Specify if due to Alzheimer’s disease, frontotemporal lobar degen- eration, Lewy body disease, vascular disease, traumatic brain injury, substance/medication use, HIV infection, Prion disease, Parkinson’s disease, Huntington’s disease, another medical condition, multiple etiologies, or unspeci�ed.

Mild Neurocognitive Disorder

A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains based on:

1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and

2. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quanti�ed clinical assessment.

B. The cognitive de�cits do not interfere with capacity for indepen- dence in everyday activities.

C. The cognitive de�cits do not occur exclusively in the context of a delirium.

D. The cognitive de�cits are not better explained by another mental disorder.

A. The criteria are met for major or mild neurocognitive disorder.

B. There is insidious onset and gradual progression of impairment in one or more cognitive domains.

C. Criteria are met for either probable or possible Alzheimer’s disease as follows:

For major neurocognitive disorder: Probable Alzheimer’s disease is diagnosed if either of the following is present; otherwise, possible Alzheimer’s disease should be diagnosed.

1. Evidence of a causative Alzheimer’s disease genetic mutation from family history or genetic testing.

2. All three of the following are present: a. Clear evidence of decline in memory and learning and at least

one other cognitive domain. b. Steadily progressive, gradual decline in cognition, without

extended plateaus. c. No evidence of mixed etiology.

For mild neurocognitive disorder: Probable Alzheimer’s disease is diagnosed if there is evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing or family history.

Possible Alzheimer’s disease is diagnosed if there is no evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing or family history, and all three of the following are present:

1. Clear evidence of decline in memory and learning. 2. Steadily progressive, gradual decline in cognition, without extended

plateaus. 3. No evidence of mixed etiology.

D. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Neurocognitive Disorders: Features and Epidemiology 431

substantia nigra, and other brain areas (Donaghy, Thomas, & O’Brien, 2015). Lewy bodies are accumulations of certain pro- teins in neurons that lead to cell damage. Lewy body disease may account for about 4 to 5 percent of cases of dementia, although signi�cant overlap with Alzheimer’s disease is often seen (Jones & O’Brien, 2014).

Vascular Disease Vascular disease, sometimes also referred to as cerebrovascular disease, is another common form of neurocognitive disorder but one caused by problems with blood vessels that supply the brain with oxygen and other nutrients (see Table 14.7; APA, 2013). The most common blood vessel problem that leads to vascular-based neurocognitive disorder, sometimes called vascular dementia, is a stroke. A stroke occurs when a blood vessel is blocked or bursts, which denies oxygen to parts of the brain; various areas of the brain, especially the cortex, can suffer potentially severe damage. Vascular disease that results in vascular dementia could also affect only subcortical areas of the brain. This can occur subcortical areas of the brain. This can occur subcortical from hypertension, diabetes, or heart disease (Smith, 2016).

A stroke is most often caused by blood clots that block a key artery to the brain—an ischemic stroke. More unusually, a stroke ischemic stroke. More unusually, a stroke ischemic

may be caused by a ruptured blood vessel—a hemorrhagic or hemorrhagic or hemorrhagic bleeding stroke. Damage from strokes may be limited, as when a person is treated quickly and perhaps only suffers moderate memory problems. Damage from a stroke can also be severe and lead to paralysis and dementia that resemble symptoms of Alzheimer’s disease (Chen et al., 2015). Severe damage is often the result of multiple strokes.

What is the difference between neurocognitive disorder due to vascular disease versus Alzheimer’s disease? The general symptoms of each disorder are quite similar, but people with vascular-based neurocognitive disorder more often experience:

• a history of stroke • faster, even abrupt, onset of dementia symptoms, such as

after a stroke

• better retention of overall cognitive functioning, especially memory

• stepwise deterioration, meaning dementia symptoms can �uctuate

TABLE 14.6 DSM-5

Major or Mild Neurocognitive Disorder with Lewy Bodies A. The criteria are met for major or mild neurocognitive disorder.

B. The disorder has an insidious onset and gradual progression.

C. The disorder meets a combination of core diagnostic features and suggestive diagnostic features for either probable or possible neurocognitive disorder with Lewy bodies.

For probable major or mild neurocognitive disorder with Lewy bodies, the individual has two core features, or one suggestive feature, with one or more core features.

For possible major or mild neurocognitive disorder with Lewy bodies, the individual has only one core feature, or one or more suggestive features.

1. Core diagnostic features: a. Fluctuating cognition with pronounced variations in attention

and alertness. b. Recurrent visual hallucinations that are well formed and

detailed. c. Spontaneous features of parkinsonism, with onset subsequent

to the development of cognitive decline. 2. Suggestive diagnostic features:

a. Meets criteria for rapid eye movement sleep behavior disorder. b. Severe neuroleptic sensitivity.

D. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Vascular dementia and partial paralysis are often caused by stroke.

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CHAPTER 14 Neurocognitive Disorders432

• focal neurological signs, meaning certain de�cits such as dif�culty writing can indicate what areas of the brain, such as the pari- etal lobe, were most affected

• patchy distribution of de�- cits, meaning some areas of cognitive functioning are left intact and others are greatly impaired (Geschwind & Belkoura, 2016)

A person with patchy dis- tribution of de�cits may retain the ability to walk and recognize others but can no longer speak or understand what others say. You can only imagine how dif- �cult such an existence can be.

Vascular dementia accounts for about 15 percent of all de-

mentias, although many people with vascular-based neuro- cognitive disorder also have Alzheimer’s disease (O’Brien & Thomas, 2015). This is mixed dementia. People with vascular- based neurocognitive disorder, like those with Alzheimer’s dis- ease, usually deteriorate with respect to mental and physical health, but death may come sooner for people with vascular problems (Roehr et al., 2015).

Parkinson’s Disease Parkinson’s disease is a progressive neurological disorder marked by abnormal movements that may lead to a neurocogni- tive disorder (see Table 14.8; APA, 2013). Abnormal movements include resting tremors in which a person has uncontrollable hand shaking or “pill-rolling” behavior with the �ngers. The tremors are called resting ones because shaking tends to be worse when the person is idle. Other abnormal movements also characterize this population, including the following (adapted from Jankovic & Tolosa, 2015):

• rigidity, or dif�culty moving muscles and feeling stiff • bradykinesia, or very slow movement or trouble initiating

movement, such as trying to walk again after stopping

• hypokinesia and akinesia, or poor quality of movement and lack of movement

• postural instability, or dif�culty standing after sitting, stay- ing in one position, maintaining balance, or standing erect

• hypomimia, or lack of facial expression • other abnormal actions such as inability to blink eyes,

maintain appropriate eye movements, swing arms, or walk without shuf�ing

Dementia occurs in about 25 to 30 percent of those with Parkinson’s disease, especially in later stages (Gatt et al., 2016).

People with Parkinson’s disease show less of the classic charac- teristics of cortical dementia found in people with Alzheimer’s disease. Instead, they often display subcortical dementia, mean- ing their primary cognitive problems include slowed thinking and dif�culty using newly acquired knowledge and retrieving information from memory (Kandiah et al., 2014). A person with advanced Parkinson’s disease may have trouble processing what others say, thinking abstractly to understand something new, and integrating visual information for tasks like driving. Language is also problematic for people with Parkinson’s disease—many have monotone, slurred, and repetitive speech. Depression and apathy are common in people with subcortical dementias due to Parkinson’s disease (Whit�eld et al., 2015). Parkinson’s disease has a chronic, progressive course that eventually leads to severe motor problems and death (Macleod, Taylor, & Counsell, 2014).

Pick’s Disease Pick’s disease is characterized mainly by deterioration in the frontal and temporal brain lobes. People with Pick’s disease demonstrate many of the major characteristics of people with

Michael J. Fox has Parkinson’s disease that has not progressed to dementia. Fox has a website with extensive information on Parkinson’s disease and how you can help: www.michaeljfox.org.

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TABLE 14.7 DSM-5

Major or Mild Vascular Neurocognitive Disorder A. The criteria are met for major or mild neurocognitive disorder.

B. The clinical features are consistent with a vascular etiology, as suggested by either of the following:

1. Onset of the cognitive de�cits is temporally related to one or more cerebrovascular events.

2. Evidence for decline is prominent in complex attention (including processing speed) and frontal-executive function.

C. There is evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging considered suf�cient to account for the neurocognitive de�cits.

D. The symptoms are not better explained by another brain disease or systemic disorder.

Probable vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise possible vascular neurocognitive disorder should be diagnosed:

1. Clinical criteria are supported by neuroimaging evidence of signi�- cant parenchymal injury attributed to cerebrovascular disease.

2. The neurocognitive syndrome is temporally related to one or more documented cerebrovascular events.

3. Both clinical and genetic evidence of cerebrovascular disease is present.

Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not available and the temporal relationship of the neurocognitive syndrome with one or more cerebro- vascular events is not established.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Neurocognitive Disorders: Features and Epidemiology 433

Alzheimer’s disease but generally experience earlier age of on- set of dementia and personality and behavioral changes. Pick’s disease is perhaps the most well-known of what is called fronto- temporal dementias, in which frontal and temporal brain lobes are affected. Frontotemporal dementias account for about 10 to 20 percent of all dementia cases, especially early-onset cases (Ferrari et al., 2014). These dementias are marked by severe personality changes that can lead to disinhibition, poor social skills, and lack of insight into one’s behavior (Mendez, Joshi, Tassniyom, Teng, & Shapira, 2013). Major features of neuro- cognitive disorder due to frontotemporal problems are listed in Table 14.9. Outward symptoms of Pick’s disease and Alzheimer’s disease are dif�cult to distinguish, and many times an accurate diagnosis can be made only at autopsy.

Other Problems Neurocognitive disorders can also arise from other problems such as traumatic brain injury (APA, 2013). In addition, severe memory problems are sometimes seen in people with chronic and exces- sive substance use. Memory problems may be anterograde, mean- ing a person has trouble forming new memories, or retrograde, meaning memories of past events and experiences are affected (Gervais, Barrett-Bernstein, Sutherland, & Mumby, 2014). People with chronic, excessive substance use may have trouble learning others’ names and remembering events that recently happened, such as what they had for dinner last night. Spontaneous recall, in which a person is asked to remember something on the spot, such as her address, can be impaired as well. The problem may be so severe a person is continually lost, unable to communicate effectively, or has dif�culty holding a job.

Korsakoff’s syndrome is a problem associated with chronic alcohol use. Ongoing memory problems of people with this syn- drome can be severe and linked to confusion and disorientation. Many people with Korsakoff’s syndrome engage in confabula- tion, or the creation of fables or stories to �ll memory gaps and hide memory problems. Korsakoff’s syndrome is caused by lack of thiamine because a person drinks alcohol instead of eating a thiamine because a person drinks alcohol instead of eating a thiamine balanced diet. Blood vessel hemorrhages and damage to neu- rons can thus occur (Kopelman, 2015). Some but not complete improvement in symptoms may result when a person withdraws from alcohol use and resumes appropriate nutrition (Rossi, Conte, & Massironi, 2015).

TABLE 14.8 DSM-5

Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease A. The criteria are met for major or mild neurocognitive disorder.

B. The disturbance occurs in the setting of established Parkinson’s disease.

C. There is insidious onset and gradual progression of impairment.

D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.

Major or mild neurocognitive disorder probably due to Parkinson’s disease should be diagnosed if 1 and 2 are both met. Major or mild neurocognitive disorder possibly due to Parkinson’s disease should be diagnosed if 1 or 2 is met:

1. There is no evidence of mixed etiology. 2. The Parkinson’s disease clearly precedes the onset of the neuro-

cognitive disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

TABLE 14.9 DSM-5

Major or Mild Frontotemporal Neurocognitive Disorder

A. The criteria are met for major or mild neurocognitive disorder.

B. The disturbance has insidious onset and gradual progression.

C. Either (1) or (2):

1. Behavioral variant: a. Three or more of the following behavioral symptoms:

i. Behavioral disinhibition. ii. Apathy or inertia. iii. Loss of sympathy or empathy. iv. Perseverative, stereotyped or compulsive/ritualistic

behavior. v. Hyperorality and dietary changes.

b. Prominent decline in social cognition and/or executive abilities.

2. Language variant: a. Prominent decline in language ability, in the form of speech

production, word �nding, object naming, grammar, or word comprehension.

D. Relative sparing of learning and memory and perceptual-motor function.

E. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

Probable frontotemporal neurocognitive disorder is diagnosed if either of the following is present; otherwise, possible frontotemporal neurocognitive disorder should be diagnosed:

1. Evidence of a causative frontotemporal neurocognitive disorder genetic mutation, from either family history or genetic testing.

2. Evidence of disproportionate frontal and/or temporal lobe involvement from neuroimaging.

Possible frontotemporal neurocognitive disorder is diagnosed if there is no evidence of a genetic mutation, and neuroimaging has not been performed.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

CHAPTER 14 Neurocognitive Disorders434

Epidemiology of Neurocognitive Disorders The U.S. Department of Health and Human Services reports that people aged 65 years and older represented 13.3 percent of the total American population in 2011, but this percentage is expected to rise to 21.0 percent by 2040. Percentages of people aged over 85 years will more than double from 1.8 percent of the population in 2011 to 3.7 percent in 2040, or from 5.7 million to 14.1 million people. This oldest age group will be one of the fastest growing age groups in the country! This trend in aging occurs in many other countries as well. The prevalence of neurocognitive disorders increases with age, so we can expect many more people to experience prob- lems of delirium and dementia over the next decades.

Delirium is a disorder that can affect anyone because the problem can result from various medical conditions, sub- stances, and other variables (Box 14.1). The prevalence of delirium does increase with age, however: 1 to 2 percent for people aged 65+ years and 10 percent for people aged 85+ years (de Lange, Verhaak, & van der Meer, 2013). Medication is a common variable that results in delirium. Patients medi- cated for a stroke-related condition often experience delirium (Perez-Protto, Harinstein, Makarova, Hata, & Popovich, 2015). About 20 percent of people in a hospital, especially those leaving surgery, have delirium (Ryan et al., 2013). People living in geri- atric hospitals and nursing homes may also have relatively high rates of delirium (range, 1.4–70.3 percent; de Lange et al., 2013).

The rate of dementia also increases with age, especially after age 80 years (Figure 14.2). Most elderly persons are still unaf-unaf-unaf fected, however—only about 5 to 7 percent of people older than

60 years have dementia (Prince et al., 2013). Rates of dementia increase sharply among persons in long-term care facilities, how- ever (62 percent; Rocha, Marques, Pinto, Sousa, & Figueiredo, 2013). The cost of treating Americans with dementia was $226 billion in 2015 and is estimated to be $1.1 trillion in 2050 (Alzheimer’s Association, 2015). Rates of Alzheimer’s disease closely follow rates of general dementia because Alzheimer’s disease comprises most cases of dementia. Approximately two thirds of people with Alzheimer’s disease are women (Mielke et al., 2014) and most are age 75 years and older (Figure 14.3).

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FIGURE 14.2 PREVALENCE OF ALL DEMENTIA BY GENDER AND AGE. Source: Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and metaanalysis. Alzheimer’s and Dementia, 9, 63-75, Table 2.

Reasons for using these medications generally surrounded the need for better concentration, study skills, and to stay awake. Ironically, however, nonusers appear to be more successful in academics than those misus- ing stimulant medication (Benson, Flory, Humphreys, & Lee, 2015).

Sleep deprivation is another common element of college life. Estimates are that 50 percent of college students have daytime sleepiness (com- pared to 36 percent in the general population) and that 70 percent do not get enough sleep. Consequences of excessive sleepiness include lower grade point averages, increased risk of academic failure and motor vehi- cle accidents, learning problems, and mood changes such as depression. Factors that most affect lack of sleep in college students include (1) alco- hol use, which creates fragmented sleep; (2) caffeine and energy drinks, the effects of which can last 5 to 8 hours; (3) stimulant medication; and (4) technology use. With respect to the latter, about 57 percent of young adults leave their phone on during sleep, but light exposure from devices can lower melatonin and delay sleep onset. Sleep deprivation impairs learn- ing and academic outcomes, but high academic performers are more likely to take a nap during the day than low academic performers (Hershner & Chervin, 2014). Stimulant medications and staying up all night may seem on the surface like good academic strategies, but the data suggest otherwise.

Focus On

One neurocognitive problem that has been investigated in college students One neurocognitive problem that has been investigated in college students is delirium, including some of the factors that are associated with this change in consciousness. Of course, substance-related issues discussed in Chapter 9 can create problems of delirium in college students. Other areas of focus have included stimulant medication use and sleep depriva- tion, which are common to those with demanding academic schedules and frequent projects, papers, and exams. Rate of stimulant medication misuse among college students is 17 percent, and commonly used medications include Adderall, Ritalin, Concerta, Dexedrine, Desoxyn, Metadate, Cylert, and Focalin. Students most likely to misuse stimulant medication included those with attention-de�cit/hyperactivity disorder (Chapter 13), problematic alcohol use, marijuana use, and membership in fraternities or sororities.

14.1

College Students Delirium

Stigma Associated with Neurocognitive Disorders 435

The prevalence of dementia, especially Alzheimer’s dis- ease, does vary somewhat across cultures. Dementia tends to be diagnosed more in developed countries, where about 60 percent of all cases occur. This trend is expected to change with time to include more cases in less developed countries. Rates of dementia are generally highest in the Americas and Europe and lower in Africa, the Middle East, and Asia. Less developed countries tend to have higher rates of vascular de- mentia, however (Prince et al., 2013; Rizzi, Rosset, & Roriz-Cruz, 2014). This discrepancy may be due to genetic, diagnostic, or cultural differences. People in certain cultures may �nd it more acceptable to have an obvious physical problem account for a mental disorder. In the United States, risk for Alzheimer’s disease is higher for African Americans and Hispanics than European Americans and Asian Americans (Alzheimer’s Association, 2015).

Vascular dementia also increases with age, but men gener- ally display vascular dementia more than women. The general prevalence of vascular dementia is about 1.5 to 4.8 percent in older adults, and about 25 to 30 percent of those who experi- ence a stroke eventually develop dementia (Black, 2011; Chui, 2013). African Americans tend to have higher rates of vascular dementia than European Americans. Reasons for this difference are unclear but could include genetic factors, cardiovascular disease, perceptions about what is normal aging and what is not, lack of access to medical care, and issues of trust between minority groups and the medical establishment (Chin, Negash, & Hamilton, 2011).

Dementia due to Parkinson’s disease does not affect men and women differently, but prevalence of the neurocognitive disorder does increase with age. The prevalence of dementia due to Parkinson’s disease is 0.3 to 0.5 percent in people older than 65 years (Aarsland & Bernadotte, 2015). Men and women

show equal rates of dementia due to Parkinson’s disease, but dementia due to Parkinson’s disease, but dementia prevalence of the disease itself is more common among men than women. This difference may be partly due to effects of sex hormones or X-linked factors, but this remains unclear (Cereda et al., 2016). Racial differences for Parkinson’s disease have been noted as well, with rates somewhat higher for Hispanics and European Americans than African Americans. Parkinson’s disease is generally less seen in Asia and Africa than Europe and North America (Lo & Tanner, 2013).

Frontotemporal dementias, which include Pick’s disease, are presenile problems that generally occur at earlier ages than other dementias, and especially in cases involving trau- matic brain injury (LoBue et al., 2015). Men may display the disorders more so than women, but other studies indicate no gender difference. The prevalence of frontotemporal dementia is 15 to 22 cases per 100,000 people. Data are scarce regard- ing cultural differences, but frontotemporal dementia may be less common in Japan than Western nations (Onyike & Diehl-Schmid, 2013).

The neurocognitive disorders we have described here are highly comorbid with one another, and a conclusive diagno- sis is often dif�cult to determine. Many people with major neurocognitive disorder also have comorbid problems such as apathy, psychosis, agitation, aggression, depression, and anxiety (Stewart et al., 2014). Changes in eating and sleep- ing patterns, wandering, and problems communicating with others are also common. Family members and clinicians often have dif�culty distinguishing someone with severe emotional problems from someone with a major neurocognitive disor- der. Maltreatment of this population is often a concern as well (see Box 14.2).

Stigma Associated with Neurocognitive Disorders

Stigma often affects those who care for people with neu-rocognitive disorders such as Alzheimer’s disease. Werner and colleagues have found that family stigma associated with Alzheimer’s disease includes caregiver, lay public, and structural stigma. Caregiver stigma includes the caregiver’s concerns about the inability of the person with Alzheimer’s disease to remember information or to engage in self-care such as toileting. Shame, embarrassment, and disgust were also commonly reported by caregivers. Lay public stigma in- cludes family concerns about how others stigmatize a person with Alzheimer’s disease such as focusing only on a person’s confusion or messy appearance, worrying about contagion, or fearing the disease. Structural stigma includes family con- cerns about social con�gurations such as health care services. Participants reported that physicians often had insuf�cient knowledge about Alzheimer’s disease and that inadequate services were available for people with dementia. Stigma, including shame and declining involvement in caregiving, accounted for a signi�cant percentage of caregiver burden (Werner, 2014).

FIGURE 14.3 AGES OF PEOPLE WITH ALZHEIMER’S DISEASE IN THE UNITED STATES. Source: Alzheimer’s Association (2015). 2015 Alzheimer’s disease facts and �gures. Alzheimer’s and Dementia, 11, 332-384, Figure 1.

85+ years, 38%

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CHAPTER 14 Neurocognitive Disorders436

Stigma can obviously affect people with Parkinson’s disease as well, given their sometimes extensive and visible physical symptoms. Conversely, some people with Parkinson’s disease show facial masking, or less expressive facial movement, that may give the appearance of apathy or social disengagement. People with high facial masking, especially women, may be seen by oth- ers as more depressed, less sociable, and less cognitively compe- tent than those with low facial masking (Hemmesch, 2014). Such negative judgments may cause some people with Parkinson’s disease to withdraw from others or to seek less treatment.

➲ Interim Summary • Normal memory and cognitive changes occur with age and

do not interfere with daily functioning. These changes may progress to more serious sets of neurocognitive disorders such as delirium and dementia.

• Delirium is an often temporary and reversible condition where a person is disoriented and has trouble with attention, concentration, and memory. Delirium may result from substance intoxication or medical situations such as anesthesia.

• Dementia is a more serious type of neurocognitive disorder that includes chronic and irreversible declines in memory and other cognitive processes. Neurocognitive disorders can be mild or major.

• The most common form of neurocognitive disorder is Alzheimer’s disease, a progressive condition marked by cognitive de�cits such as aphasia, apraxia, and agnosia and de�cits in executive functioning.

• Neurocognitive disorder due to Lewy bodies occurs when masses of proteins create neuron damage.

• Vascular dementia is a neurocognitive disorder caused by a blood vessel problem, especially a stroke. People with vascular dementia often face a more abrupt and acute onset of symptoms but less cognitive impairment than people with Alzheimer’s disease.

• Neurocognitive disorder may be due to Parkinson’s disease, a progressive neurological disorder involving severe problems in motor functioning.

• Neurocognitive disorder due to Pick’s disease is the most well known of the frontotemporal dementias, meaning de- terioration occurs in the frontal and temporal brain lobes.

• Neurocognitive disorders can also be caused by substances or medical conditions. Korsakoff’s syndrome involves intense memory problems resulting from long-term alcohol use and thiamine de�ciency.

• Dementia occurs in about 5 to 7 percent of older persons, and many people with one form of dementia also have another form of dementia.

• Caregiver, public, and structural stigma are often associ- ated with neurocognitive disorders.

➲ Review Questions 1. What normal changes in memory and general cognitive func-

tioning occur with age? 2. De�ne and contrast delirium and dementia. 3. What problems commonly lead to dementia or neurocognitive

disorder? 4. What is mixed dementia? 5. How common are different neurocognitive disorders in the

general population?

factors for elder maltreatment are disability, shared living situations, so- cial isolation of families, and abuser psychopathology (Corbi et al., 2015).

Maltreatment of an elderly person is also much more likely if a person has dementia (Roberto, 2016). Part of the reason for this may be the elderly person’s agitation or aggression toward a caregiver or a caregiver’s exhaus- tion or lack of patience. Maltreatment of elderly people with dementia may also be due to their problems communicating needs or pain to others, inabil- ity to make decisions about living arrangements, and depression and stress (Dong, 2015; Lachs & Pillemer, 2015).

Some researchers have advocated strategies for caregivers to com- bat maltreatment of people with dementia. These strategies include help- ing caregivers identify stressful situations and their own behaviors that set the stage for maltreatment as well as seeking assistance from others when needed (Anetzberger, 2012). Others have focused on coping skills to re- duce caregiver anxiety and depression (Cooper, Barber, Grif�n, Rapaport, & Livingston, 2016). Caring for someone with dementia can be dif�cult, so providing extensive support and respite is crucial to prevent maltreatment.

Focus On

Substantial media and research attention has focused on maltreatment toward children and domestic violence. One form of cruelty that receives less attention, however, is maltreatment of the elderly. Maltreatment of the elderly involves psychological or physical harm, neglect, or exploita- tion of an older person. Examples include physical and sexual aggres- sion, neglect of basic needs, and theft of assets (Lichtenberg, 2016). About 2 to 10 percent of elderly people are maltreated in some way. Some of this maltreatment occurs in nursing homes and related settings, but much is done by family members at home. The most signi�cant risk

Violence Maltreatment of the Elderly

14.2

Neurocognitive Disorders: Causes and Prevention 437

Neurocognitive Disorders: Causes and Prevention

Most disorders we have covered in this textbook generally involve a complex combination of biological and environ- mental risk factors. With neurocognitive disorders, however, biological changes play a dominant role. We thus concentrate on genetics, neurochemical changes, and major brain changes related to neurocognitive disorders. We do, however, discuss some evidence for environmental risk factors; awareness of these factors may help with prevention efforts regarding neuro- cognitive disorders.

Biological Risk Factors for Neurocognitive Disorders Genetics A genetic link to neurocognitive disorders appears to be clearer in early-onset cases. Wingo and colleagues (2012) examined thousands of people with probable Alzheimer’s disease. People with late-onset Alzheimer’s disease had an estimated herita- bility rate of 64.6 to 75.0 percent, but people with early onset Alzheimer’s disease (onset age less than 61 years) had an estimated heritability rate of 92 to 100 percent. The authors concluded that late-onset Alzheimer’s disease likely has several environmental components but that early-onset Alzheimer’s disease is almost purely a biological problem. Family and twin studies also reveal increased risk and thus a genetic basis for Alzheimer’s disease (Fogel & Geschwind, 2016).

Four main genetic factors seem related to Alzheimer’s disease:

• Amyloid precursor protein and chromosome 21 • Apolipoprotein E and chromosome 19 • Presenilin 1 and chromosome 14 • Presenilin 2 and chromosome 1

Amyloid precursor protein is a normal brain substance re- lated to a speci�c gene on chromosome 21. This gene undergoes changes, or mutations, in some people (Weick, Kang, Bonadurer, & Bhattacharyya, 2016). As these gene mutations occur, devas- tating brain changes can result because large amounts of this protein are produced (see brain features section). Alzheimer’s disease is found in a high percentage of people with Down syn- drome (Chapter 13). People with Down syndrome usually have three #21 chromosomes and thus substantial overproduction of this protein (Shaw, Zhang, & Chang, 2015).

Apolipoprotein E (APOE) is a protein related to a speci�c gene on chromosome 19. APOE, and especially one type of allele (gene part), APOE-4, are highly predictive of Alzheimer’s disease in general and declines in episodic memory in par- ticular (El Haj et al., 2016). People without APOE-4 have an estimated risk of 9 to 20 percent for developing Alzheimer’s disease, but people with one copy of the gene have a 25 to 60 percent risk and people with two copies of the gene have a 50 to 90 percent risk (Fuller, Demarch, & Winkler, 2015). Like the amyloid precursor protein, APOE-4 causes severe brain changes,

and the two substances likely interact in some way (Musiek & Holtzman, 2015).

Other key in�uences to Alzheimer’s disease include the pre- senilin 1 gene on chromosome 14 and the presenilin 2 gene on chromosome 1 (Weick et al., 2016). These genes also mutate in some people and lead to massive brain changes. Scores of muta- tions have been charted on the presenilin 1 gene alone (Zahs & Ashe, 2015). Mutations of presenilin genes may be associated with earlier onset and more familial types of Alzheimer’s dis- ease (Muchnik et al., 2015). Dozens of other genes also relate to Alzheimer’s disease, and the true cause of the disorder likely involves the interaction of these many different genes (Harrison & Bookheimer, 2016).

What about other forms of dementia? Many single-gene disorders such as sickle cell disease predispose people toward stroke, a major cause of vascular dementia. Researchers have also identi�ed genes that predispose people speci�cally toward strokes (Rivera, Veneziani, Ware, & Platt, 2016). Family his- tory and twin studies suggest a genetic link for stroke as well (Falcone, Malik, Dichgans, & Rosand, 2014). Others believe genetic factors implicated in Alzheimer’s disease, including APOE-4, are likely present in vascular dementia as well. This may help explain mixed dementia, or the presence of Alzheimer’s disease and vascular dementia in a person (Rohn, 2014).

Other neurocognitive disorders have some genetic basis as well. Early forms of Parkinson’s disease may relate to muta- tions in certain genes, called parkin genes, which cause neuron loss as well as harmful accumulation of proteins in the brain’s substantia nigra region (Scarffe, Stevens, Dawson, & Dawson, 2014). Frontotemporal dementias such as Pick’s disease may re- late to problems of the tau gene on chromosome 17. This gene is tau gene on chromosome 17. This gene is tau gene responsible for a protein that helps keep neurons from breaking apart, so mutations of the gene can lead to neuron disintegration (Ghetti et al., 2015). Problems such as Korsakoff’s syndrome may have some genetic basis as well, but conclusive evidence remains elusive (Higuchi, Matsushita, & Matsui, 2015).

Neurochemical Features Neurochemical changes also in�uence the development of dif- ferent neurocognitive disorders. Dementias are often marked by low levels of neurotransmitters, especially acetylcholine, sero- tonin, and norepinephrine. These neurotransmitter de�cits may

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be especially pertinent to key brain areas such as the limbic sys- tem, as well as connections between the frontal cortex and other brain areas (Kumar & Ekavali, 2015). This may help explain some key features of dementia, including problems of memory and other cognitive functioning, motor behavior, and emotional and personality changes. Low levels of these neurotransmitters would also help explain symptoms that commonly occur with dementia, including apathy and depression (Stella et al., 2014).

Another neurotransmitter lower among people with demen- tias, especially those with Parkinson’s disease and dementia with Lewy bodies, is dopamine. People with Parkinson’s disease show progressively lower levels of dopamine in the substan- tia nigra and other areas of the brain (Kansara, Trivedi, Chen, Jankovic, & Le, 2013). Lowered dopamine clearly relates to motor symptoms of Parkinson’s disease and may in�uence Par- kinson’s-related dementia (Gratwicke, Jahanshahi, & Foltynie, 2015). People with Lewy body dementia also have lowered do- pamine levels, though some overlap with Parkinson’s disease is likely (Siepel et al., 2016).

Other neurochemicals may occur in excess in people with dementia. One such substance is L-glutamate, which is an excit- atory neurotransmitter in the brain. High levels of L-glutamate activity are present in people with Alzheimer’s disease and may be high after an ischemic stroke, which could lead to vascular dementia (Busse et al., 2014). L-glutamate activity is important for normal learning and memory, but excessively high levels have been linked to neuron damage (Beppu et al., 2014).

Brain Features Genetic predispositions and neurochemical changes likely lead to massive brain changes in people with dementia, especially the following:

• neuro�brillary tangles, or twisted �bers inside nerve cells of the brain

• senile or neuritic plaques, or clusters of dead nerve cells and accumulations of amyloid proteins in the brain

• Lewy bodies, or deposits of alpha-synuclein proteins inside nerve cells of the brain

• atrophy, or gradual deterioration of different brain areas • oxidative stress and free radicals, or damage to brain cells

via oxygen exposure

Neuro�brillary tangles are a key aspect of dementia in general and Alzheimer’s disease in particular. Neurons consist of a microtubule, or skeleton structure held together by a protein substance called tau (Pachima, Zhou, Lei, & Gozes, 2016). Think of the neuron microtubule as the rails of a train track and the tau proteins as the railroad ties that hold the tracks together. The tau protein may become changed chemically and so the individual “railroad ties” become twisted around each other and eventu- ally collapse (Meier et al., 2016). The “tracks” of the neuron thus also collapse, and all of these pieces eventually snarl to form neuro�brillary tangles. The neurons in the brain begin to fall apart and these fragments eventually collect in spheres and other shapes.

As neuro�brillary tangles occur more frequently and affect multiple areas, the brain’s ability to coordinate behavior and communicate with the body becomes severely impaired. A per- son with neuro�brillary tangles will have enormous problems with higher-order behaviors such as thinking and memory be- cause the cortex and hippocampus of the brain are quite suscep- tible to this process (Yu, Boyle, Leurgans, Schneider, & Bennett, 2014). Lower-order behaviors such as motor skills and, eventu- ally, life-support functions, become impaired as well. This pro- cess is a slow and gradual but irreversible one and helps explain much of the progressive deterioration of functioning in people with dementia like Mr. Ponder.

Another common brain change in people with dementia is senile or neuritic plaques. These plaques are made of certain proteins—beta-amyloid proteins—that accumulate in spaces be- tween neurons in the brain (Zhao et al., 2015). Many proteins in the brain are soluble, meaning they can be dissolved or bro- ken down by enzymes in the brain, but beta-amyloid proteins become insoluble. The proteins thus gradually accumulate into globs that eventually thicken by combining with other immune

Neuro�brillary tangles, implicated in neurocognitive disorder in general and Alzheimer’s disease in particular, impair various brain functions.

Neuritic plaques are a key aspect of Alzheimer’s disease.

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and support cells in the brain. This process eventually causes massive damage and an inability to process information or even resist minor infections.

Beta-amyloid proteins are formed from a larger protein called amyloid precursor protein, or APP. Recall that large amounts of APP relate to mutations of chromosome 21. Senile or neuritic plaques are most common to the temporal and oc- cipital brain lobes and somewhat common to the parietal lobe (Nelson et al., 2013). Another plaque often found in the brains of people with Alzheimer’s disease is diffuse plaque, which is marked less by amyloid protein accumulations and is common to many elderly people and those with Down syndrome. Diffuse plaques may be a precursor to senile/neuritic plaques, but more research remains needed (Gouras, Olsson, & Hansson, 2015).

Lewy bodies also represent collections of proteins in the brain that cause damage and are found in many people with dementia. Lewy bodies are not beta-amyloid proteins but rather alpha-synuclein proteins (Winslow et al., 2014). Alpha-synuclein proteins can also become insoluble, accumulate on the synapses of neurons, and block effective transmission of information. Lewy body accumulation is likely due to genetic changes (Bras, 2015). Such accumulation has been implicated most in people with Alzheimer’s disease, Parkinson’s disease, and, of course, dementia with Lewy bodies (Morra & Donovick, 2014).

Other brain changes in people with dementia involve grad- ual atrophy, or deterioration, of key areas related to thinking, memory, personality, and other important functions. A gradual withering of the frontal and temporal lobes is seen in people with frontotemporal dementia such as Pick’s disease. This atrophy is likely the result of key genetic changes, especially on chromo- some 17, and involves intense deterioration of the neurons in these areas (Heetveld, Rizzu, & Heutink, 2015). Pick bodies may infest these areas as well and comprise various tau �brils similar to what happens in neuro�brillary tangles (Hodges, 2015).

Brain atrophy also affects the substantia nigra in people with Parkinson’s disease, which is a main dopamine pathway controlling motor behavior (O’Callaghan et al., 2016). Fewer

neurons appear over time. We mentioned earlier that Lewy bodies may also be found in people with Parkinson’s disease. Atrophy in Parkinson’s disease likely relates to the speci�c chromosomal changes we mentioned earlier.

Effects of a stroke or other cerebrovascular disease can vary tremendously in people with vascular dementia. These effects may include cortical as well as subcortical areas of the brain. Key brain areas that can be affected, other than the cor- tex, include the angular gyrus, caudate nucleus, thalamus, basal ganglia, and white matter (Iadecola, 2013). These areas are especially important for coordinating visual and auditory infor- mation, language comprehension, and motor behavior.

Other brain changes in people with dementia involve oxida- tive stress and free radicals. Brain cells are normally exposed to oxygen, which can damage the cells, but antioxidants in vitamins and other substances help prevent major damage. Oxidative stress involves general cell or tissue damage and brain in�ammation that can occur when antioxidants are insuf�cient. Oxidative stress relates closely to release of free radicals in the brain; free radicals are aggressive substances possibly produced to �ght viruses and bacteria. Oxidative stress from very high amounts of free radicals can be caused by many things, including

Many cases of neurocognitive disorder involve Lewy bodies, proteins that accumulate in the brain.

Atrophy of the frontotemporal regions of the brain occurs in people with Pick’s disease. A healthy brain would not have the large gaps seen in this photo.

Loss of neurons in the substantia nigra is a main feature of Parkinson’s disease.

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stroke, brain injury, pollution, smoking, or excessive alcohol use (Halliwell & Gutteridge, 2015). Oxidative stress with re- sulting brain injury appears to be a signi�- cant risk factor in people with dementia (Pohanka, 2014). For the major brain areas implicated in dementia, see Figure 14.4.

Environmental Risk Factors for Neurocognitive Disorders Diet Diet may be a risk factor for certain cases of Alzheimer’s disease or other dementias. Dementia is probably not connected to one type of nutrient but perhaps to different food substances (Chen, Brodaty, & Oleary, 2015). Medications or vitamins rich in antioxidants may help slow the progression of dementia. We are exposed daily to vari- ous oxidants, such as ozone (O3), but over time these can lead to beta-amyloid protein accumulation and neuron cell damage in the brain (Newton, Naiberg, & Goldstein, 2015). Ingesting antioxidants from yellow- orange fruits such as cantaloupe and green vegetables (for beta-carotene), and taking vitamins C and E, which have antioxidant qualities, are thus especially important.

High levels of antioxidants may slow (although not stop) the progression of Alzheimer’s disease, per- haps lower the risk for developing dementia, or protect against cognitive decline, though data remain mixed (Crichton, Bryan, & Murphy, 2013). In addition, supplements of vitamin E and C may provide some protection from vascular and other dementia (Polidori et al., 2015). Other researchers have examined effects of other nutrients on cognitive functioning, especially vitamins B6, B12, and folic acid. Data are mixed, however, as to whether levels of these substances relate to the presence of Alzheimer’s dis- ease and whether supplements of these nutrients help improve symptoms of dementia (Spence, 2016). Vitamin B12 and folic acid help reduce homocysteine, high levels of which can cause artery damage (Catena, Colussi, Url-Michitsch, Nait, & Sechi, 2015).

Increased saturated fat and cholesterol intake has sometimes been found related to cognitive decline, although not always (Barnard, Bunner, & Agarwal, 2014). Increased �sh or seafood intake seems related to lower risk of dementia as well in some studies (Kroger & Laforce, 2016). A healthy diet heavy in fruits, vegetables, and �sh will also help prevent cardiovascular condi- tions that could produce vascular dementia. These conditions include diabetes, hypertension, obesity, stroke, and coronary ar- tery disease (van de Rest, Berendsen, Haveman-Nies, & de Groot, 2015). A heart-healthy diet also seems useful as a brain-healthy diet. Your mom was right all along: Eat your veggies!

Alcohol and Tobacco Use People who drink moderate amounts of alcohol are less likely moderate amounts of alcohol are less likely moderate to experience dementia compared to people who abstain from alcohol (Ormstad, Rosness, Bergem, Bjertness, & Strand, 2016). People who drink large amounts of alcohol are clearly at risk for large amounts of alcohol are clearly at risk for large memory and cognitive de�cits, however. Moderate alcohol use may protect some people from vascular damage, reduce stress, enhance acetylcholine release from the hippocampus to improve memory, and increase social interaction among older adults (Di Marco et al., 2014). A key element of alcohol—�avonoids— has excellent antioxidant properties as well (Orhan et al., 2015). Flavonoids are common to certain kinds of alcohol such as red wine. Tobacco use, on the other hand, is a substantial risk factor for dementia (World Health Organization, 2014).

A diet including ample amounts of �sh, fruit, and vegetables, known as the “Mediterranean diet,” may reduce risk for neurocognitive disorder.

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Aluminum Another possible environmental risk factor for dementia is exposure to various toxins. Some researchers have focused on aluminum, a com- mon metal ingested from air, food, or water. Aluminum toxicity, which produces oxidation effects and in- creased beta-amyloid proteins and free radicals, could result in brain tissue damage and onset of age- related cognitive decline (Bondy, 2016). Aluminum can come from diet as well as drinking water, med- ications, and antacids. Aluminum is also present in neuro�brillary tangles (Zhao et al., 2013). Some recommend ingesting curry to miti- gate possible effects of aluminum, but others claim no conclusive link can yet be made between alumi- num exposure and Alzheimer’s dis- ease (Ohyagi & Miyoshi, 2013).

Cultural Factors Recall that Alzheimer’s disease may be more prevalent among Western nations and vascular dementia may be more prevalent among Asian and other non-Western nations. This may be partly explained by how dementia is considered within a cultural con- text and whether shame and stigma are associated with severe cognitive dysfunction. Native Americans tend to view dementia as a normal part of aging and as an expected part of one’s tran- sition to the next world (Cipriani & Borin, 2015). Asians often emphasize more socially acceptable physical factors to explain dementia, possibly resulting in more reported cases of vascular dementia than Alzheimer’s disease. Dementia among Nigeri- ans is seen as a debilitating condition that prevents one from completing prayer and work that requires higher-level cogni- tion. Rates of reported dementia are thus quite low (Botsford & Dening, 2015). Stigma may thus be a key reason for differences in reported dementia. Genetic and dietary differences across the world can also be fairly large and help explain cultural differ- ences in dementia (Scull, 2014).

Cultural factors may also apply to caregivers of those with dementia. Minority caregivers often report more unmet service needs for family members with dementia. This may be due to lack of information about available diagnostic and treatment services, inaccurate diagnosis, poor feedback from physicians, and less membership in support groups (Desin, Caban-Holt, Abner, Van Eldik, & Schmitt, 2016). Other reasons may include insensitivity of assessments (as discussed later in the chapter) to cultural differences in cognition, reluctance to use medical and social services perceived as not culturally-competent, and lan- guage barriers (Sun, Mutlu, & Coon, 2014). On the other hand, African Americans generally view the caregiver role as less

stressful and burdensome than European Americans, perhaps because of greater reliance on religion and extended family sup- port (Roth, Dilworth-Anderson, Huang, Gross, & Gitlin, 2015).

Other Factors Many other environmental risk factors could lead to dementia, including viral infections such as HIV and accidents leading to brain injury. Other signi�cant risk factors could include poverty, malnutrition, poor parental education, and low socioeconomic status. Family history of dementia appears to be a better pre- dictor of whether someone will acquire dementia than these variables, however (Medway & Morgan, 2014).

Stronger educational background is often linked to less de- mentia, possibly because cognitive decline is harder to identify. Highly educated people may have more cognitive reserve, or bet- ter problem-solving strategies when taking neuropsychological tests (Harrison et al., 2015). Some propose that long-term poten- tiation, or strengthening and development of new neuronal con- nections, can result from enhanced education and perhaps help reduce dementia onset (Martin & Preedy, 2015). So study hard!

Causes of Neurocognitive Disorders Many risk factors seem to come into play for neurocognitive disorders in general and severe dementia in particular. Organiz- ing these risk factors into one general causal theory has been a dif�cult task for researchers. One theory of cognitive disorders— the amyloid cascade hypothesis—has received great research attention, especially for Alzheimer’s disease. This hypothesis focuses on key brain changes that can cascade or result from

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various genetic and environmental factors and which, in the end, help produce a state of dementia (Musiek & Holtzman, 2015). Figure 14.5 illustrates a version of the amyloid cascade hypothesis.

A central aspect of the amyloid cascade hypothesis is that progressive dementias are at least partly caused by a toxic buildup of beta-amyloid proteins that lead to neuron damage and senile plaques. Amyloid precursor protein is a normal pro- tein that the body regularly splices into shorter pieces. This splicing process is done by different enzymes called secretases and, in particular, alpha-secretase, beta-secretase, and gamma- secretase (Nhan, Chiang, & Koo, 2015). This is a normal process secretase (Nhan, Chiang, & Koo, 2015). This is a normal process secretase for all of us.

For reasons still unclear, beta-secretase and gamma-secretase often combine to produce the protein A-beta, or beta-amyloid. Again, this process is normal and not usually harmful because beta-amyloid is often soluble and dissolves quickly. Beta- amyloid becomes insoluble, or fails to dissolve, in some people, however. Large deposits of beta-amyloid thus collect and form senile plaques, contribute to the development of neuro�brillary tangles and neurotransmitter changes, and perhaps force the overproduction of free radicals (Kamat et al., 2016). These toxic effects help lead to the brain damage central to dementia.

A key question in this model is what factors lead initially to changes in amyloid precursor protein splicing and toxic buildup of beta-amyloid. The answer, although still not de- �nitive, may involve a combination of genetic and dietary or

other environmental factors. We mentioned earlier that changes in chromosome 21 and presenilin genes may lead to overproduction of amyloid precursor protein, such that huge amounts of beta-amyloid are also produced. The APOE-4 gene has also been closely linked to amyloid buildup and neuro�brillary tangles (Yu et al., 2015).

Diet likely intersects with genetic factors to act as a contributor to neurocognitive disorders via toxic amyloid buildup but also as a protec- tive factor via high antioxidants. The interaction of diet and genes may help explain why people of some cultures experience less Alzheimer’s disease and other neurocognitive disorders. Those whose diets are rich in �sh, fruits, veg- etables, and curry may experience fewer cogni- tive problems than those whose diets are rich in fat, cholesterol, and possibly aluminum, although studies vary (Safouris, Tsivgoulis, Sergentanis, & Psaltopoulou, 2015).

The amyloid cascade hypothesis was largely designed as an explanation for Alzheimer’s disease. Still, genetic changes that lead to cer- tain body and brain alterations are likely main characteristics of other neurocognitive disor- ders as well. Many people are genetically pre- disposed to hypertension, diabetes, obesity, and stroke and possible vascular dementia (Sun

et al., 2015). Genetic changes are also important for aggressive neurocognitive disorders such as Pick’s disease as well as alco- holism that can lead to Korsakoff’s syndrome (Heetveld et al., 2015). Some cases of Parkinson’s disease are likely related to mutations in parkin genes that help create neuron damage and atrophy to brain areas such as the substantia nigra (Pickrell & Youle, 2015).

Discovering the true cause of these devastating and tragic disorders will likely be a high priority for future researchers given the substantially greater number of people who will be living lengthy lives. The debilitating nature of neurocognitive disorders also means a high priority for prevention, a topic we discuss next.

Prevention of Neurocognitive Disorders We mentioned earlier one factor likely important for pre- venting Alzheimer’s disease and other neurocognitive disor- ders: diet. People whose diets are healthy will be at less risk for cerebrovascular problems that could lead to dementia. General recommendations include diets that restrict calories and are rich in antioxidants, folic acid, �sh oils, cereals, and moderate amounts of red wine—the so-called Mediterranean diet. Diet may reduce risk of dementia but not necessarily its course in people strongly genetically predisposed to neu- rocognitive disorder, however (Feart, Samieri, & Barberger- Gateau, 2015).

FIGURE 14.5 SAMPLE SCHEMATIC OF THE AMYLOID CASCADE HYPOTHESIS.

Brain inflammation

Oxidative stress and

free radicals

Neurofibrillary tangles

Neuritic plaques

Neurochemical changes, neuron damage and death, brain atrophy

Cognitive decline and neurocognitive disorder

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Changes in amyloid precursor

protein

Dietary influences and toxins

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Neurocognitive Disorders: Assessment and Treatment 443

People with high-cholesterol diets or whose cholesterol is set genetically to a high level may bene�t from a class of drugs called statins. These drugs help lower cholesterol levels. Statin drugs have not prevented onset of Alzheimer’s disease or other forms of dementia, however (Daneschvar, Aronson, & Smetana, 2015). People with high cholesterol will bene�t from exercise as well. Some data indicate that exercise can increase a protective substance known as brain-derived neurotrophic factor that may enhance hippocampus activity and memory factor that may enhance hippocampus activity and memory factor (Szuhany, Bugatti, & Otto, 2015). Physical activity may help prevent cognitive decline but not necessarily dementia (Duzel, van Praag, & Sendtner, 2016).

Another focus of prevention involves cognitively stimulat- ing environments, which include surroundings that constantly challenge the brain and help develop new neuronal connections. Social interactions with others and new intellectual stimulation seem particularly important for preventing cognitive decline (Ellwardt, Van Tilburg, & Aartsen, 2015). To help prevent cogni- tive decline:

• Continue to stay as socially active as possible and meet new people.

• Continue reading and writing, but try new publications such as detective novels.

• Take a new class to learn a skill such as carpentry or mechanics.

• Learn to play a musical instrument or speak a foreign language.

• Play mentally challenging games such as chess, and as- semble puzzles.

• Travel and learn about new cultures. • Seek treatment for stress and psychological and medical

problems.

• Keep regular lists of things to do as well as a detailed daily calendar.

• Challenge your memory by recalling recent events on a reg- ular basis, such as what you had for dinner three nights ago or the name of a new person you met yesterday.

Various drugs may also help reduce beta-amyloid buildup and prevent the cascade of problems that lead to dementia (Friedrich, 2014). One such drug, crenezumab, may be effec- tive in this regard but only at very high doses (Bateman, 2014). Lack of tobacco use as well as drugs to reduce the chance of stroke, such as antihypertension and anticlotting medications, are important as well. Gene therapy will likely be the approach to revolutionize the prevention of Alzheimer’s disease and other dementias, and we discuss this more in the later treatment section (Fyfe, 2015).

➲ Interim Summary • Biological risk factors for neurocognitive disorders include

genetics; identical twins display more concordance for Alzheimer’s disease than nonidentical twins.

• Genetic changes in neurocognitive disorders include chro- mosome 21 and amyloid precursor protein, chromosome 19 and apolipoprotein E, and chromosomes 14 and 1 and presenilin 1 and 2.

• Neurochemical changes in neurocognitive disorders include low levels of acetylcholine, serotonin, norepineph- rine, and dopamine and high levels of L-glutamate.

• Brain changes in neurocognitive disorders often include neuro�brillary tangles, senile plaques, Lewy bodies, atrophy, and oxidative stress and free radicals.

• Environmental factors may also in�uence neurocognitive disorders, especially diets high in antioxidants and �sh and low in fat and cholesterol.

• Moderate alcohol use may be related to less dementia, but aluminum intake may relate to more dementia.

• The amyloid cascade hypothesis refers to various brain changes cascading from genetic and environmental factors to produce neurocognitive disorder.

• Prevention of neurocognitive disorder will likely hinge on diet, exercise, cognitive stimulation, medications, and perhaps gene therapy.

➲ Review Questions 1. Describe genetic mutations associated with neurocognitive

disorders. 2. What neurochemical and brain changes are central to dementia? 3. What dietary factors might relate closely to dementia? 4. Describe the amyloid cascade hypothesis. 5. Outline a strategy for preventing dementia.

Neurocognitive Disorders: Assessment and Treatment

We have covered some of the major features and causes of neurocognitive disorders, so we turn next to different strategies to assess and treat these devastating problems.

Assessment of Neurocognitive Disorders Interviews Interviews to gather information about someone with possible neurocognitive disorder could include the person herself but will likely also include close family members and friends. This is especially so in cases involving severe cognitive or memory problems. Interviews of signi�cant others can be especially use- ful if a person is currently in a state of delirium. Interviews for people with possible dementia are often designed to determine whether a problem is the result of normal aging or an early form of severe neurocognitive disorder.

Interviews for people with possible Alzheimer’s disease or other dementia will often cover some key topics (see Table 14.10; Gao et al., 2014). An assessor will search for recent changes in

CHAPTER 14 Neurocognitive Disorders444

behavior, thinking, and memory as well as changes in long-term skills such as language or ability to recognize others. Mr. and Mrs. Ponder’s interview led the neuropsychologist to initially conclude that some form of neurocognitive disorder was likely occurring given their confusion and memory problems. Inter- views are also commonly used in this population to assess for comorbid problems such as depression, anxiety, and psychosis.

Interviews with people with possible neurocognitive disorder are generally done to conduct a mental status exami- nation. A mental status examination involves detailed ques- tioning and observation of key areas of functioning such as appearance, mood, orientation, and odd behaviors, speech, or thoughts (Mitchell & Atri, 2014). A clinician may pay close attention to disorganized attire, incoherent speech, agitation, bizarre thought patterns, aphasic speech, motor problems, and �at affect. A person’s ability to be oriented to person, place, and time is also assessed. A clinician may ask someone to state her name, where she is, and current day and year. Failure to answer these basic questions appropriately may indicate a neurocogni- tive disorder.

Interviewing caregivers of people with neurocognitive disorder is also an extremely important assessment area. Key topics to be covered here include family history of neurocogni- tive disorder, a person’s need for help in various areas such as dressing, �nancial and other resources for care, knowledge

about dementia, physical and emotional health of the care- giver, social support, and quality of life of the family (Knight & Pachana, 2015). Recall that Mrs. Ponder said her quality of life was diminishing because her health was dwindling and she could no longer fully care for her husband.

Questionnaires Mental status examinations and assessment of cognitive func- tioning can also be done via questionnaires, which may be administered in interview format. A commonly used measure to screen for neurocognitive disorder is the Mini-Mental State Examination (MMSE-2), a 30-item questionnaire that covers orientation, verbal and written comprehension, concentra- tion, learning, writing and copying, and memory (Figure 14.6; Folstein, & Folstein, 2010). The MMSE-2 takes only 10 to 15 min- utes to administer and can distinguish people with or without dementia. Other commonly used screening tests include the Mini-Cog (Fage et al., 2015), Mini-Cog (Fage et al., 2015), Mini-Cog Dementia Severity Rating Scale (Moelter et al., 2015), Delirium Rating Scale—Revised (Thurber et al., 2015), and Confusion Assessment Method, the latter of which can evaluate delirium even with dif�cult-to-assess patients (DiLibero et al., 2016).

Screening tests for dementia can also be very brief and include asking a person to draw a clock face for a given time (Figure 14.7), tell time, make change for a dollar, and spell

TABLE 14.10

Possible Early Signs and Symptoms of Dementia

Sign Symptoms

Forgetfulness Commonly manifested as short-term memory loss for recently learned names, appointments, purpose of activities, points of conversation, and completed tasks or errands. An individual may repeat questions or requests. The degree of forgetfulness begins to interfere with daily activities and responsibilities.

Disorientation Episodic confusion regarding the exact day, date, or location.

Impaired performance on daily tasks

Dif�culty performing everyday tasks, such as preparing meals, running household appliances, cleaning, and hygiene (e.g., bathing, toileting, brushing teeth).

Impaired language Increasing dif�culty with selecting and using words. Sentences may become simpler or fragmented.

Impaired recognition Diminished ability to remember or identify familiar faces, objects, sounds, and locations.

Impaired abstract thinking

Diminished ability to think clearly about issues, to discuss complex issues and to make logical connections between them, or to comprehend fully things that were previously understood.

Impaired judgment Impairment in the ability to organize and plan and to make appropriate decisions or selections among several possibilities. A person may act in ways that were previously deemed uncharacteristic or inappropriate.

Changes in mood or behavior

Change in mood and behavior that may take many forms, including increased irritability, loss of emotional control (e.g., intense anger, frustration, tearfulness), abusive or inappropriate language, loss of pleasure in particular activities, and apathetic attitudes.

Changes in personality The person may seem less sociable or more self-centered and may act out in disruptive or disinhibited ways. He or she may also seem more suspicious, fearful, or bothered by others, and reactions to everyday stress may be out of proportion.

From Agronin, M.E. (2014). Alzheimer’s disease and other dementias: A practical guide (3rd ed.). New York: Routledge.

Neurocognitive Disorders: Assessment and Treatment 445

various words backward (Yokomizo, Simon, & de Campos Bottino, 2014). Many questionnaires are also available to assess conditions related to delirium and dementia that we covered in previous chapters. Particularly important conditions include anxiety, depression, and adaptive behavior.

Cognitive Assessment More formal tests can also be used to assess symptoms of neu- rocognitive disorders, especially if a screening questionnaire indicates delirium or dementia or if memory problems are clearly evident. A common example is the Wechsler Memory Scale (WMS-IV; Wechsler, 2009). The WMS consists of variScale (WMS-IV; Wechsler, 2009). The WMS consists of variScale - ous subtests that measure immediate and delayed memory for visual and auditory stimuli as well as working memory. A person may be asked to immediately recall different words (tree, table, dime) and then, later in the test, be asked to recall them again. The WMS is often used in research and clinical settings to as- sess Alzheimer’s disease and other dementias and was used for Mr. Ponder (Baldock, Miller, Leger, & Banks, 2016).

We covered other formal tests of cognitive functioning in previous chapters and so just mention them here. These primarily include intelligence tests such as the Wechsler Adult Intelligence Scale and neuropsychological tests such as the Intelligence Scale and neuropsychological tests such as the Intelligence Scale Halstead-Reitan (Chapters 12 and 13). These tests are useful for charting changes in cognitive ability over time to determine whether these changes are normal or an early form of neurocog- nitive disorder. Certain subtests of these scales are also useful for determining the extent of damage after a stroke. A clinician can examine certain “hold” tests such as vocabulary that tend to remain stable even after brain damage. Other methods include examining a speci�c pro�le of scores that seem predictive of people with Alzheimer’s disease (Tang et al., 2016).

Medical and Laboratory Assessment People who may have a neurocognitive disorder are often re- ferred �rst to a physician for evaluation. A medical examination will likely include tests for cardiovascular and thyroid problems, substance intoxication, HIV and other infections, dehydration, and other basic factors that could explain delirium or dementia (Inouye, Westendorp, & Saczynski, 2014). A medical examina- tion could also include more extensive laboratory procedures we discussed in Chapters 4 and 12: computerized tomography (CT scan), magnetic resonance imaging (MRI scan), magnetic resonance imaging (MRI scan), magnetic resonance imaging positron emission tomography (PET scan), and single photon emission computed tomography (SPECT). MRI and PET scans are usually recommended as more de�nitive ways of determining Alzheimer’s disease and other dementias (O’Brien, 2014; Figure 14.8).

Biological Treatments of Neurocognitive Disorders Medication Neurocognitive disorders are clearly affected by many biologi- cal variables and will certainly become more common given the rapidly aging population around the globe. The search for medical cures for neurocognitive disorder thus remains a high priority for researchers. Many drugs for people with other

Orientation to time

“What is the date?”

Naming

“What is this?” [Point to a pencil or pen.]

Reading

“Please read this and do what it says.” [Show examinee the words on the stimulus form.] CLOSE YOUR EYES

Registration

“Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are… APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words back to me.” [Repeat up to 5 times, but score only the first trial.]

Patient Male, 75 years old MMSE = 28 points

Clinical diagnosis: Probable AD

Autopsy 4 yrs later: Definite AD

FIGURE 14.6 THE MINI-MENTAL STATEATEA EXAMINATIONATIONA (MMSE) SAMPLE ITEMS. Reproduced by special permission of the publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini-Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by calling (813) 968-3003.

FIGURE 14.7 CLOCK DRAWING TEST FOR A 75-YEAR-OLD MALE WITH PROBABLE ALZHEIMER’S DISEASE. From Taylor, K.I., & Monsch, A.U. (2004). The neuropsychology of Alzheimer’s disease. In R.W. Richter & B.Z. Richter (Eds.), Alzheimer’s disease: A physician’s guide to practical management (p. 119). Reprinted by permission of Springer/ Humana Press.

CHAPTER 14 Neurocognitive Disorders446

mental disorders we described in this textbook are given to people with dementia. These drugs include antidepressants and mood stabilizers (Chapter 7) and antipsychotics (Chapter 12). These medications are useful for easing behavioral problems (such as delusions/hallucinations) associated with dementia, or depression or delirium, but are not too useful for changing severe cognitive and memory de�cits brought on by Alzheimer’s dis- ease and other dementias (Maust, Langa, Blow, & Kales, 2016).

Researchers have thus focused on cholinesterase inhibi- tors. These drugs enhance the neurotransmitter acetylcholine, which is de�cient in people with dementia and memory prob- lems. These drugs inhibit enzymes in the brain from breaking down acetylcholine so more of the neurotransmitter is available. The primary cholinesterase inhibitors that have been studied include physostigmine, tacrine, metrifonate, donepezil, rivastig- mine, and galantamine, and especially the latter three (Hyde et al., 2013). These drugs produce only a modest increase in functioning for people with mild to moderate neurocognitive disorder, however, and work better if given sooner in the disease process (Wang et al., 2014).

Another drug, memantine, helps control excess L-glutamate activity. Memantine has some bene�cial cognitive effect for people with moderate to severe neurocognitive disorder (Molino, Colucci, Fasanaro, Traini, & Amenta, 2013). People with Par- kinson’s disease, a disorder that could lead to dementia, often take the drug levodopa (levodopa (levodopa L-dopa) to increase dopamine levels in the brain, sometimes in concert with surgical strategies (Huot, Johnston, Koprich, Fox, & Brotchie, 2013). Overall, a combina- tion of medications is often used to treat dementia (Maust et al., 2016). Over time, however, the steady progression of dementia eventually overwhelms drug effectiveness.

Gene Therapy A revolutionary approach to future treatment of neurocognitive disorder will likely include gene therapy, or introduction of genes to a person to help increase neuron growth and regen- eration. Healthy genes are generally introduced not to replace but to compensate for dysfunctions from problematic genes. Gene therapy is highly experimental now but has the potential to address some of the most devastating mental and physical

disorders in humans. Some success has been shown in animal studies, but the approach requires pinpoint accuracy to prevent adverse effects (Combs, Kneynsberg, & Kanaan, 2016).

Residential and Nursing Home Care Many biological treatments for people with dementia are given in hospitals, residential hospices, and nursing homes. Psychi- atric care in these settings often consists of managing behavior problems such as hypersexuality, easing emotional issues such as depression, and reducing infections and pain (Kales, Gitlin, & Lyketsos, 2014). Hospice care is especially bene�cial to people experiencing later, end-of-life stages of dementia. A family’s de- cision to place a loved one in hospice or nursing home care can be excruciating, however, as it was for the Ponder family. Some questions for family members in this dif�cult position include the following (adapted from Mittelman et al., 2003):

• What would the person with dementia have wanted? • What is the recommendation of the person’s medical doctor? • Will entry into a hospice or nursing home help reduce a

person’s suffering?

• What are the �nancial and emotional burdens of home care versus hospice/nursing home care?

• Do most family members feel a certain way in this decision? • Do family members feel comfortable giving control of a

person’s care to others?

• What services are offered at the hospice or nursing home? • What provisions are in place at the hospice or nursing home

to maximize safety?

Psychological Treatments of Neurocognitive Disorders Biological approaches to neurocognitive disorders are a popular area of research, but their general ineffectiveness at this stage means psychological approaches to improve a person’s quality of life remain extremely important. Psychological treatments may be divided into two groups: those that target the person with neuro- cognitive disorder and those that focus on the person’s caregivers.

Psychological Approaches for People with Neurocognitive Disorders Psychological approaches targeted toward people with neurocog- nitive disorders are generally conducted in earlier stages of the disorder when confusion and disorientation are not yet severe. These approaches are designed to improve a person’s quality of life and enhance cognitive functioning to delay onset of more severe symptoms. We described some of these approaches previ- ously in this textbook, including reminiscence therapy (Chapter 7). Reminiscence therapy involves a thorough review of a person’s life to impart a sense of meaning and resolve remaining inter- personal con�icts or regrets. A person with dementia will likely lose the ability to interact with others, so such re�ection will hopefully enhance present well-being and provide a positive sense of closure to one’s life (Huang et al., 2015).

FIGURE 14.8 PET SCANS OF BRAINS OF A NORMAL ELDERLY PERSON, LEFT; A PERSON WITH ALZHEIMER’S DISEASE, MIDDLE; AND A PERSON WITH FRONTOTEMPORAL DEGENERATION, RIGHT. Courtesy, Dr. Arthur W. Toga, Laboratory of Neuro Imaging at UCLA.

Neurocognitive Disorders: Assessment and Treatment 447

Another popular psychological therapy aimed toward people with neurocognitive dis- order is reality orientation. This is a technique to reduce confusion in people with dementia and often involves constant feedback about time, place, person, and recent events (Mitchell & Agnelli, 2015). A person may be consistently reminded about his daily events, settings, and identity. Often this consists of placing clocks and calendars around the living environment, directional arrows to places such as the refrig- erator, and pictures to remind a person of loved ones. Reality orientation could be done by staff members at a nursing home or by family mem- bers at home. Reality orientation may have some initial bene�ts on cognitive functioning and may even delay nursing home placement, but these bene�ts are likely best for people in early and intermediate stages of neurocognitive disorder (Camargo, Justus, & Retzlaff, 2015).

Memory training is used for people with neurocognitive disorders as well. A person is taught to enhance memory performance by repeatedly practicing various skills such as using a microwave oven, relying on external cues and mnemonic strategies to jog memory, increasing social interaction, and sim- plifying her living environment so less needs to be remembered. Common strategies include a “memory wallet” that contains written reminders and pictures of loved ones a person can refer to when faced with loss of memory and painting various rooms in bright, different colors and cues for easy identi�cation (e.g., “blue” for bedroom with a picture of a bed). Obstacles that interfere with memory, such as depression, apathy, or cog- nitive distortions, are addressed as well (Lohman et al., 2013). Memory training is likely best for people in the early stages of a neurocognitive disorder.

Behavior therapy is another common form of treatment for people with neurocognitive disorder but one that focuses on re- ducing behavior problems and increasing frequency of self-care skills. Behavior problems typically addressed in this population include wandering alone, hypersexuality, depression, verbal and physical aggression, and agitation. Self-care skills typically ad- dressed in this population include feeding, dressing, toileting, and grooming (Boltz & Galvin, 2016). Family members are taught to positively reward appropriate behaviors and redirect or ignore (if possible) inappropriate behaviors. This approach is often used in combination with reality orientation and memory training as well as music, art, and movement therapies to increase cognitive stimulation (Aguirre, Woods, Spector, & Orrell, 2013).

Psychological Approaches for Caregivers of People with Neurocognitive Disorders Other psychological approaches for addressing people with neu- rocognitive disorder focus more on caregivers such as spouses and other family members. A critical �rst step when addressing

caregivers is to provide information about the nature of demen- tia and provide extensive social support and other resources (Boltz & Galvin, 2016). Information about dementia should in- clude its major symptoms, cause, and course over time. Caregiv- ers should know what to expect of a person in coming weeks and months, such as serious cognitive decline, and begin to plan accordingly. This often involves creating living wills and power of attorney documents, as well as resolving current or past con- �icts (Chang & Johnson, 2014; see Box 14.3).

Resources should also be established so caregivers are relieved of the everyday burden of caring for someone with dementia. Arrangements can be made to rotate or add family members to daily care, provide expert respite care, and con- sider when placement in a nursing home or hospice might be most appropriate (Heller, Gibbons, & Fisher, 2015). Spouses and caregivers of people with dementia are particularly prone to stress, burnout, and other psychological and physical problems, so easing the burden of care is crucial for their long-term health (Reuben et al., 2015).

Support groups for caregivers of people with neurocogni- tive disorders are crucial as well. These groups allow members to share information about daily care and express frustrations and sadness about their current situation. Online support groups are also available and might be particularly important for caregivers largely con�ned to their home (Boots, Vugt, Knippenberg, Kempen, & Verhey, 2014). If a caregiver has substantial depression or other psychological problems, then referral to a psychiatrist and psychologist for more formal intervention may be best.

Living with a person with Alzheimer’s disease or other form of severe neurocognitive disorder can be extremely dif�cult. The Mayo Clinic has provided some practical tips for caregivers in

Reality orientation kits are often used to help guide people with moderate Alzheimer’s disease. The reality orientation clock this woman is holding, which includes the time and days, is frequently pointed out and used in conversations with her.

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CHAPTER 14 Neurocognitive Disorders448

this situation (see Table 14.11). These tips focus on assessing the independence of a person with dementia, creating a safe environment, adjusting expectations, limiting distractions, and promoting communication. A key aspect of this day-to-day strat- egy is to frequently rethink what a person with dementia can still do and what she can no longer do. Incorporating psycho- logical interventions for people with dementia we mentioned earlier would also be important in this process.

What If Someone I Know Has a Neurocognitive Disorder? If you suspect someone you know might be experiencing symp- toms of a neurocognitive disorder, then referring him for a full medical and neuropsychological examination is important. Catch- ing these symptoms early on may be helpful to reverse delirium or slow the progression of dementia and improve someone’s quality

TABLE 14.11

Practical Tips for Caregivers of Those with Alzheimer’s Disease

Assess independence Involve loved one in tasks as much as possible. Give your mother two choices for an out�t rather than asking her to choose from a closet full. Reassess the level of assistance that is required daily. Can your husband shave by himself if you set out the supplies? Or can he shave by himself if you turn on an electric razor and put it in his hand? Or does he need you to provide assistance with the entire task?

Create a safe environment Remove throw rugs, extension cords, and any clutter. Avoid rearranging furniture. Install locks on cabinets. Make sure there is a �rst-aid kit, a �re extinguisher, and working smoke alarms. If your husband is a smoker, don’t allow him to smoke alone. Remove plug-in appliances. Set the temperature on the water heater no higher than 120° F to prevent burns.

Adjust your expectations Allow more time to accomplish everyday tasks. Try not to worry about the way things should be done. If no danger results from your father’s actions, refrain from correcting him. Try to stay �exible. If your wife refuses to do something, back off and try again later using a different approach.

Limit distractions Shut off the television and limit background noise. Encourage visitors to call before they come.

Promote communication To understand a behavior, consider what your loved one may be feeling. If your wife is pacing, it may mean she is tired, feels hungry, or needs to use the bathroom.

Sampson, 2013). Grief of this nature usually accompanies strong feelings of anxiety, anger, sadness, and guilt, especially among wives of husbands with dementia (Gibbons et al., 2014).

Spousal caregivers and child caregivers differ in their approach to grief. Children who care for a parent with dementia tend to deny the presence of dementia and focus on how a parent’s dementia affects them. Spousal caregivers, however, tend to be more open about accepting their spouse’s dementia and the burdens of care to come. Spousal caregivers also tend to focus on how a person’s dementia affects that person and not themselves. They worry and are sad about their partner’s loss of cognitive and memory abilities and grieve over the eventual loss of companionship. Child caregiv- ers respond to nursing home placement of their parent with dementia with a sense of relief, but spousal caregivers feel extensive sadness, anger, and frustration. In either case, attention to a caregiver’s grief before a person’s death is likely an important aspect of intervention in this population (Ashwill, Mulhall, Johnson, & Galvin, 2015; Reed et al., 2014).

Focus On

Treatment for people with dementia often falls to spouses who care for their loved one—most people with dementia live at home. Much has been written about the dif�culty of such treatment and how support and respite care are so important, but little has been written about the general grief spouses go through when encountering this tragic situation. Such grief often includes thoughts about gradual isolation from one’s life partner, in- creasing realization of the shortness of life, and sense of meaninglessness and hopelessness about the current situation (Chan, Livingston, Jones, &

Gender Grief in the Spouse Caregiver

14.3

Neurocognitive Disorders: Assessment and Treatment 449

of life as long as possible. If someone you know does have Al- zheimer’s disease or another severe neurocognitive disorder, then sharing and enjoying what time that person has left is essential. Resolve con�icts with the person while you can and try to fully understand what he would like you to do in later stages of his disorder (see Box 14.4). Neurocognitive disorders are among the most vicious disorders we discuss in this textbook. Pursuing what precious quality of life remains is imperative.

Long-Term Outcome for People with Neurocognitive Disorders You may have guessed from the tone of this chapter that the long-term outcome for people with Alzheimer’s disease and other major neurocognitive disorders is bleak. A person’s life span is generally about 3 to 12 years after the onset of dementia, pri- marily Alzheimer’s disease or frontotemporal dementia (Onyike & Diehl-Schmid, 2013; Todd, Barr, Roberts, & Passmore, 2013). Life span for someone developing dementia due to Parkinson’s disease is 4 to 6 years (Emre, 2015). Life span is generally shorter for people with vascular or mixed dementia, usually less than 4 years (Roehr et al., 2015). Predictors of earlier mortality in people with dementia include more severe cognitive problems or disability, presence of Lewy bodies, older age, male gender, depression, cardiovascular disease, and living in urban areas (Aikins, Sanuade, & Anie, 2016; Oesterhus et al., 2014).

Many people who experience mild cognitive impairment eventually experience dementia. Longitudinal studies indicate that about 6.7 percent of people with mild cognitive impairment progress to dementia each year. Most of this conversion is to Alzheimer’s disease, although about 1.6 percent convert to vascular dementia each year (Duff, 2015). Several researchers have tried to identify exactly which cognitive impairments are most likely

to predict Alzheimer’s disease and other major neurocognitive dis- orders. Initial problems related to episodic memory (memory of recent personal events) and auditory verbal learning are possibly related to later onset of dementia (Li et al., 2015; Ramanan et al., 2016). People with problems with attention, naming, and psycho- motor and visuospatial tasks also seem at risk for later onset of dementia (Jacobs et al., 2015; Stokholm et al., 2013).

Others note that strong predictors of the onset of major neurocognitive disorder, especially Alzheimer’s disease, include age, less education, depression, stroke, poor health, presence of APOE-4, and poor cerebral blood �ow (Agronin, 2014; Haji et al., 2015). The presence of delirium is also a risk factor for older people to develop dementia (Fong et al., 2015). People who have had a stroke and eventually progress to vascular dementia are generally those who have had less cognitive and memory abil- ity, greater depression, and several cardiovascular risk factors such as hypertension and diabetes (Sahathevan, Brodtmann, & Donnan, 2012). Predictors of eventual dementia in people with Parkinson’s disease include age, severe postural and gait problems, mild cognitive impairment, and visual hallucinations (Aarsland, & Bernadotte, 2015).

➲ Interim Summary • Interviews are commonly used to assess people with

neuro cognitive disorders and their caregivers, and top- ics often include recent changes in behavior, thinking, memory, and long-term skills such as language or ability to recognize others.

• Questionnaires are also used to screen for delirium and dementia and typically cover orientation, verbal and writ- ten comprehension, concentration, learning, writing and copying, and memory.

Another set of ethical issues in this population arises when conducting research. Key questions include use of stem cells, ability of a person to give informed consent, genetic testing for risk factors for dementia such as APOE-4, and treatment and feeding of a person with dementia who refuses such help (Strech, Mertz, Knüppel, Neitzke, & Schmidhuber, 2013). Would you want to know that you have the APOE-4 gene even though this does not necessarily mean you would develop Alzheimer’s disease? Should the general population be tested for this gene?

The eventual incapacitation of people with dementia has thrown new light onto the area of advance directives such as living wills. In advance directives such as living wills. In advance directives these directives, a person states ahead of time under what conditions nourishment and medical treatment should be given. For example, the person may direct that if he were to eventually decline to a profoundly ill state, he would no longer want extensive lifesaving practices such as ventilators to be used. The creation of a living will also helps reduce the stress of family members who may be otherwise burdened with such decisions.

Focus On

As you might guess, serious ethical issues arise when addressing people with cognitive decline and dementia. One key question is whether people who qualify for a diagnosis of major neurocognitive disorder should be told of this diagnosis. Arguments in favor of doing so include respect for the person, his participation in care decisions while still able, and acceptance of limita- tions. Arguments against doing so include the fact that treatment options are few, the person may not understand the diagnosis, knowledge of the diag- nosis could lead to depression and other psychological problems, and insur- ance may be lost (van den Dungen et al., 2014). Would you want to know?

Law and Ethics Ethical Issues and Dementia

14.4

CHAPTER 14 Neurocognitive Disorders450

• Cognitive tests such as neuropsychological and intel- ligence tests also evaluate strengths and weaknesses of people with neurocognitive disorders.

• Medical and laboratory tests, including neuroimaging techniques, can often be used to assess the development of neurocognitive disorders.

• Biological treatments for people with neurocognitive disor- ders include cholinesterase inhibitors to increase acetylcho- line in the brain, memantine to control L-glutamate activity, and L-dopa to quell symptoms of Parkinson’s disease.

• Gene therapy may be a key future way of treating people with neurocognitive disorders.

• Many biological treatments for people with neurocognitive disorders are conducted in hospice or nursing home settings.

• Psychological treatments for people with neurocognitive disorders include reminiscence therapy, reality orientation, memory training, and behavior therapy.

• Psychological treatments for caregivers of people with neurocognitive disorders include education about

dementia and providing support and respite care to pre- vent caregiver burnout and improve quality of life.

• The long-term outcome for people with major neurocogni- tive disorders is bleak; most die within 3 to 12 years of onset of the disorder.

➲ Review Questions 1. Describe various methods of assessing a person with neu-

rocognitive disorder and devise an assessment strategy you think might be most helpful.

2. What medications might be best for people with neurocogni- tive disorders?

3. What questions might family members ask themselves when considering whether to admit a loved one to a nursing home?

4. Describe psychological treatments commonly used for people with neurocognitive disorders and their caregivers.

5. Outline the long-term outcome for people with neurocognitive disorders.

Final Comments No cure exists for many major neurocognitive disorders, so preventing these problems and improving quality of life seems most important. You may �nd it easy to wait to worry about such problems until much later in life, but consider ways you can live a healthy lifestyle that will allow you substantial independence and ability to function later in life. In the meantime, enjoy every day you have and make the most of it. Carpe diem: Seize the day!

Thought Questions 1. Think about famous people (Ronald Reagan, Charlton Heston) or even your own family members

who have had Alzheimer’s disease—what about their condition seems most tragic?

2. What do you think the future will bring with respect to treating people with major neurocognitive disorders?

3. What would you say to a friend who told you a parent or grandparent seems to be developing symptoms of a neurocognitive disorder?

4. What separates “normal aging” from dementia? At what point does one “cross the line” from regular changes in thinking and memory to more serious problems?

5. What do you think can be done to reduce the prevalence of neurocognitive disorder in the general population?

451Key Terms

Key Terms delirium 425 dementia 426 neurocognitive disorders 426 major neurocognitive disorder 428 mild neurocognitive disorder 428 Alzheimer’s disease 428 Lewy bodies 430 vascular disease 431

Parkinson’s disease 432 Pick’s disease 432 Korsakoff’s syndrome 433 neuro�brillary tangles 438 senile or neuritic plaques 438 atrophy 439 oxidative stress 439 free radicals 439

amyloid cascade hypothesis 441 mental status examination 444 cholinesterase inhibitors 446 gene therapy 446 reality orientation 447 memory training 447

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Special Features

• 15.1 Graduate School and Mentors

Personal Narrative 15.1 Julia Martinez, Graduate Student in Clinical Psychology

Personal Narrative 15.2 Tiffany S. Borst, M.A., L.P.C.

• 15.2 Rights of Those Hospitalized for Mental Disorder

• 15.3 Lack of Diversity in Research

Personal Narrative 15.3 Christopher A. Kearney, Ph.D.

• 15.4 Sexual Intimacy and the Therapeutic Relationship

Introduction to the Consumer Guide

Becoming a Mental Health Professional

Becoming a Client

Treatment at the Individual Level

Treatment at the Community Level

Limitations and Caveats About Treatment

Ethics

FINAL COMMENTS

THOUGHT QUESTIONS

KEY TERMS

CHAPTER 15 Consumer Guide to Abnormal Psychology454

Introduction to the Consumer Guide

We covered many unusual, harmful, and distressing behav-iors in this textbook. We also discussed various treatment strategies for people with different types of mental disorder. You might be wondering more, though, about people who conduct therapy and what it is about treatment that helps people change their behavior. You may also have questions about providing or seeking therapy services yourself.

We focus in this chapter even more on the treatment pro- cess, with special emphasis on information most relevant to you, the consumer. We �rst discuss different types of mental health professionals and what to consider if you want to become a mental health professional or a client. We also review important components of treatment at individual and community levels, caveats about treatment, and ethics.

Becoming a Mental Health Professional

Perhaps you have been so intrigued by the material in this textbook that you are thinking of becoming a mental health professional. Good for you! In this section, we discuss different types of therapists and their quali�cations and offer suggestions for preparing yourself to become a mental health professional.

Types of Therapists and Quali�cations Professionals who assess and treat people with mental disor- ders include psychologists, psychiatrists, psychiatric nurses, marriage and family therapists, social workers, and special education teachers. Various kinds of psychologists (e.g., clinical, counseling, educational, and school) address people with

mental disorders (see Table 15.1). Clinical psychologists often have a doctoral degree (Ph.D.) that allows them to serve both as scientists, or someone who conducts research on abnor- mal behavior, and as practitioners, or someone who conducts a wide range of psychological testing and provides diagnoses and treatment to people with mental disorders. Some clinical psychologists attend Psy.D. graduate programs that may focus less on research and more on developing clinical skills. A state licensing board must certify clinical psychologists to practice independently.

Clinical psychologists obtain an undergraduate degree, usu- ally in psychology, and then attend graduate school for at least 4 years (usually 5) in addition to a 1-year internship. Many clini- cal psychologists also work in postdoctoral research positions after internship to further specialize in a given area, such as neuropsychology or substance use disorder. Many psychologists also become professors.

Clinical psychologists are often trained to work with people with severe behavior problems, and often do so using a change- oriented approach in which behavior change is the primary goal (O’Donohue & Fisher, 2012). Clinical psychologists often rely on verbal treatment strategies to change problematic emotions, thoughts, and behaviors. They do not currently prescribe medi- cation in most areas, but do in some states, and other jurisdic- tions are considering whether to give prescription privileges to clinical psychologists (McGrath, 2012).

Counseling psychologists tend to focus on people with less severe problems, such as those needing vocational counseling or marriage and family therapy (Neukrug, 2012). Counseling psychologists usually have a doctoral degree and are licensed as well. Many counseling psychologists adopt a choice-oriented approach in which the primary goal is to help a client make the right choices in her life. A client may need help deciding what

career to pursue, for example, or whether to get a divorce.

Educational and school psycholo- gists focus on children and learning- based issues. These psychologists often have a master’s or doctoral degree. Edu- cational psychologists tend to be more research-based and focus on developing effective strategies to teach children (and adults) different concepts like reading or arithmetic. School psychologists are usually af�liated with elementary, junior, and high schools and often assess chil- dren at risk for learning, developmental, and other mental disorders that could interfere with academic achievement.

Psychiatrists are physicians who can prescribe medication for people with mental disorders. Their training and background is typically from a biological perspective, so psychiatrists often rely on �nding the right medica- tion or other somatic treatment, such Clinical and counseling psychologists often work in private practice settings.

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as electroconvulsive therapy (Chapter 7), to reduce suffering. Psychiatrists are usually trained in premedical, medical, and residency programs for at least 11 years. Psychologists and psy- chiatrists often work together so that different aspects of mental disorder, especially severe mental disorders like schizophrenia or depression, can be treated. A combination of psychological treatment and medication is best for many people. A psycholo- gist or psychiatrist with specialized training in Freudian-based psychoanalysis may be referred to as a psychoanalyst.

Psychiatric nurses (R.N.s) are those who receive special- ized training in addressing the needs of people with severe men- tal disorders like schizophrenia. These professionals often work in hospital-based, inpatient psychiatric units and are usually responsible for daily management of the unit as well as admin- istering medications.

Marriage and family therapists can be licensed as a sep- arate entity in several states (check yours) and often have a master’s degree in clinical or counseling psychology. These therapists concentrate on couples with marital or relationship problems as well as families with communication or problem- solving dif�culties. Social workers usually have a master’s

School psychologists often assess youth with learning problems.

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o degree (M.S.W.) and are licensed as well. The traditional role of this profession has been to focus on social and cultural factors of psychopathology and link disadvantaged persons with mental disorders to community resources, such as residential programs or unemployment bene�ts, which could improve quality of life. Many social workers could thus be found working in prisons, hospitals, schools, and social service agencies. The role of so- cial workers has now expanded, and many work closely with psychologists and psychiatrists and/or practice therapy indepen- dently (Sue, Jackson, Rasheed, & Rasheed, 2016).

Special education teachers usually have a master’s degree and often work closely with persons with developmental dis- orders, such as severe intellectual disability or autism. These teachers are responsible for designing and implementing spe- cialized educational plans for these children and are often found in unique schools or segregated units of regular schools.

Many people also work with those with mental disorders in other ways. Paraprofessionals are those without advanced degrees who conduct assessments and interventions with peo- ple with mental disorders under the supervision of a mental health professional. One of your authors has an on-campus research-based clinic staffed by undergraduate and graduate students who assist with assessment and treatment sessions. Students with a bachelor’s degree in psychology may also work as paraprofessionals in hospitals and other community-based organizations for people with mental disorders. In addition, psychotherapist is a term sometimes used for a mental health professional who practices therapy under supervision but who is not yet licensed.

Preparing to Be a Mental Health Professional What should you do if you want to become a mental health professional? A good �rst strategy is to talk to professors in dif- ferent departments on campus, such as psychology, counseling, and social work. Do not be afraid to do this! A professor’s job includes counseling students about career options and helping them determine which options �t best for them. Talk to the in- structor of the course about her background and ask what ad- vice she has. Think about areas you might be most interested in, such as children or depression, and discuss with the professor what kinds of courses you might wish to take in the future to further develop your interests.

Next, examine different courses in these areas and see which ones appeal most to you. Take these varied courses and see if the content matches what you think you might like to do. Talk to the instructors of each course about their background, training, and advice for future work. As you do, you might �nd yourself drawn to a particular area of interest. If not, that is �ne. Keep searching!

Check also to see which professors in different departments are actively engaged in clinical research. Your current instructor may be a good person to ask �rst. One usually needs diverse clinical and research experience or internships to enter graduate school to become a mental health professional. Engage in this kind of research with different people as early as possible in

Psychiatrists are physicians who usually ascribe to a biological approach to mental disorder.

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CHAPTER 15 Consumer Guide to Abnormal Psychology456

TABLE 15.1

Common Types of Psychologists

Clinical psychologists assess and treat mental, emotional, and behavioral disorders. These range from short-term crises, such as dif�culties resulting from adolescent rebellion, to more severe, chronic conditions, such as schizophrenia. Some clinical psychologists treat speci�c problems exclusively, such as phobias or depression. Others focus on speci�c populations: young people, ethnic minority groups, gays and lesbians, and the elderly, for instance. They also consult with physicians on physical problems that have underlying psychological causes.

Cognitive and perceptual psychologists study human perception, thinking, and memory. Cognitive psychologists are interested in ques- tions such as: How does the mind represent reality? How do people learn? How do people understand and produce language? Cognitive psychologists also study reasoning, judgment, and decision making. Cognitive and perceptual psychologists frequently collaborate with behavioral neuroscientists to understand the biological bases of perception or cognition or with researchers in other areas of psychology to better understand the cognitive biases in the thinking of people with depression, for example.

Counseling psychologists help people recognize their strengths and resources to cope with their problems. Counseling psychologists do counseling/psychotherapy, teaching, and scienti�c research with individuals of all ages, families, and organizations (e.g., schools, hospitals, businesses). Counseling psychologists help people understand and take action on career and work problems. They pay attention to how problems and people differ across life stages. Counseling psychologists have great respect for the in�uence of differences among people (such as race, gender, sexual orientation, religion, disability status) on psychological well-being. They believe that behavior is affected by many things, including qualities of the individual (e.g., psychological, physical, or spiritual factors) and factors in the person’s environment (e.g., family, society, and cultural groups).

Developmental psychologists study the psychological development of the human being that takes place throughout life. Until recently, the primary focus was on childhood and adolescence, the most formative years. But as life expectancy in this country approaches 80 years, developmental psychologists are becoming increasingly interested in aging, especially in researching and developing ways to help elderly people stay as independent as possible.

Educational psychologists concentrate on how effective teaching and learning take place. They consider a variety of factors, such as human abilities, student motivation, and the effect on the classroom of the diversity of race, ethnicity, and culture that makes up America.

Engineering psychologists conduct research on how people work best with machines. For example, How can a computer be designed to prevent fatigue and eye strain? What arrangement of an assembly line makes production most ef�cient? What is a reasonable workload? Most engineering psychologists work in industry, but some are employed by the government, particularly the Department of Defense. They are often known as human factors specialists.

Evolutionary psychologists study how evolutionary principles such as mutation, adaptation, and selective �tness in�uence human thought, feeling, and behavior. Because of their focus on genetically shaped behaviors that in�uence an organism’s chances of survival, evolutionary psychologists study mating, aggression, helping behavior, and communication. Evolutionary psychologists are particularly interested in para- doxes and problems of evolution. For example, some behaviors that were highly adaptive in our evolutionary past may no longer be adaptive in the modern world.

Experimental psychologists are interested in a wide range of psychological phenomena, including cognitive processes, comparative psychology (cross-species comparisons), learning and conditioning, and psychophysics (the relationship between the physical brightness of a light and how bright the light is perceived to be, for example). Experimental psychologists study both human and nonhuman animals with respect to their abilities to detect what is happening in a particular environment and to acquire and maintain responses to what is happening. Experimental psychologists work with the empirical method (collecting data) and the manipulation of variables within the laboratory as a way of understanding certain phenomena and advancing scienti�c knowledge. In addition to working in academic settings, experimental psychologists work in places as diverse as manufacturing settings, zoos, and engineering �rms.

Forensic psychologists apply psychological principles to legal issues. Their expertise is often essential in court. They can, for example, help a judge decide which parent should have custody of a child or evaluate a defendant’s mental competence to stand trial. Forensic psychologists also conduct research on jury behavior or eyewitness testimony. Some forensic psychologists are trained in both psychology and the law.

Health psychologists specialize in how biological, psychological, and social factors affect health and illness. They study how patients handle illness; why some people don’t follow medical advice; and the most effective ways to control pain or to change poor health habits. They also develop health care strategies that foster emotional and physical well-being. Health psychologists team up with medical personnel in private practice and in hospitals to provide patients with complete health care.

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your undergraduate career—do not wait until your senior year! In addition to gaining valuable clinical and research experience, you will �nd people who might be willing to write future let- ters of recommendation for you. Remember, good grades and standardized test scores are only part of the equation for getting accepted into graduate school. Some other recommendations:

• Get involved in Psi Chi, the national honor society for psy- chology students.

• Develop contacts with on-campus social groups for certain majors, such as a psychology club.

• Talk with directors of community mental health agen- cies about openings for volunteers and paraprofessionals. Donate your time conducting assessments, observing treat- ment sessions, and engaging in telephone work, perhaps at a suicide hotline.

• Get ongoing advice from one or more faculty mentors about deciding on career options, writing a letter of intent, and choosing graduate schools of interest.

• Engage in some clinical research and, if possible, present a paper at a psychology conference.

TABLE 15.1

Common Types of Psychologists—cont’d

Source: American Psychological Association (www.apa.org/topics/psychologycareer.html#aparesources).

They educate medical staff about psychological problems that arise from the pain and stress of illness and about symptoms that may seem to be physical in origin but actually have psychological causes. Health psychologists also investigate issues that affect a large segment of society, and develop and implement programs to deal with these problems. Examples are teenage pregnancy, excessive substance use, risky sexual behaviors, smoking, lack of exercise, and poor diet.

Industrial/organizational psychologists apply psychological principles and research methods to the workplace in the interest of improv- ing productivity and the quality of work life. Many serve as human resources specialists, helping organizations with staf�ng, training, and employee development. Others work as management consultants in such areas as strategic planning, quality management, and coping with organizational change.

Neuropsychologists (and behavioral neuropsychologists) explore the relationships between brain systems and behavior. For example, behav- ioral neuropsychologists may study the way the brain creates and stores memories, or how various diseases and injuries of the brain affect emotion, perception, and behavior. They design tasks to study normal brain functions with new imaging techniques, such as positron emis- sion tomography (PET), single photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI). Clinical neuropsychologists also assess and treat people; and many work with health teams to help brain-injured people resume productive lives.

Quantitative and measurement psychologists focus on methods and techniques for designing experiments and analyzing psychological data. Some develop new methods for performing analysis; others create research strategies to assess the effect of social and educational programs and psychological treatment. They develop and evaluate mathematical models for psychological tests. They also propose methods for evaluating the quality and fairness of the tests.

Rehabilitation psychologists work with stroke and accident victims, people with intellectual disability and autism, and those with developmental disabilities caused by such conditions as cerebral palsy. They help clients adapt to their situation, frequently working with other health care professionals. They address issues of personal adjustment, interpersonal relations, the work world, and pain manage- ment. Rehabilitation psychologists are also involved in public health programs to prevent disabilities, including those caused by violence and excessive substance use. They also testify in court as expert witnesses about the causes and effects of a disability and a person’s rehabilitation needs.

School psychologists work directly with public and private schools. They assess and counsel students, consult with parents and school staff, and conduct behavioral interventions when appropriate. Most school districts employ psychologists full time.

Social psychologists study how a person’s mental life and behavior are shaped by interactions with other people. They are interested in all aspects of interpersonal relationships, including individual and group in�uences, and seek ways to improve such interactions. For example, their research helps us understand how people form attitudes toward others, and when these are harmful—as in the case of prejudice— suggests ways to change them. Social psychologists are found in a variety of settings, from academic institutions (where they teach and conduct research), to advertising agencies (where they study consumer attitudes and preferences), to businesses and government agencies (where they help with a variety of problems in organization and management).

Sports psychologists help athletes re�ne their focus on competition goals, become more motivated, and learn to deal with the anxiety and fear of failure that often accompany competition. The �eld is growing as sports of all kinds become more competitive and attract younger children than ever.

CHAPTER 15 Consumer Guide to Abnormal Psychology458

• Do your homework. Find out which schools might best �t your interests, and tailor your application toward a speci�c faculty member or two who would best match your interests.

• Review information provided for students by the American Psychological Association (Washington, DC), such as the book Graduate Study in Psychology and the “Careers in Psy- chology” brochure (www.apa.org/topics/psychologycareer. html#aparesources).

• Read the books What Can You Do with a Major in Psychol- ogy: Real People, Real Jobs, Real Rewards (New York: Wiley) by Shelley O’Hara, and Insider’s Guide to Graduate Programs in Clinical and Counseling Psychology by Tracy Mayne, John Norcross, and Michael Sayette (New York: Guilford).

• Above all, ask questions and get as much information as possible!

Becoming a mental health professional is exhausting but exciting work. Think carefully about the commitment you will make and how this will affect your life. But above all, do not get discouraged if the work seems challenging at times! Being a mental health professional is among the most rewarding profes- sions we know of, and we strongly recommend the profession to all those who feel they have such a calling.

Becoming a Client

Perhaps you are more interested in consuming mental health consuming mental health consumingservices than providing such services. What should you or someone you know do if seeking treatment for a psycho- logical problem? An important idea to consider when seeking

treatment is what goal you wish to accomplish in therapy. Are you going through a crisis that needs immediate attention? Are you en- tering an important life transition and need some direction? Do you have troublesome thoughts or be- haviors that need change? Do you have a problem that seems to occur for no reason and might be respon- sive to medication? The answers to these questions might help you decide what type of mental health professional to choose, such as a crisis intervention counselor, coun- seling or clinical psychologist, or psychiatrist.

When seeking treatment, one should also get referrals from knowledgeable people, such as psychologists in the community. Most mental health professionals focus their practice in key areas, such as anxiety disorders or mari- tal therapy, so �nd out who in your

community specializes in a given area. Find out which agencies offer low-cost services if that is what you desire. Many uni- versities offer community-based, sliding-scale cost treatment. Following this process, ask the mental health professional you are considering several questions before scheduling the �rst appointment:

• What is your fee, and does my insurance cover this fee or some portion of it and for how many sessions?

• Do you offer sliding-scale fees (based on one’s ability to pay) for those with limited �nancial resources or multiple dependents?

• What should I expect during the �rst session, and what type of assessment procedures do you use?

• What is the nature of the type of therapy you do, and what are its limits?

• What are your procedures regarding informed consent and con�dentiality? (discussed later in this chapter)

• What types of problems do you specialize in addressing? • What is your theoretical orientation and educational

background?

• What is your status as a provider? Are you, for example, a licensed clinical psychologist, board-certi�ed psychiatrist, or graduate student?

• Where are you located, and what are your hours? • What is your policy for speaking with clients after normal

business hours?

Remember, you are a consumer of treatment services and consumer of treatment services and consumer therefore entitled to speci�c answers to these and other relevant

If you are interested in a career in psychology, a discussion with your instructor might be a good place to start gathering information.

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questions. Do not be afraid to ask these questions and �nd a good �t with a therapist.

Treatment at the Individual Level

Whether you want to provide or consume mental health ser-vices, you could �nd yourself in one of many settings. Some of these settings involve treatment at the individual level, as many mental health professionals conduct therapy one-on-one in private practices. Other settings involve therapy within larger community- based institutions, such as group homes, hospitals, prisons, or schools. We next discuss important factors related to one-on-one therapy as well as practices in community-based settings.

We begin with work that largely applies to treatment at the individual level. We discuss common factors that enhance suc- cessful outcome regarding treatment. These factors are often described as active treatment ingredients and process variables. We also discuss whether therapy itself is effective for people.

Active Ingredients of Treatment We have talked much in this textbook about different kinds of treatment for mental disorders, but what is it about treatment that makes it work? You have seen that mental disorders consist of three components: unsettling physical feelings or emotions, troublesome thoughts, and maladaptive behaviors. Effective treatment strategies must therefore affect these areas in positive ways. One active treatment ingredient is enhancing self-control (Kottler, 2014). People with mental disorders learn in therapy to control their own maladaptive (1) physical responses, such as in relaxation training for panic symptoms (Chapter 5); (2) thoughts, such as in cognitive therapy for depression (Chapter 7); and (3) behaviors, such as in the stop–start procedure for premature

ejaculation (Chapter 11). Self-control will lead to mastery of certain symptoms and less distress from them (Rohde, Stein, Pascual-Leone, & Caspar, 2015).

Effective therapies and therapists also require clients to continually practice new skills. Examples include a child with practice new skills. Examples include a child with practice learning disorder practicing reading or writing or a person with social anxiety disorder practicing conversations at a party. Prac- ticing new skills may also mean a client has to take risks, per- haps by abandoning safety-seeking behaviors or doing things not previously done. A therapist will often encourage a client to boldly attempt different ways of behaving and continue to work toward treatment goals by practicing in real life what was learned in session (Hayes, Strosahl, & Wilson, 2012).

As a client works in therapy, a key goal is to help him gain greater insight into why he continues to behave in a maladaptive

Williams-Nickelson (2009) surveyed women in graduate school to de- termine if they had a mentor and what those experiences were like. Several examples of effective mentoring practices were provided. Effective mentors provided advancement opportunities, such as networking with other profes- sionals and inviting a mentee to participate in a special project. Good men- tors also provided support and helped the mentee develop self-assurance, especially during times of stress or transition. Mentors help mentees focus on goals and a vision for the future and give constructive feedback about a student’s development and progress. Mentors help facilitate independent thinking and help mentees experiment with different professional roles (e.g., as a therapist or researcher). Good mentors are also positive role models, especially with respect to maintaining balance in life (i.e., family and work) and engaging in proper self-care. Mentors help students realize their poten- tial and allow them a good amount of autonomy to challenge the ideas of the mentor. If you are considering graduate school, talk to professors in your discipline who can help mentor you. Once you are in graduate school, look for mentors who have the characteristics mentioned here.

Focus On

Graduate programs in psychology have experienced a strong surge in ap- plications from females in the past 20 years, and approximately 77.5 per- cent of current students in a clinical or counseling doctoral program are female. However, only about 45 percent of faculty members in clinical doctoral programs are female (American Psychological Association, 2012). This disparity raises the question of whether female graduate students re- ceive suf�cient or effective mentoring during their education process. This is important because well-mentored students tend to have more produc- tive careers compared with those who have less mentoring.

Gender Graduate School and Mentors

15.1

A warm, supportive therapist–client relationship is essential for successful treatment.

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CHAPTER 15 Consumer Guide to Abnormal Psychology460

way (Lehmann et al., 2015). This is especially important when personality traits interfere with success in different areas of life. A client should gain greater knowledge about himself and how his behavior affects other people. A client should also gain greater knowledge about how to control his behavior or what to do if behavior seems problematic. If a person �nds herself becoming depressed, she may wish to consult friends, become more socially active, and practice cognitive skills to reduce maladaptive thoughts.

A client should also engage in constant self-exploration or introspection to challenge internal assumptions and enjoy posi- tive life experiences. A therapist will also help a client work through hypothetical and real-life problems using more adap- tive strategies (Bresler & Starr, 2015). For example, a therapist might help someone with schizotypal personality disorder in- teract with others in more socially acceptable ways and solve problems more effectively.

As a client improves in therapy, ongoing successes will hope- fully and naturally lead to other positive, self-reinforcing events. A person who learns new interviewing skills may land a great job. Or a child who learns social skills and how to follow rules may be better able to make new friends and achieve in school. Ongoing feedback from the therapist and signi�cant others will be helpful as well (Schuman, Slone, Reese, & Duncan, 2015). Success in therapy and life in general often comes from one’s

ability to behave effectively in life situations, to resolve or come to terms with past negative experiences, to have realistic expec- tations for change, to control extremes of emotion and behavior, to seek advice from others about appropriate life choices, and to make good choices.

Process Variables in Treatment Process variables, also known as nonspeci�c factors, are those common to all treatments that also contribute to treatment suc- cess. One powerful process variable is the placebo effect, which refers to improvement in treatment due to a client’s expectation of help (Bystad, Bystad, & Wynn, 2015). Many clients, once they know a therapist has diagnosed their problem and has a po- tential solution, become much more motivated in therapy and expect good progress. This enhances treatment effectiveness. The placebo effect can be quite stable; placebo control group improvement is sometimes greater than no-treatment conditions (Wampold & Budge, 2012).

Other process variables involve the therapist speci�cally. Such variables include experience of the therapist as well as experience of the therapist as well as experience of the therapist her ability to make the therapy session a warm and respectful place. Experienced therapists do not necessarily provide better treatment than less experienced therapists, but therapists who specialize in a given area such as substance use disorders tend

I was the �rst in my family to go to college, so I have always thought of graduate school as a very special challenge and opportunity. On the general academic level, I see it as a place where there are no limits to learning or thought. It be- comes your job to think critically about every- thing, and to formulate research and ideas that have the potential to move us all forward. With respect to clinical psychology, it seems to be a relatively new �eld, with a lot of work to be done. I �nd this fact both inspiring and daunting. Lastly, I would never deny that graduate school is very dif�cult. You make a lot of emotional invest- ments, both in your work and in your own per- sonal development. Frustrations and victories are part of everyday life. Balance, tenacity, and maybe a sense of humor are all important.

Before I started graduate school, I thought a lot about what I might expect. Actually, I expect- ed a lot of awful things that have not come to pass, perhaps because I made some prepara- tions. For example, I knew that graduate school

would be a lot of hard work, but I was dead set against pulling all-nighters and then feeling terrible (a familiar experience from my under- graduate years). I thought about how I could improve my work style so I could get a decent night’s sleep. Also, a wise person, Dr. Karen Gillock, told me that graduate school would be �lled with wonderful opportunities—but that if you did not prioritize well, you could easily �nd yourself overwhelmed, with the result of getting fewer things done (really important things, like your master’s thesis). This advice turned out to be completely true, and it was helpful to ex- pect this at the start. I guess the biggest thing that I did not expect was learning all the great things that I have learned. Going in, I had no idea what exactly I would learn. For instance, I was afraid of statistics, but I have learned to love them. I did not expect to grow and change so much.

And I have changed. I used to be really sensitive about psychology being called a

“pseudo-science” or a “soft science,” but I did not have enough knowledge about the �eld to dispute this claim. Over time, I have learned a lot about the impact that well-executed re- search in psychology can have on the public good, which is clearly of importance. I have also changed personally. I wanted graduate school to be a well-rounded and scholarly experience. Although I spend a great deal of time in the lab, I also have sought other ways to broaden my horizons. I have read a lot of classic novels, taken a fencing class, practiced

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to have much knowledge about how to best treat clients with that particular problem. More experienced therapists also tend to be more effective with clients with more severe symptoms (Mason, Grey, & Veale, 2015).

A client will also feel free to com- municate private thoughts without fear of rejection or ridicule if his therapist establishes an environment based on respect, empathy, and full acceptance of his expressions (Miller, Colloca, Crouch, & Kaptchuk, 2013). Another important therapist variable is re- assurance, or regularly indicating to a client that solutions to problems can be solved if he puts forward the work to do so. Providing a rationale to a client rationale to a client rationale about why a certain treatment is impor- tant, and how it should work, is often crucial as well. People with anxiety disorders who must “face their fears” should be given a full explanation as to why, for example (Arch, Twohig, Deacon, Landy, & Bluett, 2015).

foreign languages with friends, traveled to Spain, recorded my own music, taken up the banjo, and learned to Irish jig and �amenco dance. To me, these are not unessential things; they have helped me to better under- stand and to love my work.

I would like to share four tips for those pre- paring for graduate school:

1. Know what you want going in. More speci�cally, some people want a lot of guidance from their advisors; others want to be left alone until they really need their advisors. Also, some advisors enjoy closely mentor- ing their students, while others prefer giving students more independence. It saves a lot of time and energy to identify what type of learner you are, what type of advisor would be best suited to your working style, and how you want to carry out your graduate school experience.

school seems horrible because every- one is smart and outstanding. Some people get really depressed, think- ing they have lost their identity as the “smart one.” This is not so. We all build from each other’s abilities. It really is a time to learn about every- one’s individual skills, and how we can all work together to make the world a better place. With this in mind, please also remember the next point:

4. You are not an imposter. I de�nitely have felt intimidated, feeling as if my peers had a better feel for how to do things, or how to go about life in graduate school. The truth is that everyone has a lot to learn. Never be afraid to clarify things you do not completely understand. You will learn and grow as long as you do not give too much importance to your doubts.

2. Make your cultural differences known (in a constructive way). Sometimes we differ culturally, which is �ne. It is particularly important to understand and to be sensitive to cultural dif- ferences in psychology. Yet lines of thinking, work habits, and interper- sonal exchanges can sometimes be misunderstood, regarded negatively, or not appreciated as being related to cultural differences. If you ever feel that this is the case, never be afraid to tactfully and constructively share your thoughts about relevant cultural differ- ences. This will help everyone involved to be more informed and to be a better psychologist.

3. Know about “shining star” syndrome. That is, a lot of students come into graduate school having been the shining star in their high school and college. All of a sudden, graduate

personal narrative

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Other process variables involve the therapist–client re- lationship. An important one is interactions of the therapist and client, or therapeutic alliance, which should be produc- tive, free �owing, and honest. The relationship should be a positive one built on trust, full disclosure from the client, and hard work toward treatment goals. In other cases, the mere fact a client comes to treatment and interacts with someone is important. For these clients, who may be alone or feel re- jected during the week, therapy is often an excellent means of unburdening themselves or relieving the stress of isolation. Therapeutic alliance is a good predictor of treatment outcome (Cooper et al., 2016).

Therapeutic alignment is also an important process variable in marital and family therapy. This can refer to how a therapist supports certain members of a marriage or family to “balance out” differences in power. A therapist might align herself slightly more with a dependent spouse or an intimidated child to ease communication or problem solving. This must be done carefully, however, so as not to alienate someone in ther- apy (Tuerk, McCart, & Henggeler, 2012).

Some process variables involve the client as well. Many clients report progress in therapy when they experi- ence a release of emotions, or catharsis (Greenberg, 2012). For some clients, this may involve a strong grief or anger reaction, and for others it may represent admissions of things long kept secret, such as child maltreatment or a previous rape. Certain personality characteristics of clients may be important as well. Dependent and less defensive clients may do better in group therapy situations when more struc- ture is provided by a therapist, but independent-minded people may bene�t more from less therapist direction. The degree to which people can tolerate a range of social rela- tionships, from primitive to mature, also seems to be a key outcome factor in group therapy (Piper, Ogrodniczuk, & Hernandez, 2014).

Does Treatment Work? Does treatment actually work for clients? The overall an- swer is yes—many types of psychotherapy seem effective and better than no treatment at all. One type of therapy has not been shown to be consistently and signi�cantly better than an- other type of therapy (Gold, 2015). A trend in seeing whether treatment works, however, is to examine speci�c types of treat- ment for speci�c types of disorders. We have noted in this textbook that cognitive-behavioral treatments are effective for people with many types of problems, including anxiety, depression, eating disturbances, sexual dysfunction, and schizophrenia. Other therapies are especially useful for other disorders if matched well. Examples include dialectical behavior therapy for borderline personality disorder, behavior modi�cation for autism, and medication for bipolar disorder (Nathan & Gorman, 2015).

Another trend in evaluating treatment is the development of manuals for clinicians. Manuals provide detailed instruc- tions for addressing clients with a certain problem and what techniques should be used. Researchers usually design manu- alized treatments for people with a certain type of mental disorder, such as obsessive-compulsive disorder (Foa, Yadin, & Lichner, 2012). Manualized treatments have several advantages, including empirical basis, good validity and effectiveness, and speci�c recommendations for session-by-session assessment and treatment procedures. Manuals are usually brief, such as 4 to 8 sessions, which is preferred by many clients and insur- ance companies. Manualized treatments may not apply to all people with a certain disorder, however, because they cannot account for all individual differences in clients (O’Donohue & Fisher, 2012). Also, some clients have multiple mental disorders, which could affect how a treatment manual for one disorder is implemented.

Prescriptive Treatment Manuals have been criticized for a “one-size-�ts-all” approach, so an important trend in clinical work today (and in new man- ual development) is to �nd which treatments are best for groups of people with a certain mental disorder. Researchers evaluate different subtypes of a clinical population and provide a speci�c treatment to best �t the needs of that subtype. This is sometimes referred to as prescriptive treatment or personalized treatment (Schneider, Arch, & Wolitzky-Taylor, 2015). One person with depression may feel sad because of a negative environmental event, such as death of a loved one or bankruptcy. Another person may become depressed for little reason, or “out of the blue,” because of a neurochemical imbalance. A good prescrip- tive treatment for the �rst person might be grief counseling or cognitive-behavioral therapy. A good prescriptive treatment for the second person might be medication. The idea behind prescriptive treatment is that one therapy for all people with a certain mental disorder, or a “single magic bullet,” is inad- equate. One must consider intricate individual differences when designing the best treatment for a particular client. Sometimes

Appropriate expression of strong emotions is sometimes a part of successful treatment.

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prescriptive treatment is based on form of behavior, sometimes it is based on function or reinforcements of behavior, and some- times it is based on cause of behavior.

Prescriptive treatment is important when seeking therapy. Clients should expect a therapist to conduct a thorough assess- ment of their problem to determine the best treatment. A client should also be open with the therapist when providing important personal information and should ask many questions of the thera- pist about potential treatments. The therapist and client can thus design an effective and ef�cient treatment plan together. We next discuss more speci�c suggestions for seeking treatment.

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Treatment at the Community Level

We mentioned earlier that treatment for mental disorders often involves one-on-one interactions between a thera- pist and client. Treatment can also occur at a larger, community- based level. Various forms of such treatment are sometimes included under the rubric of community psychology, which focuses on enhancing quality of life for people and concentrat- ing on their relationships with different social structures. Ex- amples of such structures include family, work, school, church, neighborhood, and culture (Moritsugu, Vera, Wong, & Duffy, 2014). We next focus on areas of intervention that often involve groups of people and community structures.

Self-Help Groups A self-help group is an association of people who share a com- mon problem or mental disorder the group tries to address (Rosner, 2013). Examples include Alcoholics Anonymous and Narcotics Anonymous, in which the goal is to reduce maladap- tive behavior, such as excessive substance use among the mem- bership. Self-help groups can also be simple neighborhood or church or online meetings for people in grief or isolation, those with a disability, or those who know others with a certain prob- lem, such as depression. Groups may also form to protect the cultural, religious, or political values of the membership or ad- vocate for resources. An example of the latter is the National Alliance for the Mentally Ill (nami.org).

A main advantage of self-help groups is that large numbers of people with problems can be helped. Such help often comes from emotional support and feedback from members, role mod- els for successful recovery, information about a problem, new ideas regarding coping, opportunities for emotional expression, �nancial aid, self-empowerment, enhanced spirituality, sense of belonging to a group, and realizing one’s problems are not unique (Kurtz, 2015). People often �nd help by listening to oth- ers “who have been there” or who can empathize and have ex- perience with the problem in question. Participation in self-help

Self-help groups offer support and guidance for people with similar problems.

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groups enhances treatment outcome for different groups, includ- ing those with substance use problems (Chapter 9).

A criticism of self-help groups is that not all have (or wish to have) mental health professionals present. Misinformation about ways to treat or cope with a problem could thus be circulated. Other potential problems with self-help groups include high drop- out rates and inadequate help for complicated issues. Still, many people report signi�cant improvements in quality of life from self-help group membership. Membership in self-help groups in addition to professional, individual intervention is an accepted treatment strategy (Donovan, Ingalsbe, Benbow, & Daley, 2013).

Aftercare Services for People with Severe Mental Disorders We described in this textbook various treatment procedures for people with severe mental disorders in inpatient settings. Examples include electroconvulsive therapy for depression, detoxi�cation for substance use disorder, and antipsychotic med- ication for schizophrenia. Historically, many people with these disorders were treated in hospital settings and then released on their own recognizance once their symptoms subsided. Unfortu- nately, this led to a situation in which many people eventually relapsed and returned to the hospital—a phenomenon known as the “revolving door” (Frick et al., 2013).

Aftercare services have thus been established in many com- munities to help people with severe mental disorders make the transition between an inpatient setting and independent living. You may have heard the term “halfway house,” which refers to an intervention provided “halfway” between a (1) restrictive hospital or rehabilitation setting and (2) a completely indepen- dent living environment. A person lives in a supervised setting, often a small home with others with severe mental disorders. Staff at the home provide support and therapy services but residents can enjoy greater personal space, choice, and indepen- dence than at a hospital. Aftercare services also include day hos- pitals where patients live with family members in the evening, as well as supervised work and occupation training centers (James, Stams, Asscher, De Roo, & van der Laan, 2013).

Aftercare services are somewhat but not highly effective for people with severe mental disorders, such as depression, substance use, and schizophrenia. Little effectiveness has been

I can’t remember a time when I did not want to be a psychologist. From as early as middle school, I dreamed of having my own practice to provide therapy to people in their time of need. I was fascinated with the human mind; the inter- action of our behaviors, emotions, and thoughts was always intriguing. I read everything on the subject that I could �nd and even subscribed to Psychology Today, a popular psychology magaPsychology Today, a popular psychology magaPsychology Today - zine. I remember sitting in the chairs of my childhood living room imagining what it would be like to have my own of�ce, my own clients.

Being sure of my career path from the be- ginning of my undergraduate program, I sought any information I could get to help me achieve my goal. Repeatedly, I was told I must get a Ph.D., “You can’t do anything in the �eld of psy- chology without a Ph.D.” I did everything that

was recommended to me, including research, publishing articles, and volunteering at local mental health agencies. I made sure that my grade point average was high and worked to get the highest GRE I could get. I knew that getting into a psychology doctoral program was very competitive, but I was willing to do whatever it took to realize my dream. I was devastated when I was an alternate to two programs. Although I was accepted into a master’s level program in counseling psychology, I worried what options I would have and planned to eventually get the Ph.D. I was convinced I would need. I never did

seek to complete that doctorate. As it turned out, my graduate program provided me with solid basic counseling skills and I soon found I was able to realize

my dream of being a therapist without further formal education.

To my surprise, there were plenty of opportunities as a master’s level counselor in the

�eld of psychology. I was fortunate enough to experience a variety of these mental health po- sitions, each further preparing me for the work I do now. First, while still in graduate school, I worked as an intake counselor at a local psychi- atric hospital. In this position, I answered crisis calls for a hotline, did initial assessments, and recommended levels of treatment for people

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shown among youth. Much of this may be due to the sever- ity and complexity of symptoms, medication refusal, unmet needs, and family dysfunction. Controversy also remains about how many people use or have access to aftercare services. Con- cern always exists as well about whether neighborhood resi- dents will accept an aftercare home in their area. Many people with a chronic mental disorder discharged from a hospital thus relapse (recidivism), end up in prison, or become homeless (Braet, Weltens, & Vleugels, 2012; Burra, Hwang, Rourke, & Stergiopoulos, 2012).

Residential Facilities for People with Developmental Disorders Another area of community-based intervention involves peo- ple with pervasive developmental disorders, such as severe intellectual disability. People with pervasive developmental disorders were traditionally housed in large residential facili- ties, such as developmental centers, but many have moved to community-oriented and usually smaller facilities that more closely resemble normal life (Racino, 2015). These smaller facilities, usually group homes or foster-care placements, often involve more daily choice in one’s routine, such as what to wear. Job training and work-oriented settings are usually associated with smaller living facilities as well.

Movement to smaller, community-based facilities is based on normalization, or the belief that people living in more normal circumstances will behave less unusually and be more valued by others. Such movement has led to substantial improvements in self-care skills and general adaptive behavior (Larson, Lakin, &

Hill, 2012). Some attribute these improvements to better material well-being, staff attention, integration with others and the com- munity, and contact with family members. Personal choice about daily activities is generally higher as well (Ticha et al., 2012). Some group homes are just as restrictive as larger residential facilities, however, which may hinder certain skills. One should thus assess level of available choice in a living environment for someone with a pervasive developmental disorder.

seeking psychiatric help. I also worked closely with the business of�ce learning how to bill insurance, check bene�ts, and justify treat- ment to receive authorization. This experience proved to be invaluable. The business side of a practice was something I did not learn in graduate school and is something I use in my current job every day.

Upon completion of my master’s program, as a new and developing therapist, I worked in group settings. I �rst worked as a therapist at a residential drug and alcohol treatment center for women. I provided individual, family, and group therapy to the women in the center, and play therapy to their children. I later worked in a group private practice, providing play therapy to kids in foster care, as well as seeing adults and adolescents for traditional outpatient therapy. In

the majority of my time is spent providing indi- vidual or family therapy, I have also run a vari- ety of groups, including expressive arts groups, educational groups, and support groups. As an L.P.C. in the state of Missouri, I am able to practice independently and bill insurance. This allows me �exibility and freedom I might not otherwise have to set my own schedule and to choose the cases I take.

Through the years I have built a successful practice, receiving referrals from physicians, school counselors, clergy, and former clients. I continue to be fascinated by the people I help and am amazed at their strength as they strive for personal healing. While my path was not what I initially thought it would be, I am now doing exactly what I always dreamed of doing and the work is just as rewarding as I imagined.

both settings, I received supervision, participat- ed in staff meetings regarding clients, and con- sulted with peers frequently. I found it essential to process the work I was doing, to check my conceptualization of clients, and to share ideas with more experienced therapists. If I could give an aspiring therapist only one piece of advice, it would be to seek good supervision and peer consultation throughout your career.

Today I am a licensed professional counselor (L.P.C.), with a master’s degree in counseling psy- chology. I have my own private practice, where my clients and I sit in those very same chairs from my childhood dreams. I treat people of all ages with a variety of mental health problems including depression, obsessive-compulsive disorder, generalized anxiety, panic attacks, posttraumatic stress disorder, and grief. While

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Forensic psychologist Catherine Howe uses a chart during her testimony at the trial of Christian Karl Gerhartsreiter, who was charged with the custodial kidnapping of his daughter.

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Criminal Justice System Other community-based interventions occur in criminal justice settings. Forensic psychology is an exciting area involving the interaction of psychological and legal principles. Forensic psy- chologists are typically involved in many aspects of evaluation and treatment that intersect with the courts and criminal justice system. Many forensic psychologists work in prisons to treat people with severe mental disorders incarcerated for some crime (Bartol & Bartol, 2014).

Other forensic psychologists conduct assessment, treat- ment, or research regarding child custody cases, criminal pro�l- ing, eyewitness testimony, police interrogations, interpersonal violence, sexual harassment, and jury selection. Forensic psy- chologists often serve as expert witnesses for speci�c cases or as general consultants for a court. Forensic work is often based on assessment of individuals, but large groups of people are also studied to identify important patterns of behavior. Examples include prisoners, rape and maltreatment victims, and juvenile offenders. Other key aspects of forensic work include accu- rately determining whether someone is dangerous to others and whether to commit someone to a hospital (Chapter 2).

Public Policy and Mental Health Community-based interventions can also include public health policy regarding people with mental disorders. This policy often comes in the form of sweeping government legislation to im- prove the quality of life for individuals. Examples include legis- lation regarding free education for all youth, services for people with severe mental disorders, health promotion and education, prenatal care, child and spousal protective services, discrimina- tion against people with mental disorder, and liability of mental health professionals, among other areas. Public policy can

also be affected by individual or groups of mental health pro- fessionals who lobby politicians, testify as expert witnesses, or �le briefs to inform judges about various mental health issues (Pirog & Good, 2013). Public policy regarding mental health has a long history in the United States and has shaped key legal rights for people hospitalized with mental disorders (see Box 15.2).

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case of someone who wishes to continue hurting himself, or with society’s right to be protected from a dangerous person.

Intervention for people with mental disorders is also based on the legal principle of least restrictive treatment, meaning a person should be effec- tively treated in a manner as least restrictive to her freedom as possible. Someone with a pervasive developmental disorder may be effectively treated in a large restrictive developmental center and in a group home. The latter is less restrictive, however, and should thus be chosen. Some people may have a severe mental disorder that requires hospitalization, but this does not mean they have lost basic rights to be treated with respect and dignity.

What do these rights mean for you? If you or someone you know is hospital- ized for a mental condition, then ask what the treatment options are, how long a stay is required, and what conditions allow for discharge. If you or someone you know is hospitalized, ask as well about side effects of procedures, such as medi- cation and electroconvulsive therapy. If you or someone you know is consider-cation and electroconvulsive therapy. If you or someone you know is consider-cation and electroconvulsive therapy. If you or someone you know is consider ing residential care for someone with a chronic mental condition, then explore different options that consider the person’s freedom, choice, and quality of life.

Focus On

A key aspect of public mental health policy involves rights for people hospitalized for mental disorder or severely dangerous behavior (Cohen & Galea, 2011). One basic right is the right to treatment itself, which man- dates that people in mental health settings receive appropriate care that provides a meaningful chance at some improvement. A person also has the right to refuse treatment, meaning he does not have to be subjected to risky psychological or medical procedures, such as surgery without proper consent. These rights often con�ict with one another, as in the

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➲ Review Questions 1.

Limitations and Caveats About Treatment

Treatment at individual and community levels works for many people with mental disorders, but not everyone. Why not? One possibility is that the most effective treatment was not chosen for a particular client. This relates to the issue of prescriptive treatment we raised earlier, or the idea that treat- ment should be tailored to meet a client’s individual needs. If a therapist uses a general treatment approach for all clients with depression, then some people with broader problems like an additional personality disorder or family con�ict may not re- spond. Inappropriate application of treatment by a therapist can delay progress as well. Therapy may not work for some people because of changes in factors noted earlier; also, some clients may have little expectation for change, another factor that jeop- ardizes treatment success.

Another limitation on the therapy process is treatment non- compliance, when a client fails to put into action the plan devel- oped with the therapist (Chapman & Rosenthal, 2015). A therapist may instruct a family to design a written contract to solve prob- lems or show a couple how to develop good communication but,

if these skills are not practiced during the week, then progress will be dif�cult. Therapists often have to explore reasons for noncom- pliance and eliminate obstacles that interfere with treatment. We next describe some speci�c obstacles to treatment.

Client–Therapist Differences One obstacle to treatment success occurs when signi�cant per- sonal differences exist between a client and therapist. If a client has very different values than his therapist, then therapy may not be productive (Proctor, 2014). Imagine a client who enters therapy with very set ideas about politics, child rearing, spousal treatment, or abortion and meets a therapist with completely opposite views on these subjects. A psychologist is expected to refrain from projecting his value system onto a client, but some cases involve too much friction to be fruitful. Severe personality con�icts can also exist between a therapist and client. Refer- ral to another therapist is recommended if the therapy process cannot progress because of these con�icts.

Cultural Differences Another important difference that affects therapy is culture. A therapist may not fully understand, properly empathize, or adjust to changes in a client’s perspective of the world. Differences in language and communication style, beliefs about mental disorder and expression of symptoms, religion, and acculturation can also complicate treatment (Paniagua & Yamada, 2013). Therapists and clients often differ as well with respect to geographical and edu- cational background and income level. These differences are not necessarily related to treatment outcome, but can affect how long a person stays in therapy or whether treatment is sought (Sue, Cheng, Saad, & Chu, 2012). A therapist should thus acknowledge differences with a client at the start of therapy and ask him if he has concerns about the differences. Special efforts to understand the client at multiple levels will also promote therapy progress (see Box 15.3).

This may be due to dif�culties accessing diverse samples for research, hesitancy of researchers to focus on sensitive issues, and bias on the part of researchers to focus more on the general population and less on individual differences that may be important in the therapy process.

Researchers must make more effort to examine ethnic, racial, and gender issues in their work. What does this mean for you? As a possible future mental health professional, and one who may be conducting re- search now, think about how individual differences can affect assessment and treatment procedures. Ask about how your research can include ques- tions about diversity, think about designing a study that speci�cally focuses on individual differences, and review research in your area of interest that has examined cultural differences. Such practices will allow you to be better prepared to assess and treat people with mental disorders from different backgrounds.

Focus On

Ethnicity is extremely relevant to the therapy process, but research re- mains sparse with respect to some mental disorders. Hartmann and colleagues (2013) examined hundreds of articles in �rst-tier psychology journals and found that only 2 percent addressed cross-cultural issues and that only 4 percent addressed ethnic minority issues. In addition, journals that most featured these issues tended to have low readership.

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Managed Care Managed care is a system of health care delivery that in�uences Managed care is a system of health care delivery that in�uences Managed care the use and cost of medical and psychological procedures. Use of managed care can limit services clients receive under certain coverage plans because insurance companies have essentially set the tone for what type of assessment and therapy a client can receive. Many insurance plans allow a client to see a therapist for only a certain number of sessions, sometimes no more than eight. This forces therapists to use brief therapies when working with clients, a practice that may not be helpful when the prob- lem is severe or complicated (Strosahl, Robinson, & Gustavsson, 2012). A therapist may also urge a client to implement treatment plans quickly—perhaps too quickly.

Other insurance plans only cover costs associated with see- ing a psychiatrist or other physician, not another mental health professional. This may lead a client toward drug or inpatient treatment for a problem when psychosocial or family treatment may have been a better long-term alternative (Sadock, Sadock, & Ruiz, 2015). Therapists may also be reluctant to treat a prob- lem that is not a formal diagnosis, such as social withdrawal or school refusal behavior, because a diagnosis is often required by insurance companies for reimbursement.

Another possible consequence of managed care is that some clients may end therapy once their insurance company stops payments. This could lead to incomplete progress, more refer- rals to low-cost agencies, more use of support groups and re- lated community services, or greater acceptance of “quick �xes” (see later section). Insurance companies prefer lower costs from treatment providers, so more emphasis may be placed on ther- apists not trained at the doctoral level, such as master’s-level therapists or paraprofessionals (Bray, 2010).

The focus on managed care raises other ethical questions as well. How much information should a therapist give an in- surance company when seeking third-party payments (Morrison & Furlong, 2014)? Information, such as a client’s name and diagnosis, are often needed, and a client must give permission for this information to be released (see later ethics sections). Very personal information, including therapist–client dialogue, should not be revealed.

Differences Between Clinicians and Researchers Another limitation to treatment is differences between clinicians in private practice and researchers in specialized clinics. Private practitioners are often eclectic or eclectic or eclectic generalist (Neukrug, 2015), generalist (Neukrug, 2015), generalist which means they use various techniques for various clients, de- pending on which seems most effective at the time. Researchers, however, often focus on very speci�c procedures for very speci�c types of clients to enhance internal validity of their studies. The problem is that many clinicians do not use research-based tech- niques even though the techniques are quite effective (Bernstein, Chorpita, Daleiden, Ebesutani, & Rosenblatt, 2015). Why?

Part of the problem is that researchers often exclude the very cases clinicians see in their practice. A researcher may exclude clients with multiple or severe diagnoses, lack of English-speaking

skills, low intelligence, medication prescriptions, or treatment compliance problems to boost internal validity of her experiment. Clients with one speci�c problem, such as obsessive-compulsive disorder only, are thus examined. Private practitioners, how- ever, usually see clients with multiple behavior problems and other complicated issues—they say many published research studies have little to do with their everyday situations. This is a common complaint about treatment manuals as well. Research- ers have thus begun to focus on more diverse populations to determine whether their procedures are effective in general community settings.

Quick Fixes Managed care and other constraints on therapy have led some people to seek solutions to problems that involve less time or ef- fort. Many people are drawn to the allure of quick but ineffective �xes for a given problem. A popular method of treating a youth with attention-de�cit/hyperactivity disorder in the 1970s was to change his diet to include less sugar or additive intake. Subse- quent studies found diet changes to be ineffective for treating this disorder (Stevenson et al., 2014).

Quick �xes for various behavior problems remain with us today. These include drug therapies for obesity, St. John’s wort for depression, and facilitated communication for autism. Facili- tated communication involves typists who supposedly translate what a nonverbal child with autism wants to communicate to parents and others. Controlled research studies, however, re- vealed that the so-called communications failed to emerge with- out biased input of the typist (Schlosser et al., 2014). This false treatment crushes the hopes of parents who want desperately to converse with their child.

Misuse of Research Related to the idea of “quick �xes” is misuse of legitimate re- search for less than honorable purposes. This refers to twisting the meaning of research �ndings or perhaps citing an isolated result out of context. Media descriptions of limited and controver- sial �ndings regarding intelligence in racial groups, immunization and potential links to developmental disorders, and vitamins and diet with respect to mental health, for example, can be overblown and have serious consequences for consumers. Use of selective statistics and a focus on certain studies over others can produce skewed conclusions as well (Coolican, 2014). You are a consumer of information from the media and other sources, so always con- sider the entire context of an original writing and do not assume someone’s description of it is necessarily accurate.

Weak Research and How to Judge a Research Article Another problem with some research, and therefore clinicians’ ability to apply it to their own practice, is weak quality. Research articles on treatment procedures could be �awed in many ways, which limits how clinicians use the results to help their clients. A research study may have included clients from particular age,

469

gender, or racial groups, which limits generalizability to the overall population (Chapter 4). Or the study may have involved unusual, expensive, or experimental procedures to which most clinicians do not have access.

What should you look for when judging the quality of a research article on treatment? Consider these questions:

• Is the sample in the study diverse and representative of the general population?

• Were there enough participants in the study to obtain a meaningful effect?

• Are dependent measures in the study varied and of good reliability and validity?

• Did the researchers rely on information gained from different sources, such as clients, parents, teachers, spouses, children, and peers?

• Are treatment procedures de�ned well, are they understand- able, and can they be applied to different clinical settings?

• What was the training of the therapists, and were different therapists used?

• How did the clients respond to treatment, and did they �nd the treatment acceptable?

• What was the long-term functioning of the clients?

Negative Therapist Characteristics Another limitation of treatment may come from negative thera- pist characteristics. Some therapists, as with some people in any profession, are bad-tempered or abrasive and may not be suit- able for certain clients. A client may leave therapy if uncomfort- able. A therapist who engages in unethical behavior should also

I knew I wanted to be a clinical child psychologist the day a former mentor of mine gave a lecture to my undergraduate developmental psychology class. He worked with children with autism in a special on-campus school and told us of one child who threw a huge temper tantrum and ran around the room screaming when a person simply turned a block on its side in the boy’s large playroom. When the block was returned to its original po- sition, the boy immediately stopped his tantrum and resumed playing in his own world as if noth- ing happened. I spent much of the next two years working in that school for children with autism.

I also spent a great deal of time learning about graduate school, and I encourage you to do the same. The most important thing I learned was to talk to many people and be persistent. Consider different areas of psychology and what kinds of people you would like to work with. Get involved with different research labs and make sure people know you are reliable and trustwor- thy around clients. Get help if you need it on the GRE and retake courses you did not do well in. It’s far better to take extra time to �x whatever de�ciencies you may have before graduation than to rush toward graduation and have trouble getting into graduate school.

I was excited to enter graduate school and �gured I would learn all I could about people with developmental disorders (Chapter 13). I found in graduate school, however, that many

different paths and popula- tions were a v a i l a b l e , and I eventu- ally extended my clinical and research work to children with anxiety disorders (Chapter 5). Many of the anxious children who came to the clinic I worked at also refused to at- tend school. No one seemed to know what to do with these kids, so I took them on and developed my dissertation around them. I’ve been study- ing kids with school refusal behavior and anxiety disorders ever since!

Today I live a full life as a college professor. I have undergraduate and graduate students who help me in different phases of research. Some have worked in my on-campus clinic for chil- dren with school refusal behavior and anxiety disorders, some in a local child protective ser- vices unit, some in a hospital setting, some in a truancy court, and some in school settings. My students work on many diverse topics for their theses and dissertations, including posttrau- matic stress disorder, perfectionism, selective mutism (refusal to speak in public situations), school absenteeism, and ethnic variables in clinical child psychology.

I also teach, have seen clients with dif- ferent psychological problems, publish journal articles and books, and consult across the country and worldwide with school districts and mental health profes-

sionals. I supervise graduate students who see clients with various mental disorders,

serve as the chair of our psychology de- partment, and review articles submitted for publication to clinical journals. I serve

on various committees and mentor students as they try to enter graduate programs and full- �edged careers. I think the best job in the world is a college professor!

My main goal in preparing this book was to say many of the things I say to my own students—mental conditions are extraordinary problems that ordinary people have and we all share aspects of the disorders discussed in this textbook. I wanted to convey that we all feel anxious, sad, worried, and even disorient- ed from time to time. I teach my students to respect people with mental disorder and not re- fer to them as schizophrenics or bulimics, but people with schizophrenia or people with buli- mia. I also wanted to share how many people with mental disorder endure so much suffer- ing. I hope you enjoyed reading the many true stories in this textbook and come away with a greater appreciation of abnormal psychology and its part in life.

15.3

Christopher A. Kearney, Ph.D. Pho

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be avoided, especially one who solicits physical contact with a client. Therapists who are evasive about issues, such as fees or therapy procedures, who constantly disagree with a client about treatment goals, and who seem uninterested in a client should also be avoided.

Lack of Access to Treatment Another reason some people do not bene�t from therapy is lack of access to treatment services. Many people cannot afford therapy, do not have insurance to pay for therapy, cannot trans- port themselves to therapy, or have dif�culty �nding low-cost services that are right for them or that are culturally sensitive (Campo, Bridge, & Fontanella, 2015). People who are members of racial or ethnic minorities or those in low-income countries have poorer access to mental health care (Patel et al., 2013).

Finding a therapist in rural settings can also be dif�cult, and seeking a therapist in a small town can risk one’s privacy. Some people may also wait until a particular problem is very severe before seeking help, and treatment at an advanced stage of men- tal disorder can be quite dif�cult. A person may be so debilitated in very advanced cases that she cannot contact someone for help. Examples include psychosis, substance intoxication, and severe depression.

These scenarios outline the importance of not only devel- oping good treatment strategies but also making sure people have access to them. Establishing home visits, marketing low- cost and self-help services, providing transportation, developing prevention efforts and online-based therapies, and integrating community, psychotherapy, and pharmacological services will likely be an increasingly important part of treatment (Prochaska & Norcross, 2013).

Ethics

All practitioners in the mental health profession are expected to follow highly stringent ethical guidelines. In this section, we outline the general ethical principles that guide work with

clients and that you should be aware of when interacting with a therapist.

General Principles Psychologists who conduct therapy are expected to follow the American Psychological Association’s Ethical Principles of Psy- chologists and Code of Conduct (American Psychological Associ- ation, 2002). These guidelines represent behaviors psychologists should aspire to in their practice, though some states incorpo- rate these guidelines into legal requirements for psychologists. The Ethical Principles are based on several general themes:

• Bene�cence and Bene�cence and Bene�cence nonmale�cence, or protecting the welfare of others

• Fidelity and responsibility, or acting professionally toward others

• Integrity, or employing high moral standards in one’s work • Justice, or exercising fairness and reasonable judgment • Respect for people’s rights and dignity, or valuing others and

minimizing con�icts

We next discuss how these themes are speci�cally imple- mented with respect to assessment, treatment, and other vari- ables. These sections each relate to a speci�c area within the Ethical Principles of Psychologists and Code of Conduct.

Assessment When assessing clients, psychologists should act in appropri- ate ways that enhance knowledge about a certain client but at the same time protect the client’s privacy. Psychologists using tests to assess clients must be competent in giving a particular test and interpreting test results for clients. These tests should also be kept secure and given only to clients in a professional relationship. Giving a personality test to people at a party, for example, would be unethical. Psychologists should also be familiar with data that support the reliability, validity, and cul- tural applicability of a given test and should design tests that have good strength in these areas. Psychologists must not use obsolete tests or outdated testing information to make clinical decisions about clients. One should be very careful about ex- amining test information about a child from several years ago because the child may have changed dramatically since then.

When explaining assessment results to others, psycholo- gists are expected to state limitations to their conclusions based on testing. A person with Alzheimer’s disease may have had great trouble paying attention to items given during an intelli- gence test, so the examiner should make this clear in her report. Psychologists must also base their statements or conclusions only on information they have received. This applies especially to child custody evaluations where parents are assessed for their capability to raise a child. If one parent refuses to participate in the evaluation and a second parent consents, then the psycholo- gist could only make conclusions about the �tness of the person who was evaluated. Refusal to take part in an assessment does

Finding psychological help in a small town can be dif�cult and may lead to concerns about violations of con�dentiality.

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not necessarily mean a person is un�t or has a mental disorder. Psychologists should also make clear what their role is before an assessment so all those being tested know what is happening.

Treatment One of the most delicate areas of psychological endeavor is treatment, which often involves discussing sensitive and personal issues with clients and interacting with other profes- sionals, such as physicians and educators. Important ethical guidelines impact the therapy process.

Informed Consent and Con�dentiality Some of the most important ethical guidelines involve informed consent and con�dentiality. Informed consent involves educat- ing potential clients about therapy, especially variables that might in�uence their decision to seek therapy. Important variables to know include nature of therapy, cost, status of a provider, risks, and con�dentiality (discussed next). If a person cannot give consent, then psychologists must still provide an explanation of what is to happen, seek the person’s verbal agreement or assent if possible, consider the person’s best interests, and obtain con- sent from a legally authorized person (Houser & Thoma, 2013). Parents can give consent for children, but many psychologists also have children verbally agree to assessment and treatment procedures. Informed consent should be documented and is ap- propriate as well for participants entering a research project or most testing situations.

Con�dentiality is based on privileged communication, which means discussions between a therapist and client should not be divulged to others unless consent is given. Many relation- ships enjoy such privilege, including husband–wife, physician– patient, lawyer–client, and clergy–parishioner relationships. Psychologists are expected to maintain the privacy of their cli- ents, even going as far as to not admit a person is in therapy. Psychologists usually obtain a release of information consent form from a client to speak with others about a particular case. This release permits them to contact teachers, medical profes- sionals, or relevant others (Houser & Thoma, 2013).

Con�dentiality is not absolute, however. Psychologists are ethically and legally allowed to break con�dentiality under cer- tain conditions. Psychologists are expected to take steps neces- sary to protect lives when a client is a clear threat to himself or others; this can even include contacting the police and/or someone else who is threatened. Con�dentiality does not ex- tend to child or elderly person maltreatment, which a psycholo- gist is legally bound to report to a child protective agency or department of aging. Con�dentiality may also be broken when a judge issues a court order for notes or testimony, when a client sues for malpractice, when a client tries to enlist a thera- pist’s help to commit a crime, or when a psychologist seeks reimbursement for services. Even in these cases, however, a psychologist gives the minimum amount of information neces- sary about a client and should consult a legal representative. Clients should be informed at the start of therapy about limita- tions on con�dentiality.

Who Is the Client? An important question that often arises in couple and family therapy is “Who is the client?” In marital cases, one spouse may have initiated therapy for the couple and is paying for it. In family cases, parents usually refer themselves for therapy and pay for it, though a teenager may be the one having behavior problems and seeing the therapist. Who is the client in these situations? Is a spouse or are parents entitled to know what the other party said? Ethically, psychologists should clarify at the outset of therapy her relationship with each person.

A psychologist might say the couple is the client and she will try to be as fair as possible and not allow secrets between a therapist and one partner. A psychologist working with a family might say all information given privately by a child will be kept con�dential unless the child is a threat to herself or others or if she allows the therapist to communicate certain information to the parents. If clients disagree with these con- ditions, then a referral to another therapist may be necessary. Psychologists should also not reveal more information than is needed for third-party payers such as insurance companies.

Sexual Intimacy Sexual intimacy with clients is another important ethical issue for psychologists, and the ethics code and legal statutes make clear that such intimacy with current clients is unacceptable. Psychologists should also not accept into therapy anyone with whom they have had a sexual relationship in the past. Psycholo- gists are expected to avoid dual relationships, meaning they should not act as a psychologist and friend, lover, signi�cant other, or business partner. A psychologist should be unbiased and objective when helping a client, which is dif�cult to do when emotional feelings are involved.

What about sexual intimacies with former clients? The former clients? The former ethics code stipulates that psychologists must wait at least 2 years after the end of therapy before such intimacy can take

Husband–wife communications are considered privileged in our society, as are communications between a therapist and client.

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place. Even if this does happen, a psychologist must show the client has not been exploited. Psychologists should generally avoid sexual and even social contact with former clients. Most cases of malpractice involve inappropriate sexual contact, and such contact is rife with potential for con�icts of interest and harm to a client (see Box 15.4).

Ending Therapy Important ethical guidelines still apply when a client nears the end of therapy. Psychologists should assist a client when she can no longer pay for services. A psychologist could make arrangements to lower the fee, see the client for fewer sessions, refer her to a low- cost provider, or make alternative payment arrangements. Thera- pists are also expected to end treatment when a client is clearly no longer bene�ting from, or is being harmed by, the process.

Psychologists should not end ther- apy abruptly but rather prepare clients for termination by dis- cussing the issue with them in previous sessions.

Public Statements Psychologists often make

public statements through advertise-

ments, printed materials, inter- views, lectures, legal proceed- ings, and in- teractions with media. Psychol- ogists must en- sure that public statements are honest and not deceptive. This

includes information about their training, credentials, services, and other public knowledge. Psychologists who provide advice through the media, such as through a radio program, are ex- pected to base their statements on available scienti�c literature and practice and perhaps remind listeners that their advice does not necessarily substitute for formal therapy. These principles are important to remember when you hear public �gures like Dr. Phil speak and dole out advice. Pay close attention to how often they refer to scienti�c literature to support their statements.

Research Ethical guidelines such as informed consent apply to research as well as clinical practice. Psychologists are expected to refrain from deceptive research unless the study is justi�ed from a sci- enti�c perspective and if participants know about important and harmful aspects of the study that might in�uence their de- cision to participate. Psychologists engaging in research must also humanely care for animals, honestly report results, and give proper credit for sources of information and authorship of publications.

Resolving Ethical Issues What should a psychologist do if she becomes aware of an ethical violation by a colleague? The psychologist should �rst speak with the colleague to informally address the issue. This might apply to a situation, for example, in which a colleague accidentally left a client’s �le on a receptionist’s desk. If the problem is very serious, however, or cannot be addressed satis- factorily by informal means, then the psychologist should refer the matter to a state licensing board or national ethics com- mittee. Client con�dentiality must still be protected in these cases, however. If a client reveals a serious ethical violation by a previous therapist but insists on con�dentiality, then the client’s request must generally be honored. Psychologists are also expected to fully cooperate in ethics proceedings involv- ing themselves or others.

Dr. Phil is a popular media psychologist. Psychologists who speak via the media are still expected to comply with ethical guidelines.

the APA ethics committee. Most cases were allegedly due to sexual mis- conduct (n = 4) and nonsexual dual relationship (n = 1).

An overwhelming percentage of psychologists clearly comply with the ethics code. Some mental health professionals, however, inexplicably cross the line into severe misconduct. Most ethicists agree that touch- ing a client— including hugs, touches of the hand, and two-handed handshakes—can be misunderstood. The professional relationship can be undermined if clients become confused about what message is being sent—is a therapist a professional or a friend? Such practice is also a “slippery slope” that can lead to even more dangerous practices, such as meeting outside of one’s of�ce or sending personal messages. Psycholo- gists empathize with clients and their concerns but usually refrain from physical contact.

Focus On

Psychologists are expected to follow a strict ethics code in their profes- sional practice. Almost all psychologists do so, but you might wonder what types of ethical violations are referred to the American Psychologi- cal Association (APA). Each year, the APA publishes an account of what ethical violations were reported. In 2014, 10 cases were opened before

Law and Ethics Sexual Intimacy and the Therapeutic Relationship

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Final Comments We have discussed in this textbook many issues related to mental disorders, clients, and therapists. The symptoms and disorders and problems clients face are many, but there remain basic ways in which people with mental disorders should be seen. People with mental disorders are often ordinary people with extraordinary problems, so remember that anyone can develop a mental disorder. A person should always be viewed �rst and his disorder second. Individuals with a particular mental disorder are always quite different, and these differences must be honored and respected. Try to avoid terms like “schizophrenic” and favor terms like “a person with schizophrenia.” People with mental disorders, especially youth, often need advocates who can work hard and ethically on their behalf. As a possible future mental health professional, keep in mind you hold enormous responsibility for the welfare of your clients.

Thought Questions 1. Think about television shows or �lms that involve therapists and their relationships with their

clients. What strikes you as realistic or not realistic about these relationships? Why?

2. If you were to see a therapist, what questions would you want to ask and what do you think the process would be like? If you have been in therapy or are currently seeing a therapist, what aspects of treatment have you appreciated most and least?

3. What are advantages and disadvantages of self-help groups, especially in contrast to seeing a mental health professional?

4. When should people be institutionalized for mental problems? What kinds of restrictions, if any, would you place on people with severe mental disorders?

5. Would you add or change anything to the ethics code that psychologists are asked to follow? Why?

CHAPTER 15 Consumer Guide to Abnormal Psychology474

Key Terms clinical psychologists 454 counseling psychologists 454 educational psychologists 454 school psychologists 454 psychiatrists 454 psychoanalyst 455 psychiatric nurses 455 marriage and family therapists 455 social workers 455 special education teachers 455 paraprofessionals 455

psychotherapist 455 self-control 459 mastery 459 insight 459 process variables 460 placebo effect 460 therapeutic alliance 462 therapeutic alignment 462 catharsis 462 prescriptive treatment 462 community psychology 463

self-help group 463 aftercare services 464 normalization 465 forensic psychology 466 right to treatment 466 right to refuse treatment 466 least restrictive treatment 466 informed consent 471 con�dentiality 471 dual relationships 471

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Normal Stress and Unhealthy Stress-Related Problems: What Are They?

Stress-Related Problems: Features and Epidemiology

Stress-Related Problems: Causes and Prevention

Stress-Related Problems: Assessment and Treatment

KEY TERMS

Appendix: Stress-Related Problems

APPENDIX Stress-Related Problems478

Normal Stress and Unhealthy Stress-Related Problems: What Are They?

Stress is a construct that means different things. Stress can be external, meaning events in our daily lives that are tax- ing for us. Examples include relationship problems, �nancial worries, and academic pressures. Stress can also be internal, meaning we perceive events as demanding and thus experience bodily changes such as muscle tension, trouble sleeping, and headaches. Ben was clearly experiencing external and internal aspects of stress. Everyone experiences stress at some level, so stress is normal and even adaptive. Stress can make us more alert and can help motivate us to prepare for upcoming tasks.

Stress can obviously become excessive, however. We have all been through times when stress was intense, such as taking �nal exams, planning a wedding, or losing someone. In most cases, intense stress eventually dissipates as time passes, and we readjust to everyday living. In other cases, however, stress continues for lengthy periods and can become physically and otherwise harmful. Ben’s ongoing and intense stress at work was clearly leading to several maladaptive physical symptoms and a lower quality of life.

A popular model for understanding acute and chronic stress and its effects on us was proposed by Hans Selye, who referred to the general adaptation syndrome. This model of stress consists of three stages (see Figure A.1). The �rst stage is alarm, which refers to the body’s initial reaction to something

stressful. This reaction may be in the form of higher adrena- line and cortisol, substances that allow the body to become energized and �ght or �ee a stressful stimulus. You may have noticed during �nal exams that you become quite energized by the stress of having to work so hard to study and concentrate and balance many demands in your life. As �nal exams pass and your intense stress level declines, so too do your body’s physical reactions.

In some periods of our life, however, intense stress contin- ues past this initial point. Some intense stressors can be chronic, such as worries about job loss or pay cuts or a child’s severe illness. The body tries to increase resistance to stress in stage resistance to stress in stage resistance 2 but, over time, physical resources to do so become depleted. Over a longer period of time, a person enters the exhaustion phase, the third level of Selye’s model, where physical resources and resistance to stress decline dramatically. This can set the stage for various stress-related physical problems that we discuss here. Ben’s chronic stress and new physical problems perhaps meant he was near the end of the resistance stage or entering the exhaustion stage.

Stress-related physical problems have been traditionally referred to as psychophysiological disorders. Psychophysi- ological disorders speci�cally refer to organ dysfunction or physical symptoms that may be at least partly caused by psychological factors such as stress. Dysfunction often occurs in gastrointestinal, cardiovascular, immune, or respiratory systems, although other areas could be affected as well. The modern terminology for these problems is psychologi- cal factors affecting other medical conditions (see Table A.1; American Psychiatric Association, 2013). This refers to a true medical condition that is in�uenced to some extent by a psy- chological factor, such as anxiety, stress, or depression. The psychological factor can affect the course or treatment of the medical condition. A person may experience such intense stress that stomach problems develop very quickly, or de- pression in another person may cause him to delay visiting a

case Ben is a 47-year-old man who is employed as a middle manager at a large corporation. He has experienced considerable stress at his job during the past 2 years, having endured downsizing of his staff, pay cuts, mandatory furloughs, and reduced bene�ts. Ben has thus been forced to take on ad- ditional responsibilities, and new rumors are swirling that his position may be cut soon. His work-related stress is beginning to cause problems at home. Ben is forced to work extended hours and thus has less time to spend with his family. His relationships with his wife and children have become strained in recent months.

Ben was able to expertly balance his responsibilities and adjust to a new pay scale initially, but the ongoing stress of his situation has begun to take a physical toll. He visited his primary physician recently and complained of trouble sleeping, abdominal pain, and headaches. Ben has gained consid- erable weight during the past few months because of a poor diet and little exercise. His blood pressure has risen since his last visit to the physician, which is a concern given Ben’s family history of heart disease. After several tests, Ben was told that he appears to be in the early stages of developing a stomach ulcer and that he must reduce his stress or face potentially more serious physical symptoms.

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FIGURE A.1 HANS SELYE’S GENERAL ADAPTATION SYNDROME. (From David G. Myers, Exploring Psychology 7th ed., p. 398. Reprinted by permission.)

Stress-Related Problems: Features and Epidemiology 479

physician for medical symptoms, which then worsen. Psycho- logical factors can also pose additional health risks, as when a fear of needles prevents someone from taking a needed medication. Finally, stress-related physical responses, such as those noted in Selye’s model, could help cause or exacerbate a medical problem such as breathing dif�culties.

Stress-related physical problems are often studied by health psychologists who specialize in examining the interaction of biological, psychological, and social variables on traditional medical disorders. Health psychologists are often employed in health and human service agencies, medical settings, or uni- versities af�liated with a hospital. Health psychologists may intersect with the area of behavioral medicine, which refers to a larger multidisciplinary approach to understanding the treat- ment and prevention of medical problems that may include a psychological approach. Health psychology and behavioral medicine may also overlap with the area of psychoneuroimmu- nology, which refers to the study of the interaction of psycho- logical variables such as stress on the nervous and immune systems of the body.

Stress-Related Problems: Features and Epidemiology

We next discuss various physical problems that may be partly caused or affected by psychological factors such as stress. Keep in mind that many physical problems can be af- fected by psychological factors, such as HIV/AIDS, cancer, and chronic fatigue syndrome. We concentrate the following mate- rial on those medical problems that tend to be more common and that have a strong research base regarding contributing psychological factors. These medical problems include ulcers, irritable bowel syndrome, headache, asthma, sleep disorders, hypertension, and coronary heart disease.

Ulcers and Irritable Bowel Syndrome Stress-related problems often affect the gastrointestinal area of the body. Ulcers refer to in�ammation or erosion of a part of the body, and often occur in gastrointestinal areas such as the esophagus, stomach, or duodenum (part of the small intestine). A peptic ulcer refers to an ulcer that occurs in the stomach or peptic ulcer refers to an ulcer that occurs in the stomach or peptic ulcer intestine that can create severe abdominal pain. Recall that Ben appeared to be in the early stages of developing a stomach ulcer, perhaps from his ongoing stress. The prevalence of ulcers is 8.4 percent, and the problem is more frequent among older and obese persons, African Americans, tobacco users, and those with lung and cardiovascular diseases. Mortality for those with the condition is about 10 percent (Lau et al., 2013; Leontiadis & Nyren, 2014).

Irritable bowel syndrome (IBS) refers to a chronic gastroin- testinal disorder involving alternating and recurrent constipation and diarrhea as well as abdominal pain. The prevalence of IBS in the general population is dif�cult to determine but is likely about 11 percent. In addition, 30 percent of people who visit a physi- cian for gastrointestinal complaints appear to have the disorder. IBS is much more common in women than men and is comorbid with anxiety, depression, and insomnia. Symptoms of IBS may be more common worldwide among those in industrialized and urbanized settings (Canavan, West, & Card, 2014).

Headache Stress-related problems can also result in headaches, as they did for Ben. Tension headaches are most common and refer to short- term mild to moderate head pain that may feel as if muscles are contracting, although the actual cause of tension headaches remains unclear. Chronic tension headaches are unusual in the general population (3 percent), but most people experience a tension headache at least occasionally. Tension headaches are generally more common in women than men (Ferrante et al., 2013; Uygunoglu & Siva, 2016).

Migraine headaches refer to chronic and severe headaches that can last hours to days. Migraine headaches are often con- centrated in one area, such as one side of the head or around the eye, and many people with a migraine headache are extremely

TABLE A.1 DSM-5

Psychological Factors Affecting Other Medical Conditions A. A medical symptom or condition (other than a mental disorder) is

present.

B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways:

1. The factors have in�uenced the course of the medical condi- tion as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition.

2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).

3. The factors constitute additional well-established health risks for the individual.

4. The factors in�uence the underlying pathophysiology, pre- cipitating or exacerbating symptoms or necessitating medical attention.

C. The psychological and behavioral factors in Criterion B are not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder).

Specify current severity:

Mild: Increases medical risk (e.g., inconsistent adherence with antihypertension treatment).

Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating asthma).

Severe: Results in medical hospitalization or emergency room visit.

Extreme: Results in severe, life-threatening risk (e.g., ignoring heart attack symptoms).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

APPENDIX Stress-Related Problems480

sensitive to light and crave total darkness. Migraines are some- times preceded by an aura, or early warning signs such as light �ashes or tingling in the limbs. Migraines can be quite debilitat- ing and may be associated with nausea and vomiting. About 5 to 9 percent of men and 12 to 15 percent of women experience migraines, and 20 percent of those with migraines experience more than one episode per month (Smitherman, Burch, Sheikh, & Loder, 2013; Uygunoglu & Siva, 2016). Migraine headaches appear to be more common among persons with lower income (Stewart, Roy, & Lipton, 2013). Cluster headaches refer to a cyclical pattern of very severe head pain that can last weeks to months at a time. The prevalence of cluster headaches is 0.2 to 0.3 percent (Uygunoglu & Siva, 2016).

Asthma Asthma refers to a chronic respiratory disease involving in�amed or constricted airways, tightening of the bronchial walls, and ex- cess mucus, all of which hinders breathing. Asthma can involve regular or occasional attacks of wheezing, coughing, shortness of breath, and tightness in the chest. Asthma attacks can begin suddenly and can lead to decreased oxygen intake, lowered alert- ness, chest pain, and even death. Asthma attacks can last for minutes or much longer and can be triggered by allergens such as dust, animals, cold air, exercise, pollen, and tobacco smoke as well as stress (Vernon, Wiklund, Bell, Dale, & Chapman, 2012). The prevalence of asthma in the general population is 8.2 per- cent. Asthma rates are generally higher for children, women, and Puerto Rican Hispanics and African Americans compared with the general population. About 250,000 people worldwide die from asthma each year (Croisant, 2014).

Sleep Disorders Sleep disorders include dyssomnias and parasomnias. Dyssom- nias refer to abnormalities in the amount, quality, or timing of sleep. Dyssomnias include problems initiating or maintaining sleep or excessive sleepiness. One of the most common dys- somnias is insomnia, which refers to dif�culties falling asleep and staying asleep during the night as well as poor quality of sleep. Insomnia may or may not be related to a medical condi- tion and is often the result of substantial stress or depression. Chronic insomnia can result in excessive sleepiness during the day, irritability or moodiness, dif�culty concentrating, and poor alertness. Insomnia can be irregular, occurring some nights but not others, or could last for several weeks to months at a time. Insomnia affects 13.5 percent of adults, 9.5 percent of college students, and 20 percent of older adults, and occurs in women at twice the rate for men. Insomnia is unrelated to ethnicity but tends to occur more in people with less education (Pallesen, Sivertsen, Nordhus, & Bjorvatn, 2014; Taylor, Bramoweth, Grieser, Tatum, & Roane, 2013).

Another dyssomnia is hypersomnia that refers to excessive hypersomnia that refers to excessive hypersomnia sleepiness. Episodes of sleep may last 8 to 12 hours or longer with dif�culty rising from bed in the morning. Frequent nap- ping is common as well. The disorder must interfere with work

and social relationships. Hypersomnia occurs in 5 to 47 percent of people at sleep disorder clinics and 0.5 to 1.6 percent over- all. The disorder occurs more frequently in men than women (Billiard & Sonka, 2016).

In contrast, narcolepsy refers to a neurological disorder involving an irresistible desire to sleep during the daytime, especially during times of low activity and often after a strong emotion. People with narcolepsy often have “sleep attacks” that happen suddenly and involve quick entry into REM sleep with sleep-related hallucinations or vivid dreams. Narcolepsy may occur with cataplexy, or sudden loss of muscle tone, and a person may experience inability to move upon wakening. The prevalence of the disorder is 0.03 percent (Partinen et al., 2014).

Circadian rhythm sleep–wake disorders refer to a collection of sleep problems that affect the timing of sleep and a person’s sleep–wake system. As such, a person has dif�culty sleeping at the times required for normal functioning at work or in other areas. This disorder could be in�uenced by environmental fac- tors such as shift work (Wright, Bogan, & Wyatt, 2013). Preva- lence is 7 percent in adolescents and younger adults but higher among older adults (Sharkey, Carskadon, Figuerio, Zhu, & Rea, 2011). Breathing-related sleep disorder refers to sleep disruption Breathing-related sleep disorder refers to sleep disruption Breathing-related sleep disorder caused by abnormal ventilation, such as sleep apnea in which sleep apnea in which sleep apnea a person repeatedly stops breathing for a few seconds or more during sleep. The disorder affects about 10 percent of 30- to 49-year-old men; 17 percent of 50- to 70-year-old men; 3 percent of 30- to 49-year-old women; and 9 percent of 50- to 70-year-old women (Peppard et al., 2013).

Parasomnias refer to abnormal behavioral or physiologi- cal events that occur throughout sleep and include nightmare disorder, sleep terrors, and sleepwalking. Nightmare disorder refers to repeated awakenings following frightening dreams. Nightmares are common in problems such as posttraumatic stress disorder (Chapter 5). About 3.5 percent of men and 4.8 percent of women report frequent nightmares (Sandman et al., 2013). Repeated nightmares alone, without a concurrent mental disorder, that cause signi�cant interference in daily functioning are uncommon, however. Sleep terrors refer to behavioral events during sleep involving screams, fear, and panicked behavior. A person, usually a child, with sleep terrors is dif�cult to awaken and has little recollection of the event. Sleepwalking refers to Sleepwalking refers to Sleepwalking rising from bed and walking about during sleep. A person who is sleepwalking is dif�cult to awaken and has little recollection of the event. The prevalence of sleep terrors and sleepwalking in adults is 2 to 4 percent (Carrillo-Solano, Leu-Semenescu, Golmard, Groos, & Arnulf, 2016).

Hypertension Hypertension refers to high blood pressure and is commonly identi�ed if systolic pressure inside your blood vessels (created systolic pressure inside your blood vessels (created systolic pressure when your heart beats) is greater than 140 millimeters of mer- cury and/or if diastolic pressure inside your blood vessels (when diastolic pressure inside your blood vessels (when diastolic pressure your heart is at rest) is greater than 90 millimeters of mercury (i.e., a reading of 140 over 90, or 140/90, or greater). Pressures below 120/80 are preferred (although not too low). Hypertension

Stress-Related Problems: Causes and Prevention 481

has few outward symptoms but is a serious risk factor for prob- lems affecting the heart, brain, and kidneys such as heart at- tack, stroke, and renal failure. Essential hypertension refers to high blood pressure caused by physical and psychological factors. Hypertension affects people of different cultures quite differently, from 23 percent in India to 52 percent in Russia (Basu & Millett, 2013). Approximately 29.1 percent of Ameri- cans have hypertension, with rates especially high for African Americans (42.1 percent) and those aged 60 years and older (65.0 percent; Nwankwo, Yoon, Burt, & Gu, 2013).

Coronary Heart Disease Coronary heart disease refers to a narrowing of the small blood vessels that supply blood and oxygen to the heart. Coronary heart disease may be manifested by angina (chest pain or angina (chest pain or angina discomfort) or myocardial infarction/heart attack (blockage of blood vessels to the heart) when advanced. Blood vessels may become blocked when plaque and other material clog the arter- ies and slow or prevent blood �ow. Coronary heart disease is the leading cause of death in the United States, accounting for 1 of 6 deaths per year. Prevalence rates of coronary heart disease in the United States differ for women who are African American (7.0 percent), Hispanic (5.9 percent), and White (4.6 percent); coronary heart disease rates also differ for men who are African American (7.2 percent), Hispanic (6.7 percent), and White (7.8 percent; American Heart Association, 2015).

Stress-Related Problems: Causes and Prevention

The stress-related problems described here all have biological factors that help cause the damaging symptoms. Stomach ulcers, for example, often involve a bacterial infection from Helicobacter pylori that requires treatment with antibiotics and anti-in�ammatory medication. In addition, genetics, poor diet, smoking, allergens, plaque accumulation, and medical problems that affect sleep are common factors that help cause stress- related problems. The following sections concentrate on psycho- social factors that often affect these medical conditions.

Sociocultural Variables Stress-related problems appear to manifest differently and for different reasons among people of varying ages, gender, and race, as noted earlier. A particularly strong risk factor for many stress-related problems is socioeconomic status, which includes economic resources, social standing, and education. People with lower socioeconomic status are at increased risk of stress-related problems, especially coronary heart disease (Lazzarino, Hamer, Stamatakis, & Steptoe, 2013). People of lower socioeconomic status may have less access to medical care, experience poor nutrition and living conditions, engage in less physical activity and more alcohol and tobacco use, and

have less control over decisions in the workplace (Aneshensel, Phelan, & Bierman, 2013).

Emotional Dif�culties Several physical problems appear to be related to emotional dif- �culties such as worry, sadness, and low self-esteem. Ulcers, irritable bowel syndrome, and pain in the head, neck, and back have long been related to stress, anxiety, depression, and lower quality of life (Levenstein, Rosenstock, Jacobsen, & Jorgensen, 2015). Pain and headache are particularly related to passive cop- ing, fear, self-perceived poor health, poor emotional well-being, and cognitive distortions about the negative consequences of pain (Smitherman & Ward, 2011). Headaches in college students are closely related to level of emotional functioning and percep- tion of stress (Baghurst & Kelley, 2014).

Asthma is clearly related to stress in many cases, which ex- acerbates autonomic function and constriction of the bronchial tubes (Trueba & Ritz, 2013). Asthma is linked to anxiety and depression in children and adults, especially panic symptoms. People with asthma may also assess and manage their asthma symptoms poorly in more severe cases (Baiardini, Sicuro, Balbi, Canonica, & Braido, 2015).

Insomnia has also been linked to mood disorders such as depression and, among college students, to self-reported child- hood adversity (Gress-Smith, Roubinov, Andreotti, Compas, & Luecken, 2013). Insomnia also appears closely related to ex- cessive worry (about daily events and about not being able to sleep), stress and life change, and overarousal (Bonnet & Arand, 2010). Other risk factors include younger age (20–35 years) and obesity (Singareddy et al., 2012).

Psychosocial risk factors for hypertension include worry about job stability (as with Ben), feeling less competent at one’s job, anger, social isolation, and symptoms of anxiety and depres- sion (Cuffee, Ogedegbe, Williams, Ogedegbe, & Schoenthaler, 2014). Depression also appears to be a signi�cant risk factor for coronary heart disease (Sin, Kumar, Gehi, & Whooley, 2016). People with depression may engage in more high-risk behavior, such as using substances excessively and exercising less, and may experience greater arterial thickening and less heart rate variability, which are associated with poor cardiac outcomes (Kemp et al., 2012). People with depression are also likely to experience higher levels of bereavement and anxiety, which may be risk factors for cardiac problems as well (Tully, Selkow, Bengel, & Rafanelli, 2014).

Personality Type Personality type may be a key psychosocial cause of some stress- related problems. The traditional focus with respect to personality type was type A personality, which refers to someone who is over- achieving and hostile and who aggressively and impatiently tries to accomplish more tasks in less time. Researchers have since focused more on hostility as a key psychosocial risk factor for cor- onary heart disease, especially in men. Impatience and hostility have also been linked to hypertension (Fernandez & Smith, 2015).

APPENDIX Stress-Related Problems482

Other work has focused on type D personality. Type D personality refers to a distressed personality pattern marked by negative affectivity and social inhibition. This means that some people experience increased distress across many different situations but do not disclose this distress in social interactions. People with type D personality tend to worry excessively, expe- rience tension and unhappiness, feel irritable and pessimistic, and are uncomfortable around strangers. They experience few positive emotions, have few friends, and fear rejection and dis- approval from others.

Type D personality has been linked to several stress-related problems, such as fatigue, irritability, depression, and low self- esteem. More important, people with type D personality seem to be at greater risk for cardiac problems compared with people without type D personality. The speci�c reason for this link re- mains under study, but some evidence indicates that people with type D personality who are socially inhibited tend to have higher blood pressure reactivity to certain stressful events. Type D personality also appears related to lower quality of life and feelings of exhaustion following a medical procedure to address a cardiac problem (O’Dell, Masters, Speilmans, & Maisto, 2011; Widdershoven, Kessing, Schiffer, Denollet, & Kupper, 2013).

Social Support Social support, or one’s access to friends and family members and others who can be of great comfort during times of trou- ble, is clearly linked to several stress-related problems. Low social and family support contribute to asthma, for example, whereas enhanced support improves asthma outcomes (Wood, Miller, & Lehman, 2015). Social support may ease the ill effects of coronary problems because it helps promote medication use and compliance, positive coping with illness-related stress, and reduced overarousal and worry (Staniute, Brozaitiene, & Bunevicius, 2013). In contrast, social isolation, being unmar- ried, or experiencing marital distress or low levels of emotional support are risk factors for coronary heart disease. Good so- cial support may help calm aspects of the autonomic nervous system and reduce activation of serotonin and fear/anxiety centers in the brain such as the hypothalamic-pituitary- adrenal axis (Chapter 5) that could help prevent hypertension and later coronary problems (Ivarsson, Ekmehag, Hesselstrand, Radegran, & Sjoberg, 2014).

Causes of Stress-Related Problems The stress-related problems described here are largely the result of a combination of biological problems exacerbated by psycho- logical and social factors. A biopsychosocial model re�ects the idea that biological, psychological (emotions, thoughts, and be- haviors), and social factors combine to cause and in�uence a medical condition. This model is similar to the diathesis-stress model discussed in several chapters of this textbook. A biopsy- chosocial model is particularly relevant to psychophysiological disorders because of the unique combination of medical and nonmedical factors.

Let’s consider coronary heart disease as an example. Several physiological factors predispose people to coronary heart disease, including genetics, in�ammation, hormonal changes, elevated lipids, and restriction of arteries, among others. Several psychological factors can, however, combine with these predispositions to increase the likelihood of cardiac effects such as unstable electrical signals or blocked blood �ow. These psychological factors include chronic anger, hostility, de- pression, and exhaustion as well as poor diet, little exercise, inadequate coping, and other unhealthy behaviors. Physiologi- cal and psychological factors can be worsened as well by social factors such as isolation from others, job stress, and low socio- economic status. These factors increasingly interact over time to predispose a person to heart attack, angina, stroke, or death (Hjemdahl, Rosengren, & Steptoe, 2012).

Other psychophysiological disorders can also be understood from a similar biopsychosocial perspective. Biological predis- positions can interact with stress, anxiety, and depression as well as social variables to help produce ulcers and IBS, cause headaches or other pain, aggravate respiratory problems such as asthma or sleep problems such as insomnia, and raise blood pressure toward hypertension. Think about someone who has experienced an injury and develops chronic pain aggravated by depression, lack of social support, and trouble sleeping. Preventing these serious and chronic problems from developing requires a focus on several different variables, and this process is illustrated next.

Prevention of Stress-Related Problems Prevention of stress-related problems focuses on wide-ranging programs to improve healthy practices and reduce the preva- lence of these problems in the general population. Many of these programs focus on primary prevention of the leading cause of death in the United States: coronary heart disease. The American Heart Association published guidelines for preventing cardiovascular disease and stroke that involve behaviors that should begin at age 20 years. These guidelines include recom- mendations for screening for potential risk factors such as fam- ily history, smoking, alcohol use, diet, physical activity, blood pressure, waist circumference, cholesterol and blood glucose level, management of diabetes, and regular use of aspirin.

Other prevention programs for coronary heart disease as well as ulcers and hypertension have focused on improving life- style choices such as proper diet, exercise regimens, and smok- ing cessation. These programs are not as effective as medications to control high levels of cholesterol and blood pressure (Brook et al., 2013). This may be due to lack of compliance, however. Women who do adhere to lifestyle guidelines for diet, exercise, and smoking cessation dramatically lower their risk of sudden cardiac death (Chiuve et al., 2011).

Other primary prevention programs are tailored more speci�cally to an individual medical condition. Prevention of asthma attacks in children, for example, involves medication and stress management, early breast-feeding, and avoidance of household dust, pets, exposure to tobacco smoke, and other

Stress-Related Problems: Assessment and Treatment 483

allergens (Brew et al., 2012; Holt & Sly, 2012). Other psycho- physiological disorders such as IBS, headache, and insomnia are usually treated after a person complains of symptoms or may be prevented by a program for another disorder. A program to prevent depression, for example, may help prevent sleep prob- lems such as insomnia (Christensen et al., 2016).

Stress-Related Problems: Assessment and Treatment

Stress-related problems require a detailed medical assessment to determine the extent of biological causes for the condi- tions as well as a course of medical treatment. Mental health professionals who specialize in psychophysiological disorders have, however, developed an array of assessment and treatment strategies that focus on the psychological factors that impact these problems. Some of these strategies overlap with those dis- cussed in other chapters, but some are unique to psychophysi- ological disorders and are summarized next.

Psychological Assessment of Stress-Related Problems Psychological assessment of stress-related problems often comes in the form of daily behavior records. Researchers will ask partici- pants to record daily symptoms such as severity of pain and dis- comfort (for ulcer and headache), bowel function (for IBS), blood pressure (for hypertension), number of hours slept (for sleep dis- orders), and respiratory distress (for asthma; Voorend-van Bergen et al., 2014). Researchers may also focus on intermittent records for variables such as weight, exercise, and cholesterol level (for coronary heart disease; Boehm & Kubzansky, 2012).

Questionnaires are often administered as well. Risk assess- ment questionnaires evaluate the degree to which a person is at risk for a certain psychophysiological disorder. A risk assess- ment questionnaire for ulcer, hypertension, or coronary heart disease, for example, might include screening questions about weight, diet, cholesterol level, blood pressure, exercise, stress, alcohol and tobacco use, and occupation. Other questionnaires such as the Health Assessment Questionnaire II focus on broader Health Assessment Questionnaire II focus on broader Health Assessment Questionnaire II health-related issues such as pain and disability, quality of life, drug side effects, and medical costs (Voshaar et al., 2013). Ques- tionnaires regarding anxiety, somatization, and depression are also helpful for people with psychophysiological disorders and were covered at length in Chapters 5, 6, and 7.

Other assessment procedures for stress-related problems have involved more speci�c areas of focus. Assessment of pain, for example, involves not just how intense pain is but also how the pain interferes with a person’s daily life and how a person thinks about a pain (e.g., “I can handle the pain”), feels about a pain (e.g., “I am really worried about my pain”), and behaves following a pain (e.g., complaining to others, using medication heavily). Pain quality may be assessed as well and refers to speci�c descriptors such as sharp, aching, hot, and cramping (Upadhyay, Cameron, Murphy, & Battistella, 2014).

Assessment measures can also target personality factors re- lated to psychophysiological disorders. Measures are available to evaluate type A and type D personality, anger, and hostil- ity. Another personality variable that has received substantial attention from researchers is stress reactivity, which refers to potentially increased physical responses to daily stressful events (Lovallo, 2016). Inventories that cover key personality variables associated with psychophysiological disorders were described in Chapter 4.

Stressful life events are also assessed by researchers be- cause they have such an intense impact on physical problems. Anders and colleagues (2012) surveyed hundreds of university and community college students to identify exposure to stressful life events and traumatic experiences. Their results are shown in Table A.2. You can see that the most common stressors often involve interpersonal relationships and events such as hurtful comments, bullying, lack of support, and exclusion. More seri- ous traumatic events also included interpersonal events such as sudden and unexpected death or illness of someone close. Of course, other stressors in college can include academic, �nan- cial, sleep, and time management problems.

Psychological Treatment of Stress-Related Problems As with assessment, psychological treatment for stress-related problems typically accompanies medical treatments such as medication or surgery. Psychological treatment for stress-related problems often consists of relaxation training, biofeedback, stress management, cognitive therapy, and support groups. Note that some of these treatments, such as relaxation training and biofeedback, are often used in combination.

Relaxation Training We discussed relaxation training in Chapter 5 as a key treat- ment for physical symptoms of anxiety-related disorders. Relax- ation training often consists of tensing and releasing different ation training often consists of tensing and releasing different ation training muscle groups to achieve a sense of warmth and rest. Relax- ation training may also consist of diaphragmatic breathing in which a person practices appropriate deep breathing to achieve a greater sense of ease and control over physical anxiety symp- toms. Meditation and hypnosis are sometimes a key part of re- laxation training as well. Meditation refers to practicing focused attention and minimizing distraction, and hypnosis refers to a state of focused attention with heightened suggestibility. Relax- ation training has also been used extensively to reduce stress in people with psychophysiological disorders, especially IBS, hypertension, sleep disorders, and headache and other pain (Peterson, Hatch, Hryshko-Mullen, & Cigrang, 2011).

Biofeedback Biofeedback refers to a procedure that allows a person to monitor internal physiological responses and learn to control or modify these responses over time. A person is attached to one or more devices that provide feedback to the person about his brain wave patterns, respiration rate, muscle tension, blood pressure, heart rate, or skin temperature. The person can learn

APPENDIX Stress-Related Problems484

TABLE A.2

Lifetime Event Exposure

University students Community college studentsniversity students Community college students

Event n % n %

Stressful Life Events

1. Someone said hurtful thingsa 685 81 207 86

2. Broken an important promisea 562 67 170 70

3. Close other unsupportivea 556 66 167 69

4. Physically or verbally bullieda 518 62 163 67

5. Non-consensual end of relationshipa 511 61 165 68

6. Witnessed the psychological mistreatment of a close otherb 508 60 153 63

7. Someone excluded participanta 487 58 160 66

8. Emotional/psychological mistreatmenta 456 54 178 74

9. Deceived about something importanta 472 56 150 62

10. Lonely for extended periods of timea 465 55 147 61

11. Undesired relationship dissolutiona 458 54 155 64

12. Social isolation for extended perioda 408 49 135 56

13. Others’ substance abuseb 394 47 141 58

14. Discriminated againsta 360 43 123 51

15. Unrequited lovea 342 41 128 53

16. Deliberately humiliated by othersa 326 39 118 49

17. Emotional or physical neglecta 321 38 117 48

18. Cheated on by romantic partnera 270 33 122 50

19. Intense homesickness for extended perioda 269 32 80 33

20. Uninvited/unwanted sexual attentiona 248 30 85 35

21. Stalkeda 118 14 53 22

22. Own substance abusea 83 10 56 23

23. Self or partner abortionc 35 4 34 14

24. Self or partner miscarriagec 15 2 26 11

Traumatic Experiences

1. Sudden and unexpected death of close otherb 388 46 128 53

2. Loved one serious accident/injury/illnessb 326 39 101 42

3. Witnessed family violenceb 231 27 94 39

4. Someone close attempted suicideb 234 28 80 33

5. Natural disastera 165 20 48 20

6. Other type of accidentc 135 16 44 18

Stress-Related Problems: Assessment and Treatment 485

TABLE A.2

Lifetime Event Exposure—cont’d

University students Community college studentsniversity students Community college students

Event n % n %

7. Close other committed suicideb 108 13 44 18

8. Threateneda 90 11 48 20

9. Physically hurt by a romantic partnera 78 9 52 22

10. Motor vehicle accidenta 91 11 31 13

11. Witnessed someone beatenb 74 9 41 17

12. 13–18 years of age, forced sexual contacta 69 8 39 16

13. Childhood physical abusea 66 8 40 17

14. Sexual assault, after 18 years of agea 59 7 30 12

15. Own life threatening illnessa 67 8 19 8

16. Robbed, mugged, or held-up using threat of forcea 49 6 28 12

17. Beaten up by a strangera 38 5 35 15

18. Before 13 years of age, forced sexual contact with someone 5+ years oldera

38 5 34 14

19. Before 13 years of age, forced sexual contact with someone close in agea

44 5 26 11

20. Lived or worked in a war zonea 22 3 11 5

Other Events

Other distressing eventsc 416 49 46 60

Other serious mental health problemsb 324 39 107 44

Own suicidal ideation/attempta 240 29 98 41

Own mental health problemsa 147 18 51 21

aDirect event. bIndirect event.cCoded as direct or indirect. Source: Anders, S.L., Frazier, P.A., & Shallcross, S.L. (2012). Prevalence and effects of life event exposure among undergraduate and community college students. Journal of Counseling Psychology, 59, 449-457.

to control these responses by relaxing, using positive imagery, and thinking more �exibly. As the person does so, he can see on a monitor that his physiological responses such as heart rate are easing. With extended practice, the person learns to lower physiological arousal even without being attached to a biofeed- back machine.

Biofeedback has been used most for people with migraine headaches and sleep problems. People with migraine head- aches are encouraged to engage in thermal biofeedback, which involves feedback about skin temperature and warming the ex- tremities (hands, feet) to improve blood �ow and reduce throb- bing head pain. People with tension headaches are encouraged to engage in EMG (electromyography) feedback, which involves

feedback about muscle contraction and physically relaxing to ease tension and reduce head pain (Jensen & Bendtsen, 2015). EMG biofeedback has also been used to help people relax to reduce insomnia and hypertension (Schoenberg & David, 2014). Biofeedback appears to be best for people who are open to and educated about the approach, who have had problems with medication, and who have problematic coping skills (Andrasik & Grazzi, 2014).

Stress Management Stress management refers to a collection of techniques to help people reduce the chronic effects of stress on a daily basis as well as problematic physical symptoms. Stress management can

APPENDIX Stress-Related Problems486

involve using relaxation techniques such as those described ear- lier, understanding stress better, managing workload effectively, incorporating spirituality and empathy, improving diet and ex- ercise regimens, practicing good sleep hygiene, complying with a medication regimen, scheduling recreational activities, resolv- ing interpersonal con�icts, and managing hostility and anger toward others (Hjemdahl et al., 2012). Anger management ofAnger management ofAnger management - ten consists of identifying triggers to anger, understanding what personal physical responses lead to anger, practicing techniques to lower physical arousal, managing social and work situations more effectively to reduce the chances of anger, and removing oneself from situations in which anger is building (Henwood, Chou, & Browne, 2015).

Another stress management technique is mindfulness, which we discussed elsewhere in this textbook. Recall that mindfulness refers to greater daily awareness and acceptance of one’s symptoms and how the symptoms can be experienced without severe avoidance or other impairment. A person is asked to engage in moment-by-moment awareness of her mental state including thoughts, emotions, imagery, and perceptions. Mind- fulness may be especially useful for people with chronic pain as well as those with intense daily stress that can aggravate most physical disorders (Cherkin et al., 2016).

Cognitive Therapy We discussed cognitive therapy throughout this textbook as an effective treatment for many different mental disorders. Cog- nitive therapy generally consists of helping people think more �exibly and realistically about their environment and interac- tions with others. Cognitive therapy may be useful for reducing anxiety and depression, which are key elements of many stress- related problems.

Cognitive therapy for people with psychophysiological disorders also involves correcting mispercep- tions about certain events. Edinger and Carney (2015) help people with insomnia in part by correct- ing misperceptions about sleep requirements, circadian rhythms, and sleep loss. This is combined with a behavioral approach that involves a standard wake-up time, rising from bed after a period of sleeplessness, avoiding behaviors incompatible with sleep in the bedroom, and eliminating napping during the day. Combined cognitive- behavioral treatment greatly im- proves maintenance of sleep.

Another type of cognitive therapy for this population is self- instruction training. Self-instruction training refers to identifying nega- tive thoughts that may occur dur- ing a painful episode (e.g., “This

pain is so awful”) and replacing these thoughts with more adaptive coping ones (e.g., “I have to allow my pain to escape my body and move forward”). Self-instruction training for pain is often accompanied by techniques to educate people about pain, distract oneself from pain, reduce anxiety, and have family members and others reinforce active and positive coping behav- iors (Warschburger et al., 2014).

Support Groups Support groups are also a key aspect of treatment for people with psychophysiological disorders. We discussed support groups in different chapters but most notably in Chapter 9 for substance- related disorders. Support groups refer to meetings of people who share a common problem, including a physical problem such as an ulcer. Support groups are useful for sharing informa- tion and tips on coping, venting frustration, developing social support and friendships, and practicing stress management and other techniques. Support groups for the stress-related prob- lems discussed here are conducted by the Crohn’s and Colitis Foundation of America (for ulcerative colitis), Irritable Bowel Syndrome Association, National Migraine Association, Asthma and Allergy Foundation of America, American Sleep Associa- tion (for sleep disorders), and American Heart Association (for cardiac problems).

What If I or Someone I Know Has a Stress-Related Problem? If you suspect that you or someone you know has a physical problem that may be at least partly caused by stress or another psychological variable, then consultation with a physician and a psychologist who specializes in health issues may be best.

Biofeedback is an essential treatment component for stress-related problems.

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Stress-Related Problems: Assessment and Treatment 487

In addition, many people do not share with their physician details about the stress of their lives, or the fact that they are depressed or lack social support. But these are important fac- tors that may affect treatment, so share these details with your physician. You may also wish to explore support groups or begin daily stress management to ease physical symptoms and adhere to sound practices such as healthy diet, sleep and ex- ercise regimens, periods of relaxation, and resolution of inter- personal con�icts.

Long-Term Outcome for People with Stress-Related Problems Stress management is an effective strategy for reducing dis- tress as well as cardiovascular risk factors such as heart rate variability and ventricular problems (Lehrer et al., 2013). Stress

management also helps lower long-term mortality rates among people with cardiovascular problems such as hypertension (Varvogli & Darviri, 2011). Stress management and relaxation training may be particularly useful for people with IBS and per- haps ulcer as well (Wilkens, Pepitone, Alex, & Schade, 2012).

Other stress-related disorders appear responsive to psycho- logical therapies. As noted earlier, relaxation training and bio- feedback are especially useful for headache. Relaxation, family therapy, medication compliance, stress reduction, and education are particularly important for resolving asthma, especially in children (Long et al., 2011). Insomnia is also commonly treated successfully using cognitive-behavioral approaches, relaxation, and sleep restriction (Carney, Berry, & Geyer, 2012). In general, long-term outcome for stress-related problems is good as long as medication as well as stress, depression, and related psychologi- cal variables are appropriately managed.

Key Terms stress 478 psychophysiological disorders 478 health psychologists 479 behavioral medicine 479 ulcers 479

irritable bowel syndrome (IBS) 479 asthma 480 sleep disorders 480 dyssomnias 480 parasomnias 480

hypertension 480 coronary heart disease 481 type D personality 482 biofeedback 483 stress management 485

G GLOSSARY

measures how close one can approach a feared object or situation.

behavioral inhibition A risk factor for anxiety- related disorders involving withdrawal from things that are unfamiliar or new.

behavioral medicine A multidisciplinary ap- proach to understanding the treatment and prevention of medical problems that may include a psychological approach.

behavioral perspective A perspective of abnor- mal behavior that assumes that problematic symptoms develop because of the way we learn or observe others.

binge eating Eating an amount of food in a lim- ited amount of time that is much larger than most people would eat in that circumstance.

binge eating disorder An eating disorder marked by recurrent episodes of binge eating but no compensatory behavior.

biofeedback A procedure that allows a person to monitor internal physiological responses and learn to control or modify these responses over time.

biological model A perspective of mental disorder that assumes that mental states, emotions, and behaviors arise from brain function and processes.

bipolar disorder A mental disturbance some- times characterized by depression and mania.

bipolar I disorder A mental disorder marked by one or more manic episodes.

bipolar II disorder A mental disorder marked by episodes of hypomania that alternate with episodes of major depression.

blood alcohol level Concentration of alcohol in the blood.

body dissatisfaction Negative self-evaluation of what one’s body looks like.

body dysmorphic disorder A disorder marked by excessive preoccupation with some perceived body �aw.

borderline personality disorder Personality disorder marked by impulsivity, dif�culty controlling emotions, and self-mutilation or suicidal behavior.

breathing retraining A treatment technique for physical anxiety symptoms that involves inhaling slowly and deeply through the nose and exhaling slowly though the mouth.

brief psychotic disorder A psychotic disorder marked by features of schizophrenia lasting 1 day to 1 month.

bulimia nervosa An eating disorder marked by binge eating, inappropriate methods to pre- vent weight gain, and self-evaluation greatly in�uenced by body shape and weight.

abnormal psychology The scienti�c study of troublesome feelings, thoughts, and behaviors associated with mental disorders to better understand and predict mental disorder and help those who are in distress.

active phase A phase of schizophrenia marked by full-blown psychotic features such as delusions and hallucinations.

acute stress disorder A mental disorder marked by anxiety and dissociative symptoms follow- ing a traumatic experience.

adaptive functioning A person’s ability to carry out daily tasks that allows her to be independent.

aftercare services Community-based services for people with severe mental disorders to ease the transition between hospital settings and independent living.

agonists Medications to treat substance-related disorders that have a similar chemical compo- sition as an addictive drug.

agoraphobia A mental disorder marked by avoidance of places in which one might have an embarrassing or intense panic attack.

alogia Speaking very little to other people.

Alzheimer’s disease A neurocognitive disorder often marked by severe decline in memory and other cognitive functioning.

amyloid cascade hypothesis A theory that genetic and environmental factors interact to produce substantial brain changes and dementia.

analogue experiment An alternative experimen- tal design that involves simulating a real-life situation under controlled conditions.

anhedonia Lack of pleasure or interest in life activities.

anorexia nervosa An eating disorder marked by refusal to maintain a minimum, normal body weight, intense fear of gaining weight, and disturbance in perception of body shape and weight.

antagonists Medications to treat substance- related disorders that block pleasurable effects and cravings for an addictive drug.

antecedents Stimuli or events that precede a behavior.

antisocial personality disorder Personality disorder marked by extreme disregard for and violation of the rights of others and impulsive behavior.

anxiety An emotional state that occurs as a threatening event draws close and is marked by aversive physical feelings, troublesome thoughts, and avoidance and other maladap- tive behaviors.

anxiety-related disorder A mental disorder involving overwhelming worry, anxiety, or fear that interferes with a person’s daily functioning.

anxiety sensitivity A risk factor for anxiety- related disorders involving fear of the potential dangerousness of one’s physical symptoms.

asthma A chronic respiratory disease involving in�amed or constricted airways, tightening of the bronchial walls, and excess mucus.

asylums Places reserved to exclusively treat people with mental disorder, usually separate from the general population.

atrophy Gradual deterioration or shrinkage of a brain area in people with dementia.

attention-de�cit/hyperactivity disorder (ADHD) A mental disorder marked by severe problems of inattention, hyperactivity, and impulsivity.

atypical antipsychotics A newer class of drugs to treat schizophrenia and related psychotic disorders.

autism spectrum disorder A pervasive devel- opmental disorder associated with multiple cognitive and social de�cits.

automatic thoughts Cognitive distortions of the negative cognitive triad that are con- stantly repeated and often associated with depression.

aversion treatment A treatment for paraphilias that involves associating paraphilic stimuli with unpleasant stimuli.

aversive drugs Medications to treat substance- related disorders that make ingestion of an addictive drug quite uncomfortable.

avoidance conditioning A theory of fear devel- opment that combines classical and operant conditioning with internal states such as driving or motivating factors.

avoidant personality disorder Personality disorder marked by anxiousness and feelings of inadequacy and socially ineptness.

avolition An inability or unwillingness to engage in goal-directed activities.

basal ganglia Brain structures that control posture and motor activity.

behavior genetics A research specialty that evaluates genetic and environmental in�u- ences on development of behavior.

behavioral assessment An assessment approach that focuses on measuring overt behaviors or responses.

behavioral avoidance test An assessment technique for anxiety-related disorders that

Glossary G-1

contingency management A behavioral treat- ment technique in which family members and friends reward appropriate behavior in an individual.

control group Those who do not receive the ac- tive independent variable in an experiment.

controlled observation A behavioral assessment technique that involves analogue tests or tasks to approximate situations people face in real life and that may elicit a certain problem behavior.

conversion disorder A somatic symptom disorder marked by odd pseudoneurological symptoms that have no discoverable medical cause.

coronary heart disease Narrowing of the small blood vessels that supply blood and oxygen to the heart.

correlational study A study that allows re- searchers to make some statements about the association or relationship between variables based on the extent to which they change together in a predictable way.

counseling psychologists Mental health profes- sionals with an M.A. or Ph.D. who help clients make choices to improve quality of life.

covert sensitization A treatment that involves associating imaginal paraphilic scenes with descriptions of negative consequences or unpleasant events.

criminal commitment Involuntary hospitaliza- tion of people charged with a crime, either for determination of competency to stand trial or after acquittal by reason of insanity.

cross-sectional study A developmental design examining different groups of people at one point in time.

cross-tolerance Tolerance for a drug one has never taken because of tolerance to another drug with a similar chemical composition.

cue exposure therapy Exposure of a person to drug cues to help him or her control urges to use the drug.

cultural-familial intellectual disability Intellec- tual disability linked less to physical factors and more to environmental ones, such as poor language stimulation and parents with low intelligence.

cultural syndrome A problem caused by cultur- ally shared beliefs and ideas that lead to high levels of stress and mental disorder.

culture The unique behavior and lifestyle shared by a group of people.

cyclothymic disorder A mental disorder marked by �uctuating symptoms of hypomania and depression for at least 2 years.

defense mechanisms Strategies used by the ego to stave off threats from the id or superego.

delayed ejaculation Delay or absence of orgasm in males during sexual activity with a partner.

perceive and think about our present and past experiences.

cognitive restructuring Therapeutic technique that helps someone think more realistically in a given situation.

cognitive schema Set of beliefs or expectations that represent a network of already accumu- lated knowledge.

cognitive therapy A treatment technique for cognitive symptoms of anxiety that involves helping a person think more realistically and develop a sense of control over anxious situations.

cohort effects Signi�cant differences in the expression of a disorder depending on age.

community psychology A branch of psychology that focuses on enhancing quality of life for people and concentrating on their relation- ships with different social structures.

community reinforcement approach Encouraging a person to change environmental conditions to make them more reinforcing than drug use.

comorbidity Two or more disorders in one person.

compensatory behaviors Inappropriate behav- iors to prevent weight gain.

competency to stand trial Whether a person can participate meaningfully in his or her own defense and can understand and appreciate the legal process that is involved.

compulsions Ongoing and bizarre ritualistic acts performed after an obsession to reduce arousal.

computerized axial tomography (CT scan) A neuroimaging technique that uses X-rays to identify structural abnormalities.

concurrent validity Whether current test or in- terview results relate to an important feature or characteristic at the present time.

conditional positive regard An environment in which others set conditions or standards for one’s life.

conduct disorder A childhood mental disorder marked by antisocial conduct in the form of aggression, property destruction, deceitful- ness, theft, and serious rule violations.

con�dentiality The idea that discussions between a therapist and a client should not be divulged to other people unless consent is given.

confounds Factors that may account for group differences on a dependent variable.

consequences Outcomes or events that follow a behavior.

construct validity Whether test or interview results relate to other measures or behav- iors in a logical, theoretically expected fashion.

content validity Degree to which test or in- terview items actually cover aspects of the variable or diagnosis under study.

case study method In-depth examination and observation of one person over time.

catastrophizing A cognitive distortion involv- ing the assumption that terrible but incorrect consequences will result from an event.

catatonic Tendency to remain in a �xed stuporous state for long periods.

catatonic behavior Unusual motor behaviors in people with schizophrenia.

category An approach to de�ning mental disor- der by examining large classes of behavior.

catharsis A nonspeci�c factor in treatment that refers to venting emotions and release of tension in a client.

central nervous system The brain and spinal cord, which are necessary to process informa- tion from our sensory organs and prompt our body into action if necessary.

cerebral cortex Gray matter of the brain that covers almost all of each hemisphere.

cholinesterase inhibitors A class of drugs to treat people with dementia that help increase levels of acetylcholine in the brain.

cirrhosis of the liver A severe medical condi- tion in which scar tissue in the liver replaces functional tissue.

civil commitment Involuntary hospitalization of people at serious risk for harming themselves or others or who cannot care for themselves.

classical conditioning Pairing of an uncondi- tioned stimulus so the future presentation of a conditioned stimulus results in a condi- tioned response.

classi�cation Arranging mental disorders into broad categories or classes based on similar features.

client-centered therapy A humanistic therapy that relies heavily on unconditional positive regard and empathy.

clinical assessment Evaluating a person’s strengths and weaknesses and formulating a problem to develop a treatment plan.

clinical psychologists Mental health profes- sionals with a Ph.D. or Psy.D. who promote behavioral change usually via psychological interventions.

codependency Dysfunctional behaviors that signi�cant others of a person with substance- related disorder engage in to care for and cope with the person.

cognitive-behavioral therapy A type of treat- ment that focuses on the connection between thinking patterns, emotions, and behavior and uses cognitive and behavioral techniques to change dysfunctional thinking patterns.

cognitive distortions Irrational, inaccurate thoughts that people have about environmen- tal events.

cognitive perspective A perspective of abnor- mal behavior that assumes that problematic symptoms develop because of the way we

GlossaryG-2

delirium A neurocognitive disorder marked by usually temporary and reversible problems in thinking and memory.

delusional disorder A psychotic disorder marked by one or more delusions without other features of schizophrenia.

delusions Irrational beliefs involving a misinter- pretation of perceptions or life experiences.

dementia A neurocognitive problem marked by usually chronic, progressive, and irreversible problems in thinking and memory.

dependent personality disorder Personality disorder marked by extreme submissiveness and a strong need to be liked and be taken care of by others.

dependent variable Variables that measure a certain outcome that a researcher is trying to explain or predict.

depersonalization/derealization disorder A dis- sociative disorder marked by chronic episodes of detachment from one’s body and feelings of derealization.

depressant A class of drugs that inhibit the central nervous system.

depressive disorder A mental disorder marked by substantial sadness and related character- istic symptoms.

detoxi�cation Withdrawing a person from an addictive drug under medical supervision.

developmental disorder A mental disorder marked by delay in key areas of cognitive, adaptive, and academic functioning.

diagnosis A category of mental disorder de�ned by certain rules that outline how many and what features of a disorder must be present.

dialectical behavior therapy Cognitive-behavioral treatment for suicidal behavior and related features of borderline personality disorder.

diathesis A biological or psychological predis- position to disorder.

dieting Deliberate attempts to limit quantity of food intake or change types of foods that are eaten.

dimension An approach to de�ning mental disorder along a continuum.

diminished capacity A reduced mental state that may mitigate a charge or sentence for someone convicted of a crime.

discrete-trial training A structured and repetitive method of teaching various skills to a child.

disinhibition The state that occurs when alcohol inhibits key inhibitory systems of the brain.

disorganized speech Disconnected, fragmented, interrupted, jumbled, and/or tangential speech.

disruptive behavior disorders A class of child- hood mental disorders that involve serious acting-out behavior problems and often include attention-de�cit/hyperactivity, oppo- sitional de�ant, and conduct disorders.

emotional reasoning A cognitive distortion involving the assumption that one’s physical feelings re�ect how things really are.

endogenous opioids Chemicals produced by the body that reduce pain, enhance positive mood, and suppress appetite.

epidemiologists Scientists who study the incidence, prevalence, and risk factors of disorders.

epidemiology The study of patterns of diseases, disorders, and other health-related behavior in a population of interest.

erectile disorder A sexual dysfunction involving dif�culty obtaining and maintaining an erection during sexual relations.

ethnicity Clusters of individuals who share cultural traits that distinguish themselves from others.

etiology Cause of mental disorders.

exhibitionistic disorder A paraphilic disorder in which the predominant focus of sexual activity is exposure of one’s genitals to others such as strangers.

exorcism An attempt to cast out a spirit pos- sessing an individual.

experiment A research method that allows sci- entists to draw cause-and-effect conclusions.

experimental group A group that receives the active independent variable.

exposure-based practices Treatment techniques for behavioral symptoms of anxiety that in- volve reintroducing a person to situations she commonly avoids.

exposure treatment An element of systematic desensitization that involves directly con- fronting a feared stimulus.

expressed emotion Family interactions charac- terized by high levels of emotional over- involvement, hostility, and criticism.

external validity Ability to generalize results from one investigation to the general population.

extrapyramidal effects A group of side effects from antipsychotic medication involving involuntary movements of different parts of the body.

factitious disorder A mental disorder marked by deliberate production of physical or psychological symptoms to assume the sick role.

family systems perspective The idea that each family has its own structure and rules that can affect the mental health of individual family members.

fear An immediate and negative reaction to imminent threat that involves fright, in- creased arousal, and an overwhelming urge to escape.

female orgasmic disorder A sexual dysfunction marked by delay or absence of orgasm during sexual activity.

dissociation A feeling of detachment or separa- tion from oneself.

dissociative amnesia A dissociative disorder marked by severe memory loss for past and/ or recent events.

dissociative disorder A class of mental disor- ders marked by disintegration of memory, consciousness, or identity.

dissociative fugue A dissociative problem marked by severe memory loss and sudden travel away from home or work.

dissociative identity disorder A dissociative disorder marked by multiple personalities in a single individual.

distal factors Causal factors that indirectly affect a particular mental disorder.

double-blind design An experimental condition meaning that neither the experimenter nor the participants know who received a placebo or an active treatment.

Down syndrome A chromosomal condition often caused by an extra chromosome 21 and that leads to characteristic physical features and intellectual disability.

dream analysis A psychodynamic technique to access unconscious material thought to be symbolized in dreams.

dual relationships A client who is also a signi�cant other in the therapist’s life; ethics standards dictate that this practice is to be avoided.

dyssomnias Abnormalities in the amount, quality, or timing of sleep.

eating disorder A class of mental disorder involving severe body dissatisfaction, weight concerns, and eating problems as well as sig- ni�cant distress, excessive limits on activities, or increased risk for medical problems.

eating problems Restricting eating/excessive dieting and lack of control of eating.

educational psychologists Psychologists typically with a Ph.D. who work in school settings or academia to study and improve learning strategies for youth and adults.

ego The organized, rational component of the personality.

electrocardiogram A psychophysiological mea- sure that provides a graphical description of heart rate.

electroconvulsive therapy (ECT) A procedure in which an electrical current is introduced to the brain to produce a seizure to alleviate severe depression.

electroencephalogram (EEG) A psychophysi- ological measure of brain activity.

electronic diaries Electronic devices for self- monitoring.

emotional processing A person’s ability to think about a past anxiety-provoking event without signi�cant anxiety.

Glossary G-3

induction defects Problems in closure of the neural tube, proper development of the forebrain, and completion of the corpus callosum, all of which may lead to develop- mental disorder.

informant report Assessment methodology in which individuals who know a person well complete ratings of his or her personality traits and behavior.

informed consent The practice of educating potential clients about the therapy process, especially variables that might in�uence their decision to seek therapy.

insanity A legal term that refers to mental incapacity at the time of the crime, perhaps because a person did not understand right from wrong or because he or she was unable to control personal actions at the time of the crime.

insight (1) An active treatment ingredient in which a client comes to understand rea- sons for his maladaptive behavior and how to address it. (2) Understanding the unconscious determinants of irrational feelings, thoughts, or behaviors that create problems or distress.

intellectual disability A pervasive developmen- tal disorder marked by below average intel- ligence, poor adaptive behavior, and onset before age 18 years.

intelligence tests Measures of cognitive func- tioning that provide estimates of intellectual ability.

internal consistency reliability Extent to which test items appear to be measuring the same thing.

internal validity Extent to which a researcher can be con�dent that changes in the depen- dent variable are truly the result of manipula- tion of the independent variable.

interoceptive exposure A treatment technique involving exposure to, and eventual control of, physical symptoms of anxiety.

interpretation A method in which a psychody- namic theorist reveals unconscious meanings of a client’s thoughts and behaviors to help the person achieve insight.

interrater reliability Extent to which two raters or observers agree about their ratings or judg- ments of a person’s behavior.

irritable bowel syndrome (IBS) A chronic gastro- intestinal disorder involving alternating and recurrent constipation and diarrhea as well as abdominal pain.

Korsakoff’s syndrome A problem marked by confusion, memory loss, and coordination problems.

lack of control over eating A feeling of poor control when eating such that excessive quantities of food are consumed.

genotype The genetic composition of an indi- vidual that is �xed at birth and received from one’s parents.

guilty but mentally ill A verdict that may mean a defendant is committed to a psychiatric facility for some period of time.

hallucinations Sensory experiences a person be- lieves to be true when actually they are not.

hallucinogens A class of drugs that produce psychosis-like symptoms.

health psychologists Psychologists who special- ize in examining the interaction of biological, psychological, and social variables on tradi- tional medical disorders.

histrionic personality disorder Personality disorder marked by excessive need for atten- tion, super�cial and �eeting emotions, and impulsivity.

hopelessness A feeling of despair often related to severe depression and suicide.

hopelessness (attribution) theory A theory of depression that people are more likely to become depressed if they make global, internal, and stable attributions about negative life events.

humanistic model A model of abnormal behav- ior that emphasizes personal growth, free will, and responsibility.

hypertension High blood pressure commonly identi�ed if systolic pressure is greater than 140 millimeters of mercury and/or if diastolic pressure is greater than 90 millimeters of mercury.

hypomanic episode A period during which a person experiences manic symptoms but without signi�cant interference in daily functioning.

hypothalamus A region of the brain below the thalamus that in�uences body temperature, food intake, sleep, and sex drive.

hypothesis A statement about the cause of an event or about the relationship between two events.

id The deep, inaccessible portion of the person- ality that contains instinctual urges.

illness anxiety disorder A somatic symptom disorder marked by excessive preoccupation with fear of having a disease.

inappropriate affect Emotion not appropriate for a given situation.

incidence Rate of new cases of a disorder that occur or develop during a speci�c time period such as a month or year.

independent variable A variable manipulated by a researcher that is hypothesized to be the cause of the outcome.

indicated prevention Preventive intervention targeting individuals at high risk for develop- ing extensive problems in the future.

female sexual interest/arousal disorder A sexual dysfunction marked by lack of interest in, or arousal during, sexual activity.

fetal alcohol syndrome A condition caused by prenatal alcohol use that results in facial abnormalities and learning problems in children.

fetishistic disorder A paraphilic disorder in which the predominant focus of sexual activity is a nonliving object or nongenital body part.

�xation Frustration and anxiety at a psycho- sexual stage that can cause a person to be arrested at that level of development.

�at affect Lack of variety in emotional expres- sion and speech.

�ooding An exposure-based therapy technique involving exposure to, and eventual extinc- tion of, one’s most intense fear.

forensic psychology A branch of psychology involving the interaction of psychological and legal principles.

fragile X syndrome A genetic condition that in- volves damage to the X chromosome and that often leads to intellectual disability, especially in males.

free association A psychodynamic technique in which a client speaks continuously without censorship.

free radicals Aggressive substances produced by the body possibly to �ght viruses and bac- teria but that, in excess, may lead to dementia.

frontal lobe An area in front of the brain that is responsible for movement, planning, organiz- ing, inhibiting behavior, and decision making.

frotteuristic disorder A paraphilic disorder in which the predominant focus of sexual activ- ity is physical contact with an unsuspecting person.

functional analysis A behavioral assessment strategy to understand antecedents and consequences of behavior.

functional MRI (fMRI) A neuroimaging tech- nique that assesses brain structure and function as well as metabolic changes.

galvanic skin conductance A psychophysiological measure of the electrical conductance of skin.

gender dysphoria A mental disorder marked by strong desire to be of the opposite gender and identifying oneself as a person of the opposite gender.

generalized anxiety disorder A mental disorder marked by constant worry about nondangerous situations and physical symptoms of tension.

gene therapy Insertion of genes into an indi- vidual’s cells and tissues to treat a disorder.

genito-pelvic pain/penetration disorder A sexual dysfunction involving pain during vaginal penetration and/or fear of pain before penetration.

GlossaryG-4

modeling Learning a new skill or set of behaviors by observing another person perform the skill or behavior.

molecular genetics Analysis of deoxyribonucleic acid (DNA) to identify links between speci�c genetic material and mental disorders.

monoamine oxidase inhibitor (MAOI) A class of antidepressant drug that inhibits monoamine oxidase, which breaks down neurotransmitters, to increase levels of those neurotransmitters.

mood-stabilizing drugs Medications used to help people control rapid shifts in mood.

motivational interviewing A type of interview for substance-related disorders that focuses on obtaining information and propelling a person to change behavior.

multicultural psychology Examines the effect of culture on the way people think, feel, and act.

multidimensional family therapy A family-based treatment approach that focuses on develop- ing a strong parent–adolescent bond and correcting related problems.

multisystemic treatment An intensive family- and community-based treatment program designed to address conduct-related problems in children.

Munchausen syndrome A severe factitious disorder in which a person causes symp- toms and claims he has a physical or mental disorder.

narcissistic personality disorder Personality disorder marked by grandiosity, arrogance, and a tendency to exploit others.

natural experiment An observational study in which nature itself helps assign groups.

naturalistic observation A behavioral assess- ment technique that involves observing a person in his or her natural environment.

negative cognitive triad Cognitive distortions involving the self, world, and the future.

negative correlation Two variables highly re- lated to one another such that an increase in one variable is accompanied by a decrease in the other variable.

negative reinforcement Removing an aversive event following a behavior to increase fre- quency of the behavior.

negative symptoms Symptoms such as �at affect and alogia that represent signi�cant de�cits in behavior.

neurochemical assessment Biological assessment of dysfunctions in speci�c neurotransmitter systems.

neurocognitive disorder A mental disorder that involves mild to severe impairment in major cognitive functions.

neurodevelopmental hypothesis An etiological model for psychotic disorders that assumes early changes in key brain areas and gradual

marijuana A drug produced from the hemp plant that contains THC.

marriage and family therapists Mental health professionals with an M.A. or Ph.D. who specialize in working with couples and families.

mass madness Groups of individuals af�icted at the same time with the same disorder or abnormal behaviors.

mastery An active treatment ingredient involving strong control over one’s symptoms to the point they are not problematic to the individual.

masturbation training A treatment for people with paraphilic disorder that involves practic- ing effective masturbation and stimulation to enhance orgasm.

memory training A psychological treatment to enhance a person’s memory by repeatedly practicing skills relying on external cues and mnemonic strategies to jog memory, increas- ing social interaction, and simplifying a living environment.

mental disorder A group of emotional (feelings), cognitive (thinking), or behavioral symptoms that cause distress or signi�cant problems.

mental hygiene The science of promoting mental health and thwarting mental disorder through education, early treatment, and pub- lic health measures.

mental status examination An assessment strategy involving evaluation of appear- ance, mood, orientation, and odd behaviors, speech, or thoughts.

mesolimbic system A reward-based area in the brain implicated in substance-related disorders.

metabolites By-products of neurotransmitters that can be detected in urine, blood, and cerebral spinal �uid.

migration defects Problems in cell growth and distribution in the second to �fth month of pregnancy, which can lead to underdeveloped brain areas and develop- mental disorder.

mild neurocognitive disorder A mental disorder marked by emerging problems in thinking and memory.

milieu therapy An inpatient treatment approach involving professionals and staff members encouraging a person with a severe mental disorder to engage in prosocial and therapeu- tic activities.

mindfulness A therapy technique that empha- sizes how a person can accept symptoms but still function in a given situation.

MMPI-2 clinical scales Subscales of the MMPI-2 used to identify various problematic behaviors and personality styles.

MMPI-2 validity scales Subscales of the MMPI-2 used to identify a person’s defensiveness during testing and response sets.

model A systematic way of viewing and explaining what we observe.

latent content The symbolic meaning of a dream’s events.

learned helplessness A theory related to depression that people act in a helpless, passive fashion upon learning their actions have little effect on their overall environment.

learning disorder A limited developmental disorder marked by academic problems in reading, spelling, writing, arithmetic, or some other important area.

least restrictive treatment A principle according to which people with mental disorders should receive effective treatment that impinges least on their freedom.

lethal dose Dose of a substance that kills a certain percentage of test animals.

Lewy bodies Clusters of alpha-synuclein pro- teins that accumulate in the brain and may lead to dementia.

lifetime prevalence Proportion of those who exhibit symptoms of a disorder up to the point they were assessed.

limbic system An area of the brain in the fore- brain that regulates emotions and impulses and is responsible for basic drives like thirst, sex, and aggression.

limited developmental disorders A developmen- tal disorder in which one area but not many areas of functioning are affected.

longitudinal study A developmental design examining the same group of people over a long period of time.

magnetic resonance imaging (MRI) A neuroim- aging technique that can produce high- resolution images of brain structure.

major depressive disorder A mental disorder often marked by multiple major depressive episodes.

major depressive episode A period of time, two weeks or longer, marked by sad or empty mood most of the day, nearly every day, and other symptoms.

major neurocognitive disorder A mental disor- der marked by severe problems in thinking and memory.

maladaptive behavior A behavior that interferes with a person’s life, including ability to care for oneself, have good relationships with others, and function well at school or at work.

male hypoactive sexual desire disorder A sexual dysfunction involving a lack of fantasies or desire to have sexual relations.

malingering Deliberate production of physical or psychological symptoms with some exter- nal motivation.

manic episode A period during which a person feels highly euphoric or irritable.

manifest content The literal meaning of a dream.

Glossary G-5

phenylketonuria (PKU) An autosomal recessive disorder that leads to buildup of phenylalanine and possible intellectual disability.

Pick’s disease A neurocognitive disorder characterized mainly by deterioration in the frontal and temporal brain lobes.

placebo effect The improvement in treatment due to a client’s expectation of help.

pleasure principle The rule of conduct by the id to seek pleasure and avoid pain.

positive correlation Two variables highly related to one another such that an increase in one variable is accompanied by an increase in the other variable.

positive reinforcement Presenting a pleasant event or consequence after a behavior to increase frequency of the behavior.

positive symptoms Symptoms such as delusions and hallucinations that are obvious and excessive.

positron emission tomography (PET scan) An invasive neuroimaging procedure to assess brain structure and functioning.

postpartum depression A major depressive episode during weeks following childbirth.

postpartum psychosis A mental condition marked by psychotic symptoms in a mother following the birth of her child.

posttraumatic stress disorder A mental disorder marked by a traumatic event and the reexperiencing of the event through unwanted memories, nightmares, �ashbacks, and images.

predictive validity Whether test or interview results accurately predict some behavior or event in the future.

premature (early) ejaculation A sexual dysfunc- tion in men marked by orgasm that occurs before the person wishes.

premenstrual dysphoric disorder A mental dis- order marked by depressive symptoms during most menstrual periods.

prescriptive treatment Assigning a speci�c treatment to an individual with a speci�c mental health problem or subtype of a problem.

prevalence Rate of new and existing cases of a condition observed during a speci�c time period.

prevention Interventions intended to arrest the development of later problems.

primary prevention A type of prevention target- ing large groups of people who have not yet developed a disorder.

primary process The irrational and impulsive type of thinking that characterizes the id.

process variables General ingredients common to most psychological treatments that promote mental health in a client.

panic disorder A mental disorder marked by ongoing and uncued panic attacks, worry about the consequences of these attacks, and, sometimes, agoraphobia.

paranoid personality disorder Personality disorder marked by general distrust and suspiciousness of others.

paraphilias Preferential, intense, and/or persis- tent sexual interests that may be odd but are not a mental disorder.

paraphilic disorders A class of mental disorder involving problems arising from sexual behavior or fantasies of highly unusual activities.

paraprofessionals Persons without advanced degrees who often work in mental health settings and assist with assessment and treatment procedures.

parasomnias Abnormal behavioral or physi- ological events that occur throughout sleep.

parietal lobe An area of the brain behind the frontal lobe that is associated with the sensa- tion of touch.

Parkinson’s disease A progressive neurologi- cal disorder marked by abnormal movements that may lead to a neurocognitive disorder.

partial agonists Medications to treat substance- related disorders that may act as an agonist or antagonist depending on how much of a certain neurotransmitter is produced.

pedophilic disorder A paraphilic disorder in which the predominant focus of sexual activity is with children.

peripartum depression Symptoms of depression or a major depressive episode that occurs during pregnancy.

peripheral nervous system The somatic and autonomic nervous system that controls muscles and voluntary movement, impacts the cardiovascular and endocrine system, assists with digestion, and regulates body temperature.

persistent depressive disorder (dysthymia) A depressive disorder involving a chronic feeling of depression for at least 2 years.

personality assessment Instruments measuring different traits or aspects of character.

personality disorders Mental disorders involv- ing dysfunctional personality traits and associated problems such as relationship disturbances and impulsive behavior.

personality trait A disposition or readiness to act in a certain way.

pervasive developmental disorders A devel- opmental disorder in which many areas of functioning are affected.

phenomenological approach An assumption that one’s behavior is determined by perceptions of herself and others.

phenotype Observable characteristics of an individual.

progression over the life span to full-blown symptoms.

neuro�brillary tangles Twisted �bers inside nerve cells of the brain that may lead to dementia.

neuron The basic unit of the nervous system that comprises a cell body, dendrites, axon, and terminal buttons.

neuropsychological assessment Indirect mea- sures of brain and physical function by evaluating a person’s performance on standardized tests and tasks that indicate brain–behavior relationships.

neurotransmitters Chemical messengers that allow a nerve impulse to cross the synapse.

normalization The idea that people with mental disorders in regular living environments will behave more appropriately than those in large institutions.

objective personality measures Measures of per- sonality that involve administering a standard set of questions or statements to which a person responds using set options.

obsessions Ongoing and bizarre ideas, thoughts, impulses, or images that a person cannot control.

obsessive-compulsive disorder A mental disor- der marked by ongoing obsessions and com- pulsions lasting more than 1 hour per day.

obsessive-compulsive personality disorder Personality disorder marked by rigidity, per- fectionism, and strong need for control.

occipital lobe An area of the brain behind the parietal and temporal lobes and associated with vision.

operant conditioning A learning principle that behavior followed by positive or pleasurable consequences is likely to be repeated but behavior followed by negative consequences is not likely to be repeated.

opiates A class of drugs commonly used to relieve pain.

oppositional de�ant disorder A childhood mental disorder marked by hostile and nega- tive behavior that includes noncompliance, argumentativeness, anger, spitefulness, and annoyance of others.

organismic variables A person’s physiological or cognitive characteristics important for under- standing a problem and determining treatment.

orgasmic reconditioning A treatment for paraphilic disorders that involves initial masturbation to a paraphilic stimulus and later masturbation to more appropriate sexual stimuli.

oxidative stress Damage to the brain from extensive exposure to oxygen and related matter.

panic attack A brief episode of intense fear and physical symptoms that increases and decreases suddenly in intensity.

GlossaryG-6

bipolar disorders that involves rapidly chang- ing magnetic �elds.

repression A defense mechanism that involves keeping highly threatening sexual or aggres- sive material out of conscious awareness.

residual phase A phase of schizophrenia usu- ally after the active phase involving peculiar thoughts and behaviors similar to the prodro- mal phase.

resilience Ability of an individual to withstand and rise above extreme adversity.

response (or ritual) prevention A treatment technique for obsessive-compulsive disorder involving exposure to an obsession such as thoughts of dirty hands without engaging in a related compulsion such as hand washing.

restricted eating Deliberate attempts to limit quantity of food intake or change types of foods that are eaten.

restricting behaviors Eating less overall, avoid- ing foods with high calories, and engaging in excessive exercise.

reuptake A feedback mechanism that informs a neuron about the amount of neurotransmitter needed to be released in the future.

reward de�ciency syndrome The theory that some people may not be able to derive much reward from everyday events and so resort to excesses such as drug use.

right to refuse treatment A principle according to which clients have the right to refuse risky or unconventional or discom�ting treatments.

right to treatment A principle according to which clients have the right to receive treat- ment that provides a meaningful chance of improvement in their condition.

risk factor An individual, contextual, or environmental characteristic correlated with an outcome or condition such as a mental disorder that precedes the development of the disorder.

satiety Feeling of fullness from eating.

schizoaffective disorder A psychotic disorder marked by symptoms of schizophrenia and depression or mania.

schizoid personality disorder Personality disor- der marked by social isolation and restricted emotional expression.

schizophrenia A psychotic disorder marked by positive symptoms such as delusions and hallucinations, negative symptoms such as �at affect and withdrawal, and disorganized behavior.

schizophreniform disorder A psychotic disorder marked by symptoms of schizophrenia that last 1 to 6 months.

schizotypal personality disorder Personality disorder marked by social anxiety, paranoid fears, and eccentric behavior, perceptions, and thoughts.

psychotherapist A generic mental health profes- sional, or one not currently licensed as a psychologist or psychiatrist.

psychotic disorders A class of mental disorder marked by schizophrenia and/or related problems.

psychotic prephase A phase of schizophrenia between the prodromal and active phases involving the onset of the �rst positive symp- tom of schizophrenia.

public health model A model that focuses on promoting good health and good health practices to avert disease.

public stigma The general disgrace the public confers on people with mental disorder that can result in prejudice, stereotyping, and discrimination.

purging Ridding oneself of food or bodily �uids (and thus weight) by self-induced vomiting or misuse of laxatives or diuretics.

quasi-experimental method A study in which an independent variable is manipulated but people are not randomly selected or assigned to groups.

race A socially constructed category typically based on physical characteristics.

randomization Selecting and assigning people to groups so each person has the same chance of being assigned to any one group.

reaction formation The process that occurs when an unconscious impulse is consciously expressed by its behavioral opposite.

reality orientation A psychological treatment to reduce confusion in people using constant feedback about time, place, person, and recent events.

reality principle The rule of conduct by the ego that defers grati�cation of instinctual urges until a suitable object and mode of satisfac- tion are discovered.

regression A defense mechanism that occurs when a person returns to a life stage that once provided substantial grati�cation.

rehabilitation Regarding substance-related disorders, treatment involving complete abstinence, education about drugs and conse- quences of their use, and relapse prevention.

relaxation training A treatment technique for physical anxiety symptoms that may involve having a person tense and release (relax) different muscle groups.

reliability Consistency of test scores or diagnoses.

reminiscence therapy A treatment procedure for older adults with depression involving a systematic review of one’s life and resolution of regrets.

repetitive transcranial magnetic stimulation (rTMS) A procedure to treat depressive and

prodromal phase An initial phase of schizophre- nia marked by peculiar thoughts and behav- iors but without active psychotic features.

projection A defense mechanism used when a person attributes his or her unconscious feelings to someone else.

projective hypothesis The assumption that, when faced with unstructured or ambiguous stimuli or tasks, individuals impose their own structure and reveal something of themselves.

projective tests Psychological testing tech- niques based on the assumption that people faced with an ambiguous stimulus such as an inkblot will project their own needs, person- ality, con�icts, and wishes.

protective factor A factor that buffers one against the development of a mental disorder.

proximal factors Causal factors that more directly affect a particular mental disorder.

pseudoseizures Seizure-like activity such as twitching or loss of consciousness without electrical disruptions in the brain.

psychiatric nurses Specialized nurses with an R.N. who often work on inpatient psychiatric wards and have training speci�c to mental disorders.

psychiatrists Mental health professionals with an M.D. who often adopt a medical or biological model to treat people with mental disorders.

psychic determinism An assumption of psycho- dynamic theory that everything we do has meaning and purpose and is goal-directed.

psychoanalyst A mental health professional that specializes in Freudian psychoanalysis to treat people with mental disorders.

psychodynamic model A model of abnormal behavior that assumes all mental states, emo- tions, and behaviors arise from unconscious motives and intrapsychic con�icts.

psychoeducation A treatment technique that involves educating a person about the physi- cal, cognitive, and behavioral components of anxiety or other problems and how these components occur in sequence for that person.

psychopathologists Professionals who study mental problems to see how disorders develop and continue and how they can be prevented or alleviated.

psychopathy Diagnostic construct related to antisocial personality disorder that focuses on problematic interpersonal styles such as arro- gance, lack of empathy, and manipulativeness.

psychophysiological assessment Evaluating bodily changes possibly associated with certain mental conditions.

psychophysiological disorders Organ dysfunc- tion or physical symptoms that may be at least partly caused by psychological factors such as stress.

psychosexual stages of development A series of developmental stages marked by a particular erogenous zone of the body.

Glossary G-7

stimulants A class of drugs that activate the central nervous system.

stop–start procedure A treatment for premature ejaculation that involves pinching the tip of the penis when sexual stimulation becomes intense.

stress External events in our daily lives that are taxing for us as well as internal events such as perceptions that external events are demand- ing as well as certain physical symptoms.

stress-induced relapse Relapse to excessive substance use following stress and a period of abstinence.

stress management A collection of techniques to help people reduce the chronic effects of stress on a daily basis as well as problematic physical symptoms.

structured interviews A type of clinical inter- view that requires an interviewer to ask standardized questions in a speci�ed sequence.

substance intoxication A usually reversible condition triggered by excessive alcohol or other drug use.

substance-related disorder A class of mental disorders characterized by substance use disorder as well as substance intoxication and withdrawal.

substance use A nonmaladaptive use of alcohol or other drug.

substance use disorder A mental disorder involving repeated use of substances to the point that recurring problems are evident.

substance withdrawal Maladaptive behavioral changes that result when a person stops us- ing a particular drug.

suicide The act of killing oneself.

superego A component of the personality representing the ideals and values of society as conveyed by parents.

synapse A small gap between ends of neurons.

syndrome Symptoms that cluster or group together within individuals.

systematic desensitization An exposure-based treatment technique involving gradual exposure to feared objects or situations and relaxation/breathing training.

Tay-Sachs disease A genetic condition leading to severe motor and sensory disabilities as well as intellectual disability and early death.

temporal lobe A middle area of the brain associ- ated with auditory discrimination.

teratogen A potentially harmful agent that affects fetuses during the prenatal stage and which may lead to developmental disorders.

tertiary prevention A type of prevention aimed to reduce the severity, duration, and nega- tive effects of a mental disorder after it has occurred.

sexual dysfunction A mental disorder involving disturbance of the normal sexual response cycle.

sexual masochism A paraphilic disorder in which the predominant focus of sexual activity is a desire to be humiliated or made to suffer.

sexual sadism A paraphilic disorder in which the predominant focus of sexual activity is a desire to humiliate or make suffer.

sickle cell disease A genetic condition that leads to damaged red blood cells, poor oxy- genation of cells, and potential intellectual disability.

single-subject experimental design Experimen- tal designs that involve one person or a small group of persons who are examined under certain conditions.

skills training A treatment for substance-related disorders involving functional analysis of drug use and skills to avoid or cope with high-risk situations.

social phobia/social anxiety disorder A mental disorder marked by panic attacks in, and avoidance of, situations involving performance before others or possible negative evaluation.

social workers Mental health professionals with an M.A. or Ph.D. who work to improve qual- ity of life for people with mental disorders.

sociocultural perspective A perspective of abnormal behavior that focuses on in�uences that other people, social institutions, and so- cial forces exert on a person’s mental health.

somatic control exercises Treatment techniques to help people with anxiety-related disorders decrease severity of their aversive physical feelings.

somatic symptom disorder A mental disorder in which a person experiences physical symp- toms that may or may not have a discover- able physical cause, as well as distress.

somatization A tendency to communicate distress through physical symptoms and to pursue medical help for these symptoms.

special education teachers Specialized teachers with an M.A. or Ph.D. who work primarily with youth with developmental disorders in academic settings.

speci�c phobia A mental disorder marked by panic attacks surrounding, and avoidance of, objects and situations other than those in- volving social interaction and/or performance before others.

spectator role The process of attending more to, and worrying about, sexual behavior and performance than the enjoyment and plea- sure of sexual activity.

standardization Administering or conducting clinical assessment measures in the same way for all examinees.

stigma A characterization by others of disgrace or reproach based on an individual characteristic.

school psychologists Psychologists with an M.A. or Ph.D. who typically work in school settings to evaluate youth with learning and behavioral problems.

school refusal behavior A child-motivated refusal to attend school and/or dif�culties remaining in classes for an entire day.

scienti�c method A set of agreed-upon rules for systematically gathering information that in- volves generating a hypothesis, developing a research design, and analyzing and interpret- ing data to test the hypothesis.

screening interview A type of assessment that helps clinicians obtain information about recent and lifetime use of alcohol and other drugs.

secondary prevention A type of prevention that addresses emerging problems while they are still manageable and before they become resistant to intervention.

secondary process The rational and self- preservative type of thinking that character- izes the ego.

selective prevention Preventive intervention targeting subgroups of people at risk for a particular problem.

selective serotonin reuptake inhibitor (SSRI) A class of antidepressant medication that speci�cally affects serotonin levels and has fewer side effects than other antidepressants.

self-actualization Striving to be the best one can be.

self-control An active treatment ingredient whereby a client learns to control wayward impulses or emotions to improve quality of life.

self-help group An association of people who share a common problem such as a mental disorder that the group tries to address.

self-monitoring A behavioral assessment technique in which individuals observe and record their own emotions, thoughts, and behaviors.

self-stigma The disgrace people assign them- selves because of public stigma.

senile or neuritic plaques Clusters of dead nerve cells and accumulations of amyloid proteins in the brain that may lead to dementia.

sensate focus A treatment for sexual dysfunc- tion that helps couples reestablish intimacy while gradually rebuilding pleasurable sexual behaviors.

separation anxiety disorder A mental disorder marked by extreme and developmentally inappropriate distress when separation from home or close family members occurs or is anticipated.

sequential design A developmental design involving aspects of longitudinal and cross- sectional studies.

sex reassignment surgery A treatment for people with gender dysphoria that involves physical transformation to the opposite gender.

GlossaryG-8

universal prevention Preventive intervention targeting large groups of people not af�icted by a particular problem.

unstructured interview A type of clinical inter- view in which clinicians ask any questions in any order.

validity Extent to which an assessment technique measures what it is supposed to measure.

vascular disease A contributing factor to vascular dementia or neurocognitive disorder caused by problems with blood vessels.

voyeuristic disorder A paraphilic disorder in which the predominant focus of sexual activ- ity is secretly watching others undress or engage in sexual activity without being seen.

weight concerns A focus on, and often negative evaluation of, one’s weight.

withdrawal Maladaptive behavioral changes when a person stops using a drug.

worry A largely cognitive construct that refers to concern about possible future threat.

worry exposure A treatment technique for gen- eralized anxiety disorder involving extensive concentration on an anxious thought and alternatives to the worst-case scenario.

trephination Ancient technique that involved cutting a hole in a person’s skull to help release a harmful spirit.

tricyclic antidepressants A class of antidepres- sant medication that affects different neurotransmitter systems and often comes with many side effects.

triple-blind design Experiments in which participants, experimenters, independent raters of outcome, and data managers are unaware of who received a placebo or active treatment.

type D personality A distressed personality pattern marked by negative affectivity and social inhibition.

typical antipsychotics A class of older drugs to treat schizophrenia and related psychotic disorders primarily by reducing excess levels of dopamine in the brain.

ulcer In�ammation or erosion of a part of the body such as the esophagus, stomach, or duodenum.

unconditional positive regard An environment in which a person is fully accepted as she is and allowed to pursue her own desires and goals.

unconscious motivation Motivation that resides outside conscious awareness.

test–retest reliability Extent to which a person provides similar answers to the same test items across time.

thalamus A structure within the forebrain that re- lays sensory information to the cerebral cortex.

theory of mind An understanding of the thoughts and beliefs of others.

therapeutic alignment A nonspeci�c factor in treatment in which a therapist sides with a particular individual to balance communica- tions or power.

therapeutic alliance A nonspeci�c factor in treatment that refers to the relationship between the therapist and a client.

thought-action fusion A risk factor for obsessive- compulsive disorder involving a belief that thinking something is the same as doing it.

token economy An operant conditioning system in which desired behaviors are promoted through reinforcements.

tolerance The need to ingest greater amounts of a drug to achieve the same effect.

transference A key phenomenon in psycho- dynamic therapy in which a client reacts to the therapist as if the latter represented an important �gure from the client’s past.

transvestic disorder A paraphilic disorder in which the predominant focus of sexual activity is cross-dressing.

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I-1

GNAME INDEX N

A Aarsland, D., 435, 449 Aartsen, M.J., 443 Abbott, M.J-A., 88 Abbott, M.J., 132 Abbott, R.D., 402 Abdul-Quader, A.S., 268 Abidi, N., 206 Abner, E.L., 441 Abramowitz, J.S., 117 Abrial, E., 194 Accurso, E.C., 236, 239 Acosta, C., 147 Adams, C.E., 195, 201 Adan, R.A.H., 227 Addington, J., 354 Adinoff, B., 260 Adler, B.A., 388 Adshead, G., 147 Agabio, R., 268 Agarwal, U., 440 Agency for Healthcare Research

and Quality, 58 Aggarwal, R., 147 Aggen, S.H., 298 Agnelli, J., 447 Agnew-Blais, J., 375, 418 Agras, W.S., 223, 231 Agrawal, A., 259 Agronin, M.E., 444, 449 Aguirre, E., 447 Ahern, D.K., 155 Ahern, J., 276 Ahmari, S.E., 120 Ahmed, A.G., 339 Ahmed, U., 307 Ahuja, M.S., 23 Aigner, M., 236 Aikins, A.D., 449 Aissi, M., 372 Ajdacic-Gross, V., 321, 328 Al Ha�d, N., 393 Alabed, S., 365 Alaggia, R., 126 Albanese, E., 434, 435 Alberg, C., 267 Alberts, N.M., 150 Albuquerque, A., 426, 428, 449 Alcoholics Anonymous World

Services, Inc., 277 Alcorn, J.L., 264 Alda, M., 367 Alegria, M., 124 Alegría, M., 266 Alex, B., 487 Alexander, M., 395 Ali, A., 116 Allam, J., 297 Allan, N.P., 410 Allan, S., 228 Allen, C.T., 322

Allen, K.E., 402 Allen, K.J.D., 122 Alloway, T., 81 Alloy, L.B., 189 Alonso, P., 338 Alpers, G.W., 135 Altemus, M., 188 Alterman, A.I., 269 Althaus, A., 145 Alukal, J.P., 326 Alvarez-Jimenez, M., 373 Alvaro, E.M., 188 Alves, D., 35 Alzheimer’s Association, 434, 435 Amari, E., 258 Amawi, N., 124 Amenta, F., 446 American Heart Association, 481 Amirthavasagam, S., 298 Amminger, G.P., 366 Ammirati, R., 84 Amsel, R.M., 320 Amstadter, A.B., 137 Anacker, A.M.J., 395 Anastopoulos, A.D., 415 Anders, S.L., 483, 484–485 Anderson, D., 192 Anderson, D.A., 236 Anderson, H.D., 204 Anderson, I.M., 200, 206 Anderson, J.L., 288 Anderson, T., 195 Anderson, T.M., 305 Andoh, J., 149 Andrade-Moraes, C.H., 24 Andrasik, F., 485 Andreasen, N.C., 368 Andreatta, S., 41 Andreazza, A.C., 192 Andreotti, C., 481 Aneja, J., 117 Aneshensel, C.S., 42, 64, 481 Anestis, M.D., 203 Anetzberger, G.J., 436 Angel, O.H., 377 Anglin, D.M., 162 Angold, A., 137 Angst, J., 321, 328 Angstadt, M., 107 Angus, L., 35 Anie, K.A., 449 Annen, S., 202 Anstey, K.J., 265 APA American Psychiatric Associa-

tion., 41, 42, 75, 76, 77, 90, 91, 103, 104, 105, 106, 107, 108, 109, 110–112, 113, 114, 142, 143, 144, 145, 146, 147, 157, 158, 159, 160, 161, 175, 177, 178, 179, 181, 182, 183, 184, 185, 186, 217, 218, 219, 220, 222, 245, 246,

247, 284, 285, 286, 287, 288, 289, 290, 291, 293, 294, 314, 315, 316, 317, 318, 329, 330, 331, 332, 333, 334, 343, 344, 353, 357, 358, 359, 360, 361, 362, 386, 387, 388, 389, 390, 391, 399, 405, 406, 407, 408, 409, 426, 427, 428, 430, 431, 432, 433, 456–457, 458, 459, 470, 478

Appel, K., 193 Appleby, B.S., 428 Arad, M., 333 Arand, D.L., 481 Arch, J.J., 35, 101, 134, 461, 462 Ardani, A.R., 190 Areal, L.B., 260 Armour, C., 163 Armstrong, J.G., 167 Armstrong, K., 272 Arnberg, F.K., 131 Arnone, D., 191, 370 Arnsten, A.F.T., 415 Arntz, A., 296, 415 Arnulf, I., 480 Aronson, M.D., 443 Arvilommi, P., 206, 210 Asadpour, Z., 190 Asbury, E.T., 365 Aschner, M., 428 Aseltine, R.H., 68 Ashe, K.H., 437 Ashe, M.L., 264 Ashwill, R., 448 Asmundson, G.J.G., 149 Asscher, J.J., 417, 464 Assink, M., 417 Atagun, M., 369 Atay, J.E., 377 Atkins, D.C., 307 Atri, A., 444 Au, J.S., 210 Auer, M.K., 343 Auerbach, R.P., 41 Aunger, R., 122 Austin, J.K., 148 Avenevoli, S., 57, 61, 407 Aybek, S., 151 Ayer, L., 124 Ayonrinde, 338 Ayuso-Mateos, J.L., 190 Azevedo, F.A.C., 24

B Babchishin, K.M., 338 Bachmann, S., 374 Baethge, C., 360 Bagby, M., 153 Bagby, R.M., 304 Bagge, C.L., 203 Baghurst, T., 481 Baglioni, C., 194

Bagnall, A-M., 145 Bahrke, M.S., 273 Baiardini, I., 481 Bailer, F., 146 Bailer, U.F., 226, 227 Bailey, B.E., 122 Baillie, A.J., 320, 323 Baker, C.W., 236 Baker, J.H., 226 Bakshi, V.P., 120 Balan, I.C., 207 Balbi, F., 481 Baldessarini, R.J., 205, 206, 211 Baldinger, P., 120 Baldo, B.A., 120 Baldock, D., 445 Baldwin, J., 332 Baler, R.D., 261–262 Balestri, M., 299 Balla, D.A., 400 Ballan, M.S., 391 Balsis, S., 291, 304 Bambico, F.R., 192 Banks, S.J., 445 Barabasz, A.F., 157 Barabasz, M., 157 Barber, J., 436 Barber, J.P., 308 Barberger-Gateau, P., 442 Barbot, B., 60 Bardo, M.T., 260 Bardone-Cone, A.M., 237 Barker, J.M., 262 Barker, M., 223 Barkley, R.A., 407, 415, 416 Barlow, D.H., 126, 135 Barnard, N.D., 440 Barnes, T., 317 Barney, L., 117 Barr, S., 449 Barrantes-Vidal, N., 370 Barrett-Bernstein, M., 433 Barrett, B., 263 Barrett, C., 413 Barrett, P.M., 126 Barron, R.W., 402 Barskey, A.E., 266 Barsky, A.J., 149, 151, 154, 155 Barth, J., 327, 328 Bartlett, M.S., 388 Bartol, A.M., 466 Bartol, C.R., 466 Barzilay, S., 187 Basch, M.C., 152 Baslet, G., 149, 151 Bass, C., 147 Basu, S., 481 Batanova, M., 253 Bateman, 443 Bateman, A.W., 304, 305, 307, 308 Batra, A., 259

Name IndexI-2

Bradley, V., 391 Brady, J.E., 251 Brady, M.P., 397 Braet, A., 464 Braet, C., 415 Brahler, E., 209 Brahmbhatt, M., 145 Braido, F., 481 Brain, C., 377 Brake, C.A., 135 Bramoweth, A.D., 480 Bramson, H., 266 Branas, C.C., 251 Brand, B.L.,169 Brand, B., 163 Brand, B.L., 163, 168, 169 Brandys, M.K., 227 Brannann, S.K., 193 Bras, J.M.T., 439 Braswell, H., 187 Bratland-Sanda, S., 222 Braxton, L., 324 Bray, B., 33 Bray, J.H., 468 Breen, C., 273, 274 Breiding, 116 Brelau, N., 115 Brendgen, M., 412 Brennan, D., 355, 357 Brennan, P.A., 188, 194 Brent, D.A., 200 Breslau, J., 115, 460 Bresnahan, M., 403 Brew, B.K., 483 Brewer, R.D., 249 Bridge, J.A., 470 Bridges, M.S., 398 Briere, J., 161, 167 Brietzke, E., 210 Briken, P., 343 Britton, P.C., 60 Brock, S.E., 191 Brodaty, H., 440 Brodie, J.D., 69 Brodman, D.M., 128 Brodsky, B., 296 Brodt, M., 190 Brodtmann, A., 449 Brom, M., 338 Bromet, E.J., 188 Brook, D.W., 413 Brook, J.S., 413 Brook, R.D., 482 Brooke-Sumner, C., 364 Brooks, J., 365 Broome, M.R., 298 Brotchie, J.M., 446 Brotto, L.A., 323 Broudy, C., 296 Broussard, B., 364 Brousse, G., 270 Brouwers, E.P., 258 Brown, D., 62, 65, 301 Brown, G.K., 202 Brown, J.R., 190 Brown, R., 105, 137 Brown, R.J., 142

Bobashev, G., 266 Bockting, C.L., 200 Bodamer, O.A., 393 Boddez, Y., 101 Boddy, L.M., 388 Bodell, L.P., 210 Boden, J.M., 124, 412 Bodenmann, G., 42 Boehm, J.K., 483 Boettcher, H., 135 Boettcher, J., 301 Bogan, R.K., 480 Bogels, S.M., 117 Bogojevic, G., 373 Bois, K., 323 Boland, E.M., 104 Bolinskey, P.K., 81, 153, 364, 367 Bolton, J., 189 Bolton, P., 396 Boltz, M., 425, 447 Bombel, G., 84 Bomyea, J., 122 Bonadurer, G.F., 437 Bonanno, G.A., 62 Bonci, A., 261 Bond, G.R., 379 Bond, K., 200 Bond, R., 136 Bondy, S.C., 441 Bonifacci, P., 403 Bonnet, M.H., 481 Bonta, J., 33 Bontempo, D.E., 398 Bookheimer, S.Y., 437 Boomsma, D.I., 289, 371 Boone, L., 227 Boots, L.M.M., 447 Bor, H., 154 Borge, L., 377 Borin, G., 441 Borkevec, T.D., 131 Bornstein, R.F. Boros, M., 390 Bortolon, C., 430 Borum, R., 407 Bosmans, G., 124 Bostwick, J.M., 147 Both, S., 338 Botsford, J., 441 Bouck, E.C., 391 Bougatsos, C., 166, 300 Bouman, 148, 152 Bourgeron, T., 393 Bourget, D., 340 Bouvard, M., 303 Bouvet, L., 388 Bowen, C.N., 401 Bowen, S., 268, 275 Bowie, C.R., 370 Boyd, R.C., 198 Boyden, P., 354 Boyle, P.A., 438 Boysan, M., 165 Boysen, G., 292 Boysen, G.A., 165 Brackbill, R.M., 124 Bradford, J.B., 334

Bergem, A.L.M., 440 Berger, R.P., 396 Bergeron, S., 323 Berglund, P., 55, 56, 57, 61, 115,

187, 189 Bergman, H., 201 Bergvall, L., 322 Berk, M., 193 Berkman, N.D., 238 Berlim, M.T., 206 Bernadotte, A., 435, 449 Bernal, G., 195 Berninger, V.W., 402 Bernstein, A., 468 Bernstein, H.-G., 192 Berrettini, W.H., 226 Berridge, C.W., 415 Berry, M.D., 322 Berry, R.B., 487 Bershadsky, J., 391 Bertelsen, A., 365 Bertram, J., 131 Bet, P.M., 205 Bhat, K.M., 364 Bhat, R., 206 Bhatia, V., 196 Bhattacharyya, A., 437 Bhattacharyya, S., 41 Bhugra, 338 Biancosino, B., 201 Bielanska, A., 44, 373 Bierman, A., 42, 64, 481 Biesheuvel-Leliefeld, K.E.M., 200 Bigler, E.D., 89 Bijanki, K.R., 368 Billiard, M., 480 Binik, Y.M., 320, 321 Biondi, M., 201 Birkhoff, J.M., 337 Birnbaum, G.E., 322 Bissada, H., 227 Biswas, J., 159 Bitzer, J., 318 Bjertness, E., 440 Bjork, J.M., 264 Bjorvatn, B., 480 Black, D.W., 288, 293, 309 Black, S.E., 435 Blackburn, J.K., 95 Blackman, J.S., 332 Blackmore, E.R., 365 Blagov, P.S., 304 Blair, R.J.R., 410 Blais, J., 33, 292 Blanco, C., 207, 266 Blasczyk-Schiep, S., 222 Blaustein, M.E., 409 Blazer, D.G., 208 Blazina, I., 166, 300 Bleichhardt, G., 155 Blodgett, J.C., 268, 273 Blom, J.D., 162 Blonigen, D.M., 274, 275, 276 Bloom, M., 64, 66 Blow, F.C., 446 Bluett, E.J., 461 Blum, K., 261, 337

Battaglia, A., 394 Batterham, P.J., 117 Battistella, M., 483 Bauer, J., 262 Baumeister, S.E., 193 Baur, E., 337 Baur, J., 114 Bavarian, N., 415 Baxter, A.J., 58, 115 Baygani, S.K., 378 Bayley, N., 399 Beach, S.D., 396 Beach, S.R., 131 Beadel, J.R., 130 Beardslee, W.R., 191, 199 Bech, P., 201 Bechara, A., 260 Beck, A.T., 37, 38, 39, 122, 195,

202, 297, 299, 300 Beck, J.G., 164 Beck, J.S., 86 Beck, V., 148 Becker, C.B., 231 Becker, E.S., 151 Becker, J.V., 332, 336, 342,

343, 345 Becker, L.G., 266 Becker, T., 380 Beckers, T., 101 Becoña, E., 265 Bedard et al., 415 Bedics, J.D., 307 Beech, A.R., 334, 336, 337, 342 Beekman, A.J., 346 Beekman, A.T.F., 210 Beelen, I., 415 Beers, Clifford, 13–14 Beesdo-Baum, K., 137 Beghi, M., 203 Behnke, M., 395 Belgard, T.G., 395 Belkoura, C.R., 432 Bell, J.A., 480 Beller, E., 406, 407 Bellini, S., 401 Belujon, P., 262, 370 Belva, B.C., 400 Ben-Sasson, M.P., 333 Benbow, J., 463 Bender, D.S., 291 Bender, K.A., 163 Bendtsen, L., 485 Bengel, J., 481 Benishek, L.A., 275 Benítez, C.I.P., 61 Benítez-Burraco, A., 388 Benjamin, C.L., 128 Benjamin, L.S., 304 Bennett, D.A., 438 Benoit, K.E., 123 Benson, K., 434 Bentley, K.H., 117 Beppu, K., 438 Berendsen, A.A., 440 Berez, C., 359 Berg, J.M., 41 Berge, J.M., 228

Name Index I-3

Chisholm, D., 61 Chiu, W.T., 55, 56, 57, 115, 189 Chiuve, S.E., 482 Choi-Kain, L.W., 298 Choi, K.W., 123 Chong, H.Y., 363 Chorot, P., 123 Chorpita, B.F., 468 Chou, S., 297, 486 Chou, S.P., 61 Chow, E.T., 152 Christensen, H., 483 Christodoulou, J., 393 Chronis-Tuscano, A., 121 Chu, J.A., 159 Chu, J.P., 467 Chugani, C.D., 292 Chui, C.Y., 197 Chui, H.C., 435 Ciapparelli, A., 194 Cicchetti, D., 412 Cicchetti, D.V., 400 Cigrang, J.A., 483 Cima, M., 296 Cipriani, G., 441 Ciraulo, D.A., 206, 259, 267 Claes, L., 222 Clark, A.K., 273 Clark, C.G., 207 Clark, L.A., 117, 310 Clarke, M., 307, 355, 357, 371, 380 Clarke, T.K., 226 Clarkin, J.F., 307, 308 Claudino, A.M., 239 Clayton, A.H., 318, 320, 326 Cleary, S.D., 413 Clement, S., 16 Clements, K., 275 Clemow, D.B., 415 Clerici, M., 338 Clifford, A., 265 Clulow, C., 209 Cmcec, 403 Coalson, D., 399 Coccaro, E.F., 298 Cocchi, E., 372 Cockcroft, K., 81 Cohen-Kettenis, P.T., 343, 346 Cohen, J.A., 169 Cohen, J.M., 115 Cohen, J.S., 128 Cohen, N., 466 Collins, K.P., 413 Collishaw, S., 57 Colloca, L., 461 Colucci, E., 323 Colucci, L., 446 Colussi, G., 440 Comabella, C.C., 190, 203 Combs, B., 446 Compas, B.E., 481 Compton, M.T., 359, 364 Comtois, K.A., 211 Condon, B., 191 Conduct Problems Prevention

Research Group, 412, 414 Conkey, L.C., 309–310

Castelein, S., 322 Castellanos, F.X., 411 Castle, D., 198, 364 Castonguay, L.G., 107, 117, 119,

122, 135 Catalano, R.F., 266 Catalisano, D., 134 Catena, C., 440 Catts, H.W., 398 Cauffman, E., 411 Cavanagh, J., 191 Cavanagh, K., 136 Caye, A., 407 Cechnicki, A., 44, 373 Center for Behavioral Health

Statistics and Quality, 254 Centers for Disease Control and

Prevention, 60, 388, 391 Cepeda, A., 197 Cereda, E., 435 Cerri, C., 203 Cervantes, P.E., 391 Chae, Y., 162 Chalmers, J.A., 88 Chan, 448 Chan, C.L.W., 187, 446 Chancellor, J., 62 Chanen, A., 310 Chanen, A.M., 300, 301 Chang, C.-M., 194 Chang, E., 447 Chang, K.T., 437 Chaplin, T.M., 196 Chapman, A.L., 467 Chapman, J., 407 Chapman, K.R., 480 Charlson, F., 206 Charlson, F.J., 58 Cheavens, J.S., 300 Chebli, S.S., 388 Cheek, S.M., 195 Chemerinski, E., 285, 286, 297 Chen, A., 431 Chen, B.T., 261 Chen, C.N., 266 Chen, F., 365 Chen, J., 107 Chen, J.A., 395 Chen, R., 265 Chen, S., 438 Chen, T.F., 17 Chen, X., 24 Chen, X.S., 440 Cheng, H-L., 17, 124 Cheng, J.C., 339 Cheng, J.K.Y., 467 Cheng, R., 259 Cherkasova, M., 418 Cherkin, D.C., 486 Chertkow, H., 429 Chervin, R.D., 434 Chiang, K., 442 Chiappetta, L., 211 Childs, K., 408 Chin, A.L., 435 Chiocchetti, A.G., 410 Chiriboga, D.A., 188

Cahill, N., 223 Cain, N.M., 291 Cairncross, M., 149 Caito, S., 428 Calafat, A., 265 Calandreau, L., 119 Calati, R., 299 Calear, A.L., 200 Callanan, V.J., 190 Caltagirone, C., 354 Calugi, S., 236 Camara-Fuentes, L., 195 Camargo, C.H.F., 447 Cameron, G., 124 Cameron, K., 483 Camodeca, M., 412 Campbell, J., 64 Campbell, J.C., 64 Campellone, T.R., 365 Campling, S., 330, 334 Campo, J.V., 470 Canavan, C., 479 Candy, B., 326 Canino, G., 117 Cannon, M., 380 Cannon, T.D., 370 Cano-Vindel, A., 124 Canonica, G.W., 481 Cantor, J.M., 338, 339, 346 Cao, S., 320 Capaldi, D.M., 267 Caplan, P.J., 116 Caplan, S., 145 Caponigro, J.M., 365 Caporino, N.E., 117 Cappai, A., 370 Caqueo-Urízar, A., 379 Caramanica, K., 124 Caravita, S., 412 Card, T., 479 Cardena, E., 168 Cardish, R.J., 309 Carey, K.B., 67, 268 Carey, M.P., 43, 67, 268 Carlomagno, S., 388 Carlson, E., 167 Carlson, E.B., 167 Carnes, P.J., 330, 334 Carney, C.E., 486 Carney, P.R., 487 Carpenter, R.W., 289, 298 Carpentier, J., 335, 336 Carra, G., 267 Carrillo-Solano, M., 480 Carrive, P., 122 Carroll, J.L., 342 Carron-Arthur, B., 190, 225 Carskadon, 480 Carson, K.V., 274 Carta, M.G., 364 Carter, M.M., 230 Carvalho, A.F., 194 Casner, R., 292 Caspar, F., 459 Cassells, R.C., 412 Cassisi, J.E., 379 Castagnini, A.C., 365

Brown, S., 64 Brown, S.L., 152 Brown, T.A., 107, 126 Browne, K.D., 297, 486 Brownley, K.A., 236 Brownson, C., 190 Brozaitiene, 482 Bruchas, M.R., 259 Bruder, J., 390 Bruess, C.E., 323 Bruggeman, L., 161 Brugha, T., 403 Brune, M., 202 Brunelle, C., 269 Brunetti, M., 120 Brunner, J., 292 Bruns, G.L., 230 Bryan, J., 440 Bryant, C.D., 259 Bryant, R., 114 Bryce, R., 434, 435 Brzustowicz, L., 262 Buchanan, L., 68 Buchmann, A., 368 Buck, T.R., 400 Buckley, P., 364, 370, 372 Buckner, J.D., 122 Budge, S.L., 460 Buettner, P., 124 Bufferd, S.J., 194 Buf�ngton-Vollum, J.K., 33 Bugatti, M., 443 Bugental, J.F.T., 35 Buka, S., 370 Bulik, C.M., 226, 228, 236, 239 Bundy, H., 363 Bunevicius, 482 Bunner, A.E., 440 Burch, R., 480 Burch�eld, K., 341 Bureau, J.-F., 298 Burke, M.J., 149 Burke, M.M., 396 Burke, W.H., 339 Burns, T., 291 Burra, T.A., 464 Burstein, M., 61 Burstein, R., 58 Burt, V., 481 Burton, M.C., 147 Busch, A.J., 291, 304 Busch, V., 148 Bush, S.H., 427 Buss, C., 192 Busse, S., 438 Butcher, J.N., 81, 82 Buyske, S., 145 Byrd, D.A., 124 Byrne, G., 147 Bystad, C., 460 Bystad, M., 460 Bzdok, D., 165

C Caban-Holt, A.M., 441 Cacciola, J.S., 269 Cadima, J., 148

Name IndexI-4

Dickter, C.L., 263 DiClemente, R.J., 337 Diedrich, A., 294, 300 Diehl-Schmid, J., 435, 449 Diehl, A., 191 Diemer, J., 135 Diers, M., 149 DiLibero, J., 444 Dilworth-Anderson, P., 441 Dimaggio, G., 308 Dingemans, A.E., 224 Dinger, U., 189 Dishion, T.J., 264 Disney, K.L., 294, 295, 300 Dix, Dorothea, 13 Dixon, L.B., 365 Dizon, D.S., 326 Dobbelstein, C.R., 148 Dobos, G., 148 Dobson, K., 200 Docherty, N.M., 355 Dodge, K., 412, 413 Dodge, K.A., 412 Doer�er, L.A., 418 Dold, M., 236 Dolhanty, J., 236 Domínguez, T., 370 Domschke, K., 120 Donaghy, P., 431 Dong, X.Q., 436 Donnan, G.A., 449 Donovan, D.M., 463 Donovick, P.J., 439 Dorahy, M.J., 159, 164 Doty, T.J., 122 Dougherty, D.D., 120 Douglas, H., 275 Dour, H.J., 223 Doust, J., 406, 407 Douzenis, A., 150 Downar, J., 149 Downey, A., 225 Downey, G., 266 Downs, M.F., 195 Downs, S.J., 388 Doyle, A-B., 197 Doyle, L.R., 411 Dozois, D.J.A., 38, 195, 202 Drago, A., 372 Drake, H., 209 Drake, K.L., 123 Drake, R.E., 379 Drake, R.J., 359 Drevets, W.C., 120, 192 Driessen, E., 32 Dring, K., 332 Droutman, V., 260 Drum, D.J., 190 Drummer, O.H., 272 Druss, B.G., 266 Ducharme, S., 120 Duchesne, S., 197 Dude, Kim, 70–71 Duff, K., 449 Duffy, K.G., 463 Dugas, M.J., 101 Dulac, O., 394

de Campos Bottino, C.M., 445 De Clercq, B., 296, 300 De Fruyt, F., 296 De Graaf, R., 210 de Groot, L.C., 440 De Houwer, J., 216 de Jong, J., 124, 151, 162, 165 de Kovel, C.G.F., 227 de Lange, E., 434 De Marco, M., 388 de Portugal, E., 365 De Ronchi, D., 299 De Roo, A.K., 464 De Silva, M., 61 De Soir, E., 165 De Sousa, A., 274 De Vries, A.L., 346 Deacon, B.J., 461 Deavers, F., 379 Debast, I., 310 Debbane, M., 165 Deblinger, E., 169 Deck, C., 396 Deckersbach, T., 196 Deco, G., 425 DeCoster, J., 188 Defazio, G., 150 Defrin, R., 333 Degen, C., 374 Degenhardt, L., 58 Degnan, K.A., 121 DeGue, S., 64 Del Casale, A., 298 del Re, E.C., 367, 368 Delaney, A.L., 189 Delforterie, M.J., 237 Demarch, E., 437 Demler, O., 55, 56, 57, 61, 115,

187, 189 Denenny, D., 365 Dening, K.H., 441 Denis, C.M., 269 Denmark, A.B., 190 Denney, R.L., 147 Dennis, J., 126 Denollet, J., 482 DePape, A.M., 391 Derby, K.M., 402 Des Jarlais, D.C., 266 Desai, R.A., 407 Desan, P.H., 374 Deschênes, S.S., 101 Desin, P.J., 441 Desmedt, A., 119 Desrocher, D., 323 Detsky, A.S., 320 Devries, K.M., 210 DeVylder, J.E., 365 DeWitt, M., 402 Di Ceglie, D., 344, 345 di Giacomo, E., 338 Di Marco, L.Y., 440 Di, J., 441 Diamond, G.M., 209 Diamond, G.S., 209 Dichgans, M., 437 Dick, D., 24

Crunk, E., 35 Cserhati, Z., 151 Cuellar, A.K., 199 Cuffee, Y., 481 Cui, L., 192 Cuijpers, P., 195, 208 Culpepper, N., 370, 372 Cumming, G.F., 340 Cummings, C.M., 117 Cummings, J.R., 266 Curtis, S., 61 Curtis, V., 122 Curwen, T., 403 Cusimano, M.D., 397

D D’Angelo, V., 134 Daban, C., 193 Dabby, F.C., 64 Dadds, M., 199 Dadds, M.R., 410 Dagirmanjian, F.B., 60 Daisy, N.V., 166 Dakwar, E., 275 Dale, P., 480 Daleiden, E.L., 468 Dalena, K.L., 418 Dalenberg, C., 167 Daley, D.C., 463 Dalgleish, T., 131 Dalle Grave, R., 236 Dalley, J.W., 261, 273 Daly, 191 Daly, K., 333 Damiano, S.R., 228 Daneschvar, H.L., 443 Danforth, J.S., 418 Daniels, J.K., 163 Danitz, S.B., 136 Daren, A., 44, 373 Darviri, 487 Das, J., 61 Das, P., 193 Daskalakis, Z.J., 206, 370 Dasse, M.N., 168 Daum, I., 371 Davey, G.C.L., 133 Davey, J., 272 David, A.S., 136, 163, 485 David, M., 84 Davies, C.D., 101 Davies, G., 415 Davila, J., 196 Davis, D., 426, 428, 449 Davis, E., 198 Davis, E.P., 192 Davis, J., 373 Davis, M.S., 190 Davis, S., 321 Davis, T.E., 129 Davison, S., 293 Davoli, M., 273, 274 Dawson, T.M., 437 Dawson, V.L., 437 de Bildt, A., 400 de Boer, M.K., 322 De Caluwé, E., 300

Conners, C.K., 375, 415 Connor, D.F., 418 Connors, G.J., 322 Conte, D., 433 Contractor, A.A., 152 Conway, C.C., 310 Coolican, H., 468 Coon, D., 441 Cooper, A., 264 Cooper, A.A., 462 Cooper, C., 436 Cooper, K., 328 Cooper, M., 126 Cooper, S., 61 Copeland, S., 61 Copeland, W.E., 137 Copello, E., 81 Coppola, G., 412 Corbera, S., 374 Corbi, G., 436 Corcoran, R., 354 Cormac, I., 377 Cornaggia, C.M., 203 Corrado, R.R., 298 Corrieri, S., 126 Corrigan, F.M., 167 Corrigan, P., 296 Corrigan, P.W., 16, 17, 365 Corsini, R.J., 34, 35 Cossette, A., 335 Costafreda, S.G., 192 Costello, E.J., 61, 137, 407 Coston, N., 292 Cotter, K.L., 64 Coulston, C.M., 193 Counsell, 432 Couture, J., 410 Couturier, J., 236 Cowdery, G.E., 402 Cowley, D.S., 131 Cox, B.J., 310 Craddock, N., 191 Crafa, D., 396 Craig, R.J., 251 Craig, S.G., 415 Craighead, W.E., 208, 209 Cramer, H., 148 Cranford, J.A., 276 Craske, M.G., 101, 310 Crawford, M.J., 287, 308 Creed, F.H., 148, 368 Creed, L., 355 Crego, C., 287 Crichton, G.E., 440 Crider, R.A., 377 Crino, R., 135 Cristóbal-Narváez, P., 370 Crits-Christoph, P., 308 Croft, H.A., 320, 326 Croisant, S., 480 Croll-Lampert, J., 228 Crosby, A.E., 189 Crosby, J.M., 122 Crouch, R.A., 461 Crow, T.J., 368 Crump, J., 285 Crunelle, C.L., 261

Name Index I-5

Folstein, S.E., 444 Foltynie, T., 438 Foltz, P.W., 370 Fonagy, P., 305 Fone, K., 357 Fong, T.G., 426, 428, 449 Fontanella, C.A., 470 Fontenelle, L.F., 222 Forbes, M.K., 320, 323 Forbes, P.W., 191 Ford, J.D., 409 Ford, J.M., 355 Forestell, C.A., 263 Forney, K.J., 224 Forth, A.E., 292 Foshee, V.A., 411 Foster, K., 365 Foulon, H., 41 Fountoulakis, K.N., 189, 198, 210 Fowler, J.S., 260, 261, 263, 267 Fox, B.H., 412 Fox, N.A., 121 Fox, P.T., 165 Fox, S.H., 446 Fraile, S.C., 370 Francis, J.L., 137 Frank, G.K.W., 226 Frank, Y., 394, 400 Franke, B., 410 Franken, I.H., 260 Franken, I.H.A., 122 Frankenburg, F.R., 309–310 Franklin, J., 360 Franko, D.L., 221, 222, 237, 238 Fraser, M.W., 64 Fredrickson, B.L., 63 Freeman, D., 354 Freeman, N.J., 342 Freeman, T.R., 96 Freidl, M., 163 Freitag, C.M., 410 Frenkel, T.I., 121 Freud, Sigmund, 29–30 Frewen, P., 163 Frewen, P.A., 163 Friborg, O., 117 Frick, P.J., 411, 413, 418 Frick, U., 464 Friderici, K., 411 Friedberg, R.D., 133 Friederich, H.C., 234 Friedman, A.F., 81, 153 Friedrich, B., 17, 443 Frijters, J.C., 402 Frisell, T., 338 Frith, C.D., 354 Fritsch, E.J., 409 Fröjd, S., 413 Frühauf, S., 327, 328 Fruzzetti, A.E., 292 Fu, C.H.Y., 192 Fuchs, D., 403 Fuchs, L.S., 403 Fuh, I.L., 268 Fuligni, A.J., 265 Fulkerson, J.A., 228 Fuller, K.S., 437

Fecteau, S., 259, 267 Fedoroff, J.P., 334, 339, 340 Fein, D., 401 Feingold, A., 267 Feinstein, A., 149 Feinstein, B.A., 196 Feldman, H.H., 429 Feldman, K.W., 396 Felix, E.D., 117 Ferguson, C.J., 222, 290 Ferguson, K.M., 163 Fergusson, D.M., 124, 412 Fergusson, G.M., 206 Fernandez, 66 Fernandez, E., 481 Fernández-Hermida, J.R., 265 Ferrante, T., 479 Ferrari, A.J., 58 Ferrari, G., 264 Ferrari, R., 433 Ferraro, G., 41 Ferri, C.P., 434, 435 Fertel, 319 Fertuck, E., 296 Festa, F., 300 Field, A.P., 133 Figueiredo, D., 434 Figuerio, 480 Fila-Witecka, K., 222 File, 196 File, A.A., 207 Finch, S.J., 413 Findling, R.L., 189 Fineberg, A.M., 370 Fingerhut, H., 165 Fink, M., 206 Finney, J.W., 268, 273, 274,

275, 276 First, M.B., 80, 153, 201, 233,

304, 364, 367, 380 Fischbach, R.L., 391 Fisher, A.D., 342 Fisher, J.E., 454, 462 Fisher, M.H., 396 Fisher, P.A., 121 Fisher, W.A., 317 Fitch, R.H., 395 Fitzgerald, J., 427 Fitzgerald, P.B., 206 Fitzmaurice, G.M., 309–310 Fitzsimmons-Craft, E.E., 42 Flack, D., 275 Flament, M.F., 227 Flavin, J., 273 Flaxman, A.D., 58 Flay, B.R., 415 Fleming, M., 153 Fletcher, B., 223 Fletcher, D., 62 Flor, H., 149 Flory, K., 434 Flynn, A., 145 Foa, E.B., 462 Fogel, B.L., 437 Fok-Trela, A., 323 Foland-Ross, L.C., 192 Folstein, M.F., 444

Epperson, C.N., 188 Eranti, S.V., 363 Erdi, P., 120 Erhardt, D., 415 Erickson, N.S., 361 Erickson, T.M., 107, 117, 119,

122, 135 Erol, A., 189 Erskine, H.E., 58 Erskine, J., 403 Escoffery, C., 148 Escudero, J., 379 Espejo, E.P., 194 Espinoza, L., 266 Essali, A., 365 Essali, N., 365 Ethofer, T., 120 Ettinger, U., 297, 367 Eurviriyanukul, K., 205 Evans, C.B.R., 64 Evans, D.A., 430 Evans, G.W., 412 Evans, S.W., 416 Evans-Lacko, S., 16 Evans-Smith, B., 402 Everaerd, W., 338 Ey, E., 393 Eyden, J., 298 Eynan, R., 287

F Fabiano, G.A., 416 Fadem, B., 146, 147 Fage, B.A., 444 Fagioli, S., 354 Fagnant, R., 116 Failla, M.D., 191 Fairburn, C.G., 233, 236, 237, 239 Fairchild, G., 411 Fairclough, S.J., 388 Falcone, G.J., 437 Fales, J.L., 152 Falk, S.J., 326 Falkenburg, J., 363 Fallgatter, A.J., 259 Falzer, P.R., 407 Fanetti, M., 333 Fang, L., 77 Fang, M.L., 258 Fanning, J.R., 298 Faraci, P., 134 Faraone, S.V., 367, 370 Farfel, M.R., 124 Farkas, G., 413 Farmer, C., 400 Farmer, M.A., 321 Faron-Gorecka, A., 194 Farrington, D.P., 410 Fasanaro, A.M., 446 Faurholt-Jepsen, M., 87 Fava, G.A., 131, 150, 151, 153 Fay, D., 331 Fay, M.L., 391 Fayed, N., 149 Fazel, S., 291, 338, 366 Fazio, R.L., 147 Feart, C., 442

Dumitrascu, N., 84 Dumont, R., 399 Duncan, B., 460 DuPaul, G.J., 391, 413, 415, 416 Duran, C.R., 413 Durkheim, Emile, 187 Duzel, E., 443 Dvorak, R.D., 195 Dwyer, R.G., 339 Dyb, G., 152 Dyck, I., 137 Dymond, S., 124

E Eapen, V., 403 Easterbrooks, M.A., 298 Eaton, N.R., 60, 105 Eberle, H., 148 Ebersole, A., 292 Ebesutani, C.K., 128, 468 Ebmeier, K.P., 192 Ebneter, D.S., 225 Ecker, A.H., 122 Eckert, T.L., 416 Edinger, J.D., 486 Edmunds, J.M., 128 Edwards, M.J., 155 Effting, M., 101 Egan, V., 33 Ehlers, C.L., 266 Ehlers, R., 367 Ehrensaft, D., 345 Ehrenthal, J.C., 189 Ehrlich, A., 192 Eichhammer, P., 148 Eickhoff, S.B., 165 Eijlers, R., 122 Eikeseth, S., 401 Einstein, Albert, 6 Eipper, J.W., 178 Eisen, M.L., 162 Eisenberg, D., 55, 195, 223 Eisenberg, M.E., 228 Eisenberg, N., 412 Eisner, L., 196 Ekavali, 438 Ekmehag, B., 482 El Haj, M., 425 El-Guebaly, N., 267 Elbogen, E.B., 305 Elias, A., 206 Elias, J.A., 122 Elias, S.M.S., 208 Elkins, G.R., 168 Elliott, I.A., 333 Elliott, J.C., 67, 268 Elliott, R., 35 Ellis, A.J., 197, 210 Ellison, J.W., 395 Ellman, L.M., 370 Ellwardt, L., 443 Elvevåg, B., 370 Elzinga, B.M., 121, 193 Emre, M., 449 Emsley, R., 374 England, M.J., 148 Ennett, S.T., 411

Name IndexI-6

Gutheil, T.G., 159 Gutiérrez-Maldonado, J., 379 Gutteling, B.M., 306 Gutteridge, J.M.C., 440 Guul, A., 365

H Haas, S.A., 121 Hacker, D., 377 Haddad, P.M., 377 Haddadi, H., 331 Hadiyono, J., 117 Hadjistavropoulos, H.D., 150 Haeri, S., 189 Haertel-Petri, R., 253 Hagan, C.R., 41, 196, 199, 210 Hagberg, J.E., 394 Hagerman, R.J., 395 Haigh, E.A.P., 37, 122, 300 Hajek, T., 367 Haji, M., 449 Hales, R.E., 203, 429 Hall, G.C.N., 16 Halladay, A.K., 60 Haller, H., 148 Halligan, P., 147 Hallion, L.S., 116 Halliwell, B., 440 Halperin, D.M., 237 Hämäläinen, J., 403 Hameed, M.A., 62 Hamer, M., 481 Hames, J.L., 196, 210 Hamilton, R., 435 Hamilton, S., 354 Hammen, C., 188, 194 Hammett, P.J., 263 Han, B., 189 Han, C., 194 Han, H., 260 Han, S., 251 Hancock, S., 248, 263 Handiwala, L., 320, 326 Hankin, B.L., 188 Hanrahan, F., 133 Hansen, M., 163 Hanson, C., 228 Hansson, O., 439 Hanuszkiewicz, I., 44, 373 Happel, R.F., 333 Hardeveld, F., 210 Harinstein, L., 434 Hariri, A.R., 28, 446 Harmer, C.J., 205 Harned, M.S., 307 Harrigan, S., 366 Harris, A.J., 341 Harris, G.T., 332 Harris, P.W., 416 Harrison, P., 400 Harrison, S.L., 441 Harrison, T.M., 437 Harsh, V., 318 Harshaw, C., 175 Hart, L.M., 222 Hart, S.A., 410 Hart, S.E., 191

Grace, E.J., 388 Graham, D.M., 411 Graham, R., 178 Grande, I., 205 Granillo, M.T., 222 Grant, B.F., 61 Grant, J.E., 342 Grant, P., 400 Grassi-Oliveira, R., 378 Grassi, L., 201 Grattan, L.M., 95 Gratwicke, J., 438 Grazzi, L., 485 Greden, J.F., 118 Green, B.A., 330, 334 Green, K.M., 189 Greenberg, J.S., 323 Greenberg, L., 236 Greenberg, R.P., 462 Greene, A.L., 105 Greene, E., 33 Greenhill, L.L., 415, 416 Greer, T.L., 192 Gregg, K.J., 228 Gregg, N., 403 Grégoire, C., 323 Gregory, B., 132 Gress-Smith, J.L., 481 Grey, N., 461 Grierson, A.B., 194 Grieser, E.A., 480 Griesler, P.C., 265 Grif�n, M., 436 Grif�n, M.M., 396 Grif�ths, J., 117 Grif�ths, K.M., 117, 129, 190, 225 Grif�ths, R.R., 253 Grob, G.N., 12 Groen, W.B., 391 Groos, E., 480 Gropalis, M., 155 Gross, A.L., 441 Gross, E.R., 266 Gross, J.J., 122 Gross, M., 336 Grossman, S., 303 Growdon, M.E., 426, 428, 449 Grupe, D.W., 120 Gu, J., 136 Gu, Q., 481 Guadalupe, T., 396 Guaiana, G., 131 Guajardo, J.G., 126 Gudmundsdottir, B.G., 411 Guerdjikova, A.I., 236 Guerriero, R.M., 152 Guidi, J., 131 Guido, M.A., 259 Guimond, T., 309 Guirguis, M., 168 Gulliver, A., 129 Gullotta, T.P., 64, 66 Gundersen, T.D., 255 Gunderson, J., 304, 305, 307, 308 Gunderson, J.G., 305, 310 Gunturu, S., 332 Gustavsson, T., 468

Ghaffar, O., 149 Ghali, M.N., 292 Ghanem, H., 316, 318 Ghetti, B., 437 Gibbons, C., 448 Gibson, L.E., 365 Giel, K.E., 227 Giesbrecht, T., 159 Gigante, A.F., 150 Gilbert, E., 370 Gilbert, P., 115, 122 Gilbody, S., 131 Gilder, D.A., 266 Gilissen, C., 397, 401 Gillespie-Lynch, K., 392 Gillespie, N., 24 Gillham, J.E., 196 Gilliam, K.S., 121 Gillig, P.M., 168 Gilman, S.E., 115 Ginsburg, G.S., 123 Ginzburg, K., 333 Gitlin, L.N., 441, 446 Gizer, I.R., 266, 269 Gkika, S., 132 Gladstone, T.R.G., 191 Glaesmer, H., 209 Glass, L., 411 Glasziou, P., 406, 407 Glatt, S.J., 370 Glazebrook, C., 195 Glenn, A.L., 288, 293, 298 Gloster, A.T., 126 Glozier, N., 366 Godwin, J., 412 Gold, 66 Gold, C., 462 Goldenberg, H., 44 Goldenberg, I., 44 Goldenberg, S.L., 320 Goldin, P.R., 122 Goldney, R.D., 200 Goldstein, B.I., 440 Goldstein, R.B., 61 Goldstein, T.R., 200, 209 Golmard, J.L., 480 Goltz, H.H., 320 Gonzales, N., 265 Gonzalez, H.M., 197 Gonzalez, L.S., 332 Good, E.M., 466 Goodman, G.S., 162 Goodwin, B., 326 Goodwin, R.D., 137 Gordon, I., 388 Gorlin, E.I., 130 Gorman, D.A., 416 Gorman, J.M., 39, 64, 462 Gormley, M.J., 391 Gough, B., 338 Gouin, J.P., 101 Goulding, S.M., 364 Gouras, G.K., 439 Goyal, A., 191 Gozes, I., 438 Grabe, H.J., 193 Grace, A.A., 262, 370

Furlong, B., 468 Furnham, A., 285 Furukawa, T.A., 205 Fusar-Poli, P., 364, 376 Fuss, J., 343 Futterman, S.E., 286 Fyfe, I., 443

G Gabbard, G.O., 28, 337 Gabrieli, J.D., 396 Gadassi, R., 189 Gagnon, J., 307 Gaha, L., 372 Galanter, M., 267 Galea, S., 124, 466 Galizio, M., 322 Gallinat, J., 192 Gallop, R., 292 Galvin, J.E., 447, 448 Gambescia, N., 325, 327 Gao, S., 443 Garber, J., 197 Garbutt, J.C., 273 Garcia-Albea, J., 142 Garcia-Parajua, P., 142 Garcia, F., 265 Garcia, F.D., 342 Gard, A.M., 411 Gardner, C.O., 42 Gardner, D., 416 Gardner, T.J., 305 Garety, P., 354 Garey, L., 67, 268 Gar�nkel, S.N., 120 Garofalo, C., 166 Garretsen, H.F., 258 Gassab, L., 372 Gast, D.L., 401 Gaston, J.E., 132 Gatt, A.P., 432 Gattner, K., 154 Gatto, G.J., 41 Gau, S.S-F., 148 Geddes, J.R., 208 Gee, B.L., 129 Gehi, A.K., 481 Geider, F.J., 374 Geiger, M.J., 120 Geisler, D., 370 Geisner, I.M., 195 Gelfuso, E.A., 120 Gellatly, R., 122 Geller, S., 197 Gély-Nargeot, M.C., 430 Gemignani, A., 194 Gentile, J.P., 168 Gerger, H., 327, 328 Gerlinger, G., 365 Gernsbacher, M.A., 388 Gerow, S., 388 Gersons, B.P.R., 121 Gervais, N.J., 433 Geschwind, D.H., 395, 437 Geschwind, M.D., 432 Geyer, J.D., 487 Gfroerer, J., 189

Name Index I-7

Ittermann, T., 193 Ivarsson, B., 482 Iverson, K.M., 292 Ivleva, E.I., 370 Iza, M., 115

J Jääskeläinen, E., 380 Jackson, J.C., 33 Jackson, J.S., 198 Jackson, K.F., 455 Jacobi, C., 231 Jacobs, H.I., 449 Jacobsen, R.K., 481 Jacoby, R.J., 117 Jacova, C., 429 Jaffee, S.R., 288, 309, 418 Jäger, M., 380 Jahanshahi, M., 438 Jahng, S., 287, 291, 292, 295 Jainer, A., 154 Jakubovski, E., 137 James, C., 464 Jameson, N., 211 Janca, A., 293 Jankovic, J., 432, 438 Jannini, E.A., 321 Japee, S., 122 Jaracz, J., 154 Jarrett, R.B., 200 Jasinska, A.J., 261 Jasper, A.D., 391 Jaspers, L., 326 Jastreboff, A.M., 262 Jauhar, S., 191 Jay, E-L., 163 Jazaieri, H., 122 Jelovac, A., 206 Jeltova, I., 191 Jennings, W.G., 412 Jensen, R., 485 Jeon, H.J., 195 Jern, P., 326 Jernigan, K., 411 Jerram, M.W., 161 Jeste, S.S., 396 Jiang, L., 368 Jin, R., 55, 56, 57, 61, 115,

187, 189 Jinks, M., 307 Jobes, D.A., 210 Joe, S., 198 John, T., 120 Johns, B.H., 402 Johns, D.J., 190 Johns, N., 58 Johnson, A., 447 Johnson, A.K., 288, 293, 298 Johnson, D.K., 448 Johnson, D.P., 116 Johnson, J., 62, 402 Johnson, M.I., 145 Johnson, S.C., 305 Johnson, S.L., 199 Johnson, W.W., 33 Johnston, C., 418 Johnston, J.A., 236

Hopley, A.A.B., 269 Hopp, J.L., 155 Hopwood, C.J., 310 Horan, J., 262 Horan, W.P., 357 Horowitz, A.V., 12 Horwood, L.J., 124, 412 Hosain, G.M., 320 Hosanagar, A., 107 Hosseini, F.F., 190 Houser, R.A., 471 Hovens, J.E., 366 Howard, R.C., 292 Howell, E.F., 160 Howes, O., 370 Howes, O.D., 370, 371 Howieson, D.B., 89 Howlett, N., 223 Howlin, P., 389, 403 Hryshko-Mullen, A.S., 483 Hsu, L., 295 Hsu, S.H., 275 Hu, M.C., 265 Huang, B., 61 Huang, C-H., 188 Huang, F.Y., 77 Huang, H.C., 446 Huang, J., 441 Huband, N., 307 Huber, A.M., 266 Huffman, J.C., 131 Hughes, A.K., 320 Hughes, J.R., 253 Hughto, J.M.W., 343 Hugtenburg, J.G., 205 Huguet, G., 393 Hui, C.L.M., 361 Huijding, J., 122 Hultcrantz, M., 131 Hulvershorn, L., 211 Hummelen, B., 286 Humphreys, K., 268, 273 Humphreys, K.L., 434 Hunt, J., 55 Hunter, J., 393 Huntjens, R.J.C., 164 Huot, P., 446 Hurd, Y.L., 256 Hwang, S.W., 464 Hwu, H-G., 148 Hyde, L.W., 28, 446

I Iadecola, C., 439 Iavarone, A., 388 Ibrahim, A.K., 195 Iftikhar, M., 298 Iga, J., 177 Imhoff, R., 371 Ingalsbe, M.H., 463 Ingvar, M., 122 Inouye, S.K., 426, 428, 445, 449 Institute of Medicine, 66 Irving, C.B., 377 Isidori, A.M., 328 Isohanni, M., 380 Isometsa, E., 211

Hibberd, C., 391 Hien, D.A., 166 Hiersteiner, D., 391 Higashi, K., 377 Higgo, R., 43 Higuchi, S., 437 Hilbert, A., 228 Hildebrandt, T.B., 225 Hill, M., 364 Hill, S., 465 Hillemeier, M.M., 413 Hiller, W., 155 Hillman, J., 323 Hilt, L.M., 188 Himelein, M.J., 322 Hingson, R., 66 Hinkelmann, K., 193 Hinshaw, S.P., 411 Hinton, D.E., 109, 124, 151 Hinton, L., 197 Hippocrates, 12 Hirjak, D., 356, 368 Hirsch, 66 Hirsch, J.K., 60 Hirsch, L., 416 Hirschfeld, R.M.A., 203 Hirvonen, N., 380 Hisley, S.M., 394 Hjemdahl, P., 482, 486 Ho, M-H.R., 41 Hoberman, H.M., 337 Hodapp, R.M., 396 Hodges, J.R., 439 Hodis, B., 368 Hoedeman, R., 155 Hoeft, F., 396 Hoek, H.W., 162, 221, 222 Hoeve, M., 417 Hof, P.R., 28 Hoff, A.L., 124 Hoffart, A., 137 Hoffer, M., 207 Hofmann, S.G., 39, 109, 124 Hoge, C.W., 124 Holaday, E., 147 Holbrook, J.R., 418 Hollocks, M.J., 391 Hollon, S.D., 200 Holloway, J., 136 Holman, E.A., 152 Holoyda, B.J., 337, 341 Holshausen, K., 370 Holt-Lunstad, J., 62 Holt, P.G., 483 Holtom-Viesel, A., 228 Holtzman, D.M., 437, 442 Holzel, B., 196 Holzer, C.E., 61 Hone-Blanchet, A., 259, 267 Honea, R., 368 Hong, P.Y., 292 Hongo, S., 368 Hoogendijk, W.J.G., 205 Hooley, J.M., 358 Hopkins, T.A., 330, 334 Hopko, 196 Hopko, D.R., 207

Hartmann, W.E., 467 Harvey, P.D., 370 Hasin, D.S., 61 Hassan, G., 323 Hassija, C.M., 322 Hata, J.M., 434 Hatch, J.P., 483 Hatzimanolis, A., 367 Hauser, J., 154 Haut, K.M., 368 Haveman-Nies, A., 440 Havranek, M.M., 124 Haw, C., 190, 203 Hawes, D.J., 410 Hawkins, L., 413 Hawton, K., 190, 203 Hay, P.J., 239 Hayasaka, Y., 205 Hayashi, N., 211 Hayashino, D., 126 Hayes, S.C., 258, 459 Hayes-Skelton, S.A., 131 Hazel, N.A., 188 Hazlett, G.A., 161 He, E., 197 He, J., 407 He, J.P., 61, 407 He, Z., 298 Head, K., 192 Healy, O., 85, 136 Heaner, M.K., 220 Heart, M.Y.H.B., 266 Hebert, L.E., 430 Hechtman, L., 415, 418 Hedley, L.M., 137 Heetveld, S., 439, 442 He�in, A.H., 169 Heider, N., 216 Heilbrun, K., 33 Heiman, J.R., 317 Heimberg, R.G., 105, 122 Heintz, E., 131 Helland, T., 403 Heller, W., 101 Hellerstein, D.J., 178 Helmer, D.A., 320 Hemmesch, A.R., 436 Henderson, C., 16 Henderson, H.A., 121 Henderson, L., 115 Hengartner, M.P., 321, 328 Henggeler, S.W., 417, 462 Henwood, K.S., 486 Hermans, D., 164 Hernandez, A., 266 Hernandez, C.A.S., 462 Hershenberg, R., 196 Hershner, S.D., 434 Hertlein, K.M., 325, 327 Herzog, A., 153 Herzog, W., 234 Hesdorffer, D.C., 148 Hesselstrand, R., 482 Hettema, J.M., 119 Heutink, P., 439, 442 Hewison, D., 209 Hewitt, A.S., 400

Name IndexI-8

Krause-Utz, A., 298 Kreifelts, B., 120 Krentzman, A.R., 276 Kreukels, B.P., 343, 344, 345, 346 Krikke-Workel, J.O., 378 Kring, A.M., 365 Kristensen, C.H., 378 Kroger, 440 Krompinger, J.W., 122 Krueger, R.B., 336 Krueger, R.F., 288, 304 Krüger, O., 120 Kruse, O., 130 Krypotos, A-M., 101 Kubzansky, L.D., 483 Kuerbis, A., 267 Kuhn, C., 41 Kulesza, M., 258 Kumar, 438 Kumar, A.D., 481 Kumar, R.G., 191 Kunze, S., 390 Kupper, N., 482 Kurtz, L.F., 377, 463 Kurtz, M.M., 374 Kushner, H.I., 187 Kuyken, W., 131, 200 Kvrgic, S., 365 Kwan, K-L.K., 17 Kwapil, T.R., 203, 370

L L’bate, L., 15 La Via, M., 236 Laan, E., 317, 327, 338 Labate, A., 149 Lachs, M.S., 436 Lacourse, E., 412 Laforce, 440 LaFrance, W.C., 155 Lagattuta, K.H., 7 Lahey, B.B., 406, 410 Lai, H., 441 Lainhart, J.E., 395 Lakin, C., 465 Lalumiere, M.L., 332, 340 Lalvani, P., 391 Lami, L., 403 Lamis, D.A., 195 LaMontagne, A.D., 190 Lampe, L., 293, 299 Lancman, M., 153 Landy, L.N., 461 Lane, J.D., 401 Lane, M., 57, 58 Lang, F.U., 380 Lang, L., 265 Lang, R., 388 Lang, S., 380 Langa, K.M., 446 Langeveld, J., 366 Långström, N., 338 Lanius, R., 163, 168 Lanius, R.A., 163 Lanius, U.F., 163, 167 Lanovaz, M.J., 388 Lapid, M.I., 147

Kirkpatrick, B., 356 Kirmayer, L.J., 292 Kirz, N.E., 223 Kiss, T., 120 Kivimies, K., 371 Kjellberg, A., 394 Klabunde, M., 236 Klanecky, A., 161 Klaus, K., 149, 209 Kleber, R.J., 148 Kleijn, W., 162, 165 Kleiman, E.M., 195 Klein, D.N., 194, 210 Kleinman, A., 77 Kleinstauber, M., 154 Klerman, G.L., 154 Klibert, J., 148 Kling, C., 331 Klink, D., 343 Klintwall, L., 401 Klonsky, E.D., 187 Klucken, T., 130 Kluft, R.P., 168 Klumpp, H., 107 Kluwe-Schiavon, B., 378 Knack, N.M., 340 Knapp, M., 61 Knappe, S., 117, 137 Knegtering, H., 322 Kneynsberg, A., 446 Knight, B.G., 444 Knippenberg, R.J.M., 447 Knipscheer, J.W., 148 Knobloch, L.K., 189 Knowles, R., 354 Knowles, Z.R., 388 Knüppel, H., 449 Ko, M., 266 Koelen, J.A., 155 Koenders, M.A., 194 Koenen, K.C., 115, 119 Koh, Y.W., 197 Kohlenberg, B., 258 Kohling, J., 189 Kohn, R., 380 Kokaridas, D., 377 Kole, L.A., 259 Kolla, N.J., 69 Kolshus, E., 206 Koman, S.L., 236 Koo, E.H., 442 Koob, G.F., 264 Koot, 414 Kopelman, M.D., 433 Kopp, M.S., 151 Koprich, J.B., 446 Korenis, P., 332 Kösters, M., 380 Kotlar, A.V., 367 Kotov, R., 194 Kottler, J.A., 459 Kottmel, A., 318 Kovacs, M., 202 Kozlowska, K., 122 Krabbenborg, M.A.M., 233 Kraepelin, Emil, 23 Kramer, A., 326

Kauth, M., 320 Kawachi, I., 190 Kazen, M., 222 Kearney, C.A., 114, 163 Keefer, L., 154 Keel, P.K., 224 Keeler, A.R., 188 Kehrer, C.A., 306, 307 Keightley, M., 193 Keiser, H.N., 299 Kellaher, D.C., 337, 341 Keller, M.B., 137 Kelley, B.C., 481 Kellner, C.H., 206 Kelly, E.B., 394 Kelly, J.F., 276 Kelly, S.J., 195 Kemp, A.H., 88 Kemp, D.E., 205, 481 Kempen, G.I.J.M., 447 Kendall, P.C., 117, 128 Kendler, K.S., 24, 42, 119, 149,

226, 259, 297, 298, 299 Kenez, S., 16 Kennealy, P., 33 Kennedy, A.M., 394 Kennedy, J.L., 370 Keogh, F., 371 Kern, L., 163 Kernberg, O.F., 307 Kerner, B., 191 Kerr, L.K., 162 Kessing, D., 482 Kessler, R.C., 55, 56, 57, 61, 115,

153, 187, 188, 189, 407 Kesting, M.R., 253 Ketcham, P.L., 415 Keuter, E.J.W., 155 Keyes, C.L.M., 195 Khabazianzadeh, F., 190 Khadivi, A., 332 Khandakar, G.M., 380, 396 Khanlou, N., 63 Khera, M., 323 Kiehl, K.A., 288 Kieling, C., 407 Kihlstrom, J.F., 165, 168 Kilmer, J.R., 195 Kim, D., 190 Kim, D.J., 192 Kim, G., 188 Kim, J., 377 Kim, J.C., 41 Kimber, J., 273, 274 Kimber, M., 236 Kimmel, R.J., 131 Kindt, M., 101 King, A., 96 King, C.A., 60, 68 King, M., 326 King, P.A.L., 197 Kingston, D.A., 340 Kinnear, S.H., 391 Kinon, B.J., 378 Kinsella, A., 371 Kintz, P., 273 Kirkham, A.J., 201

Johnston, T.H., 446 Johnstone, E.C., 388 Joiner, T.E., 41, 196, 199, 203, 210 Jones, 448 Jones, C., 377 Jones, D.J., 60, 416 Jones, F.W., 133 Jones, J., 119 Jones, L., 326 Jones, M., 231 Jones, P.B., 380, 396 Jones, S.V., 431 Jonsson, U., 131 Jordaan, G.P., 374 Jorde, L.B., 394 Jorgensen, T., 481 Jorm, A.F., 196, 222 Joseph, J., 374 Joshi, A., 433 Joyal, C.C., 335, 336 Juan, M., 265 Juckel, G., 203 Juengst, S., 191 Juliano, L.M., 253 Jun, J.M., 411 June, J.D., 211 Jung, J., 61 Juola, P., 380 Justus, F.F., 447 Jutras-Aswad, D., 256

K Kafka, M.P., 337 Kagan, J., 121 Kåhlin, I., 394 Kailish, S., 152 Kaiser, N., 416 Kaiser, S., 117 Kales, H.C., 446 Kalra, G., 274 Kaltiala-Heino, R., 413 Kamat, P.K., 442 Kamkar, K., 197 Kanaan, N.M., 446 Kandel, D.B., 265 Kandiah, N., 432 Kang, H., 437 Kanny, D., 249 Kansara, S., 438 Kanuri, N., 115 Kaplan, C., 124 Kaplan, M.S., 336 Kaptchuk, T.J., 461 Karatsoreos, I.N., 194 Karayiorgou, M., 367 Karg, R.S., 80, 153, 201, 233 Karpel, M.G., 161 Karriker-Jaffe, K.J., 411 Karterud, S., 286 Kas, M.J., 227 Kasari, C., 402 Kaser-Boyd, N., 330 Kasper, S., 236 Kass, E., 415, 416 Katz, C., 189 Katz, L.Y., 310 Kaur, H., 163

Name Index I-9

M Ma, Y-L., 148, 368 Maack, D.J., 128 Maahs, J.R., 338 Maayan, N., 201 MacCabe, J.H., 363 MacDonald, A., 292, 360, 363,

364, 367 MacDonald, A.A., 28 MacDonald, P., 292 MacDonald, P.A., 28 Macedo, T., 63 Mackay, C.E., 192, 368 MacKinnon, D.F., 175 MacLane, C., 292 Macleod, 432 MacMahon, D., 355 MacMaster, E., 377 Maczuga, S., 413 Maeda, N., 395 Maes, H., 24 Maggi, M., 341, 342 Magiati, I., 389, 403 Magnotta, V.A., 368 Mahar, I., 192 Mahurin, R.K., 193 Maisel, N.C., 268, 273 Maisto, S.A., 322, 482 Makarova, N., 434 Makoroff, K.L., 396 Malherbe, P.J., 367 Malhi, G.S., 193, 366 Malik, R., 437 Malla, A.K., 364 Mallett, K., 195 Mallett, K.A., 265 Mallinckrodt, B., 124 Malloy, M., 190 Malone, P.S., 195 Man, D.W., 378 Mancebo, M.C., 137 Mandal, S., 154 Manderscheid, R.W., 377 Maneeton, B., 205 Maneeton, N., 205 Manicavasagar, V., 210 Manna, D., 205 Mannarino, A.P., 169 Mansur, R.B., 210 Marchand, C., 303 Marcus, M.D., 239 Marder, S.R., 356 Margraf, J., 151 Marhe, R., 260 Marighetto, A., 119 Markiewicz, D., 197 Markon, K.E., 304 Markowitsch, H.J., 158, 164,

165, 169 Markowitz, J.C., 209 Marmai, L., 201 Marmar, C.R., 263 Marques, A., 434 Marrs, J.A., 261 Marshall, L.E., 342

Liu, H.L., 441 Liu, R.T., 195 Liu, W.S., 441 Liu, Y., 249 Liu, Y.S., 398 Livesley, W.J., 308 Livingston, 448 Livingston, G., 436 Livingston, J.D., 258 Livrea, P., 150 Llera, S.J., 107, 117, 119,

122, 135 Lo, R.Y., 435 Lobbestael, J., 296 LoBue, C., 435 Lock, J., 234, 236, 239 Lockwood, B., 416 Loder, E., 480 Loewenstein, R.J., 163, 168 Lo�and, K.B., 401 Loftus, E.F., 161 Logan, D.E., 152 Lohman, M.C., 447 Long et al., 487 Long, J.S., 317 Lonigan, C.J., 410 Loth, K., 228 Louche, A., 430 Loukas, A., 253 Lovallo, W.R., 483 Love, S.R., 400 Loveless, J., 305 Lovett, M.W., 402 Low, D.A., 163 Lowe, B., 145, 149 Lowenstein, L., 326 Lowy, A.S., 237 Lü Y.L., 441 Lu, H., 249 Lu, J., 268 Luberto, C.M., 128 Lucas, C.V., 148 Lucas, M., 190 Lucassen, P., 154 Luckasson, R., 387 Luecken, L.J., 481 Lui, F., 162 Luijten, M., 260 Lule, D., 224 Luman, M., 411 Luna, J.V., 222 Lund, C., 61 Luoma, J.B., 258 Luppa, M., 208 Lupton, D., 325 Lurie, I., 380 Lussier, P., 298 Luxton, D.D., 211 Luyten, P., 227, 305 Lydon, S., 85, 136 Lyketsos, C.G., 446 Lykken, D.T., 288 Lynn, S.J., 159 Lyons-Ruth, K., 298 Lytle, R., 341 Lyubomirsky, S., 62 Lyytinen, H., 403

Lejuez, C.W., 207 Lemberg, R., 42, 222 Lemmens, L.H.J.M., 209 Lemphers, A., 291 Lende, D.H., 266 Lennox, N., 391 Lent, R., 24 Leonard, L.B., 391 Leontiadis, G.I., 479 Leoutsakos, J.M.S., 429 Lerner, J.W., 402 Leslie, H.H., 276 Lessard, M-J., 115 Lett, T.A., 370 Leu-Semenescu, S., 480 Leung, C.M.C., 148, 368 Leurgans, S., 438 Levak, R.W., 81, 153 Levav, I., 380 Levay, S., 332 Levecque, K., 197 Levenstein, S., 481 Lever, C., 120 Levine, B., 370 Levine, M.P., 223, 229 Levine, S.Z., 380 Levinson, D.F., 191 Levy, B., 190 Levy, K.N., 189 Levy, S.A., 209 Lewis, A.J., 62 Lewis, C.E., 395 Lewis, G., 396 Lewis, K.M., 124 Lewis, M., 63 Lewis, R.W., 320, 321, 323 Leykin, Y., 199 Lezak, M.D., 89 Li, G., 251 Li, H., 148 Li, J.Q., 449 Li, M., 192 Liamputtong, P., 16 Libby, A.M., 204 Libero, D.Z., 167 Lichner, T.K., 462 Lichtenberg, P.A., 436 Lichtenstein, P., 338 Lichtman, J.H., 210 Liddle, H.A., 276 Lieberman-Betz, R., 401 Lieberman, J.A., 364, 367, 380 Ligsay, A., 395 Lilienfeld, S.O., 84, 159 Lim, A., 162 Lin, J., 325 Lindholm, J., 203 Lindsay, S., 391 Linehan, M.M., 302, 305,

306, 307, 308 Link, B.G., 391 Links, P.S., 287, 309 Linton, S.J., 131 Liong, C.C.M., 323 Lipov, E., 121 Lipton, R.B., 480 Lishner, D.A., 292

Lapierre, V., 335 Laracy, S.D., 391 Large, M.M., 366 Larimer, M., 258 Larkin, C., 371 Larsen, J.K., 237 Larson, S., 465 Larson, S.A., 400 Larsson, H., 370 Laruelle, M., 370 Lasalvia, A., 190 Lasher, M.P., 340 Lassonde, M., 394 Latimer, L.A., 253 Latini, D.M., 320 Latner, J.D., 225 Lau et al., 479 Lauche, R., 148 Laugharne, R., 145 Laulik, S., 297 Laumann, E.O., 319, 320 Laurens, K.R., 372 Laurent, H.K., 121 Laursen, T.M., 365 Lavelle, J., 124 Lavender, J.M., 224 Lavretsky, H., 63 Law, M.R., 320 Lawless, M., 68 Lawlor, E., 357 Lawlor, P.G., 427 Lawrence-Wood, E., 114 Lawrence, A.A., 343, 344,

345, 346 Lawrence, R.E., 364, 367, 380 Layous, K., 62 Lazar, S.W., 196 Lazarus, S.A., 300 Lazzarino, A.I., 481 Le Bas, G., 198 Le Cook, B., 44 Le Foll, B., 131 Le Grange, D., 234, 236, 238 Le, W., 438 Leblanc, J-S.,307 Lebow, J.L., 305 Lebowitz, E.R., 119 Lebowitz, M.S., 408 Leclerc, E., 210 Lee, A.M., 197 Lee, B.R., 416 Lee, E., 77 Lee, H., 266 Lee, J.Y., 413 Lee, M-B., 148 Lee, R., 298 Lee, S., 148, 368 Lee, S.S., 434 Leeners, B., 321, 328 Leger, G.C., 445 Lehman, H.K., 482 Lehmann, M.E., 460 Lehrer, P., 487 Lehrner, A., 320 Lei, P., 438 Leibenluft, E., 418 Leiber, M.J., 413

Name IndexI-10

Morra, L.F., 439 Morris, Jr., J.G., 95 Morris, M., 371 Morris, S.B., 17 Morrison, A.S., 105, 122 Morrison, E.E., 468 Morse, G.A., 132 Morson, E.M., 388 Mortensen, P.B., 365 Moscicki, E.K., 203 Moss, A., 152 Muchnik, C., 437 Mueser, K.T., 374 Mueser, K.Y., 132 Mugesh, G., 205 Muhlberger, A., 135 Mulder, R., 304, 305, 307, 308 Mulder, R.T., 124, 295 Mulhall, J.P., 321 Mulhall, S., 448 Mulhern, T., 136 Mulle, J.G., 367 Muller, C.L., 395 Mulryan, N., 403 Mulsant, B.H., 358 Mulvey, M.R., 145 Mumby, D.G., 433 Mumuni, A.N., 191 Munder, T., 327, 328 Munoz, J., 332 Munoz, R.F., 199 Mura, G., 364 Muralidharan, A., 208, 209 Muralidharan, P., 261 Muris, P., 366, 415 Murphy, E., 388 Murphy, E.S., 36 Murphy, K.J., 440 Murphy, L., 334, 340, 341, 483 Murray, A.M., 145 Murray, C.J.L., 58 Murray, R.J., 165 Murray, R.M., 363, 370, 371 Musiek, E.S., 437, 442 Musil, R., 380 Mutlu, A., 441 Myers, B., 266 Myers, D.G., 478 Myers, L., 153 Myrick, A.C., 169

N N Sergentanis, T., 442 Naci, L., 28 Nacul, L., 267 Nadarasa, J., 396 Nader, E.G., 197 Naghibzadeh, B., 190 Nagl, M., 224, 239 Nagy, W., 402 Naiberg, M.R., 440 Naigles, L., 401 Nair, K.R., 109 Nair, M., 341 Nait, F., 440 Najman, J., 188 Nakamura, K., 177

Miles, A.A., 373 Millan, M.J., 357 Miller, J.B., 66, 445 Miller, B.D., 482 Miller, B.J., 370, 372 Miller, D.T., 263 Miller, F.G., 461 Miller, G.A., 101 Miller, M.L., 256 Miller, M.W., 119 Millett, C., 481 Milligan, R., 81 Millon, C., 303 Millon, T., 297, 303 Mills, J., 124 Milne, T., 258 Milner, A., 190 Milosevic, I., 123, 124 Miltenberger, R.G., 86 Mineka, S., 189, 310 Miner, M.H., 334, 336, 337, 342 Miranda, D., 358 Miret, M., 190 Mitchell, G., 447 Mitchell, J.E., 236, 239 Mitchell, K.S., 119, 228, 239 Mitchell, M.B., 444 Mitchell, P.B., 205 Mittal, D., 117 Mittelman, M.S., 446 Miyoshi, K., 441 Mizrahi, M., 322 Moczko, J., 154 Modinos, G., 357 Moeschler, J.B., 391 Mof�tt, T.E., 418 Mohnke, S., 339 Mohr, C., 297 Moitra, E., 137 Molina, B.S., 413 Molina, K.M., 266 Molino, I., 446 Moll, K., 390 Moller, H.-J., 380 Mollica, R.F., 124 Monsch, A.U., 445 Montagne, B., 306 Montague, R., 199 Montejo, A., 338 Montuschi, M., 403 Moore, K.A., 263 Moore, T.M., 28 Moos, R.H., 274, 275, 276 Mora, M.C.S., 154 Moran, G., 197 Moran, P., 371 Moreira, F.A., 261, 273 Moreno, T., 336 Morey, L.C., 291, 304 Morgan, C.A., 161 Morgan, K., 441 Morgan, P.L., 366, 413 Mori, N., 236 Morina, N., 95 Moritsugu, J., 463 Morken, F., 403 Morley, T.E., 197

McGrath, R.J., 340 McGraw, S.A., 321 McGuire, J.K., 346 McGuire, P., 357 McGuire, P.K., 364 McIndoo, C.C., 196, 207 McIntosh, C., 135 McKechanie, A.G., 388 McKim, W.A., 248, 263 McKinnon, A., 131 McKown, C., 402 McLaughlin, K.A., 266 McLaughlin, T.F., 402 McLean, L., 122 McLean, S.A., 228 McLeish, A.C., 128 McLoughlin, D.M., 206 McMahon, R.J., 414 McMahon, T., 168 McMain, S.F., 298, 309 McMaster, A., 286 McMurran, M., 307 McNally, R.J., 151, 164 McNulty, J.K., 28 McPherson, L., 391 McSweeney, F.K., 36 Meaden, A., 377 Meana, 319 Mechawar, N., 192 Mechlin, C., 326 Mechri, A., 372 Medway, C., 441 Mehler, P.S., 224 Mehta, M., 152 Meier, S., 438 Melrose, S., 178 Meltzer, H.Y., 376, 377 Menchón, J.M., 338 Mendez, M.F., 337, 433 Menon, M., 354 Mercer, K.B., 367 Merckelbach, H., 159 Meredith, S.E., 253 Merikangas, K.R., 24, 55, 56, 57,

61, 115, 187, 189, 211, 259, 407 Merrill, A.C., 401 Mertz, M., 449 Mesite, L., 401 Messing, J.T., 64 Meston, C., 340 Meuser, K.T., 379 Mewes, R., 209 Meyer, F., 396 Meyer, G.J., 84 Meyer, M.L., 197 Meyhofer, I., 367 Micali, N., 228 Michaelides, M., 256 Michaels, P.J., 17 Michalopoulos, L., 198 Mielke, M.M., 60, 429, 434 Miettunen, J., 380 Mihura, J.L., 84 Miklowitz, D.J., 208, 209 Mikolajewski, A.J., 410 Mikulincer, M., 322 Milaneschi, Y., 191

Marshall, W.L., 342 Marsman, A., 193 Martel, M.M., 411 Martin-Santos, R., 41 Martin, A., 151, 209 Martin, C.R., 441 Martin, P., 272 Martin, V., 388 Martinussen, M., 117 Marttunen, M., 413 Marwaha, S., 298 Maslow, Abraham, 33–34 Mason, A.E., 227 Mason, L., 461 Massironi, S., 433 Massoud, F., 429 Masters, K.S., 482 Mataix-Cols, D., 119 Mathes, B.M., 122 Mathias, C.J., 163 Matson, J.L., 391, 400 Matsui, T., 437 Matsumoto, N., 177 Matsushita, S., 437 Matte, B., 407 Matthews, S., 117 Matthias, E., 149 Matthys, W., 410 Mattick, R.P., 273, 274 Mattson, S.N., 411 Maughan, B., 57, 61 Maust, D.T., 446 May, A.M., 187 May, Rollo, 34–35 Mayberg, H.S., 193 Mayer, B., 253 Mayer, B.M., 95 Maykut, 319 Mayne, T., 458 McBride, N.M., 263 McBurnett, K., 414, 416 McCabe, J.E., 177, 183, 362 McCabe, M.P., 315, 318, 320, 323 McCabe, R.E., 123, 124 McCahill, J., 85 McCall, W.V., 206 McCallion, P., 403 McCarrick, S.M., 195 McCarron, M., 403 McCart, M.R., 462 McCarty, D., 266 McChargue, D.E., 161 McClair, V.L., 259 McClintock, A.S., 195 McClure, J.M., 133 McCormack, M., 357 McCuish, E.C., 298 McCullough, A.R., 326 McCutcheon, L., 300, 301 McDuff, P., 323 McElroy, S.L., 236 McEwen, B.S., 194 McFarlane, A.C., 114 McGorry, P., 373 McGorry, P.D., 366 McGrath, 454 McGrath, P.B., 122

Name Index I-11

Patil, M., 326 Patrick, C.J., 298 Patton, M.H., 370 Paul, A.R., 388 Paulsen, S.L., 167 Pavlov, Ivan, 36, 123 Paxton, S.J., 222, 228 Paykel, E., 201 Pearlson, G.D., 24 Peat, C.M., 236 Peck, J.H., 413 Peckham, A.D., 199 Pedersen, G., 286 Peebles, R., 237 Pehrs, C., 192 Peinado, A.G., 370 Pelham Jr, W.E., 413 Pelham, W.E., 416 Pellicciari, R., 150 Pelly, F., 236 Pelon, S., 320 Pemment, J., 89 Peñagarikano, O., 395 Penas-Lledo, E., 226 Pendergast, L.L., 203 Peng, S., 148 Peng, Y., 148 Penn, D.L., 16, 379 Pennington, B.F., 390 Penninx, B.W.J.H., 121, 193, 205 Pentel, P.R., 274 Penttilä, M., 380 Peperkorn, H.M., 135 Pepitone, C., 487 Peppard, P.E., 480 Perez-Edgar, K., 121 Perez-Protto, S., 434 Perez-Rodriguez, M.M., 297 Perez, D.L., 149, 151, 159 Perez, J.A., 119 Perich, T., 210 Perkins, A., 343, 345 Perrine, K., 153 Perron, B.E., 276 Perry, S., 187 Petermann, F., 149 Peters, L., 132 Peterson, A.L., 483 Peterson, B., 321 Peterson, J.K., 33 Peterson, L., 62, 65, 301 Peterson, R.L., 390 Petretto, D.R., 364 Petrosyan, K., 190 P�ffner, L.J., 414, 416 P�altz, M.C., 117 Pham, A.V., 413 Phan, K.L., 107, 298 Phelan, J.C., 42, 64, 481 Phillips, K.A., 109 Phillips, L.J., 372 Piazza-Bonin, E., 35 Picardi, A., 201 Pickering, R.P., 61 Pickles, A., 57 Pickrell, A.M., 442 Pierce, M.D., 388

Onyike, C.U., 435, 449 Oosterlaan, J., 411 Oosterling, I.J., 391 Orakçıo_ lu, I., 223 Orhan, I.E., 440 Ormstad, H., 440 Orrell, M., 447 Orsillo, S.M., 131, 136 Ortega, L.A.G., 189 Orth, U., 210 Osman, O., 124 Oswalt, S.B., 323 Otero, T.L., 401 Otowa, T., 119 Otto, M.W., 443 Oudman, E., 251 Overgard, K.T., 117 Owen, A.M., 28 Owen, L.D., 267 Owens, A.P., 163 Owens, D.G.C., 388 Owens, E.B., 411 Ozdemir, D.F., 147 Ozdemir, O., 165 Ozdemir, P.G., 165 Ozsivadjian, A., 391

P Pace, W.D., 204 Pachana, N.A., 444 Pachankis, J.E., 343 Pachima, Y.I., 438 Padilla, J., 336, 337 Pagel, T., 360 Paksarian, D., 189 Palagini, L., 194 Palermo, T.M., 152 Palfai, T.P., 268 Palilla, J., 90 Pallanti, S., 206 Pallesen, S., 480 Palmen, J.M.C., 28 Paltrow, L.M., 273 Panchal, B.N., 158 Paniagua, F.A., 162, 292, 304, 467 Pantelis, C., 372 Papish, A., 17 Paracelsus, 13 Pardini, D., 413, 418 Paris, J., 292, 295, 304, 305,

308, 309 Park, S., 251 Parker, N., 397 Parker, G., 210 Parks, S.E., 189 Parry, J.W., 33 Parsons, A., 117, 190, 225 Partinen, M., 480 Pasalich, D.S., 414 Pascual-Leone, A., 259, 267, 459 Pashayan, N., 267 Passingham, D., 368 Passmore, A.P., 449 Pastor, P.N., 413 Pastuszak, A.W., 323 Patchell, B., 64 Patel, V., 61, 470

Nonacs, R.M., 162 Noordermeer, S.D., 411 Norcross, J., 458 Norcross, J.C., 46–47, 470 Nord, D., 400 Nordhus, I.H., 480 Norman, R.E., 58 Norra, C., 203 Norris, E., 117 Norton, E.S., 396 Novianti, P., 117 Nowosielski, K., 318 Noyes, R., 148 Nuechterlein, K.H., 380 Nugent, N.R., 137 Nurnberger, J., 211 Nusbaum, M.R., 324 Nuss, P., 121 Nwankwo, T., 481 Nyren, O., 479

O O’Brien, J.T., 431, 432, 445 O’Callaghan, C., 439 O’Callaghan, E., 371 O’Callaghan, O., 136 O’Connor, T.G., 23 O’Dell, K.R., 482 O’Donnell, A., 275 O’Donohue, W., 333 O’Donohue, W.T., 454, 462 O’Donovan, 191 O’Farrell, T.J., 275 O’Gara, J.S., 236 O’Halloran, P., 16 O’Hara, M.W., 177, 183, 362 O’Hara, S., 458 O’Hare, T., 370 O’Loughlin, D., 198 O’Melia, A.M., 236 O’Reilly, CL., 17 Oakland, T., 400 Odgers, C.L., 288, 309, 418 Oesterhus, R., 449 Of�ce of Juvenile Justice and

Delinquency Prevention, 413 Of�dani, E., 131 Ogawa, Y., 205 Ogedegbe, C., 481 Ogedegbe, G., 481 Ogloff, J.R., 291 Ogrodniczuk, J.S., 305, 462 Ohmori, T., 177 Ohtsubo, T., 368 Ohyagi, Y., 441 Okereke, O.I., 66 Olatunji, B.O., 151, 155 olde Hartman, T.., 155 Oldham, M.A., 206, 374 Oleary, F., 440 Oleski, J., 310 Olff, M., 121 Oliveira, F.I., 148 Ollendick, T.H., 123, 124 Olsen, S.A., 164 Olsson, T.T., 439 Oltmanns, T.F., 291, 304

Nakao, M., 155 Narayan, A., 412 Nascimento, A.L., 222 Nascimento, M., 179 Nasir, L., 124 Nathan, P.E., 39, 64, 462 National Center for Learning

Disabilities, 391 National Institute on Alcohol

Abuse and Alcoholism, 250, 252 Navas, M., 142 Nay, W., 105 Neal, D., 400 Neale, M.C., 24, 259 Nederlof, A.F., 366 Neely, L., 388 Neff, A., 154 Negash, S., 435 Negy, C., 290 Neimeyer, R.A., 35 Neitzke, G., 449 Nelson, B., 364, 373 Nelson, E.B., 191 Nelson, H.D., 166, 300 Nelson, J., 168 Nelson, M., 394 Nelson, M.T., 372 Nelson, P.T., 439 Nestor, B.A., 195 Neufang, S., 120 Neuhoff, N., 390 Neukrug, E.S., 454, 468 Neumark-Sztainer, D., 228 Neville, C., 208 New, A.S., 297 Newby, J.M., 131 Newlin, D.B., 266 Newman, C.F., 133 Newman, M.G., 107, 115, 117, 119,

122, 135, 264 Newton-Howes, G., 308, 310 Newton, D.F., 440 Newton, R., 198 Nguyen, E., 17 Nguyen, L.S., 395 Nguyen, T., 402 Nhan, H.S., 442 Nichols, D.S., 81, 153 Nicklett, E.J., 223 Niedtfeld, I., 298 Nielsen, D.C., 398 Nielssen, O.B., 366 Nieratschker, V., 259 Nierenberg, A.A., 196 Nieweglowski, K., 296 Nigg, J., 418 Nigg, J.T., 411 Nijboer, T.C., 251 Nijdam, M.J., 121 Nijs, M., 306 Nikolas, M., 411 Niles, A.N., 101 Nishith, P., 132 Nitschke, J.B., 120 Nobrega, J.N., 192 Nolen-Hoeksema, S., 116, 188 Nolen, W.A., 210

Name IndexI-12

Rocks, T., 236 Rodgers, R.F., 237 Roeder, K., 223 Roehr, S., 432, 449 Roelofs, J., 415 Roemer, L., 131, 136 Roepke, 291, 292, 299 Roerig, J., 236 Rogers, Carl, 34 Rogosch, F.A., 412 Rohde, K.B., 459 Rohde, L.A., 407 Rohleder, N.H., 253 Rohlof, H.G., 148 Rohn, T.T., 437 Rohr, S., 228 Rolls, E.T., 425 Rolls, G., 159 Rommel, N., 253 Ronimus, M., 403 Rooney, M., 416 Roos, J.L., 367 Roozen, S., 253 Roque, F.L., 148 Roriz-Cruz, M., 435 Rorschach, Hermann, 84 Rosand, J., 437 Rosell, D.R., 286 Rosen, N.O., 323 Rosen, R.C., 317 Rosenbaum, J.F., 203 Rosenberg, M., 165 Rosenblatt, A. 468 Rosenbloom, D., 268 Rosenfeld, J.A., 395 Rosengren, A., 482, 486 Rosenhan, D.L., 371 Rosenkrantz, T.S., 395 Rosenstock, S., 481 Rosenstrom, T., 194 Rosenthal, M.Z., 300, 467 Rosenthal, S.M., 345 Rosenvinge, J.H., 117 Roser, P., 202 Rosner, R., 463 Rosness, T.A., 440 Ross, R.J., 104 Ross, S.R., 299 Rossberg, J.I., 377 Rosset, I., 435 Rossi, R.E., 433 Rössler, W., 321, 328 Rostant, O.S., 320 Roth, B.L., 259 Roth, D.L., 441 Rothwell, J.C., 163 Rottenberg, J., 198 Roubinov, D.S., 481 Rourke, S.B., 464 Roussos, P., 285, 286, 297 Rowe, C.A., 60 Rowse, G., 354 Roy-Byrne, P.P., 131 Roy, G., 205 Roy, J., 480 Ruan, W.J., 61 Rubino, I.A., 354

Reich, D.B., 309–310 Reid, R., 190, 225, 415 Reilly, E., 403 Reinares, M., 209 Reinelt, E., 121 Reis, R., 151 Reising, M.M., 197 Reisman, Y., 326 Reisner, S.L., 343 Reiss, F., 61 Reivich, K., 196 Rellini, A., 323 Rellini, A.H., 317 Remington, G., 354 Renneberg, B., 301 Resnick, B., 425 Rettew, D.C., 300 Retzlaff, G., 447 Reuben, C.A., 413 Reuben, D.B., 447 Reyes-Rodriguez, M.L., 195 Rhebergen, D., 178 Ribeiro, J.D., 210 Ribeiro, W., 434, 435 Ricciardi, L., 155 Richards, 210 Richards, C., 223 Richards, S.B., 397 Richardson-Vejlgaard, R., 296 Richter-Levin, G., 119 Ricks, J.M., 337 Ridgeway, R., 322 Riedel, M., 380 Rief, W., 151, 154, 209 Riemann, D., 194 Rienecke, R.D., 236 Rietschel, M., 259 Riley, B., 24 Ringrose, J.L., 160, 168 Rink, L., 360 Riper, H., 269 Risch, N., 24 Rispoli, M., 388 Ritchie, E.C., 121 Ritz, T., 481 Rivera-Medina, C.L., 195 Rivera, C.P., 437 Rizvi, S.L., 233 Rizzi, L., 435 Rizzu, P., 439, 442 Roane, B.M., 480 Robbins, S.P., 162 Roberson-Nay, R., 105, 119, 130 Roberto, K.A., 436 Roberts, A.L., 115 Roberts, M., 449 Robertson, G.J., 375, 400 Robin, A.L., 407, 416 Robinson, A.L., 236 Robinson, C.A., 43 Robinson, E.A., 276 Robinson, P., 468 Robinson, S., 403 Rocca, W.A., 60, 429, 434 Rocha, V., 434 Roche, B., 124 Roche, E., 355

Proulx, J., 339 Przeworski, A., 107, 117, 119,

122, 135 Psaltopoulou, T., 442 Pull, C.B., 126 Pullen, N., 388 Purcell, R., 366 Pushparajan, S., 109 Putnam, F.W., 167, 169

Q Qin, J., 162 Quilty, L.C., 304 Quinsey, V.L., 339 Quintana, D.S., 88

R Rabanea-Souza, T., 373 Rabinovitch, A.E., 209 Rachman, S., 151 Racino, J.A., 465 Radegran, G., 482 Rafacz, J.D., 17 Rafaeli, E., 189 Rafanelli, C., 481 Raffard, S., 430 Raine, A., 288, 293, 298 Rajbhandari, A., 120 Rajji, T.K., 358 Raleigh, M.D., 274 Ramanan, S., 449 Ramey, D., 85 Ramirez, L.F., 201 Ramírez-Fernandez, M.,

272Ranger, R., 340 Rangmar, J., 253 Rao, U., 197 Rapaport, M.H., 370, 372 Rapaport, P., 436 Rapee, R.M., 123, 132 Rasheed, J.M., 455 Rasheed, M.N., 455 Rasic, D., 367 Ratanasiripong, P., 126 Ratelle, C.F., 197 Rathus, S., 29 Raul, J.S., 396 Raval, C.M., 158 Ray, A.E., 265 Ray, J.V., 408, 411 Ray, O., 250 Raymond, N.C., 342 Raza, M., 147 Re, L., 337 Rea, 480 Read, J.P., 116 Read, S.J., 260 Real, E., 338 Reddy, J., 365 Redgrave, G.W., 236 Reed, G.M., 287, 308 Reese, R.J., 460 Reeves, G., 365 Regalia, P.A., 266 Regehr, C., 126 Rehm, J., 58, 251

Pierson, J.F., 35 Pihl, R.O., 265 Pike, K.M., 234 Pilkington, P.D., 196 Pillemer, K.A., 436 Pilling, J., 151 Pincus, A.L., 291 Pinderhughes, E.E., 414 Pine, D.S., 121 Pine, K.J., 223 Pineda, R.G., 399 Pinel, Philippe, 13 Pinto, A.V.O., 24 Pinto, M., 434 Piper, W.E., 305, 462 Piras, F., 120, 354 Pirkis, J., 190 Pirkola, S., 211 Pirog, M.A., 466 Piskulic, D., 373 Pistorello, J., 292 Pittig, A., 101 Pitts, A., 126 Pitts, S.C., 365 Pizzagalli, D.A., 192 Plagerson, S., 61 Platt, M.O., 437 Ploderl, M., 190 Podlogar, M.C., 41, 199 Pohanka, M., 440 Polanco-Roman, L., 162 Polanczyk, G.V., 407 Poletti, S., 123 Polidori, M.C., 440 Pollatos, O., 149 Polyakova, M., 208 Pomeroy, E., 167 Pompili, M., 190 Ponde, M.P., 418 Poole, R., 43 Pope, K.S., 162 Pope, M.A., 364 Popova, S., 395 Popovic, D., 364 Popovich, M., 434 Porst, H., 326 Portnoy, J., 410 Posner, J.E., 415, 416 Postma, A., 251 Power, T.J., 415 Prater, K.E., 107 Preddy, T., 207 Preedy, V.R., 441 Prentice, D.A., 263 President’s New Freedom Commis-

sion on Mental Health, 59 Presnall, J.R., 283 Price, J.L., 192 Price, M.J., 410 Prince, J., 126 Prince, M., 61, 434, 435 Pringle, A., 205 Pringsheim, T., 416 Prinstein, M.J., 76, 304 Prochaska, J.O., 470 Proctor, G., 467 Promodu, K., 109

Name Index I-13

Shapiro, F., 135 Shapiro, S.K., 401 Sharabi, L.L., 189 Sharkey, 480 Sharma, A., 410 Sharma, P., 168 Sharp, P.B., 101 Shaver, P.R., 322 Shaw, D.S., 28, 446 Shaw, J.L., 437 Shaw, P., 418 Shechter, A., 326 Shedler, J., 304 Sheehan, L., 296 Sheikh, H., 480 Shen, C., 370 Shen, M., 272 Sher, K.J., 287, 291, 292, 295 Sher, L., 362 Sherrer, M., 370 Shi, Z., 298 Shiban, Y., 135 Shield, K.D., 251 Shih, P.A.B., 226 Shillingsburg, M.A., 401 Shimada-Sugimoto, M., 119 Shinozaki, Y., 155 Shiozawa, T., 120 Shochet, I., 199 Shorey, R.C., 28 Shrestha, R., 428 Shrivastava, A., 274 Shu, H., 396 Sicuro, F., 481 Siddaway, A.P., 122 Siegel, J.T., 188 Siegelman, A., 210 Siepel, F.J., 438Sierra, M., 163 Sierra-Siegert, M., 163 Siever, L.J., 285, 286, 297 Sikkema, K.J., 123 Silber, K. Silber, T.J. Silberg, J.L., 165, 167 Silberschmidt, A., 148 Silbersweig, D.A., 149, 151 Silove, D., 115 Silver, R.C., 152 Simmons, M., 291 Simon et al., 328 Simon, R.I., 203 Simon, S.S., 445 Simons, D.A., 336 Simons, L.E., 152 Simpson, H.B., 120 Sin, N.L., 481 Singareddy, R., 481 Sinha, R., 262 Sinnott-Armstrong, W.P.., 288 Sireling, L., 201 Sirri, L., 150, 151 Siva, A., 479, 480 Sivertsen, B., 480 Sjoberg, T., 482 Skeem, J., 33 Skeldon, S.C., 320 Sklar, P., 191

Schonfeld, L., 263 Schonknecht, P., 206 Schonleber, J., 227 Schopler, E., 400 Schrag, A.E., 149 Schröder, J., 374 Schubert, F., 192 Schuckit, M.A., 246, 259,

276Schulte, I.E., 149 Schulte-Körne, G., 390 Schultz, B.K., 416 Schulz, A., 160 Schulz, J., 122 Schulz, S.C., 148 Schulze, L., 301 Schumacher, R.F., 403 Schumacher, S., 135 Schuman, D.L., 460 Schutter, D.J.L.G., 410 Schwartz, T.L., 377 Schweckendiek, J., 130Scott, J., 377 Scott, K.M., 115 Scott, T., 208 Scott-Sheldon, L.A.J., 67, 268 Scribano, P.V., 396 Scull, A., 441 Seal, M.L., 372 Sechi, L.A., 440 Sedlacek, D., 161 Seethaler, P.M., 403 Seewald, K., 366 Segal, Z., 208 Segraves, R.T., 328 Segrin, C.G., 196 Seidman, L.J., 367, 368, 370,

375, 418 Seidman, T.I., 266 Selby, E.A., 199 Selemon, L.D., 373 Seligman, M.E.P., 196 Selkow, T., 481 Sellbom, M., 153, 288 Sellers, R., 57 Selph, S.S., 166, 300 Selvaraj, S., 370 Selye, H., 478 Sendtner, M., 443 Senn, T.E., 43 Sera�ni, G., 192 Seretis, D., 150 Serretti, A., 299, 372 Setiawan, E., 262 Seto, M.C., 331, 332, 339,

340, 342 Sevig, T., 17 Sexton, C., 192 Sexton, H., 137 Seymour-Smith, S., 338 Shackelford, T.K., 198 Shadick, R., 60 Shaffer, L.G., 395 Shakra, M.A., 265 Shallcross, A.J., 200, 208 Shamloul, R., 316, 318 Shanahan, L., 137 Shannon, G.D., 267 Shapira, J.S., 337, 433

Sandman, N., 480 Sania, A., 190 Sansone, L.A., 295 Sansone, R.A., 295 Santiago, P.N., 112 Santoro, G., 388 Sanuade, O.A., 449 Sanvicente-Vieira, B., 378 Sar, V., 161 Sareen, J., 189 Sarin, S., 320 Sarkar, M., 62 Sarkar, S., 192 Sarmah, S., 261 Sarnat, H.B., 394 Saroglou, V., 63 Sarris, J., 205 Sartirana, M., 236 Sartor, C.E., 119 Sarvaiya, N., 188 Sato, S., 194 Sattler, J.M., 399 Saunders, K., 190, 203 Sayette, M., 458 Scaer, R., 163 Scaglione, N., 265 Scarffe, L.A., 437 Schachar, R., 410 Schade, R.R., 487 Schag, K., 227 Schalock, R.L., 387 Scharfstein, L.A., 119 Schatz, N.K., 416 Schatz, R.B., 401 Schaub, D., 203 Schauenburg, H., 189 Schechter, N.L., 152 Schef�er, K., 120 Schennach, R., 358, 380 Schepp, K.G., 251 Schermer, J.A., 149 Scherr, P.A., 430 Schibuk, L., 415 Schiffer, A., 482 Schiffman, J., 365 Schilling, E.A., 68 Schlosser, R.W., 468 Schlund, M.W., 124 Schmahl, C., 298 Schmidhuber, M., 449 Schmidt, H.M., 327, 328 Schmidt, R., 228 Schmidt, U., 228 Schmieder, M., 203 Schmitt, F.A., 441 Schmitz, C., 28 Schneider, A., 395 Schneider, J.A., 438 Schneider, K., 35 Schneider, K.J., 35 Schneider, R.L., 35, 134, 462 Schniering, C.A., 320, 323 Schoenberg, P.L.A., 136, 485 Schoenthaler, A., 481 Schoevers, R.A., 322 Scholte, R.H.J., 237 Scholzman, S.C., 162

Rubinsten, O., 390 Rüch, N., 365 Rudenstine, S., 210 Rudolph, K.D., 63 Ruether-Wolf, K.V., 318 Ruiz, P., 468 Ruíz, P.C., 370 Runtz, M., 161 Runyon, M.K., 169 Ruocco, A.C., 298 Rus-Calafell, M., 378, 379 Rusch, N., 17 Rush Burkey, C., 332, 338 Russo-Ponsaran, N.M., 402 Russo, J., 402 Rutter, L.A., 107 Rutter, M., 412, 413 Ryan, D.J., 434 Ryan, S.M., 196 Ryan, T.G., 403 Ryba, 196 Ryder, A.G., 292

S Saad, C.S., 467 Sabioni, P., 131 Sabri, B., 64 Sacco, P., 267 Sachdev, P.S., 425 Sachs, K., 224 Saczynski, J.S., 445 Sadek, M.L., 395 Sadock, B.J., 468 Sadock, V.A., 468 Saffer, B.Y., 187 Safouris, A., 442 Sagar, R., 152 Saha, T.D., 61 Sahathevan, R., 449 Saini, M., 126 Saint Onge, J.M., 197 Saitz, R., 268 Sajatovic, M., 201, 205 Sakdalan, J.A., 33 Salekin, R.T., 288 Salerno, S., 15 Salgado-Pineda, P., 369 Salguero, J.M., 124 Salomone, A., 273 Salum, G.A., 407 Samieri, C., 442 Samokhvalov, A.V., 251 Sample, L.L., 341 Sampson, 448 Sampson, N.A., 407 Samuel, I.A., 409 Samyn, N., 272 Sanchez-Arribas, C., 123 Sanchez-Moreno, J., 190 Sand, M.S., 317 Sander, C., 206 Sanders, J.F., 147 Sanders, S., 406, 407 Sandin, B., 123 Sandler, I., 414 Sandler, J.C., 342 Sandman, C.A., 192

Name IndexI-14

Talevski, D., 291 Talley, C.L., 364 Tamminga, C.A., 370, 376 Tanaka, J.W., 388 Tang, C.S.K., 197 Tang, J.Y.M., 445 Tanimoto, S., 402 Tanious, M., 193 Tanner, C.M., 435 Tasse, M.J., 386 Tassniyom, K., 433 Tatum, J.I., 480 Taub, D.J., 60 Tay, X.W., 389, 403 Taylor, 432 Taylor, C.B., 115, 223, 231 Taylor, D.J., 480 Taylor, J., 410 Taylor, J.R., 262 Taylor, K.I., 445 Taylor, P.J., 122 Taylor, R.L., 397 Taylor, R.W., 409 Taylor, S., 128, 149 Taylor, Z.E., 412 Teachman, B.A., 130 Teasdale, J., 208 Tek, S., 401 Telch, C.F., 233 Teloken, P.E., 321 Telzer, E.H., 265 ten Bensel, T., 332, 338 Teng, E., 433 Tenyi, 372 Terhune, D.B., 168 Tetzlaff, A., 228 Teufel, M., 227 Thapar, A., 57 Theberge, J., 163 Thege, B.K., 151 Theran, S.A., 223 Thibodeau, E., 412 Thime, W.R., 374 Thoma, P., 371 Thoma, S., 471 Thomas, A., 432 Thomas, A.J., 431 Thomas, R., 406, 407 Thomeer, M.B., 61 Thompson, E., 365 Thompson, J., 60 Thompson, R., 402 Thompson, S.J., 163 Thornicroft, G., 16 Thornton, D., 334, 336, 337, 342 Thornton, L.C., 411 Thurber, S., 444 Thurm, A., 400 Tibber, M.S., 370 Ticha, R., 400, 465 Tierney, K., 357 Timko, C., 276 Timko, C.A., 276 Timulak, L., 35 Ting, T.T., 266 Todd, S., 449 Toga, A.W., 446

Stinson, J.D., 332, 336, 342 Stochl, J., 396 Stockl, H., 64 Stokholm, J., 449 Stone, A.L., 266 Stoner, G., 415 Storebø, O.J., 415 Strack, S., 297 Strakowski, S.M., 191 Strand, B.H., 440 Strassberg, D.S., 320, 322 Stratton, K., 137 Strauss, C., 136 Strayhorn, G., 324 Strech, D., 449 Streiner, D.L., 309 Strickler, D.C., 379 Stringaris, A., 418 Stroe-Kunold, E., 234 Strong, J.V., 299 Strosahl, K., 468 Strosahl, K.D., 459 Strother, E., 42, 222 Stroud, C.B., 196 Stryer, L., 41 Stuart, C., 429 Stuart, E.A., 189 Stuart, G.L., 28 Su, Q., 149 Suarez-Pinilla, P., 236 Suarez-Torres, A., 195 Subica, A., 124 Subramaniam, M., 198 Substance Abuse and Mental Health

Services Administration, 254 Suchindran, C., 411 Sue, D.W., 455 Sue, S., 467 Sugaya, L.S., 407 Sulla, E.M., 418 Sullivan, 191 Sun, F., 441 Sun, J-H., 442 Sun, X., 226 Sund, R., 211 Sundgot-Borgen, J., 222 Sunohara, M., 292 Superbo, M., 150 Surendera Babu, A., 266 Susser, E., 403 Sutherland, R.J., 433 Sutton, K.S., 338, 339, 346 Svanoe, K., 137 Sverduk, K., 126 Swan, S.C., 322 Swarup, V., 395 Swendsen, J., 61 Swentosky, A., 411 Swinbourne, J., 117, 224 Swinkels, J.A., 155 Szatmari, P., 236 Szepsenwol, O., 322 Szuhany, K.L., 443

T Tajika, A., 205 Takeshima, N., 205

Spencer, D., 400 Sperry, L., 298 Sperry, S.H., 203 Spettigue, W., 227 Spiegel, D., 163, 168 Spielmans, G.I., 236 Spijker, A.T., 121, 193 Spijker, J., 210 Spilt, 414 Spinelli, E., 35 Spinhoven, P., 338 Spinrad, T.L., 412 Spittal, M.J., 190 Spitzer, R.L., 80, 153, 201,

233, 304 Spokas, M., 202 Spruyt, A., 216 Srisurapanont, M., 205 St-Amand, 307 Stadnik, R., 169 Staff, J., 413 Staines, W.R., 149 Stallard, P., 117 Stamatakis, A.M., 260 Stamatakis, E., 481 Stams, G.J.J., 417 Stams, G.J.J.M., 464 Stan, A.D., 376 Stancliffe, R.J., 400 Stan�eld, A.C., 388 Stanford, S.C., 42, 222 Staniloiu, A., 158, 164, 169 Staniute, 482 Stanley, B., 296 Stanley, B.G., 226 Stark, R., 130 Starr, K., 460 Staufenbiel, S.M., 121, 193 Stauffer, V.L., 378 Stautz, K., 264 Stead, L.F., 273 Steckler, T., 357 Steel, Z., 4 Steensma, T.D., 346 Steffen, K., 236 Steffens, M., 367 Stef�an, G., 161 Stein, D.J., 115, 120, 137, 266 Stein, E.A., 261 Stein, M., 459 Stein, M.B., 85 Steinberg, L., 411 Steinberg, M.H., 167, 393 Steiner, H., 192 Stella, F., 438 Stellman, S.D., 124 Stene, L.E., 152 Stephens, S., 339 Steptoe, A., 481, 482, 486 Stergiopoulos, V., 464 Stern, T.A., 131 Stevens, D.A., 437 Stevenson, J., 468 Stewart, R., 435 Stewart, W.F., 480 Stice, E., 68, 221, 230, 231,

233, 239

Skodol, A.E., 283, 284, 291, 310 Slama, H., 372 Slate, R.N., 33 Slone, N.C., 460 Sly, P.D., 483 Smetana, G.W., 443 Smigelsky, M., 35 Smink, 238 Smink, F.R.E., 221, 222 Smit, E., 415 Smith, D.P., 401 Smith, A.L., 395 Smith, C., 199 Smith, D.G., 261 Smith, G.E., 431 Smith, J.D., 411 Smith, K.L., 226 Smith, S., 167 Smith, S.E., 190 Smith, S.M., 61 Smith, T.L., 276 Smith, T.W., 481 Smith, V., 365 Smith, V.C., 395 Smitherman, T.A., 480 Smithson, J., 205 Smits, M., 260 Smolak, L., 223, 229 Snidman, N., 121 Snir, A., 165 Snow, John, 55 Snowling, M.J., 403 Snyder, J., 411 Snyder, M., 168 Soares-Weiser, K., 201 Soares, M.L.P., 148 Sockol, L.E., 116 Sodowska, P., 318 Sodowski, K., 318 Soenens, B., 227 Soffer-Dudek, N., 161 Sokol, K.A., 365 Soko_a, K., 222 Solodukhin, E., 292 Soloff, P.H., 211 Solomon, Z., 165 Solowij, N., 371 Somashekar, B., 154 Song, S.J., 124 Song, W., 428 Soni, V., 323 Sonino, N., 150, 151, 153 Sonka, K., 480 Sousa, L., 434 South, M., 90 Southwick, S., 161 Sowislo, J.F., 210 Spalletta, G., 354 Sparks, G.M., 189 Sparrow, E.P., 415 Sparrow, S.S., 400 Speckens, A., 154 Spector, A., 447 Speer, N., 55 Speilmans, G.I., 482 Spellmann, I., 380 Spence, J.D., 440

Name Index I-15

Vuilleumier, P. Vuorilehto, M., 190 Vythilingum, B., 115

W Wade, T.D., 226 Wagenpfeil, S., 253 Wagner, A.K., 191 Wagner, M., 367 Wagner, S.A., 152 Wake�eld, J.C., 284 Walder, D.J., 370 Waldman, I.D., 406, 410 Walker, E.F., 359 Walker, K.L., 60 Walker, O.L., 121 Walker, P., 122 Waller, G., 239 Waller, N.G., 304 Walsh, B.T., 220 Walsh, D., 371 Walsh, J.L., 43 Walsh, M.A., 203 Walter, A., 403 Walters, E.E., 55, 56, 57, 61,

115, 187, 189 Waltes, R., 410 Wampold, B.E., 460 Wang, C-W., 187, 446 Wang, G.-J., 260, 261, 263, 267 Wang, H., 331 Wang, P.S., 57, 58 Wang, S., 208, 266 Wang, X., 148 Ward, S.L., 394 Ware, R.E., 437 Warfa, N., 396 Warren, M.B., 147 Warschburger, P., 486 Warsini, S., 124 Washburn, J.J., 407 Watanabe, Y., 368 Watson, J.C., 35 Weaver, C.A., 168 Webb, C.M., 299 Weber, D., 154 Weber, K.P., 402 Wechsler, D., 80, 375, 445 Weck, F., 155 Wedding, D., 34, 35 Wedig, M.M., 293, 310 Weeks, G.R., 325, 327 Wei, M., 195 Weick, J.P., 437 Weinbrecht, A., 301 Weinstein, N., 35 Weisberg, R.B., 323, 325, 327 Weiss, A.R.D., 226 Weiss, M.D., 415 Weissman, M.M., 209 Welling, L.L.M., 198 Welliver, R.C., 326 Wellman, G.J., 400 Wells, A., 132 Weltens, C., 464 Wen, H., 266 Wenzel, A., 202

Van Ryzin, M.J., 264 Van Strien, J.W., 122 Van Tilburg, T.G., 443 van Tol, M.J., 368 Van Weeghel, J., 258 van Weel, C., 154 Van Wijngaarden-Cremers,

P.J., 391 van Zoonen, K., 66 VanBergen, A., 165 Vance, S.R., 345 Vanderschuren, L.J.M.J., 410 Vankar, G., 145 VanZomeren-Dohm, A., 412 Varcin, K., 396 Varvil-Weld, L., 265 Varvogli, 487 Vasey, M.W., 124 Vasquez, M.J.T., 162 Vater, 291, 292, 299 Veale, D., 461 Veenstra-VanderWeele, J., 395 Vega, W.A., 266 Veijola, J., 380 Veilleux, J.C., 292 Vellante, M., 198 Veltman, J.A., 397, 401 Vemuri, P., 60, 429, 434 Veneziani, A., 437 Ventura, J., 372 Vera, E., 463 Verdeli, H., 209 Verhaak, P.F.M., 434 Verhey, F.R.J., 447 Verhulst, B., 259 Vermetten, E., 163, 168 Vernon, M.K., 480 Vernon, P.A., 149 Verschuere, B., 164 Verstraete, A.G., 272 Veselka, L., 149 Vickerstaff, V., 326 Vieira, R., 428 Vieta, E., 189, 190, 205 Vilain, J., 364 Vilardo, B., 416 Villodas, M.T., 414, 416 Vincenti, M., 273 Vinci, C., 122 Vishal, G., 145 Vissers, L.E., 397, 401 Vitaro, F., 412 Vito, G.F., 338 Vleugels, A., 464 Voderholzer, U., 294, 300 Voineskos, A.N., 370 Volkow, N.D., 260, 261–262,

263, 267 Völzke, H., 193 Voorend-van Bergen, S., 483 Vos, T., 58, 115 Voshaar, M.A.H.O., 483 Vriends, N., 117 Vries, S.L., 417 Vrshek-Schallhorn, S., 189 Vuachet, M., 303 Vugt, M.E., 447

Uher, R., 205, 367 Uliaszek, A.A., 305 Umberson, D., 61 Undurraga, J., 205 Ungerleider, L.G., 122 Unrod, M., 275 Upadhyay, C., 483 Upadhyaya, S., 158 Urakami, T., 368 Url–Michitsch, M., 440 Urso, V., 134 Urstadt, K.R., 226 Urwyler, P., 430 Ury, J., 275 Urzúa, A., 379 Usher, K., 124 Utzinger, L.M., 238 Uygunoglu, U., 479, 480

V Vago, D.R., 149, 151 Valdes, M., 41 Valdez, A., 197 Valenti, M., 185 Valentiner, D.P., 122 Valiente, R.M., 123 Valmaggia, L., 364 Valuck, R.J., 204 van Amsterdam, J.G.C., 121 Van Boekel, L.C., 258 Van Bourgondien, M.E., 400 Van Cappellen, P., 63 van de Rest, O., 440 van de Wetering, B.J., 260 van den Berg, D.P.G., 135 van den Bosch, L.M.C., 306 van den Dungen, P., 449 Van den Eynde, F., 163, 206 van der Feltz-Cornelis, C.M., 155 Van der Gaag, R.J., 391 van der Kloet, D., 159 van der Laan, P.H., 464 Van der Linden, T., 272 van der Meer, K., 434 Van der Stigchel, S., 251 van der Velden, A.M., 208 Van Deurzen, P.A., 391 van Dongen, J., 371 van Dooren, K., 391 Van Dorn, R., 366 van Duijl, M., 162, 165 van Eeten, E., 391 van Elburg, A.A., 227 Van Eldik, L.J., 441 van Engeland, H., 28 van Furth, E.F., 224 van Hoeken, D., 221, 222 Van Hooff, M., 114 Van Houtem, C.M.H.H., 119 van Lier, 414 van Lunsen, R.H.W., 327 Van Meter, A.R., 189 van Minnen, A., 164 van Praag, H., 443 van Ravesteijn, H., 154 Van Rossem, R., 197 van Rossum, E.F.C., 121, 193

Tohen, M., 211 Tol, W.A., 124 Tolan, P.H., 412, 413 Tolosa, E., 432 Tom, S.E., 429 Tomasi, D., 260, 261, 263, 267 Tomba, E., 131 Tomko, R.L., 287, 289, 291,

292, 295 Tomlinson, M., 390, 391 Tookman, A., 326 Torppa, M., 403 Torregrossa, M.M., 262 Torres, A.R., 151 Tortelli, A., 371 Toth-Gauthier, M., 63 Toth, S.L., 412 Tottenham, N., 395 Toussaint, A., 145, 148, 151 Townsend, M.C., 339 Trace, S.E., 226 Tracy, D.K., 363 Traini, E., 446 Tranel, D., 89 Trankner, A., 206 Treadway, M.T., 192 Treasure, J., 228, 236 Treutlein, J., 259 Triebwasser, J., 285, 286, 297 Trim, R.S., 276 Tripodi, F., 326 Triscari, M.T., 134 Trivedi, A., 438 Trivedi, M.H., 192 Trost, L., 326 Trueba, A.F., 481 Trull, T.J., 76, 84, 95, 287, 289,

291, 292, 293, 295, 298, 304 Trussler, M., 394 Tsai, A.C., 190 Tsang, M.M., 378 Tseng, M-C.M., 148 Tseng, W-L., 148 Tseng, W-S., 42, 90, 91 Tsivgoulis, G., 442 Tsoy, E., 190 Tsuang, D.W., 367 Tsuang, M.T., 367, 370 Tuerk, E.H., 462 Tull, M.T., 203 Tully, P.J., 481 Turberville, D., 42, 222 Turchik, J.A., 322 Turnbull, D.L., 310 Turrisi, R., 265 Twohig, M.P., 461 Tye, C., 396 Tyler, K.A., 268 Tymoczko, J.L., 41 Tyrer, P., 287, 308

U U.S.Department of Health and

Human Services, 425 Uchino, B.N., 62 Üçok, A., 365 Udina, M., 41

Name IndexI-16

Youngstrom, E.A., 189 Yu, L., 438, 442 Yuan, J., 328 Yudofsky, M.D., 429 Yung, A.R., 364, 366

Z Zahs, K.R., 437 Zammit, S., 396 Zanarini, M., 148 Zanarini, M.C., 309–310 Zaretsky, A.E., Rizvi, S.,

& Parikh, S.V. Zecevic, N., 373 Zeien, E., 368 Zeigler-Hill, V., 198 Zhang, H., 61 Zhang, L., 396 Zhang, R., 428 Zhang, S., 437 Zhang, X.C., 151 Zhao, H.H., 441 Zhao, X., 298 Zhao, Y., 438 Zhong, C., 42 Zhou, F.C., 261 Zhou, L.Y., 438 Zhou, X., 148 Zhu, 480 Zielinski, M.J., 292 Zigmund, D., 373 Zijlema, W.L., 153 Zimbardo, P., 115 Zinbarg, R.E., 310 Zinik, G., 336, 337 Zipfel, S., 227, 238 Ziravac, L., 373 Zlodre, J., 291 Zollman, G., 323 Zubera, A., 147 Zucker, K.J., 343, 344, 345, 346 Zunhammer, M., 148 Zvara, B.J., 43 Zvonkovic, A., 33 Zwick, M.E., 367

Wright, A.G., 291 Wright, D.B., 121 Wright, K.P., 480 Wrobel, B., 318 Wu, K.D., 122 Wuerz, T., 428 Wuntakal, B., 154 Wurtele, S.K., 336 Wyatt, J.K., 480 Wygant, D., 153 Wygant, D.B., 288, 289 Wylie, K., 345 Wynn, R., 460 Wyshak, G., 154

X Xia, Z., 396 Xiang, P., 272 Xu, K., 265 Xu, X., 412 Xu, Y., 116

Y Yadin, E., 462 Yamada, A-M., 467 Yang, L.H., 365 Yang, Y., 264 Yap, M.B.H., 196 Yeomans, F.E., 307 Yeterian, J.D., 276 Yiend, J., 201, 291 Yilmaz, E., 165 Yip, P.S.F., 187, 446 Yoder, J.R., 163 Yokomizo, J.E., 445 Yokum, S., 231 Yolken, R., 370 Yonkers, K.A., 182 Yoon, S.S., 481 You, S., 117 Youle, R.J., 442 Young, C.M., 263 Young, G.S., 402 Young, J., 128 Young, L.T., 192

Williams, M., 208 Williams, N.J., 481 Williams, V.J., 395 Williamson, D., 418 Willinger, R., 396 Wilson G.T., 239 Wilson, A.C., 152 Wilson, H.A., 33 Wilson, J.F., 24 Wilson, J.S., 64 Wilson, K.G., 459 Wilson, S.J., 264 Wimo, A., 434, 435 Wincze, J.P., 323, 325, 327 Winder, B., 338 Wine, B., 96 Wingo, T.S., 437 Winkler, P.A., 437 Winslow, A.R., 439 Winstanley, E.L., 273 Winter, D., 298 Winter, M., 268 Wise, R.A., 264 Wise, T.N., 153 Witkiewitz, K., 275, 414 Witt, K., 366 Wolf, E.J., 119 Wolfberg, P., 402 Wolff, J.J., 395 Wolitsky-Taylor, K.B., 35,

134, 462 Wonderlich, S.A., 239 Wong, F.Y., 463 Woo, J.S.T., 323 Wood, A.M., 62, 122 Wood, B.L., 482 Wood, C.M., 124 Wood, M., 291 Wood, P.K., 287, 291, 292, 295 Woods, R.T., 447 Woodside, D.B., 226 Woodward, T.S., 374 World Health Organization, 190,

266, 440 Woud, M.L., 151 Wray, R., 63

Werner, P., 435 Wertheim, E.H., 228 Wesche, D., 234 Wessel, I., 164 West, C., 124 West, D.R., 204 West, J., 479 Westen, D., 304 Westendorp, R.G., 445 Weuve, J., 430 Wexler, B.E., 374 Weyandt, L., 410, 411 Whisman, M.A., 116 White, A., 66 Whiteford, H.A., 58, 115 Whit�eld et al., 432 Whitton, A.E., 192 Whooley, M.A., 481 Wiborg, J.F., 149 Widaman, K.F., 412 Widdershoven, J., 482 Widiger, T.A., 283, 287 Widom, C.S., 262 Wiebe, D.J., 251 Wiersma, D., 322 Wiguna, T., 373 Wijnia, J.W., 251 Wiklund, I., 480 Wilbourne, P.L., 268, 273, 274,

275, 276 Wild, B., 234 Wilder, C.M., 273 Wil�ey, D.E., 223, 231 Wilhelm, S., 116 Wilhelmsen, K.C., 266 Wilkens, T., 487 Wilkinson, G.S., 375, 400 Wilkinson, P., 236 Willcutt, E.G., 407 Wille, S.M., 272 Williams-Nickelson, C., 459 Williams, C.L., 82 Williams, J.B., 80, 153, 201, 233 Williams, J.B.W., 304 Williams, J.F., 395 Williams, K., 61

I-17

SUBJECT INDEX S

A Abnormal behavior

assessing, 76–77 classifying, 76 criteria for determining, 5–7 defining, 74–76 forms, 74 studying, 92–97

Abnormality defining, 7–8 statistical definition, 5–6, 6f

Abnormal psychology definitions, 4, 8t features continuum, 11f history, 11–14 introduction to, 4 themes, 14–17 types of prevention, 15

Academic skills training developmental disorders and, 402 disruptive behavior disorders and, 416

Acetylcholine, 25t Achievement test, 399–400 Acquaintance rape, 337 Acrotomophilia, 335t Active schizophrenia phase, 358, 358f Acute stress disorder, 112, 113t, 114 Acute transient psychosis, 365 Adaptation dif�culties, 6–7 Adaptive Behavior Scales, Second Edition, 400 Adaptive functioning, 386 Addiction Potential Scale, 269 Addictions Acknowledgement Scale, 269 Addiction Severity Index, 269 ADHD. See Attention-de�cit/hyperactivity See Attention-de�cit/hyperactivity See

disorder (ADHD) ADHD Rating Scale-5, 415 Adolescent Dissociative Experiences Scale

(A-DES), 167, 168t Adverse life events and schizophrenia,

370–371 Age

dementia. See DementiaSee DementiaSee elder abuse, 436 mental disorders and, 60–61, 61t neurocognitive disorders and, 435 normal neurocognitive changes, 425–426 Parkinson’s disease and, 435 sexual dysfunction and, 318, 319t, 320t

Aggression, 28. See also Violence Agonist

partial, 273–274 substance-related disorders and, 273

Agoraphobia features, 105, 105t prevalence rates, 115f

Al-Anon, 276 Alateen, 276 Alcohol

blood levels of. See Blood alcohol levelSee Blood alcohol levelSee blood test and, 272

driving under the influence of, 257, 257f drug interactions, 252t effects, 246, 247 epidemiology, 256–257, 257f gender and blood alcohol level, 250t genetics and, 259 intoxication, 246t neurocognitive disorders and, 440 tolerance, 245–246 violence and, 264 withdrawal, 245–246, 247t

Alcohol use disorder diagnostic categories, 248t–249t diathesis-stress model, 53f effects, 247–249, 251, 253 gender differences, 41 prevention, 66–68

Alcoholics Anonymous, 276, 277t, 463 Alcoholism

brain and, 259–261, 261f defined, 251

Alcohol use disorder, 245–246, 245t Alogia, 354t, 355, 357 Altruistic suicide, 187 Aluminum, and dementia, 441 Alzheimer’s disease

assessing, 443–445, 445f, 447f features, 428–430, 430t genetics and, 437 long-term outcomes, 449 prevalence rates, 435, 435f reality orientation and, 447 tips for caregivers, 448, 448t video about, 437

Amnesia anterograde, 433 dissociative, 157–158, 158t retrograde, 433

Amniocentesis, 397 “Amok, running,” 41 Amphetamines

excessive use, 253–254 diagnostic categories of excessive use,

248t–249t Amygdala

anxiety disorders and, 119–120 substance-related disorders and,

260, 260f Amyloid cascade hypothesis, 441–442,

442f, 443f Analogue experiments, 95 Angelman syndrome, 394t Anger management, 486 Anhedonia, 354t, 357 Anomic suicide, 187 Anorexia nervosa

defined, 42, 43f features, 217–220, 217t prevalence rates, 221–222, 222t

Antagonists, and substance related disorders, 273

Antecedent, 85 Anterior cingulate

obsessive-compulsive behavior and, 120 substance-related disorders and, 260, 260f

Anthrophobia, 41–42, 42f Antianxiety medication, 130–131, 131t Antidepressant

anxiety disorders and, 130–131, 131t for depressive and bipolar disorders, 203–206

Antipsychotic medication compliance, 378 ethics and, 376 psychotic disorders and, 376–377, 376t, 377f

Antisocial personality disorder epidemiology, 291 features, 288–289, 289t

Anxiety continuum, 102f defined, 101 Freudian theory and, 30 hierarchy, 134, 135f sensitivity, 123

Anxiety disorder. See also speci�c types age of onset, 56–57 assessing, 127–129 biological risk factors, 118–122 brain and, 119f causes, 124–126 comorbidity, 117 continuum, 102f–103f cultural factors, 117, 124 defined, 102 environmental risk factors, 122–124 epidemiology, 114–117 evolution and, 121 family-based contributions, 123 features, 103–110, 112, 114 gender and, 115, 116 genetics and, 118–119 global, 115–116, 117 interview and, 127–128 learning experiences, 123–124 medications for, 131t prevalence rates, 115f preventing, 126–127 prognosis, 137 screening questions, 137t self-evaluating, 136–137 stigma associated with, 117–118 treatment, 130–136 treatment seekers, 115

Anxiety Disorders Interview Schedule for DSM-V (ADIS), 128DSM-V (ADIS), 128DSM-V (

Anxiety Sensitivity Index, 128, 129t Anxiolytic, diagnostic categories of excessive

use, 248t–249t Anxious/fearful personality disorder

biological risk factors, 299 causes, 300, 300f cognition examples, 300t environmental risk factors, 299–300

Subject IndexI-18

for dramatic personality disorders, 298 for eating disorders, 225–227 for gender dysphoria, 344 for neurocognitive disorders, 437–441 for odd or eccentric personality

disorders, 297 for paraphilic disorder, 337 for sexual dysfunctions, 322 for somatic symptom disorders, 149 for substance-related disorders, 259–262 for suicide, 191–194

Biopsychosocial model, 47 Bipolar disorder. See also Depressive disorders

defined, 175 long-term outcomes, 210–211 mood-stabilizing drugs, 205–206 prevention, 199–200 schizophrenia and, 193f

Bipolar I disorder cycle, 186f features, 181, 185, 185t

Bipolar II disorder cycle, 186f features, 185, 186t

Bipolar mood disorder mood-stabilizing drugs, 205t stigma associated with, 190 video about, 200

Bipolar schizoaffective disorder, 360 Bleeding stroke, 431 Blood alcohol level

defined, 247 expected behavior and, 251t relationships among variables, 250t

Blood test, for substance-related disorders, 272 Body dissatisfaction

continuum, 217, 218f–219f defined, 216, 229 questionnaires for assessing, 234t

Body dysmorphic disorder, 109 diagnostic criteria, 109t response prevention for, 136

Body Image Avoidance Questionnaire, 234t Body image disturbance

defined, 229 questionnaires for assessing, 234t

Body mass index (BMI), and eating disorders, 234, 235t

Body Shape Questionnaire (BSQ), 234t Borderline personality disorder, 290t

epidemiology, 291 features, 289

Bradford Sexual History Inventory, 340 Brain

Alzheimer’s disease and, 437 anxiety disorders and, 119–120 assessing function, 87, 89 assessing metabolic changes, 87 assessing structural abnormalities, 87 bipolar disorder and, 193f conversion disorder and, 151f dementia and, 438–440, 440f depressive and bipolar disorders and,

191–192, 192f, 193f developmental disorders and, 396f disruptive behavior disorders

and changes, 411 dissociative disorders and, 163, 163f

B Basal ganglia

obsessive-compulsive behavior and, 120 schizophrenia and, 368

Bayley Scales of Infant and Toddler Development-Third Edition, 399

Beck Anxiety Inventory, 130t Beck Depression Inventory-II, 202 Beck Hopelessness Scale, 202 Beck’s cognitive theory, 37 Behavior

blood alcohol level and, 251t continuum, 10f–11f criteria for abnormal, 5–7 degree of normality, 8–11 maladaptive, 6

Behavioral activation, for depression, 207 Behavioral assessment, 85–87 Behavioral avoidance test, and anxiety

disorders, 129 Behavioral inhibition, and anxiety disorders,

121–122 Behavioral observation

developmental disorders and, 400 disruptive behavior disorders and, 415

Behavioral perspective, 36–37 Behavior Assessment System for Children,

Third Edition, 415 Behavior genetics, 23–24 Behavior management (school-based), 416 Behavior problem, addressing, 403 Behavior therapy. See also Cognitive-behavioral

therapy (CBT) neurocognitive disorders and, 447 somatic symptom disorders and, 154–155 substance-related disorders and, 275

Bender Visual-Motor Gestalt test (Bender-Gestalt II), 90

Benton Visual Retention test, 89–90, 89f Benzodiazepine, 130–131, 131t Biastophilia, 335t Binge drinking

defined, 66 effects, 249–251

Binge eating, 220 Binge eating disorder

compensatory behaviors, 222t features, 220–221, 222t prevalence rates, 222t questionnaires for assessing, 234t

Binge Eating Scale, 234t Biofeedback, 483

and anxiety disorders, 136 and stress, 483, 485

Biological assessment, 87 Biological model

evaluating, 25 mental disorders and, 22, 23

Biological risk factor for anxiety disorders, 118–122 for anxious/fearful personality

disorders, 299 for depressive and bipolar disorders,

191–194 for developmental disorders, 392–396 for disruptive behavior disorders, 410–411 for dissociative disorders, 163–164

epidemiology, 295 features, 284, 293–295

Apotemnophilia, 335t Arbitrary inference, 37 Asperger’s disorder features, 389 Asphyxiophilia, 333 Assessment

behavioral, 85–87 biological, 87 clinical, and culture, 91 ethics and, 470 neurochemical, 87 neuropsychological, 89–90 personality, 81–85 stress, 483

Assessment technique intelligence test, 80–81 MMPI-2 clinical scale, 82–84, 82t, 83f MMPI-2 validity scale, 81–84 neuroimaging, 87 objective personality measure, 81–84 observation, 85–86 projective personality measure, 84–85 Rorschach test, 84 self-monitoring, 86–87

Asthma, and stress, 480 Asylum, 13 Ataque de nervios, 90, 116 Atrophy, brain, 439 Attention-de�cit/hyperactivity (ADHD)

brain changes and, 411 causes, 413 culture and, 412–413 defined, 404–405 features, 405–406, 408t genetics and, 410 long-term outcomes, 418–419 neurochemical changes and, 410 sample multifactorial model, 413, 413f treatment (biological), 415–416

Attraction to Sexual Aggression Scale (revised), 340 Attribution theory, 195 Attrition, in longitudinal studies, 96 Autagonistophilia, 335t Authenticity, 34–35 Autism Diagnostic Interview-Revised, 400 Autism spectrum disorder

CARS2 rating sheet sample items, 400t concordance rate, 393–394 epidemiology, 390–391 features, 387–389, 388t severity of, 388–389, 389t video about, 401

Autistic disorder. See Autism spectrum disorderSee Autism spectrum disorderSee Autogynephilia, 334 Automatic thoughts, 195 Automatic Thoughts Questionnaire-Revised, 202 Autonepiophilia, 335t Autosomal recessive disorder, 393 Autosuggestibility, 146 Aversion treatment, and paraphilias, 341–342 Aversive drug, 274 Avoidance conditioning, 38, 39f Avoidant personality disorder, 293t

environmental risk factors, 299–300 features, 293 gender and, 295

Avolition, 353, 354t, 357

Subject Index I-19

Clinician rating and depressive and bipolar disorders, 201–202

Club drugs, 256 Cluster headaches, 480 Cocaine

brain and, 261f excessive use, 253

Cocaine Anonymous, 276 Codeine, 254 Codependency, and substance-related disorders,

265–266 Cognition

disruptive behavior disorders and, 412 normal changes during aging, 425–426

Cognitive assessment, of psychotic disorders, 375

Cognitive-behavioral model assessment, 38–39 evaluating, 40 example, 38 learning principles, 36–37 overview, 36–40 treatment, 38–40

Cognitive-behavioral therapy (CBT) defined, 39 eating disorders and, 236–238, 238f for personality disorders, 305 psychotic disorders and, 377–378 sample maintenance plan, 239f substance-related disorders and, 275

Cognitive beliefs dramatic personality disorders and,

299, 299t of odd/eccentric personality disorders,

297, 297t Cognitive de�cit, and schizophrenia, 370 Cognitive distortion

anxiety disorders and, 122 defined, 37 depressive and bipolar disorders and, 195 paraphilic disorders and, 338 for substance-related disorders, 263

Cognitive perspective, 37 Cognitive principles, 37 Cognitive psychologist, job description, 456t Cognitive rehearsal, 39 Cognitive risk factor, for anxiety disorders,

122–123 Cognitive schema, 37 Cognitive test, for developmental disorders,

398–399 Cognitive therapy

anxiety disorders and, 132–133 behavioral. See Cognitive-behavioral See Cognitive-behavioral See

therapy (CBT) depressive and bipolar disorders and,

207–208 paraphilic disorders and, 341–342 somatic symptom disorders and, 154–159 for stress, 486

Cohort effect children and, 57 in cross-sectional studies, 96

Collectivist culture, 44 College Alcohol Study, 249, 251 College students

ADHD and, 410 alcohol use disorders and, 66–68, 67f, 268

mental disorder risk factors (Jana), 59 neurocognitive disorders (William and Laura

Ponder), 424 obsessive-compulsive disorder

(Jonathan), 108 personality disorder (Michelle), 282 personality disorder (Treva Throneberry), 5 perspectives (Mariella), 22 posttraumatic stress (Marcus), 109 schizophrenia (James), 352 schizotypal personality disorder

(Jackson), 286 sexual dysfunction (Douglas and Stacy), 314 somatization (Gisela), 142–143 stress (Ben), 478

Case study, as study tool, 96 Catalepsy, 356 Catastrophizing, 122 Catatonia, 353 Catatonic behavior, and schizophrenia, 356, 357 Catatonic schizophrenia, 359f Categorical approach, to behavioral

de�nitions, 74 Catharsis, 462 Caudate nucleus, 120 CBT. See Cognitive-behavioral therapy (CBT)See Cognitive-behavioral therapy (CBT)See Central nervous system function, 24 Cerebellum

function, 25 schizophrenia and, 368

Cerebral cortex function, 25 Cerebrovascular disease, 431–432 Child Behavior Checklist, 415 Childhood Autism spectrum disorder Rating

Scale, Second Edition (CARS2), 400, 400t Child maltreatment, preventing, 65t, 300, 301t Child molestation, 332 Children’s Depression Inventory, 202t Children’s Manifest Anxiety Scale, 130t Cholera deaths, 55 Cholinesterase inhibitor, 446 Chorionic villus sampling, 397 Chromosomal aberration, and developmental

disorders, 394, 394t Chromosome, de�ned, 23 Circadian rhythm, and depressive and bipolar

disorders, 194 Circadian rhythm sleep-wake disorders, 480 Cirrhosis, of the liver, 251 Civil commitment, 33 Clang association, 355 Clarke Sex History Questionnaire for Males

(Revised), 340 Classical conditioning theory, 36, 37f Classi�cation, de�ned, 76 Client-centered therapy, 34 Client identi�cation, 471 Clinical assessment

culture and, 91 defined, 76

Clinical psychologist job description, 456t qualifications, 454

Clinician compared to researcher, 468 cultural responsibilities, 91

Clinician-Administered Dissociative States Scale, 167

DLB and, 430–431 eating disorders and, 226, 226f imaging techniques, 87, 88f intellectual disability and, 395–396 major depression and, 193f major features, 26f–27f memory and, 425–426 normal changes during aging, 425 overview, 24–25 paraphilias and, 337, 338f Parkinson’s disease and, 439 personality disorders and, 298 Pick’s disease and, 432–433 schizophrenia and, 367–369, 369f somatic symptom disorders and, 149, 150f substance-related disorders and, 259–262,

260f, 261f, 262f symmetry and developmental disorders,

395–396 vascular disease and, 431–432

Brain fag, 42 Breathalyzer, 272 Breathing-related sleep disorder, 480 Breathing retraining, for anxiety

disorders, 132 Brief Psychiatric Rating Scale, 201 Brief psychotic disorder

epidemiology, 365 features, 353t, 362, 362t

Broca’s area, 368 Bulimia nervosa

binge-purge cycle, 236, 237f CBT monitoring sheet, 238f features, 218–220, 219t prevalence rates, 221–222, 222t sample maintenance plan, 239f video about, 227

C Caffeine

diagnostic categories of excessive use, 248t–249t excessive use, 253

CAGE alcohol measure, 270 Cannabis diagnostic categories of excessive use,

248t–249t Cannabis sativa, 255–256 Case

abnormal behavior (Travis), 2 antisocial personality disorder (Duane), 288 anxiety disorders (Angelina), 100 binge drinking (Sam Spady), 252 bulimia nervosa (Lisa), 218 delusional disorder (Jody), 362 dependent personality disorder (Betty), 294 depressive and bipolar disorders and suicide

(Katey), 174 developmental behavior disorder

(Robert), 384 diagnosis and assessment (Professor Smith), 74 disruptive behavior disorder (Will), 405 dissociative disorders (Erica), 156 drug use (Elon), 244 eating disorder (Sooki), 216 excessive use of alcohol (DeShawn), 52 gender dysphoria (Austin), 343 indecent exposure (Tom), 330 learning disorder (Alison), 389

Subject IndexI-20

Decatastrophizing, 133, 134 Defense mechanism

examples, 31t overview, 30 use, 29

Delayed ejaculation, 317, 317t Deliberate self-harm, 187 Delirium

causes, 426–427 defined, 425 differential diagnosis, 429t features, 427t

Delirium Rating Scale-Revised, 444 Delirium tremens (DT), 246 Delusion. See also speci�c types

defined, 353 schizophrenia and, 353–354

Delusional disorder epidemiology, 365 features, 353t, 361–362, 362t

Dementia advance directives, 449 Alzheimer’s type, 428–430, 435. See also

Alzheimer’s disease brain and, 440f brain changes and, 438–440 defined, 426 differential diagnosis, 429t due to Parkinson’s disease, 432, 435 ethics and, 449 with Lewy bodies (DLB), 430–431, 439 long-term outcomes, 449 Pick’s disease, and, 433 prevalence rates, 434f, 435 signs and symptoms, 444t types, 428

Deoxyribonucleic acid (DNA) and mental disorders, 24

Dependent personality disorder, 294t environmental risk factors, 300 epidemiology, 295 features, 294 gender and, 295

Dependent variable, 92 Depersonalization disorder, 160–161, 161t Depressant, excessive use, 247–249, 251, 253 Depression. See also Major depression

associated disorders, 201t biologically oriented, 199 brain activity and, 192f brain and, 193f continuum, 176f–177f defined, 175 developmental pathway, 198f differential diagnosis, 429t elderly people and, 208 endogenous, 199 environmentally oriented, 199 exogenous, 196, 199 family factors, 197 gender differences, 41 Hamilton Rating Scale, 202t interpersonal factors, 196 medications for, 25, 205t nonbiological, 196 stigmas, 225t women and, 182–183

Controlled observation, 86 Controlled weight gain, 234, 236 Conversion disorder, 146t

behavior therapy and, 154 brain changes and, 149, 151f features, 146 prevalence rates, 148t

Coping, and depression, 207 Coprophilia, 335t Coronary heart disease, and stress, 481 Corpus callosum, 368 Correlation, de�ned, 94 Correlational studies, 94 Correlation coef�cient, 94, 95f Cortisol, and anxiety disorders, 121 Counseling psychologist

job description, 456t qualifications, 454

Couples therapy. See Marital therapySee Marital therapySee Covert sensitization, and paraphilias, 341, 342 Craving, 259 Criminal commitment, 33 Criminal insanity, 33, 69 Criterion-referenced test, 399 Cross-dressing, 331t

transvestic fetishism and, 334 Cross-sectional study, 96 Cross-tolerance, 273 Cue exposure therapy, 275 Cultural-familial intellectual disability, 396 Cultural idioms of distress, 151 Culture

anxiety disorders and, 117, 124 clinical assessment and, 91 defined, 41 depression and, 189f depressive and bipolar disorders and,

197–198 diagnosis and, 77 disruptive behavior disorders and, 412–413 dissociation and, 162 dissociative disorders and, 165 eating disorders and, 229–230 emotion and, 7 expression and, 7 gender identity and, 344 mental disorder development and, 90–91 mental disorders and, 42t neurocognitive disorders and, 441 paraphilic disorders and, 338–339 schizophrenia and, 371 sexual dysfunction and, 323, 324t somatic symptom disorders and, 151 substance-related disorders and, 266 suicide rates and, 190f

Culture syndrome, 41–42, 224 Cyclothymia. See Cyclothymic disorderSee Cyclothymic disorderSee Cyclothymic disorder

cycle, 186f features, 185, 186t

D Dangerousness and commitment, 33 Date rape, 337 Date rape drugs, 256, 257 Day hospital, 464

autism and, 392 delirium and, 434 depression and, 195 dissociation and, 161 eating disorders and, 223 paraphilic interests and, 335 personality disorders and, 292 psychotic symptoms, 365 sexual dysfunctions and, 322 sexual fantasies and, 335 somatic symptoms, 148 suicide and, 60 trauma and trauma-related disorders, 116

Commitment civil, 33 criminal, 33 to a treatment statement, 210

Community mental disorders and, 43 psychotic disorder interventions, 379, 379f

Community psychology, 463 Community reinforcement, and

substance-related disorders, 275

Comorbidity, 56 Compartmentalization, 164 Compensatory behavior

for binge eating, 222t bulimia nervosa and, 219

Competency to stand trial, 33 Composite International Diagnostic

Interview, 153 Compulsion, 108 Computerized axial tomography (CT) scan

as assessment tool, 87 neurocognitive disorders and, 445

Concordance, and developmental disorders, 393–394

Concurrent validity, 79, 79t Conditional positive regard, 34 Conditioned response (CR), 36 Conditioned stimulus (CS), 36, 37f Conditioning, and anxiety disorders, 123–124 Conduct disorder

defined, 405 features, 406–407, 409t genetics and, 410 neurochemical changes and, 410 sample multifactorial model, 413, 414f

Confabulation, 433 Con�dentiality, 471 Confound, 94 Confusion Assessment Method, 444 Conners Rating Scales, 415 Conscience, 30 Consequence, 85 Construct validity, 79, 79t Content validity, 79, 79t Contingency management

for depression, 207 somatic symptom disorders and, 154 substance-related disorders and, 275

Continuous Performance Test, 415 Continuous Performance Test II, 375 Continuum of intervention, 64, 66f Control delusion, 354 Control group, 92

Subject Index I-21

Dissociative Experiences Scale (DES), 167 Dissociative fugue, 158 Dissociative identity disorder, 158–160

defined, 42 features, 159t

Dissociative trance disorder, 165 Distal factor, 267 Distress, as abnormal behavior, 7 Distress tolerance skills training, 305 Diversity, 16. See also Culture; Ethnicity; Race

anxiety disorders, sociocultural factors and, 115–116

culture and diagnosis, 77 depression and, 208 influence on emotion, 7 influence on expression, 7 research limitations, 467 schizophrenia and, 364

Dopamine functions, 25t schizophrenia and, 25, 369–370

Dopamine, and eating disorders, 227 Double-blind designs, 93 Double depression, 178 Double Trouble in Recovery, 276 Down syndrome, 394 Dramatic personality disorder

biological risk factors, 298 causes, 299 cognition examples, 299 environmental risk factors, 298–299 epidemiology, 293 features, 284

Dream analysis, 31 Driving factor, 38 Driving under the in�uence, 257, 257f Drug cue, 259 Drugs, 253–256, 257t. See also

Substance-related disorder alcohol interactions, 252t categories of excessive use of, 247–256 first-time use, 258, 258f testing for and ethics, 273 type of illicit use, 257, 257t

DSM-V acute stress disorder and, 112, 113t ADHD, 408t agoraphobia and, 105t alcohol intoxication, 246t alzheimer’s disease, 430t anorexia nervosa, 217t anxiety disorders and, 130t autistic disorder, 388t binge eating disorder, 222t brief psychotic disorder, 362t bulimia nervosa features, 219t categorical approach of, 75 causes of delirium, 428t conduct disorder, 409t culture and, 91, 91t cyclothymic disorder features, 186t delirium, 427t delusional disorder, 362t depersonalization disorder symptoms, 161t derealization disorder symptoms, 161t disruptive mood dysregulation disorder

features, 184t

eating disorders and, 225, 230 implications, 54 mental disorders and, 59 overview, 52–54 substance-related disorders and, 266

Diet dementia and, 440 neurocognitive disorders and, 440

Dietary restraint questionnaires, 234t Dieting, 216–217 Diffuse plaque, 439 Dimensional approach, to behavioral

de�nitions, 74–75 Directionality, 94 Direct learning and anxiety disorders, 123 Disability, 59f Discrete-trial training, 401 Disengaged family, 43 Disinhibition, 247 Disorganized schizophrenia, 359f Disorganized schizophrenia dimension, 359f Disorganized speech, 355–356 Disorientation, 426 Disruptive behavior disorder

assessing, 414–415 biological risk factors, 410–411 causes, 413 continuum, 406f–407f defined, 404, 405 environmental risk factors, 411–413 epidemiology, 407–408 features, 405–407 genetics and, 410 interview and, 415 long-term outcomes, 417–419 neurochemical changes and, 410 prevention, 413–414 screening questions, 417t stigma associated with, 408–409 treatment (biological), 415–416 treatment (multisystemic), 417 treatment (psychological), 416–417 treatment (residential), 416

Disruptive mood dysregulation disorder, 184t

Dissociation, 157, 158f–159f Dissociative amnesia, 157–158, 158t Dissociative disorder

assessing, 167 biological risk factors, 163–164 brain and, 163f causes, 165 continuum, 158f–159f cultural factors, 165 defined, 157 environmental risk factors, 164–165 epidemiology, 161–163 gender and, 161–162 historical introduction, 142 interview and, 167 long-term outcomes, 169 prevention, 166 stigma associated with, 163 treatment (biological), 167–168 treatment (psychological), 168–169 types, 157 violence and, 166

Depressive disorders, 179. See also Depression assessing, 201–203 biological risk factors, 191–194 brain and, 193f causes, 198–199 cognitive factors, 195–196 culture and, 197–198 environmental risk factors, 194–198 epidemiology, 187–189 evolution and, 198 genetics and, 191 interview and, 201–202 long-term outcomes, 210–211 persistent, 183t prevention, 199–200 screening questions, 210, 210t stigma associated with, 190 treatment (biological), 204–206 treatment (psychological), 207–210 types, 175–187

Depressive schizoaffective disorder, 360 Derealization disorder, 160–161, 161t Designer drugs, 256 Detoxi�cation, 274 Development

continuum, 384f–385f normal, 385, 404

Developmental design, 96 Developmental disability. See Developmental See Developmental See

disorder Developmental disorder. See also speci�c types

addressing problem behaviors, 403 assessing, 398–400 biological risk factors, 392–396 causes, 396 environmental risk factors, 396 epidemiology, 391 ethics and, 394 genetics and, 392–395 interview and, 400 long-term outcomes, 403 normalization, 465 patient residential facilities, 464–465 prevention, 396–398 sample final common pathway, 397f stigma associated with, 391–392 testing for and ethics, 399 treatment (biological), 400–401 treatment (psychological), 401–403 types, 384–385

Developmental psychologist, job description, 456t Deviance from the norm as abnormal

behavior, 5–6 Dexamethasone suppression test (DST), 203f Dhat, 116 Dhat syndrome, 41 Diagnosis

advantages, 75 categorical, 74 culture and, 77

Diagnostic and Statistical Manual of Mental Disorders (DSM-V). See DSM-V

Dialectical behavior therapy, 305–307 Diathesis, 47, 52 Diathesis-stress model

anxiety disorders and, 124 defined, 47

Subject IndexI-22

paraphilic disorders and, 337–339 psychotic disorders and, 370–371 somatic symptom disorders and, 149–151 substance-related disorders and, 262–266

Epidemiologist, 54 Epidemiology, 54 Episodic memory and aging, 425 Erectile disorder/dysfunction, 316, 317t

culture and, 323 model, 324f treatment (biological), 325–326

Erogenous zone, 30 Erotomanic delusion, 361 Erratic personality disorder, 284 Esteem needs, 33 Ethical Principles of Psychologists and Code

of Conduct, 470 Ethics

dementia and, 449 developmental disorders and, 394, 399 drug testing and, 273 electroconvulsive therapy and, 206 ending therapy, 472 exposure-based practices and, 138 humanistic perspective and, 35 mental disorder treatment and, 470–472 mental health professionals and, 470–472 pro-anorexia websites, 237 recovered memories and suggestibility, 162 resolving issues, 472 rights of the hospitalized, 466 sex offenders and, 341 sexual intimacy with clients, 471–472

Ethnicity. See also Diversity ADHD and, 412–413 defined, 41 mental disorders and, 61, 61t research limitations, 371 schizophrenia and, 364 substance-related disorders and, 266

Etiology, 54 Euphoria, 175 Evening people, 344 Evidence examination, and anxiety disorders,

132–133 Evolution

anxiety disorder and, 122 depressive and bipolar disorders and, 198 paraphilic disorders and, 338–339 schizophrenia and, 371 somatic symptom disorders and, 151 substance-related disorders and, 266

Excess dopamine hypothesis, 369–370 Exhibitionism

features, 330, 331t focus of arousal, 329t

Existential psychology, 34 Exorcism, 12 Expectancy, 37 Experiment

analogue, 95 natural, 94–95 as study tool, 92–93

Experimental designs, 94–96 Experimental group, 92 Experimental psychologist, job

description, 456t

features, 217–221 gender and, 223 genetics and, 225–226 interview and, 231–233 long-term outcomes, 238–239 prevalence rates, 221–222, 222t prevention, 68, 230–231 questionnaires for assessing, 234t screening questions, 240t self-monitoring, 233–234 stigma associated with, 224–225, 225t treatment (biological), 234, 236 treatment (psychological), 236–238

Eating Disorder Diagnostic Scale, 233, 233t Eating Disorders Examination (EDE), 233 Eating Disorders Inventory-2 (EDI-2), 234t Echolalia, 356, 388 Echopraxia, 356 Education, and mental disorders, 61, 61t Educational psychologist

job description, 456t qualifications, 454

Ego, 29 Ego ideal, 30 Ejaculation

delayed, 317, 318t premature. See Premature ejaculationSee Premature ejaculationSee

Elder abuse, 436 Electrocardiogram, 88 Electroconvulsive therapy (ECT)

for depression, 206 ethical dilemmas, 206

Electroencephalogram (EEG), 89, 89f Electronic diary, and eating disorders, 233–234 Emotion

continuum, 10f–11f culture and, 7

Emotional dysregulation, 301 Emotional personality disorder, 284 Emotional processing, 122–123 Emotional reasoning, 122 Emotional regulation skills training, 305 Emotion regulation training, 301, 302t Emphysema, 264 Employment and mental disorders, 61t Endogenous opioid, 227 Engineering psychologist, job description, 456t Enlarged ventricle

developmental disorders and, 395 psychotic disorders and, 367 schizophrenia and, 368f

Enmeshed family, 43 Environmental risk factors

anxiety disorders and, 122–124 anxious/fearful personality disorders and,

299–300 avoidant personality disorder and, 299–300 dependent personality disorder and, 300 depressive and bipolar disorders and,

194–198 developmental disorders and, 396 disruptive behavior disorders and, 411–413 dissociative disorders and, 164–165 dramatic personality disorders and, 298–299 eating disorders and, 227–230 neurocognitive disorders and, 440–443 odd or eccentric personality disorders and, 297

dissociative amnesia, 158t dissociative identity disorder, 159t dysthymia, 183t eating disorder diagnostic scale, 233 exhibitionism, 331t fetishism, 331t frotteuristic disorder, 331t generalized anxiety order and, 107, 107t hypomanic episode, 185t intellectual disability features, 386 learning disorder specific, 391t lewy body, 431t major depressive disorder, 178t manic episode features, 184t mood-stabilizing drugs for bipolar disorder,

205–206 obsessive-compulsive disorder and, 108, 108t oppositional defiant disorder, 409t panic disorder, 103, 104t paraphilic disorders, 329t Parkinson’s disease, 433t persistent depressive disorder, 183t personality disorder organization, 284 posttraumatic stress disorder and, 109–114,

110t–112t premature ejaculation, 318t schizoaffective disorder, 360t schizophrenia, 358t schizophreniform disorder features, 359t separation anxiety disorder and, 114, 114t sexual masochism, 333t social anxiety disorder and, 105, 106t somatization disorder classification, 144t specific phobia and, 106, 106t transvestic fetishism, 335t voyeurism, 335t

DTs (delirium tremens), 246 Dual relationships, 471 Durham rule, 69 Dutch Eating Behavior Questionnaire

(DEBQ), 234t Dyscalculia, 390 Dysfunctional Thought Record, 86, 86f Dyslalia, 390 Dyslexia, 390 Dysnomia, 390 Dysphasia, 390 Dyspraxia, 390 Dyssomnias, 480 Dysthymia

features, 178–179, 183t prevalence rates, 188f

E Early ejaculation. See Premature ejaculationSee Premature ejaculationSee Early morning wakening, 175 Eating disorder

biological risk factors, 225–227 causes, 230, 230f cognitive factors, 229 continuum, 217, 218f–219f culture and, 229–230 defined, 216 diagnostic scale sample items, 233t environmental risk factors, 227–230 epidemiology, 221–224

Subject Index I-23

prevention, 344–345 treatment (biological), 345 treatment (psychological), 345 video about, 346

Gender expectation, 42 Gender identity, 42 Gene, de�ned, 23 Gene damage, and developmental disorders,

393–404 General Behavior Inventory, 202–203 Generalized anxiety disorder

causes, 126 cognitive therapy examples for, 133t exposure-based therapy examples for, 134t features, 106–107, 107t genetics and, 119 prevalence rates, 115f psychoeducation example for, 132t somatic control exercise example for, 132t

Gene therapy dementia and, 446 developmental disorders and, 401

Genetics alcohol and, 259 Alzheimer’s disease and, 437 anxiety disorders and, 118–119 behavior genetics, 23–24 conduct disorder and, 410 depressive and bipolar disorders and, 191 developmental disorders and, 392–395 disruptive behavior disorders and, 410 eating disorders and, 225–226 mental disorders and, 23–24 molecular genetics, 24 neurocognitive disorders and, 437 obsessive-compulsive disorder and, 118–119 panic disorder and, 119 Parkinson’s disease and, 437 posttraumatic stress disorder and, 119 psychotic disorders and, 367, 368f social anxiety disorder and, 119 somatic symptom disorders and, 149 specific phobia and, 119 stroke and, 437 substance-related disorders and, 259

Genito-pelvic pain/penetration disorder, 318, 318t

Genotype, 23 Ghost dance, 287 Glutamate, 25t Graduate school mentoring programs, 460–461 Grandiose delusion, 354, 361 Grandiosity, 175, 184t Gray matter, and schizophrenia, 368, 369f Grossly disorganized behavior, 356 Group therapy for substance-related

disorders, 276 Gynemimetophilia, 335t

H Hair analysis, for substance-related

disorders, 272 Halfway house, 464 Hallucination

defined, 353 schizophrenia and, 355

Fixation, 30 Flashing, 330 Flat affect, 353, 354t, 356 Flavonoid, 440, 441f Flight of ideas, 180 Flooding

anxiety disorders and, 135 defined, 40

Focal testing, 89 Folie à deux, 361 Forensic psychologist, job description, 456t Forensic psychology, 466 Fragile X syndrome, 392–393 Free association, 31 Free radicals, 439–440 Freudian slip, 28, 31 Freudian theory

defined, 28 psychosexual stages, 30, 30t

FRIENDS workbook, 126 Frontal lobe

function, 25 normal changes during aging, 425

Frontotemporal dementia features, 433, 433t genetics and, 439 prevalence rates, 435

Frotteurism features, 331–332, 331t focus of arousal, 329t

Functional analysis, 38–39, 85 Functional MRI (fMRI), 87 Functional somatization, 145

G GABA. See Gamma-aminobutyric acid (GABA)See Gamma-aminobutyric acid (GABA)See Galvanic skin conductance, 88–89 Gamma-aminobutyric acid (GABA)

anxiety and, 25 anxiety disorders and, 120 functions, 25t

Gender anxiety disorder and, 115, 116 date rape drugs and, 256, 257 dementia caregivers and grief, 448 depression and, 182–183 dissociative disorder and, 161–162 dysthymia and, 189f eating disorders and, 223 graduate school mentoring programs,

460–461 major depression and, 189f mental disorders and, 41, 42–43, 60, 61t neurocognitive disorders and, 435 personality disorders and, 295, 296 sexual dysfunction and, 319, 319t, 320, 320t

Gender development, 343 Gender dysphoria, 343

in adolescents, 344t in adults, 344t assessing, 345–346 causes, 344–345 in children, 344t defined, 343 features, 343 long-term outcomes, 346

Exposure-based practices anxiety disorders and, 134–136 ethics and, 138

Exposure treatment, 40 Expressed emotion

defined, 44 eating disorders and, 228 schizophrenia and, 373

Expressive speech, 401 External validity, 93 Extrapyramidal effect, 377 Eye movement desensitization and reprocessing

(EMDR), 135

F Fa’afa�ne, 344 Factitious disorder, 146–147

imposed on others, 147t self-imposed, 147t

Fakaletti, 344 Family

activity, 43 affect, 43 anxiety disorders and, 118–119, 123 control, 43–44 depression and, 197 depressive and bipolar disorders and, 191 disruptive behavior disorders and, 411–412, 416 eating disorders and, 227–228 environment, 43–44 mental disorders and, 43–44 paraphilic disorders and, 337–338 problematic environments, 43–44 problematic relationships, 43 substance-related disorders and, 259,

265–266, 267 Family suicide, 41 Family systems perspective, 43 Family therapy

defined, 44 for depressive and bipolar disorders, 209 eating disorders and, 236 psychotic disorders and, 379 substance-related disorders and, 275–276

Fantasy training, 327 Fast Track model for disruptive behavior

prevention, 414 Fatalistic suicide, 187 Fear

brain and, 119–120, 120f continuum, 102f defined, 101–102 as learned response, 124

Fear Questionnaire, 130t Fear Survey Schedule for Children-Revised, 130t Female orgasmic disorder, 316–317, 317t Female Sexual Function Index, 325, 326t Female sexual interest/arousal disorder, 315, 316t Femicide, 64 Fetal alcohol effects, 395 Fetal alcohol syndrome, 251, 253, 253f, 261

brain damage to a newborn with, 262f Fetishism, 329t, 331, 331t Final common pathway, 396 First-degree relative, and anxiety disorders,

118–119

Subject IndexI-24

substance-related disorders and, 269 unstructured interview, 80

Intimate partner violence, 28 Intrapsychic, 28 Irresistible impulse, 69 Irritable bowel syndrome (IBS), and

stress, 479 Ischemic stroke, 431

J Jealous delusion, 361 Jinn, 162 Juvenile delinquency, 406

K Kathoey, 344 Kegel exercises, 327 Kiddie Schedule for Affective Disorders

and Schizophrenia, 201 Kids Eating Disorders Survey (KEDS), 234t Kleptophilia, 335t Klinefelter syndrome, 394t Klismaphilia, 335t Koro, 116 Korsakoff’s syndrome

alcohol use and, 251 features, 433

L La belle indifference

conversion disorder and, 150 defined, 146

Laboratory assessment of depressive and bipolar disorders, 203 of neurocognitive disorders, 445 of substance-related disorders, 272

Lack of control over eating, 217 Lack of insight, and schizophrenia, 354t, 357 Language training, and developmental

disorders, 401 Latah, 116 Latent content, of dreams, 31 Learned helplessness, 195 Learning disorder

concordance rate, 395 epidemiology, 391 features, 389–390 specific, 391t

Learning experience anxiety disorders and, 123–124 paraphilic disorders and, 338 substance-related disorders and, 263–264

Lethal dose (LD), 247–248 Lewy body

defined, 430, 439 dementia and, 430–431, 439 features, 431t Parkinson’s disease and, 432

Lifetime prevalence defined, 54–55 of mental disorders, 57f rates, 56, 56f

Light therapy for SAD, 206 Limbic system, 25 Limited developmental disorder, 385 Longitudinal study, 96

Inappropriate affect, 353 Incidence, 54 Indecent exposure, 330 Independent variable, treatment as, 92 Indicated prevention, 66 Induction defect, 395 Industrial psychologist, job description, 457t Infantile autism. See Autism spectrum disorderSee Autism spectrum disorderSee In�exible family, 43 Informant report for personality disorder

assessment, 304 Information transfer, and anxiety disorders, 123 Informed consent, 138, 471 Inhalants

defined, 256 diagnostic categories of excessive use, 248t–249t

Insanity competency to stand trial, 33 criminal, 33, 69 personality and, 305

Insight, 31 Insomnia, and stress, 480 Insula, and substance-related disorders,

260, 260f Insular cortex, and substance-related disorders,

260, 260f Integrative psychotherapy, 46–47 Intellectual disability

chromosomal aberrations and, 394t epidemiology, 391 features, 385–390, 386t severity subtypes, 387

Intelligence test as assessment technique, 80–81 developmental disorders and, 399

Internal consistency reliability, 77t, 79 Internal validity, 93 International Diagnostic Checklists, 153 International Index of Erectile

Dysfunction, 325 Interoceptive exposure, 135 Interpersonal effectiveness skills training, 305 Interpersonal factors, and depressive and

bipolar disorders, 196 Interpersonal therapy (IPT), for depression,

208–209 Interpretation in psychodynamic

therapy, 31–32 Interrater reliability, 77t, 79 Intervention, brief, and substance-related

disorders, 274–275 Interview

anxiety disorders and, 127–128 as assessment technique, 80 depressive and bipolar disorders and,

201–202 developmental disorders and, 400 disruptive behavior disorders and, 415 dissociative disorders and, 167 eating disorders and, 231–233 neurocognitive disorders and, 443–444 paraphilic disorders and, 340 personality disorders and, 303t, 304 psychotic disorders and, 374 sexual dysfunction and, 325 somatic symptom disorders and, 153 structured interview(s), 80. See also specific

types

Hallucinogens diagnostic categories of excessive use, 248t–249t excessive use, 254–255

Halstead-Reitan Neuropsychological Test Battery, 89, 445

Halstead-Reitan test, 375 Hamilton Rating Scale for Depression, 201, 202t Headaches, and stress, 479–480 Health psychologist, job description,

456t–457t Hemorrhagic stroke, 431 Heritability, 24, 24f Heroin

excessive use, 254 Vietnam soldiers and, 263

Heteromodal association cortex, 368 Hierarchy of needs, 34f High school student suicide prevention, 68 Hippocampus and substance-related disorders,

260, 260f Histrionic personality disorder, 291t

epidemiology, 292 features, 289–290

Home and School Situations Questionnaire, 415t Hopelessness, 203 Hopelessness theory, 195 Hormonal features of depressive and bipolar

disorders, 192–193 Humanistic assessment, 35 Humanistic model, 32–36 Humanistic treatment, 35 Hypersomnia, 175, 480 Hypertension, 480–481 Hypnosis, and dissociative disorders, 168 Hypnotics, 248t–249t Hypoactive sexual desire disorder, 315, 316t Hypomanic episode, 179–180, 184t, 185t Hypomanic Personality Scale, 202–203 Hypothalamic-pituitary-adrenal (HPA) system

and anxiety disorders, 121 Hypothalamus

eating disorders and, 226, 226f function, 25

Hypothesis anxiety disorders and, 133 as experimental tool, 92

Hypoxic ischemia, and psychotic disorders, 370 Hypoxyphilia, 333

I Id, 29 Illness anxiety disorder, 145, 146t

cognitive therapy and, 154 features, 145–146 prevalence rate, 148t

Illness Attitude Scales, 153 Illness attribution, 150–151 Illness behavior and somatic symptom

disorders, 150 Illness Behaviour Questionnaire, 153 Illness belief, 150–151 Impact of Event Scale, 130t Impotence, 316, 317t Impulsivity

defined, 52–53 eating disorders and, 227 substance-related disorders and, 264

Subject Index I-25

Methadone treatment, 273 Methamphetamine, excessive use, 253–254 “Meth” epidemic, 254 Miami-Dade Juvenile Assessment Center

Post-Arrest Diversion Program, 417 Michigan Alcohol Screening Test, 270 Migraine headaches, 479–480 Migration defect, 395 Milieu therapy, 377 Millon Clinical Multiaxial Inventory-III, 269 Millon Clinical Multiaxial Inventory-IV, 303 Mind

Freud’s structure, 29f structure and mental disorders, 29–30

Mindfulness, 486 anxiety disorders and, 136 personality disorders and, 305 as treatment for depression, 208

Mini-Cog dementia screening test, 444 Mini-Mental State Examination (MMSE), 445f Mini-Mental State Examination (MMSE-2),

444, 445f Minnesota Multiphasic Personality Inventory-2

(MMPI-2), 153, 269, 303 Mixed dementia, 432, 437, 440 Mixed design study, 94 MMPI-2 clinical scale, 82–84,

82t, 83f MMPI-2 validity scale, 81–84 M’Naghten rule, 69 Mobility Inventory, 130t Modeling

anxiety disorders and, 136 defined, 38

Model(s). See also speci�c types defined, 22 uses, 23f

Molecular genetics, 24 Monoamine oxidase inhibitor (MAOI),

205, 205t Mood

continuum, 176f–177f cycling, 185 disorder, age of onset of, 56–57 normal changes in, 174–175

Mood-stabilizing drugs for bipolar disorder, 205–206, 205t for depression, 205–206, 205t

Morphine, excessive use, 254 Motivating factor, 38 MRI. See Magnetic resonance imaging (MRI)See Magnetic resonance imaging (MRI)See Mukhannathun, 344 Multicultural psychology, 16 Multidimensional Anxiety Scale for

Children, 130t Multidimensional Inventory of Development,

Sex, and Aggression, 340 Multiphasic Sex Inventory, 340 Multiple personality disorder. See Dissociative See Dissociative See

identity disorder Munchausen syndrome, 147 Myograph, 340

N Nar-Anon, 276 Narcissistic personality disorder, 291t

epidemiology, 292 features, 290–291

Mental disorder age of onset, 56–57, 57f assessing, 76–77 biological assessment, 25 biological model, 22, 23 classifying, 76 consumer perspective, 15–16 criminal justice system and, 466 defined/defining, 4–11, 74–76 dimensional perspective, 14 disability and, 59f features, 75 genetics as cause, 23–24 heritability, 24, 24f media research, 96 models describing, 22–23 perspectives explaining, 46t prevalence rates, 55–57, 57f prevention, 63–69 prevention perspective, 14–15 protective factors, 61–63, 62t psychogenic perspectives, 14 relevance of understanding, 8–11 research use and quality, 469 rights of the hospitalized, 466 risk factors, 59–61, 61t severe, and aftercare services, 463–464 severity rates, 56f somatogenic perspectives, 14 studying, 92–97 treatment. See Mental disorder treatmentSee Mental disorder treatmentSee

Mental disorder treatment active ingredients, 459–460 aftercare services, 463–464 biological, 25 caveats, 467 client-therapist differences, 467 clinicians vs. researchers, 468 cost, 58 cultural differences, 467 effectiveness, 462 ethics and, 470–472 lack of access, 470 managed care, 468 manualized, 462 noncompliance, 467 nonspecific factors, 460 prescriptive, 462–463 for preventing child maltreatment, 65t process variables, 460–462 quick fixes, 469 rights of the hospitalized, 466 seekers, 458–459 seeking, 57–58 self-help groups, 463–464

Mental health, public policy, 466 Mental health professional

ethics and, 470–472 preparation, 455, 457–458 seeking treatment from, 458–459 types, 454–455

Mental hygiene, 14 Mental hygiene movement, 13–14 Mental status examination, 444 Mesolimbic system, and substance-related

disorders, 259, 260f Metabolite and neurochemical

assessment, 87

Long-term memory and aging, 425 Loose association, 355 Lycanthropy, 13

M MacAndrew Alcoholism Scale, 269 Magnetic resonance imaging (MRI)

as assessment tool, 87 function, 25 healthy, 28f neurocognitive disorders and, 445 schizophrenia, 28f

Major depression brain and, 193f features, 177–178 prevalence rates, 189f

Major depressive disorder cycle of, 179f features, 177–178, 178t

Major depressive episode, 175–177 Maladaptive behavior, 6 Male erectile disorder, 317t. See also Erectile

disorder/dysfunction Male hypoactive sexual desire disorder,

315, 316t Malingering, 147 Maltreatment

anxiety disorders and, 123 disruptive behavior disorders and, 412 elder abuse, 436

Managed care, 468 Mania, 175 Manic depression. See Bipolar I disorderSee Bipolar I disorderSee Manic episode, 179–180, 184t Manifest content, of dreams, 31 MAOI, for depression, 205, 205t Marijuana, excessive use, 255–256 Marital status, and mental disorders, 61, 61t Marital therapy, 44

depressive and bipolar disorders and, 209 substance-related disorders and, 275

Marriage and family therapist quali�cations, 455 Maslow’s hierarchy of needs, 34f Mass madness, 12 Masturbation training, 327 Masturbatory reconditioning, 342 Masturbatory satiation, 342 Maudsley Obsessional-Compulsive

Inventory, 130t Meaninglessness, de�ned, 35 Measurement psychologist, job

description, 457t Media

eating disorders and, 228–229 mental disorders and, 96

Medication. See also speci�c types for depressive and bipolar disorders, 25,

204–206, 205t for eating disorders, 236 for neurocognitive disorders, 445–446 token economy and compliance with, 378

Medulla, function, 25 Megan’s laws, 341 Melancholia, 175 Memory

change and dissociative disorders, 164, 165f problems continuum, 426f–427f training, 447

Subject IndexI-26

Olfactophilia, 335t Operant conditioning, 36, 38f Opiate/Opioid, excessive use, 248t–249t, 254 Oppositional de�ant disorder

defined, 406 features, 406–407, 409t sample multifactorial model, 413, 414f

Orbitofrontal cortex obsessive-compulsive behavior and, 120 substance-related disorders and, 260f, 261

Organismic variable, 85 Organizational psychologist, job

description, 457t Orgasmic reconditioning, and paraphilias, 341, 342 Other-centeredness, 34 Oxidative stress, 439–440

P Painkiller, excessive use, 254 Pa-leng, 116 Panic and Agoraphobia Scale, 130t Panic attack, 103–104, 104t Panic disorder

causes, 125 cognitive therapy examples for, 133t diagnostic criteria, 104t exposure-based therapy examples for, 134t features, 104–105 genetics and, 119 prevalence rates, 115f psychoeducation example for, 132t somatic control exercise example for, 132t

Paranoid personality disorder, 284t, 285t, 364f Paraphilic disorder

assessing, 340–341 atypical, 334, 335t causes, 339 defined, 329 deviant sexual interest and, 335t environmental risk factors, 337–339 epidemiology, 335–336 evolution and, 338–339 features, 329t, 330–334 interview and, 340 long-term outcomes, 342 physiological assessment, 340–341 prevalence rates, 335–336, 335t prevention, 339 sample developmental pathway, 339, 339f screening questions, 342t treatment (biological), 341 treatment (psychological), 341–342

Paraprofessional quali�cations, 455 Parasomnias, 480 Parasuicidal behavior, 187 Parietal lobe

function, 25 learning disorders and, 396 schizophrenia and, 368

Parkin gene, 437 Parkinson’s disease, 432

brain atrophy and, 439 dementia and, 432, 435 features, 433t genetics and, 437 prevalence rates, 435

Neuropsychological testing, 399–400 Neuropsychologist, 457t Neurosis, 352 Neurotic disorder, 353 Neurotransmitter

anxiety disorders and, 120 defined, 24 mental disorders and, 25t

Nicotine, excessive use, 253 Nicotine replacement therapy, 273 Nightmare disorder, 480 Nocturnal penile testing, 325 Nonassociative theory of fear, 124 Nondirective treatment, 35 Noonan syndrome, 394t Norepinephrine

anxiety disorders and, 121 depression and, 25 functions, 25t

Normal behavior, de�ned, 4–5 Normal impulsivity, 282f–283f Normalization, 465 Normal mood change, 174–175 Normal rambunctious behavior, 404 Norm-referenced test, 399 No-suicide contract, 210

O Objective personality measure, 81–84 Obscene phone calls, 330 Observation

as assessment technique, 85–86 controlled, 86 of depressive and bipolar disorders, 203 of developmental disorders, 400 of disruptive behavior disorders, 415 naturalistic, 85 of psychotic disorders, 374–375 of substance-related disorders, 271

Obsession, 108 Obsessive-compulsive disorder, 109. See also

Anxiety disorder brain features and, 120 cognitive distortions and, 122–123 cognitive therapy examples for, 133t exposure-based therapy examples for, 134t features, 108, 108t genetics and, 118–119 prevalence rates, 115f psychoeducation example for, 132t related disorders, 108–109 somatic control exercise example for, 132t stigma associated with, 117–118

Obsessive-compulsive personality disorder, 294t environmental risk factors, 300 epidemiology, 294–295 features, 294–295

Occipital lobe function, 25 schizophrenia and, 368

Odd/eccentric personality disorder biological risk factors, 297 causes, 297–298, 297f environmental risk factors, 297 epidemiology, 287 features, 285–288

Narcolepsy, 480 Narcotics, excessive use. See Substance use See Substance use See

disorder Narcotics Anonymous, 276, 463 Narratophilia, 335t National Alliance for the Mentally Ill, 463 National Eating Disorders Awareness Week, 230 National Institute of Mental Health Diagnostic

Interview Schedule for Children, 415 Natural experiments, 94–95 Natural incidental training, 401 Naturalistic observation, 85 Necrophilia, 335t Needs, human, 33 Negative affectivity, 117 Negative cognitive triad, 195, 195f Negative correlation, 94 Negative reinforcement, 37 Negative schizophrenia dimension, 359f Negative thought pattern, and anxiety

disorders, 122 Neighborhood and mental disorders, 43 Neologism, 355 Neonatal Intensive Care Unit Network

Neurobehavioral Scale, 399 Nervous system, and mental disorders, 24 Neuritic plaque, 438–439 Neurochemical assessment, of neurotransmitter

systems, 87–88 Neurochemical change

ADHD and, 410 neurocognitive disorders and, 437–438

Neurochemical features of depressive and bipolar disorders, 192–193 of eating disorders, 226–227 of schizophrenia, 369–370 of substance-related disorders, 261–262

Neurocognitive assessment, 445 Neurocognitive disorder. See also speci�c types

aging and, 425 assessing, 443–445 biological risk factors, 437–441 case study, 424 causes, 441–442 continuum, 426f–427f environmental risk factors, 440–443 epidemiology, 434–435 features, 426–433, 430t genetics and, 437 interview and, 443–444 long-term outcomes, 449 major disorders, 430t maltreatment of patients, 436 minor disorders, 430t prevention, 443 stigma associated with, 435–436 treatment (biological), 445–446 treatment (nursing home), 446 treatment (psychological), 446–447 treatment (residential), 446

Neurodevelopmental hypothesis, 371–372 Neuro�bromatosis, 394t Neuro�bromatosis tangles, 438 Neuroimaging, 87 Neuron, 24f Neuropsychological assessment, 89–90 Neuropsychological problems, and rape, 337

Subject Index I-27

psychoeducation example for, 132t somatic control exercise example for, 132t stigma associated with, 117–118

Poverty, and disruptive behavior disorders, 412 Prader-Willi syndrome, 394t Predictive validity, 79

defined, 79t Preferential rape, 338 Prefrontal cortex, 260f

anxiety disorders and, 120 substance-related disorders and,

260–261, 260f Premature ejaculation

features, 317, 318t treatment, 325

Premenstrual dysmorphic disorder, 182t Prenatal complication

developmental disorders and, 394–395 schizophrenia and, 370, 371f

Preparedness and anxiety disorders, 122 Presenile dementia, 428 Presenting somatization, 145 Pretherapy, 35 Prevalence rates, of major mental disorders.,

56, 56f. See also speci�c disorders Prevention, of mental disorders, 63–69 Primary gain, 150 Primary prevention

of alcohol use disorders, 66–68 defined, 64 of suicidal behavior, 68

Priming, 259 Privileged communication, 471 Pro-anorexia websites, 237 Problem behavior, addressing, 403 Problem-solving skills training, 207 Process variable, 35 Prodromal schizophrenia phase, 357–358, 358f Prognosis, 137 Projection, 30 Projective hypothesis, 31 Projective personality measure, 84–85 Projective technique, 31 Protective factor

for children, 63 mental disorders and, 61–63, 62t

Proximal factor, 267 Pseudoseizure, 146 Psychiatric nurse (R.N.) quali�cations, 455 Psychiatrist quali�cations, 454–455 Psychic determinism, 29 Psychoanalyst quali�cations, 455 Psychobiological theory, of personality

disorders, 297 Psychodynamic model

assessment, 30–32 evaluating, 32 mental disorders and, 28–32 overview, 29–30 treatment, 30–32

Psychodynamic perspective principles, 28–29 Psychoeducation and anxiety disorders,

131–132, 132t Psychological autopsy, and suicide, 203 Psychological drug dependence, 245 Psychological factors affecting medical

conditions, 479t

clinical psychology study (Julia Martinez), 460–461

counseling psychologist (Tiffany S. Borst), 464–465

depression (anonymous), 78–79 depression (Karen Gormandy), 180–181 dissociative identity disorder (Heather Pate),

160 eating disorders (Rachel Webb), 232 integrative psychology (Dr. J. C. Norcross),

46–47 schizophrenia (John Cadigan), 360–361 substance-related disorders, 270–271 suicide (Alison Malmon), 18–19 transsexuality (Sam), 348–349 Wellness Resource Center (Kim Dude), 70–71

Person-centeredness, 34 Perspective

defined, 22 uses, 23f

Pervasive developmental disorder, 385 PET scan. See Positron emission tomography See Positron emission tomography See

(PET scan) Phallometric testing, 340 Phencyclidine (PCP), 256 Phencyclidine, excessive use, 248t–249t Phenomenological approach, 33 Phenotype, 23 Phenylketonuria (PKU), 393 Phii bob, 163 Phong tap, 151 Physical assessment and eating disorders, 234 Physiological assessment

of anxiety disorders, 130 of psychotic disorders, 375–376 of sexual dysfunctions, 325

Physiological needs, 33 Pick’s disease

brain atrophy and, 439 dementia and, 433 features, 432–433

Placebo effect, 93, 460 Planum temporale, and learning disorders, 396 Playboy bunnies, and eating disorders, 228 Pleasure principle, 29 Plethysmography, 340–341 Polygenic transmission, 191 Pons, 25 Positive correlation, 94 Positive psychology, 35 Positive regard, 34 Positive reinforcement, 36–37 Positron emission tomography (PET scan)

as assessment tool, 87 neurocognitive disorders and, 445, 446f

Possession disorder, and culture, 162 Possession trance disorder, 165 Postpartum depression, 182t–183t Postpartum psychosis, 362 Posttraumatic stress disorder (PTSD)

cognitive therapy examples for, 133t culture and, 124 dissociation, 165 exposure-based therapy examples for, 134t features, 109–110, 110t–112t, 112, 114 genetics and, 119 prevalence rates, 115f

Partial agonist, and substance-related disorders, 273–274

Partialism, 335t PCP (Phencyclidine), 256 Pedophilic disorder

features, 332–333, 332t focus of arousal, 329t Screening Scale for Pedophilic Interests, 340t subtypes, 333

Peer in�uence, and disruptive behavior disorders, 412

Peer-mediated intervention, 402 Penetration disorder, 318, 318t Penile plethysmograph, 340 Penn State Worry Questionnaire, 130t Perceptual psychologist, job description, 456t Perfectionism, and eating disorders, 227 Perinatal complication, and developmental

disorders, 394–395 Peripheral nervous system, 24 Persecutory delusion, 354, 361 Persistent depressive disorder

cycle of, 179f features, 183t

Personal distress as abnormal behavior, 7 Personality

disruptive behavior disorders and, 411 and insanity, 305 stress-related problems and, 481–482 substance-related disorders and, 264–265 trait, 283

Personality assessment as assessment technique, 81–85 somatic symptom disorders and, 153

Personality Diagnostic Questionnaire-4 (PDQ-4), 303, 303t

Personality disorder, 284t. See also speci�c types assessing, 303–304 assessment method comparison, 303t cognitive-behavioral therapy and, 305 dialectical behavior therapy and, 305–307 dimensional model of, 284–285 features, 283–284 gender and, 295, 296 general personality disorder, 284t impulsivity continuum, 282f–283f, 283 interview and, 304 long-term outcomes, 307–310 organization, 284 paraphilic disorders and, 336 prevalence rates, 287 prevention, 300–301 screening questions, 307, 307t short-term psychodynamic therapy and, 305 stigma associated with, 295 treatment (biological), 304 treatment (psychological), 304–307 violence and, 292

Personalization, 37 Personal Journal of Body Image, 231 Personal narrative

ADHD (Toni Wood), 418–419 anorexia nervosa (Kitty Westin), 220–221 anxiety disorders (anonymous), 128–129 author’s note (Christopher A. Kearney), 469 borderline personality disorder (anonymous),

308–309

Subject IndexI-28

Right to treatment, 466 Risk factor. See also speci�c types

for depressive and bipolar disorders, 191–198 for gender dysphoria, 344 for mental disorders, 59–61, 61t for suicide, 191–198

Risky drug use, 245 Ritual prevention, and obsessive-compulsive

behavior, 135 Roo�e, 337 Rorschach test, 84f

as assessment technique, 84 psychodynamic assessment and, 31

“Running amok,” 41

S SAD. See Seasonal affective disorder (SAD)See Seasonal affective disorder (SAD)See Sadism

features, 333 focus of arousal, 329t rape, 337

Sadness continuum, 176f–177f Sadomasochism, 333 Safety/security needs, 34f St. Vitus’s dance, 13 Saliva test, for substance-related disorders, 272 Satiety, 226 Scatterplot, 95f Schedule for Affective Disorders and

Schizophrenia (SADS), 374 Schedule for Affective Disorders and

Schizophrenia and Structured Clinical Interview, 201

Schizoaffective disorder epidemiology, 364 features, 353t, 359–360, 360t

Schizoid personality disorder, 285, 286t, 364f Schizophrenia

adverse life events and, 370–371 bipolar disorder and, 193f brain and, 367–369, 368f, 369f cognitive deficits, 370 culture and, 371 differential diagnosis, 429t dimensions, 359f dopamine and, 25 epidemiology, 363–365 evolution and, 371 features, 353–357, 354t, 358t labeling and, 371 MRI results, 28f negative symptoms, 353, 354t, 356–357, 364f neurochemical features, 369–370 other criteria, 357 phases, 357–358, 358f positive symptoms, 353–357, 354t prenatal complications, 370, 371f prevalence rates, 367, 367f spectrum disorders, 364f stigma associated with, 365 substance use disorder and, 370–371, 371t two-hit model for prevention, 373 video about, 373 violence and, 366

Schizophreniform disorder epidemiology, 364 features, 353t, 358–359, 359t

paraphilias and, 340 for personality disorder assessment, 303, 303t for sexual dysfunction assessment, 325 for somatic symptom disorder assessment, 153

R Race. See also Diversity

anxiety disorder and, 115–116 defined, 41 eating disorders and, 222 mental disorders and, 61, 61t personality disorders and, 287

Randomization, 92 Rape

preferential, 338 violence and, 337

Rapid-eye-movement (REM) sleep, and depressive and bipolar disorders, 194

Rating scale developmental disorders and, 400 disruptive behavior disorders and, 415

Reaction formation, 30 Reality orientation, 447 Reality principle, 29 Recidivism rate, 342 Referential delusion, 354 Regression, 30 Rehabilitation

psychotic disorders and, 378 substance-related disorders and, 274

Rehabilitation psychologist, job description, 457t

Relapse prevention paraphilic disorders and, 339 substance-related disorders and, 268

Relaxation training, 131, 483 Reliability of assessment measures, 77–78, 77t Religion, as a protective factor, 63, 63f Reminiscence therapy

for dementia, 446 for depression, 207

REM-sleep, and depressive and bipolar disorders, 194

Repetitive transcranial magnetic stimulation (rTMS), 206

Repression, 30 Research design, 92–93 Researcher vs. clinician, 468 Residual schizophrenia phase, 358, 358f Resilience, 62–63, 62t Resiliency factor, 62–63 Resourceful Adolescent Program-Adolescents

(RAP-A), 199 Resourceful Adolescent Program-Family

(RAP-F), 199 Response prevention, in obsessive-compulsive

behavior, 135 Restricted eating, 216–217 Restricting behavior, and anorexia nervosa, 217,

217t Reticular activating system, 25 Retrospective analysis, and suicide, 203 Rett’s disorder, 394t Reuptake, 24 Reward de�ciency syndrome, 261, 337 Right to least restrictive treatment, 466 Right to refuse treatment, 466

Psychological predisposition, 53 Psychological risk factor

for gender dysphoria, 344 for sexual dysfunctions, 322–323

Psychological testing, and substance-related disorders, 269–270

Psychological treatment, of anxiety disorders, 131–136

Psychologist public statements by, 472 types, 454, 456t–457t

Psychopathologist, 8 Psychopathy, 264, 288 Psychophysiological assessment, 88–89 Psychophysiological disorders, 478–479 Psychosexual development stages, 30, 30t Psychosis, 353, 357 Psychosomatic, 144 Psychotherapist quali�cations, 455 Psychotherapy, and dissociative

disorders, 168 Psychotic disorder. See also speci�c types

adverse life events and, 370–371 alternatives to hospital care, 379f antipsychotic medication and, 377f assessing, 374–376 biological risk factors, 367–370 causes, 371–373 continuum, 354f–355f environmental risk factors, 370–371 epidemiology, 363–365 examples, 353 features, 353–363 interview and, 374 long-term outcomes, 380 prevention, 373 sample developmental pathway, 372f screening questions, 380t substance use disorder and, 370–371 treatment (biological), 376–377 treatment (psychological), 377–379 types, 353t

Psychoticism subscale, 375t Psychotic schizophrenia dimension, 359f Psychotic schizophrenia prephase, 358, 358f Psychotic Symptoms Rating Scales, 374 PTSD. See Posttraumatic stress disorderSee Posttraumatic stress disorderSee Public health model, and abnormal

psychology, 15 Public policy, 466 Public stigma, 16, 17f Purging

anorexia nervosa and, 217t bulimia nervosa and, 219

Purkinje cell, 395

Q Qualitative assessment, 35 Quantitative psychologist, job

description, 457t Quasi-experimental method, 94 Questionnaire

for anxiety disorder assessment, 128, 130t for dissociative disorders assessment, 167 for eating disorder assessment, 233, 234t for mood disorder assessment, 202–203 for neurocognitive disorders, 444–445

Subject Index I-29

features, 105–106, 106t genetics and, 119 prevalence rates, 115f sample developmental pathway, 125f

Social Anxiety Scale for Children-Revised, 130t Social impairment from substance use, 245 Social Interaction Anxiety Scale, 130t Socialization differences, 42 Socialization training, for developmental

disorders, 401–402 Social needs, 34f Social norming, and substance use disorder

prevention, 66–68 Social phobia. See also Social anxiety disorder

cognitive therapy examples for, 133t exposure-based therapy examples for, 134t psychoeducation example for, 132t somatic control exercise example for, 132t

Social Phobia and Anxiety Inventory, 130t Social play group, 401–402 Social psychologist, job description, 457t Social skills training

for depression, 207 disruptive behavior disorders and, 416 for schizophrenia, 378

Social worker quali�cations, 455 Sociocultural assessment, 44 Sociocultural model, 40–45 Sociocultural perspective, 40–41 Sociocultural treatment, 44 Socioeconomic status, and mental disorders,

60–61 Somatic control exercises, 131, 132t Somatic delusion, 354, 361 Somatic symptom disorder, 143–145. See also

speci�c types assessing, 153 biological risk factors, 149 brain and, 150f causes, 151–152 continuum, 144f–145f defined, 143 environmental risk factors, 149–151 epidemiology, 147–148 evolution and, 151 features, 144–147, 144t guidelines, 153t historical introduction, 142 interview and, 153 long-term outcomes, 155 prevalence rates, 148t prevention, 152 stigma associated with, 148 treatment (biological), 154 treatment (psychological), 154–155

Somatization, 142 Somatoform disorder. See Somatic symptom See Somatic symptom See

disorder Somatoform Disorders Schedule, 153 Somatosensory Ampli�cation Scale (SAS),

153, 154t Somatosensory awareness, 151 Special education teacher quali�cations, 455 Speci�c phobia

causes, 126 cognitive therapy examples for, 133t exposure-based therapy examples for, 134t

Sex offender, 332, 341 Sex Offender Treatment Intervention and

Progress Scale, 340 Sex reassignment surgery, 346 Sex therapy, 325–327 Sexual arousal measurement, 340 Sexual behavior

continuum, 314f–315f, 328f–329f factors affecting, 325f normal, 314, 329

Sexual desire, normal, 329 Sexual disorder/dysfunction. See also speci�c

types age and, 318, 319t, 320t assessing, 325–327 biological risk factors, 322 causes, 323, 325f continuum, 314f–315f, 328f–329f culture and, 323, 324t defined, 314 epidemiology, 318, 320 features, 315–321 gender and, 319, 319t, 320, 320t, 324t interview and, 325 long-term outcomes, 328 prevalence rates, 319t, 320t prevention, 323 psychological risk factors, 322–323 screening questions, 327t stigma associated with, 321 treatment (biological), 325–326 treatment (physiological), 325 treatment (psychological), 326–327

Sexual fantasy, 329 Sexual intimacy, with clients, 471–472 Sexual masochism, 329t, 333, 333t Sexual response cycle, 315 Shame therapy, 342 Shock therapy

for depression, 206 ethical dilemmas, 206

Short-term memory, normal changes, 425–426 Short-term psychodynamic therapy, 305 Sickle cell disease, 393–394 Sign language, 401 Single photon emission computed tomography

(SPECT), 445 Single-subject experimental designs, 95–96 Skills training. See also speci�c types

depressive and bipolar disorders and, 207 developmental disorders and, 402–403 disruptive behavior disorders and, 416 for emotion regulation, 301, 302t personality disorders and, 300–301, 305 psychotic disorders and, 373, 378 schizophrenia and, 378 substance-related disorders and, 275

Sleep de�ciency, and depressive and bipolar disorders, 194

Sleep disorders, 480 Sleep terrors, 480 Sleepwalking, 480 Smith-Magenis syndrome, 394t Social anxiety disorder

behavioral inhibition and, 121 characteristics, 9–10 example, 9

Schizotypal personality disorder, 285–287, 287t, 364f

School psychologist job description, 457t qualifications, 454

School Refusal Assessment Scale-Revised, 130t School refusal behavior, 114 Scienti�c method, 92–96 Screening for Somatoform Disorders (SOMS), 153 Screening for Somatoform Disorders-7

(SOMS-7), 153 Screening Scale for Pedophilic Interests (SSPI),

340, 340t Seashore rhythm test, 89 Seasonal affective disorder (SAD)

features, 178 light therapy, 206

Secondary gain, 150 Secondary prevention, de�ned, 64, 66 Sedative

diagnostic categories of excessive use, 248t–249t

excessive use, 247–249, 251, 253 Selective prevention of eating disorder, 68 Selective serotonin reuptake inhibitor (SSRI)

for depression, 204–205, 205t for eating disorders, 236

Self-actualization, 33, 34f Self-care skills training, 402 Self-control therapy

for depression, 207 as treatment, 459

Self-help group mental disorders and, 463–464 substance-related disorders and, 276

Self-injurious behavior, 388 Self-instruction training, 486 Self-monitoring

as assessment technique, 86–87, 128–129 depressive and bipolar disorders and, 203 eating disorders and, 233–234 sexual dysfunction and, 325 substance-related disorders and, 275

Self-report questionnaire as assessment technique, 128, 130t depressive and bipolar disorders

and, 202–203 eating disorders and, 233 personality disorders and, 303

Self-stigma, 16–17, 17f Senile dementia, 428 Senile plaque, 438–439 Sensate focus, 325–326 Separation anxiety disorder

cognitive therapy examples for, 133t exposure-based therapy examples for, 134t features, 114, 114t prevalence rates, 115f psychoeducation example for, 132t somatic control exercise example for, 132t

Septal-hippocampal system, and anxiety disorders, 119–120

Sequential design, 96 Serotonin

anxiety disorders and, 120, 121f depression and, 24 functions, 25t

Subject IndexI-30

Tarantism, 12–13 Tardive dyskinesia, 377 TAT. See Thematic Apperception Test (TAT)See Thematic Apperception Test (TAT)See Tay-Sachs disease, 393 Teacher Report Form, 415 Telephone scatalogia, 330 Temporal lobe

function, 25 schizophrenia and, 368

Tension headaches, 485 Teratogen

developmental disorders and, 394–395 disruptive behavior disorders and, 411

Terrorism, and medically unexplained symptoms, 152

Tertiary prevention, 66 Test-retest reliability, 77, 77t Thalamus

function, 25 obsessive-compulsive behavior and, 120 schizophrenia and, 368

Thematic Apperception Test (TAT) as assessment technique, 84–85, 85f psychodynamic assessment and, 31

Theory of mind, 372 Therapeutic alignment, 462 Therapeutic alliance, 462 Therapeutic relationship, 472 Therapist

client-therapist differences, 467 clinicians vs. researchers, 468 negative characteristics, 469–470 types, 454–455

Therapy. See speci�c types Thinking problems continuum, 426f–427f Third variable problem, 94 Thought

continuum, 10f–11f primary process and id, 29 secondary process and ego, 29

Thought-action fusion, 122 Three-Factor Eating Questionnaire

(TFEQ-R), 234t Tip-of-the-tongue phenomenon, 425 Tobacco

diagnostic categories of excessive use, 248t–249t

epidemiology, 257 neurocognitive disorders and, 440

Token economy defined, 40 medication compliance and, 378 milieu therapy and, 377

Transference, 32 Transsexualism. See Gender dysphoriaSee Gender dysphoriaSee Transvestic fetishism

features, 334, 335t focus of arousal, 329t

Transvestism, 334 Trauma

dissociative disorders and, 164–165 resilience and, 62, 62t stigma associated with, 117–118

Trauma Symptom Checklist for Children, 167 Trephination, 12 Triangular relationship, 43 Trichotillomania, 117

causes, 266–267 comorbidity, 258 continuum, 246f–247f defined, 245 environmental risk factors, 262–266 epidemiology, 256–258 evolution and, 266 features, 245–256 genetics and, 259 interview and, 269 long-term outcomes, 276 prevalence rates, 257–258, 266 prevention, 267–268 stigma associated with, 258–259 treatment (biological), 273–274 treatment (inpatient), 274 treatment (psychological), 274–276 treatment (residential), 274 treatment seekers, 258 urinalysis and, 272, 272t

Substance tolerance, 245–246 Substance use

age of onset, 56–57 categories of, 247–256 normal, 244–245 schizophrenia and, 371t

Substance withdrawal, 245–246 Suicidal behavior

defined, 186–187 prevention, 68

Suicidal ideation, 187 Suicidality

assessing, 203 long-term outcomes, 211 models, 199 schematic for assessing, 203, 204f, 205f spectrum, 185–191, 187f treatment, 209–210

Suicide attempt, 187 biological risk factors, 191–194 college students and, 60 completion, 187 depressive and bipolar disorders and, 186–187 epidemiology, 189–190 gender and, 190 prevention, 200 transcultural variation and, 190f

Superego, 30 Supervised training center, 464 Support groups, 486 Supportive psychotherapy, 377–378 Sweat test, for substance-related disorders, 272 Symphorophilia, 335t Symptom Checklist 90-R Crime-Related PTSD

Scale, 130t Synapses, and mental disorders, 24 Syndrome, de�ned, 23, 75 Systematic desensitization

anxiety disorders and, 134 defined, 39

T Tactual performance test, 89 Taijin kyofusho, 116 Tangentiality, 355–356

features, 106, 106t genetics and, 119 prevalence rates, 115f psychoeducation example for, 132t somatic control exercise example for, 132t

SPECT (single photon emission computed tomography), 445

Speech imitation, 401 Spirituality, as a protective factor, 63, 63f Sports psychologist, job description, 457t SSRI. See Selective serotonin reuptake inhibitor See Selective serotonin reuptake inhibitor See

(SSRI) Standardization, of assessment measures,

79–80 State-Trait Anxiety Inventory, 130t Steroids, 256 Stigma, 16–17, 17f. See also speci�c disorders Stimulant, excessive use, 253–254

diagnostic categories of, 248t–249t Stress

assessing, 483 causes, 481–482 culture and, 90–91 defined, 47, 478 depressive and bipolar disorders and, 194 diathesis and, 53 lifetime event exposure and nomination

as worst event, 484t–485t long-term outcomes, 487 management of, 485–486 prevention, 482–483 social support, 482 substance-related disorders and, 262–263 treatment, 483, 485–486

Stress-induced relapse, 262 Stria terminalis

anxiety disorders and, 120 substance-related disorders and, 260, 260f

Stroke causes, 431 genetics and, 437 vascular disease and, 431–432

Structured Clinical Interview, 233 Structured Clinical Interview for Dissociative

Disorders-Revised (SCID-D-R), 167 Structured Clinical Interview for DSM-5

Personality Disorders, 304 Structured Clinical Interview for DSM-5, 153 Structured interview, 80 Student Bodies, 231 Subcortical dementia, 431 Substance use disorder, 245–255

continuum, 246f–247f diagnostic categories, 248t–249t features, 245 schizophrenia and, 370–371 social norming and prevention, 66–68 stigma associated with, 258 stimulant, excessive use. See Stimulant, See Stimulant, See

excessive use street names, 250t

Substance dependence, 245 Substance intoxication, 246 Substance-related disorder, 245–246, 245t

assessing, 269–272 biological risk factors, 259–262 causal model, 267f

Subject Index I-31

Vulnerability to anxiety disorders, 124–125, 125f to depressive and bipolar disorders, 198–199 to dramatic personality disorders, 298, 299f to eating disorders, 230

W Waxy �exibility, 356 Wechsler Adult Intelligence Scale

neurocognitive disorders and, 445 overview, 80–81 psychotic disorders and, 375 simulated examples, 81f, 81t

Wechsler Memory Scale (WMS-IV), neurocognitive disorders and, 445

Weight concern continuum, 217, 218f–219f defined, 216

Whiteley Index, 153 Wide Range Achievement Test (4th edition)

(WRAT-4), 375, 399–400 Williams syndrome, 394t Worry

continuum, 102f defined, 101

Worry exposure, 136

Z Zoophilia, 335t

V Vaginal photoplethysmograph, 340 Validity

of assessment measures, 78–79 of experimental studies, 93 types, 79t

Variable (experimental), 92–93 Vascular dementia, 432t Vascular disease

features, 431–432 prevalence rates, 434–435

Vascular neurological disorder, 431–432, 432t

Vicarious conditioning, 38 Vineland Adaptive Behavior Scales, Third

Edition (Vineland-3), 400 Violence, 28

alcohol and, 264 dissociative disorders and, 166 elder abuse, 436 juvenile arrests and diversion, 417 personality disorders and, 292 predisposition to, 28 prevention, 64 rape, 337 schizophrenia and, 366 somatic symptom disorders and, 152

Virtual reality therapy, 135 Voyeurism, 329t, 334, 335t

Tricyclic antidepressant, 205 for depression, 205t

Triple-blind designs, 93 Troilism, 335t Turner syndrome, 394t Twin study

anxiety disorders and, 119 depressive and bipolar disorders

and, 191 schizophrenia and, 367

Two-hit model for schizophrenia, 373 Type D personality, 482

U Ulcers, and stress, 479 Unconditional positive regard, 34 Unconditioned stimulus (UCS), 36, 37f Unconscious, 28–29 Unconscious motivation, 29 Unipolar depression, 177–178 Unipolar disorder, 175 Universal prevention

of alcohol use disorders, 66–68 defined, 64 of suicidal behavior, 68

Unstructured interview, 80 Urinalysis, and substance-related disorders,

272, 272t Urophilia, 335t

Neurodevelopmental Disorders Intellectual Disabilities Intellectual Disability (Intellectual

Developmental Disorder)/Global Developmental Delay/Unspeci�ed Intellectual Disability (Intellectual Developmental Disorder)

Communication Disorders Language Disorder/Speech Sound

Disorder/Childhood-Onset Fluency Disorder (Stuttering)/Social (Pragmatic) Communication Disorder/Unspeci�ed Communication Disorder

Autism Spectrum Disorder Autism Spectrum Disorder

Attention-Deficit/Hyperactivity Disorder Attention-De�cit/Hyperactivity Disorder/

Other Speci�ed Attention-De�cit/ Hyperactivity Disorder/Unspeci�ed Attention-Defi it/Hyperactivity Disorder

Specific Learning Disorder

Motor Disorders Developmental Coordination Disorder/

Stereotypic Movement Disorder

Tic Disorders Tourette’s Disorder/Persistent (Chronic)

Motor or Vocal Tic Disorder/Provisional Tic Disorder/Other Speci�ed Tic Disorder/Unspecifi Tic Disorder

Other Neurodevelopmental Disorders Other Speci�ed Neurodevelopmental

Disorder/Unspeci�ed Neurodevelopmental Disorder

Schizophrenia Spectrum and other Psychotic Disorders Schizotypal (Personality) Disorder Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoa�ective Disorder�ective Disorder� Substance/Medication-Induced Psychotic

Disorder Psychotic Disorder Due to Another

Medical Condition Catatonia Associated with Another

Mental Disorder Catatonic Disorder due to Another

Medical Condition

Unspeci�ed Catatonia Other Speci�ed Schizophrenia Spectrum

and Other Psychotic Disorder Unspeci�ed Schizophrenia Spectrum and

Other Psychotic Disorder

Bipolar and Related Disorders Bipolar I Disorder/Bipolar II Disorder/

Cyclothymic Disorder/Substance/ Medication-Induced Bipolar and Related Disorder/Bipolar and Related Disorder Due to Another Medical Condition/ Other Speci�ed Bipolar and Related Disorder/Unspeci�ed Bipolar and Related Disorder

Depressive Disorders Disruptive Mood Dysregulation Disorder/

Major Depressive Disorder/Persistent Depressive Disorder (Dysthymia)/ Premenstrual Dysphoric Disorder/ Substance/Medication-Induced Depressive Disorder/Depressive Disorder Due to Another Medical Condition/ Other Speci�ed Depressive Disorder/ Unspeci�ed Depressive Disorder

Anxiety Disorders Separation Anxiety Disorder/Selective

Mutism/Speci�c Phobia/Social Anxiety Disorder (Social Phobia)/ Panic Disorder/Panic Attack Speci�er/ Agoraphobia/Generalized Anxiety Disorder/Substance/Medication-Induced Anxiety Disorder/Anxiety Disorder Due to Another Medical Condition/Other Speci�ed Anxiety Disorder/Unspeci�ed Anxiety Disorder

Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder/Body

Dysmorphic Disorder/Hoarding Disorder/Trichotillomania (Hair-Pulling Disorder)/Excoriation (Skin-Picking) Disorder/Substance/Medication- Induced Obsessive-Compulsive and Related Disorder/Obsessive-Compulsive and Related Disorder Due to Another Medical Condition/Other Speci�ed Obsessive-Compulsive and Related Disorder/Unspeci�ed Obsessive- Compulsive and Related Disorder

Trauma- and Stressor- Related Disorders Reactive Attachment Disorder/Disinhibited

Social Engagement Disorder/Post- traumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 Years and Younger)/Acute Stress Disorder/Adjustment Disorders/ Other Speci�ed Trauma- and Stressor- Related Disorder/Unspeci�ed Trauma- and Stressor-Related Disorder

Dissociative Disorders Dissociative Identity Disorder/Dissociative

Amnesia/Depersonalization/ Derealization Disorder/Other Speci�ed Dissociative Disorder/Unspeci�ed Dissociative Disorder

Somatic Symptom and Related Disorders Somatic Symptom Disorder/Illness

Anxiety Disorder/Conversion Disorder (Functional Neurological Symptom Disorder)/Psychological Factors A�ecting Other Medical Conditions/�ecting Other Medical Conditions/� Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another)/Other Speci�ed Somatic Symptom and Related Disorder/Unspeci�ed Somatic Symptoms and Related Disorder

Feeding and Eating Disorders Pica/Rumination Disorder/Avoidant/

Restrictive Food Intake Disorder/ Anorexia Nervosa (Restricting type, Binge-eating/Purging type)/Bulimia Nervosa/Binge-Eating Disorder/Other Speci�ed Feeding or Eating Disorder/ Unspeci�ed Feeding or Eating Disorder

Elimination Disorders Enuresis/Encopresis/Other Speci�ed

Elimination Disorder/Unspeci�ed Elimination Disorder

Sleep-Wake Disorders Insomnia Disorder/Hypersomnolence

Disorder/Narcolepsy

DSM-5 CLASSIFICATIONS

Breathing-Related Sleep Disorders Obstructive Sleep Apnea Hypopnea/

Central Sleep Apnea/Sleep-Related Hypoventilation/Circadian Rhythm Sleep-Wake Disorders

Parasomnias Non-Rapid Eye Movement Sleep Arousal

Disorders/Nightmare Disorder/Rapid Eye Movement Sleep Behavior Disorder/ Restless Legs Syndrome/Substance/ Medication-Induced Sleep Disorder/ Other Speci�ed Insomnia Disorder/ Unspeci�ed Insomnia Disorder/Other Specifi d Hypersomnolence Disorder/ Unspecifi d Hypersomnolence Disorder/ Other Speci�ed Sleep-Wake Disorder/ Unspeci�ed Sleep-Wake Disorder

Sexual Dysfunctions Delayed Ejaculation/Erectile Disorder/

Female Orgasmic Disorder/Female Sexual Interest/Arousal Disorder/ Genito-Pelvic Pain/Penetration Disorder/Male Hypoactive Sexual Desire Disorder/Premature (Early) Ejaculation/ Substance/Medication-Induced Sexual Dysfunction/Other Speci�ed Sexual Dysfunction/Unspeci�ed Sexual Dysfunction

Gender Dysphoria Gender Dysphoria/Other Specifi d

Gender Dysphoria/Unspeci�ed Gender Dysphoria

Disruptive, Impulse-Control, and Conduct Disorders Oppositional De�ant Disorder/Intermittent

Explosive Disorder/Conduct Disorder/ Antisocial Personality Disorder/ Pyromania/Kleptomania/Other Speci�ed Disruptive, Impulse-Control, and Conduct Disorder/Unspeci�ed Disruptive, Impulse-Control, and Conduct Disorder

Substance-Related and Addictive Disorders

Substance-Related Disorders Alcohol-Related Disorders: Alcohol Use

Disorder/Alcohol Intoxication/Alcohol Withdrawal/Other Alcohol-Induced Disorders/Unspeci�ed Alcohol-Related Disorder

Ca�eine-Related Disorders: Ca�eine-Related Disorders: Ca� �eine �eine � Intoxication/Ca�eine Withdrawal/Other �eine Withdrawal/Other � Ca�eine-Induced Disorders/Unspe�eine-Induced Disorders/Unspe� ci�ed Ca�eine-Related Disorder�eine-Related Disorder�

Cannabis-Related Disorders: Cannabis Use Disorder/Cannabis Intoxication/ Cannabis Withdrawal/Other Cannabis- Induced Disorders/Unspeci�ed Cannabis-Related Disorder

Hallucinogen-Related Disorders: Phencyclidine Use Disorders/ Other Hallucinogen Use Disorder/ Phencyclidine Intoxication/Other Hallucinogen Intoxication/Hallucinogen Persisting Perception Disorder/Other Phencyclidine-Induced Disorders/ Other Hallucinogen-Induced Disorders/ Unspeci�ed Phencyclidine-Related Disorders/Unspeci�ed Hallucinogen- Related Disorders

Inhalant-Related Disorders: Inhalant Use Disorder/Inhalant Intoxication/Other Inhalant-Induced Disorders/Unspeci�ed Inhalant-Related Disorders

Opioid-Related Disorders: Opioid Use Disorder/Opioid Intoxication/Opioid Withdrawal/Other Opioid-Induced Disorders/Unspeci�ed Opioid-Related Disorder

Sedative-, Hypnotic-, or Anxiolytic- Related Disorders: Sedative, Hypnotic, or Anxiolytic Use Disorder/Sedative, Hypnotic, or Anxiolytic Intoxication/ Sedative, Hypnotic, or Anxiolytic Withdrawal/Other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders/ Unspeci�ed Sedative-, Hypnotic-, or Anxiolytic-Related Disorder

Stimulant-Related Disorders: Stimulant Use Disorder/Stimulant Intoxication/ Stimulant Withdrawal/Other Stimulant- Induced Disorders/Unspeci�ed Stimulant-Related Disorder

Tobacco-Related Disorders: Tobacco Use Disorder/Tobacco Withdrawal/Other Tobacco-Induced Disorders/Unspeci�ed Tobacco-Related Disorder

Other (or Unknown) Substance-Related Disorders: Other (or Unknown) Substance Use Disorder/Other (or Unknown) Substance Intoxication/Other (or Unknown) Substance Withdrawal/ Other (or Unknown) Substance-Induced Disorders/Unspeci�ed Other (or Unknown) Substance-Related Disorder

Non-Substance-Related Disorders Gambling Disorder

Neurocognitive Disorders Delirium

Major and Mild Neurocognitive Disorders Major or Mild Neurocognitive Disorder

Due to Alzheimer’s Disease Major or Mild Frontotemporal

Neurocognitive Disorder Major or Mild Neurocognitive Disorder

with Lewy Bodies Major or Mild Vascular Neurocognitive

Disorder Major or Mild Neurocognitive Disorder

Due to Traumatic Brain Injury Substance/Medication-Induced Major or

Mild Neurocognitive Disorder Major or Mild Neurocognitive Disorder

Due to HIV Infection Major or Mild Neurocognitive Disorder

Due to Prion Disease Major or Mild Neurocognitive Disorder

Due to Parkinson’s Disease Major or Mild Neurocognitive Disorder

Due to Huntington’s Disease Major or Mild Neurocognitive Disorder

Due to Another Medical Condition Major and Mild Neurocognitive Disorders

Due to Multiple Etiologies Unspeci�ed Neurocognitive Disorder

Personality Disorders

Cluster A Personality Disorders Paranoid Personality Disorder/Schizoid

Personality Disorder/Schizotypal Personality Disorder

Cluster B Personality Disorders Antisocial Personality Disorder/Borderline

Personality Disorder/Histrionic Personality Disorder/Narcissistic Personality Disorder

Cluster C Personality Disorders Avoidant Personality Disorder/Dependent

Personality Disorder/Obsessive- Compulsive Personality Disorder

Other Personality Disorders Personality Change Due to Another

Medical Condition/Other Speci�ed Personality Disorder/Unspeci�ed Personality Disorder

DSM-5 CLASSIFICATIONS

Paraphilic Disorders Voyeuristic Disorder/Exhibitionist

Disorder/Frotteuristic Disorder/Sexual Masochism Disorder/Sexual Sadism Disorder/Pedophilic Disorder/Fetishistic Disorder/Transvestic Disorder/ Other Speci�ed Paraphilic Disorder/ Unspeci�ed Paraphilic Disorder

Other Mental Disorders Other Speci�ed Mental Disorder Due to

Another Medical Condition/Unspeci�ed Mental Disorder Due to Another Medical Condition/Other Speci�ed Mental Disorder/Unspeci�ed Mental Disorder

Medication-Induced Movement Disorders and Other Adverse Effects of Medication Neuroleptic-Induced Parkinsonism/Other

Medication-Induced Parkinsonism/ Neuroleptic Malignant Syndrome/

Medication-Induced Acute Dystonia/ Medication-Induced Acute Akathisia/ Tardive Dyskinesia/Tardive Dystonia/ Tardive Akathisia/Medication-Induced Postural Tremor/Other Medication- Induced Movement Disorder/ Antidepressant Discontinuation Syndrome/Other Adverse E�ect �ect � of Medication

Other Conditions That May Be a Focus of Clinical Attention

Relational Problems Problems Related to Family Upbringing Other Problems Related to Primary

Support Group

Abuse and Neglect Child Maltreatment and Neglect Problems Adult Maltreatment and Neglect Problems

Educational and Occupational Problems Educational Problems Occupational Problems

Housing and Economic Problems Housing Problems Economic Problems

Other Problems Related to the Social Environment

Problems Related to Crime or Interaction with the Legal System

Other Health Service Encounters for Counseling and Medical Advice

Problems Related to Other Psychosocial, Personal, and Environment Circumstances

Other Circumstances of Personal History Problems Related to Access to Medical

and Other Health Care Nonadherence to Medical Treatment

DSM-5 DISORDERS FOR FURTHER STUDY

Th DSM-5 Task Force judged that these disorders do not currently have su�cient supporting data for inclusion in DSM-5 and therefore require further study. In fact, only a few of these proposed dis- orders will ultimately meet criteria, and others will be excluded from further con- sideration. Many of the more interesting disorders are discussed in one or more appropriate chapters.

Attenuated Psychosis Syndrome Key features include delusions, halluci- na tions, or disorganized speech that na tions, or disorganized speech that na dis tresses and disables the individual; the symptoms are like psychosis but not ex treme enough to be considered a full ex treme enough to be considered a full ex psychotic disorder.

Depressive Episodes with Short-Duration Hypomania Key features of this disorder are depressive episodes and episodes resembling hypomanic episodes but having a shorter duration (at least 2 days but below the 4-day minimum for hypomanic episodes).

Persistent Complex Bereavement Disorder Key feature is intense grief for a year or more a�er the death of someone close to the bereaved individual.

Caffeine Use Disorder Key features of this disorder are constant ca�eine use and an inability �eine use and an inability � to control use.

Internet Gaming Disorder Key features of this disorder are the fixa tion on Internet games and continually playing them, at the expense of school, work, and/or social interactions.

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure �e key feature is diminished behavioral, cognitive, or adaptive functioning due to prenatal alcohol exposure.

Suicidal Behavior Disorder Key feature is a suicide attempt within the past 2 years that is not related to confusion or delirium.

Nonsuicidal Self-Injury Key feature is repeated, yet nonserious, self-infl cted bodily damage. �e indi- vidual engages in these acts due to inter- personal problems, negative feelings, or uncontrollable and/or intense thoughts about the act of injuring themselves.

Source: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

DSM-5 CLASSIFICATIONS

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Cover
Contents
Preface
Chapter 1: Abnormal Psychology And Life

C Travis / What Do You Think��
Introduction To Abnormal Psychology��
What Is A Mental Disorder��

C Treva Throneberry / What Do You Think?
Deviance From The Norm��
Difficulties Adapting To Life Demands
Experience Of Personal Distress��
Defining Abnormality
Dimensions Underlying Mental Disorders Are Relevant to Everyone

Interim Summary��
Review Questions��
History Of Abnormal Psychology��

Early Perspectives��
Early Greek And Roman Thought��
Middle Ages��
Renaissance��
Reform Movement��
Modern Era��
Interim Summary��
Review Questions��

Abnormal Psychology And Life: Themes��

Dimensional Perspective��
Prevention Perspective��
Consumer Perspective��
Diversity��
Stigma��
Interim Summary��
Review Questions��

Final Comments��
Key Terms��
Special Features

1.1 Focus On Diversity: Emotion And Culture
Continuum Figure 1.2 Continuum Of Emotions, Cognitions, And Behaviors��
1.2 Focus On Law And Ethics: Heal Thyself: What The Self-help Gurus Don’t Tell You
Personal Narrative 1.1 Alison Malmon��

Chapter 2: Perspectives On Abnormal Psychology

C Mariella / What Do You Think��
Introduction��
The Biological Model��

Genetics��
Nervous Systems And Neurons��
Brain��
Biological Assessment And Treatment��
Evaluating The Biological Model��
Interim Summary��
Review Questions��

The Psychodynamic Model��

Brief Overview Of The Psychodynamic Model��
Psychodynamic Assessment And Treatment��
Evaluating The Psychodynamic Model��
Interim Summary��
Review Questions��

The Humanistic Model��

Abraham Maslow��
Carl Rogers��
Rollo May��
Humanistic Assessment And Treatment��
Evaluating The Humanistic Model��
Interim Summary��
Review Questions��

The Cognitive-behavioral Model��

Behavioral Perspective��
Cognitive Perspective��
A Cognitive-behavioral Model��
Cognitive-behavioral Assessment And Treatment��
Evaluating The Cognitive-behavioral Model��
Interim Summary��
Review Questions��

The Sociocultural Model��

Culture��
Gender��
Neighborhoods And Communities��
Family��
Sociocultural Assessment And Treatment��
Evaluating The Sociocultural Model��
Interim Summary��
Review Questions��

Final Comments��
Key Terms��
Special Features

2.1 Focus On Violence: A More Complex Approach
2.2 Focus On Law And Ethics: Dangerousness And Commitment
2.3 Focus On Gender: A More Complex Approach
Personal Narrative 2.1 An Integrative Psychologist: Dr. John C. Norcross��

Chapter 3: Risk And Prevention Of Mental Disorders

C Deshawn / What Do You Think��
The Diathesis-stress Model��

Diathesis, Stress, And Mental Health��
Diathesis-stress: The Big Picture��
Diathesis-stress: The Little Picture��
Implications Of The Diathesis-stress Model��
Interim Summary��
Review Questions��

Epidemiology: How Common Are Mental Disorders��

Prevalence Of Mental Disorders��
Treatment Seeking��
Treatment Cost��
Interim Summary��
Review Questions��

Risk, Protective Factors, And Resilience��

C Jana / What Do You Think��
Risk Factors��
Protective Factors��
Interim Summary��
Review Questions��

Prevention��

Prevention On A Continuum��
Three Types Of Prevention��
Prevention Programs For Mental Disorders��
Interim Summary��
Review Questions��

Final Comments��
Key Terms��
Special Features

3.1 John Snow: A Pioneer In Epidemiology And Prevention
3.2 Focus On College Students: Suicide
3.3 Focus On Violence: Prevention Of Femicide
3.4 Focus On Law And Ethics: Constructs Related To Insanity
Personal Narrative 3.1 Kim Dude And The Wellness Resource Center��

Chapter 4: Diagnosis, Assessment, and Study Of Mental Disorders

C Professor Smith / What Do You Think��
Defining Abnormal Behavior And Mental Disorder

Dimensions And Categories��
Dsm��
Advantages Of Diagnosis��
Interim Summary��
Review Questions��

Classifying And Assessing Abnormal Behavior and Mental Disorder

Assessing Abnormal Behavior And Mental Disorder��
Reliability, Validity, And Standardization��
Interview��
Intelligence Tests��
Personality Assessment��
Behavioral Assessment��
Biological Assessment��
Psychophysiological Assessment��
Neuropsychological Assessment��
Interim Summary��
Review Questions��

Culture And Clinical Assessment��

Culture And The Development Of Mental Disorders��
Culture And Clinical Assessment��
Interim Summary��
Review Questions��

Studying Abnormal Behavior And Mental Disorder��

Experiment��
Correlational Studies��
Quasi-experimental Methods��
Other Alternative Experimental Designs��
Developmental Designs��
Case Study��
Consuming The Media’s Research��
Interim Summary��
Review Questions��

Final Comments��
Key Terms��
Special Features

4.1 Focus On Diversity: Culture And Diagnosis
Personal Narrative 4.1 Anonymous��
4.2 Focus On Law And Ethics: Who Should Be Studied In Mental Health Research

Chapter 5: Anxiety, Obsessive-compulsive, And Trauma-related Disorders

C Angelina / What Do You Think?
Worry, Anxiety, Fear, And Anxiety; Obsessive- Compulsive; And Trauma-Related Disorders: What Are They?
Anxiety, Obsessive-compulsive, And Trauma-Related Disorders: Features and Epidemiology

Panic Attack��
Panic Disorder��
Social Phobia��
Speci C Phobia��
Generalized Anxiety Disorder��
C Jonathan / What Do You Think��
Obsessive-compulsive Disorder��
Obsessive-compulsive-related Disorders��
Posttraumatic Stress Disorder And Acute Stress Disorder��
C Marcus / What Do You Think��
Separation Anxiety Disorder And School Refusal Behavior��
Epidemiology Of Anxiety, Obsessive-compulsive, And Trauma-related Disorders��

Stigma Associated With Anxiety, Obsessive- Compulsive, And Trauma-Related Disorders

Interim Summary��
Review Questions��

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Causes and Prevention

Biological Risk Factors For Anxiety, Obsessive-compulsive, And Trauma-related Disorders��

Environmental Risk Factors For Anxiety, Obsessive-compulsive, And Trauma-related Disorders��
Causes Of Anxiety, Obsessive-compulsive, And Trauma-related Disorders��
Prevention Of Anxiety, Obsessive-compulsive, And Trauma- Related Disorders��
Interim Summary��
Review Questions��

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders: Assessment and Treatment

Assessment Of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders
Biological Treatment Of Anxiety, Obsessive-compulsive, And Trauma-related Disorders��
Psychological Treatments Of Anxiety, Obsessive-compulsive, And Trauma-related Disorders��
What If I Have Anxiety Or An Anxiety-related Disorder?
Long-term Outcome For People With Anxiety, Obsessive-Compulsive, And Trauma-related Disorders
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 5.1 Worry, Anxiety, And Fear Along A Continuum
Continuum Figure 5.2 Continuum Of Emotions, Cognitions, And Behaviors Regarding Anxiety-Related Disorders
5.1 Focus On College Students: Trauma And Ptsd
5.2 Focus On Gender: Are There True Gender Differences In Anxiety-related Disorders
5.3 Focus On Diversity: Anxiety-related Disorders And Sociocultural Factors
V The Continuum Video Project Darwin / Ptsd��
Personal Narrative 5.1 Anonymous��
5.4 Focus On Law And Ethics: The Ethics Of Encouragement In Exposure-based Practices

Chapter 6: Somatic Symptom And Dissociative Disorders

Somatic Symptom And Dissociative Disorders: A Historical Introduction��
Somatization And Somatic Symptom Disorders: What Are They��
C Gisela / What Do You Think?
Somatic Symptom Disorders: Features And Epidemiology��

Somatic Symptom Disorder��
Illness Anxiety Disorder��
Conversion Disorder��
Factitious Disorder And Malingering��
Epidemiology Of Somatic Symptom Disorders��

Stigma Associated With Somatic Symptom Disorders��

Interim Summary��
Review Questions��

Somatic Symptom Disorders: Causes And Prevention��

Biological Risk Factors For Somatic Symptom Disorders��
Environmental Risk Factors For Somatic Symptom Disorders��
Causes Of Somatic Symptom Disorders��
Prevention Of Somatic Symptom Disorders��
Interim Summary��
Review Questions��

Somatic Symptom Disorders: Assessment And Treatment��

Assessment Of Somatic Symptom Disorders��
Biological Treatment Of Somatic Symptom Disorders��
Psychological Treatments Of Somatic Symptom Disorders��
What If I Or Someone I Know Has A Somatic Symptom Disorder��
Long-term Outcome For People With Somatic Symptom Disorders��
Interim Summary��
Review Questions��

Dissociative Disorders��
C Erica / What Do You Think?
Normal Dissociation And Dissociative Disorders: What Are They��
Dissociative Disorders: Features And Epidemiology��

Dissociative Amnesia��
Dissociative Identity Disorder��
Depersonalization/derealization Disorder��
Epidemiology Of Dissociative Disorders��

Stigma Associated With Dissociative Disorders��

Interim Summary��
Review Questions��

Dissociative Disorders: Causes And Prevention��

Biological Risk Factors For Dissociative Disorders��
Environmental Risk Factors For Dissociative Disorders��
Causes Of Dissociative Disorders��
Prevention Of Dissociative Disorders��
Interim Summary��
Review Questions��

Dissociative Disorders: Assessment And Treatment��

Assessment Of Dissociative Disorders��
Biological Treatment Of Dissociative Disorders��
Psychological Treatments Of Dissociative Disorders��
What If I Or Someone I Know Has A Dissociative Disorder��
Long-term Outcome For People With Dissociative Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 6.1 Continuum Of Somatization And Somatic Symptom Disorders

6.1 Focus On College Students: Somatization
6.2 Focus On Violence: Terrorism And Medically Unexplained Symptoms
Continuum Figure 6.4 Continuum Of Dissociation And Dissociative Disorders��
Personal Narrative 6.1 Heather Pate��
6.3 Focus On College Students: Dissociation
6.4 Focus On Law And Ethics: Recovered Memories And Suggestibility
6.5 Focus On Diversity: Dissociation And Culture
6.6 Focus On Violence: Dissociative Experiences And Violence Toward Others
V The Continuum Video Project Lani And Jan / Dissociative Identity Disorder��

Chapter 7: Depressive And Bipolar Disorders And Suicide

C Katey / What Do You Think?
Normal Mood Changes And Depression And Mania: What Are They��
Depressive And Bipolar Disorders And Suicide: Features And Epidemiology��

Major Depressive Episode��
Major Depressive Disorder��
Persistent Depressive Disorder (dysthymia��
Other Depressive Disorders��
Manic And Hypomanic Episodes��
Bipolar I Disorder��
Bipolar Ii Disorder��
Cyclothymic Disorder��
Suicide��
Epidemiology Of Depressive And Bipolar Disorders��
Epidemiology Of Suicide��

Stigma Associated With Depressive And Bipolar Disorders��

Interim Summary��
Review Questions��

Depressive And Bipolar Disorders And Suicide: Causes And Prevention��

Biological Risk Factors For Depressive And Bipolar Disorders And Suicide��
Environmental Risk Factors For Depressive And Bipolar Disorders And Suicide��
Causes Of Depressive And Bipolar Disorders And Suicide��
Prevention Of Depressive And Bipolar Disorders And Suicide��
Interim Summary��
Review Questions��

Depressive And Bipolar Disorders And Suicide: Assessment And Treatment��

Interviews And Clinician Ratings��
Self-report Questionnaires��
Self-monitoring And Observations From Others��
Laboratory Assessment��
Assessment Of Suicide��
Biological Treatment Of Depressive And Bipolar Disorders And Suicide��
Psychological Treatments For Depressive And Bipolar Disorders And Suicide��
What If I Am Sad Or Have A Mood Disorder��
Long-term Outcome For People With Depressive And Bipolar Disorders And Suicide��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 7.1 Continuum Of Sadness And Depression
Continuum Figure 7.2 Continuum Of Happiness, Euphoria, and Mania
Personal Narrative 7.1 Karen Gormandy��
7.1 Focus On Gender: Forms Of Depression Among Women
7.2 Focus On College Students: Depression
V The Continuum Video Project Emilie / Bipolar Disorder��
7.3 Focus On Law And Ethics: Ethical Dilemmas In Electroconvulsive Therapy
7.4 Focus On Diversity: Depression In The Elderly

Chapter 8: Eating Disorders

C Sooki / What Do You Think?
Weight Concerns, Body Dissatisfaction, And Eating Disorders: What Are They��
Eating Disorders: Features And Epidemiology

Anorexia Nervosa��
Bulimia Nervosa��
C Lisa / What Do You Think��
Binge-eating Disorder��
Epidemiology Of Eating Disorders��

Stigma Associated With Eating Disorders��

Interim Summary��
Review Questions��

Eating Disorders: Causes And Prevention��

Biological Risk Factors For Eating Disorders��
Environmental Risk Factors For Eating Disorders��
Causes Of Eating Disorders��
Prevention Of Eating Disorders��
Interim Summary��
Review Questions��

Eating Disorders: Assessment And Treatment

Assessment Of Eating Disorders��
Treatment Of Eating Disorders��
Biological Treatments Of Eating Disorders��
Psychological Treatments Of Eating Disorders��
What If I Have Weight Concerns Or An Eating Disorder��
Long-term Outcome For People With Eating Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 8.1 Continuum Of Body Dissatisfaction, Weight Concerns, And Eating Behavior
Personal Narrative 8.1 Kitty Westin (Anna’s Mother)
8.1 Focus On College Students: Eating Disorders
8.2 Focus On Gender: Why Is There A Gender Difference In Eating Disorders
V The Continuum Video Project Sara / Bulimia Nervosa��
Personal Narrative 8.2 Rachel Webb��
8.3 Focus On Law And Ethics: How Ethical Are Pro-Ana (Pro-Anorexia) Websites

Chapter 9: Substance-Related Disorders

C Elon / What Do You Think?
Normal Substance Use And Substance-related Disorders: What Are They��
Substance-related Disorders: Features And Epidemiology��

Substance Use Disorder��
Substance Intoxication��
Substance Withdrawal��
Types Of Substances��
Epidemiology Of Substance-Related Disorders

Stigma Associated With Substance-related Disorders��

Interim Summary��
Review Questions��

Substance-Related Disorders: Causes And Prevention

Biological Risk Factors For Substance-Related Disorders

Environmental Risk Factors For Substance-related Disorders��
Causes Of Substance-related Disorders��
Prevention Of Substance-related Disorders��
Interim Summary��
Review Questions��

Substance-related Disorders: Assessment And Treatment��

Interviews��
Psychological Testing��
Observations From Others��
Laboratory Testing��
Biological Treatment Of Substance-related Disorders��
Psychological Treatment Of Substance-related Disorders��
What If I Or Someone I Know Has A Substance-related Problem Or Disorder?
Long-term Outcome For People With Substance-related Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 9.1 Continuum Of Substance Use And Substance-related Disorders
9.1 The Sam Spady Story
9.2 The “Meth” Epidemic
9.3 Focus On Gender: Date Rape Drugs
9.4 Focus On Violence: Alcohol And Violence
V The Continuum Video Project Mark / Substance Use Disorder��
9.5 Focus On College Students: Substance Use
Personal Narrative 9.1 One Family’s Struggle With Substance- Related Disorders��
9.6 Focus On Law And Ethics: Drug Testing

Chapter 10: Personality Disorders

C Michelle / What Do You Think?
Personality Traits, Unusual Personality, And Personality Disorder: What Are They��
Organization Of Personality Disorders��
Odd Or Eccentric Personality Disorders: Features And Epidemiology��

Paranoid Personality Disorder��
Schizoid Personality Disorder��
Schizotypal Personality Disorder��
C Jackson / What Do You Think?
Epidemiology Of Odd Or Eccentric Personality Disorders��
Interim Summary��
Review Questions��

Dramatic Personality Disorders: Features And Epidemiology��

C Duane / What Do You Think?
Antisocial Personality Disorder��
Borderline Personality Disorder��
Histrionic Personality Disorder��
Narcissistic Personality Disorder��
Epidemiology Of Dramatic Personality Disorders��
Interim Summary��
Review Questions��

Anxious/fearful Personality Disorders: Features And Epidemiology��

Avoidant Personality Disorder��
Dependent Personality Disorder��
C Betty / What Do You Think?
Obsessive-Compulsive Personality Disorder
Epidemiology Of Anxious/fearful Personality Disorders��

Stigma Associated With Personality Disorders��

Interim Summary��
Review Questions��

Personality Disorders: Causes And Prevention��

Biological Risk Factors For Odd Or Eccentric Personality Disorders��
Environmental Risk Factors For Odd Or Eccentric Personality Disorders��
Causes Of Odd Or Eccentric Personality Disorders��
Biological Risk Factors For Dramatic Personality Disorders��
Environmental Risk Factors For Dramatic Personality Disorders��
Causes Of Dramatic Personality Disorders��
Biological Risk Factors For Anxious/Fearful Personality Disorders
Environmental Risk Factors For Anxious/Fearful Personality Disorders
Causes Of Anxious/fearful Personality Disorders��
Prevention Of Personality Disorders��
Interim Summary��
Review Questions��

Personality Disorders: Assessment And Treatment��

Assessment Of Personality Disorders��
Biological Treatments Of Personality Disorders��
Psychological Treatments Of Personality Disorders��
What If I Or Someone I Know Has A Personality Disorder��
Long-term Outcomes For People With Personality Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 10.1 Continuum Of Normal Personality And Personality Disorder Traits Related to Impulsivity
10.1 Focus On College Students: Personality Disorders
10.2 Focus On Violence: Personality Disorders And Violence
10.3 Focus On Gender: Mirror Images Of Personality Disorders
10.4 Focus On Law And Ethics: Personality And Insanity
V The Continuum Video Project Tina / Borderline Personality Disorder��
Personal Narrative 10.1 Anonymous��

Chapter 11: Sexual Dysfunctions, Paraphilic Disorders, And Gender Dysphoria

Normal Sexual Behavior And Sexual Dysfunctions: What Are They?
C Douglas And Stacy / What Do You Think?
Sexual Dysfunctions: Features And Epidemiology��

Male Hypoactive Sexual Desire Disorder��
Female Sexual Interest/arousal Disorder��
Erectile Disorder��
Female Orgasmic Disorder��
Delayed Ejaculation��
Premature (Early) Ejaculation
Genito-Pelvic Pain/Penetration Disorder
Epidemiology Of Sexual Dysfunctions��

Stigma Associated With Sexual Dysfunctions��

Interim Summary��
Review Questions��

Sexual Dysfunctions: Causes And Prevention��

Biological Risk Factors For Sexual Dysfunctions��
Psychological Risk Factors For Sexual Dysfunctions��
Causes Of Sexual Dysfunctions��
Prevention Of Sexual Dysfunctions��
Interim Summary��
Review Questions��

Sexual Dysfunctions: Assessment And Treatment��

Assessment Of Sexual Dysfunctions��
Biological Treatment Of Sexual Dysfunctions��
Psychological Treatments Of Sexual Dysfunctions��
What If I Or Someone I Know Has A Sexual Dysfunction?
Long-Term Outcomes For People With Sexual Dysfunctions
Interim Summary��
Review Questions��

Normal Sexual Desires, Paraphilias, And Paraphilic Disorders: What Are They��
Paraphilic Disorders: Features And Epidemiology��

Exhibitionistic Disorder��
C Tom / What Do You Think?
Fetishistic Disorder��
Frotteuristic Disorder��
Pedophilic Disorder��
Sexual Masochism And Sexual Sadism��
Transvestic Disorder��
Voyeuristic Disorder��
Atypical Paraphilic Disorders��
Epidemiology Of Paraphilic Disorders��
Interim Summary��
Review Questions��

Paraphilic Disorders: Causes And Prevention��

Biological Risk Factors For Paraphilic Disorders��
Environmental Risk Factors For Paraphilic Disorders��
Causes Of Paraphilic Disorders��
Prevention Of Paraphilic Disorders��
Interim Summary��
Review Questions��

Paraphilic Disorders: Assessment And Treatment��

Assessment Of Paraphilic Disorders��
Biological Treatment Of Paraphilic Disorders��
Psychological Treatment Of Paraphilic Disorders��
What If I Or Someone I Know Has A Paraphilic Disorder?
Long-Term Outcomes For People With Paraphilic Disorders

Interim Summary��
Review Questions��
Normal Gender Development And Gender Dysphoria: What Are They��
C Austin / What Do You Think��
Gender Dysphoria: Features And Epidemiology��
Gender Dysphoria: Causes And Prevention��
Gender Dysphoria: Assessment And Treatment��

Assessment Of Gender Dysphoria��
Biological Treatment Of Gender Dysphoria��
Psychological Treatment Of Gender Dysphoria��
What If I Or Someone I Know Has Questions About Gender Or Gender Dysphoria?
Long-term Outcomes For People With Gender Dysphoria��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 11.1 Continuum Of Sexual Behavior And Sexual Dysfunctions
11.1 Focus On Gender: Gender Biases In Sexual Dysfunctions And Disorders
11.2 Focus On College Students: Sexual Dysfunctions
Continuum Figure 11.4 Continuum Of Sexual Behavior And Paraphilic Disorders��
11.3 Focus On College Students: Sexual Fantasies And Paraphilic Interests
11.4 Focus On Violence: Rape
11.5 Focus On Law And Ethics: Sex Offender Notification And Incarceration
Personal Narrative 11.1 Sam��
V The Continuum Video Project Dean / Gender Dysphoria��

Chapter 12: Schizophrenia And Other Psychotic Disorders

C James / What Do You Think?
Unusual Emotions, Thoughts, And Behaviors And Psychotic Disorders: What Are They��
Psychotic Disorders: Features And Epidemiology��

Schizophrenia��
Phases Of Schizophrenia��
Schizophreniform Disorder��
Schizoaffective Disorder��
Delusional Disorder��
C Jody / What Do You Think?
Brief Psychotic Disorder��
Epidemiology Of Psychotic Disorders��

Stigma Associated With Schizophrenia��

Interim Summary��
Review Questions��

Psychotic Disorders: Causes And Prevention��

Biological Risk Factors For Psychotic Disorders��
Environmental Risk Factors For Psychotic Disorders��
Causes Of Psychotic Disorders��
Prevention Of Psychotic Disorders��
Interim Summary��
Review Questions��

Psychotic Disorders: Assessment And Treatment��

Interviews��
Behavioral Observations��
Cognitive Assessment��
Physiological Assessment��
Biological Treatments Of Psychotic Disorders��
Psychological Treatments Of Psychotic Disorders��
What If I Or Someone I Know Has A Psychotic Disorder?
Long-term Outcome For People With Psychotic Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 12.1 Continuum Of Unusual Emotions, Cognitions, And Behaviors And Psychotic Disorder
Personal Narrative 12.1 John Cadigan��

12.1 Focus On Diversity: Ethnicity And Income Level In Schizophrenia
12.2 Focus On College Students: Psychotic Symptoms
12.3 Focus On Violence: Are People With Schizophrenia More Violent
V The Continuum Video Project Andre / Schizophrenia��
12.4 Focus On Law And Ethics: Making The Choice Of Antipsychotic Medication

Chapter 13: Developmental And Disruptive Behavior Disorders

Developmental And Disruptive Behavior Disorders��
C Robert / What Do You Think?
Normal Development And Developmental Disorders: What Are They��
Developmental Disorders: Features And Epidemiology��

Intellectual Disability��
Autism Spectrum Disorder��
Learning Disorder��
C Alison / What Do You Think?
Epidemiology Of Developmental Disorders��

Stigma Associated With Developmental Disorders��

Interim Summary��
Review Questions��

Developmental Disorders: Causes And Prevention��

Biological Risk Factors For Developmental Disorders��
Environmental Risk Factors For Developmental Disorders��
Causes Of Developmental Disorders��
Prevention Of Developmental Disorders��
Interim Summary��
Review Questions��

Developmental Disorders: Assessment And Treatment��

Cognitive Tests��
Achievement Tests��
Interviews��
Rating Scales��
Behavioral Observation��
Biological Treatment For Developmental Disorders��
Psychological Treatments For Developmental Disorders��
What If I Think Someone Has A Developmental Disorder?
Long-term Outcome For People With Developmental Disorders��
Interim Summary��
Review Questions��

Normal Rambunctious Behavior And Disruptive Behavior Disorders: What Are They��
C Will / What Do You Think?

Disruptive Behavior Disorders: Features And Epidemiology��
Attention-Deficit/Hyperactivity Disorder
Oppositional Defiant Disorder And Conduct Disorder
Epidemiology Of Disruptive Behavior Disorders��

Stigma Associated With Disruptive Behavior Disorders��

Interim Summary��
Review Questions��

Disruptive Behavior Disorders: Causes And Prevention��

Biological Risk Factors For Disruptive Behavior Disorders��
Environmental Risk Factors For Disruptive Behavior Disorders��
Causes Of Disruptive Behavior Disorders��
Prevention Of Disruptive Behavior Disorders��
Interim Summary��
Review Questions��

Disruptive Behavior Disorders: Assessment And Treatment��

Interviews��
Rating Scales��
Behavioral Observation��
Biological Treatments For Disruptive Behavior Disorders��
Psychological Treatments For Disruptive Behavior Disorders��
What If I Think A Child Has A Disruptive Behavior Disorder?
Long-Term Outcome For Children With Disruptive Behavior Disorders
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 13.1 Continuum Of Normal Development And Developmental Disorder
13.1 Focus On College Students: Autism
13.2 Focus On Law And Ethics: Key Ethical Issues And Developmental Disorders
13.3 Focus On Diversity: Testing For People With Developmental Disorders
V The Continuum Video Project Whitney / Autism Spectrum Disorder��
Continuum Figure 13.4 Continuum Of Disruptive Behavior And Disruptive Behavior Disorder��
13.4 Focus On College Students: Adhd
13.5 Focus On Violence: Juvenile Arrests And “diversion
Personal Narrative 13.1 Toni Wood��

Chapter 14: Neurocognitive Disorders

C William And Laura / What Do You Think?
Normal Changes During Aging And Neurocognitive Disorders: What Are They��
Neurocognitive Disorders: Features And Epidemiology��

Delirium��
Dementia And Major And Mild Neurocognitive Disorder��
Alzheimer’s Disease��
Lewy Bodies��
Vascular Disease��
Parkinson’s Disease��
Pick’s Disease��
Other Problems��
Epidemiology Of Neurocognitive Disorders��

Stigma Associated With Neurocognitive Disorders��

Interim Summary��
Review Questions��

Neurocognitive Disorders: Causes And Prevention��

Biological Risk Factors For Neurocognitive Disorders��
Environmental Risk Factors For Neurocognitive Disorders��
Causes Of Neurocognitive Disorders��
Prevention Of Neurocognitive Disorders��
Interim Summary��
Review Questions��

Neurocognitive Disorders: Assessment And Treatment��

Assessment Of Neurocognitive Disorders��
Biological Treatments Of Neurocognitive Disorders��
Psychological Treatments Of Neurocognitive Disorders��
What If Someone I Know Has A Neurocognitive Disorder��
Long-term Outcome For People With Neurocognitive Disorders��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

Continuum Figure 14.1 Continuum Of Thinking And Memory Problems And Neurocognitive Disorder
14.1 Focus On College Students: Delirium
14.2 Focus On Violence: Maltreatment Of The Elderly
V The Continuum Video Project Myriam / Alzheimer’s Disease��
14.3 Focus On Gender: Grief In The Spouse Caregiver
14.4 Focus On Law And Ethics: Ethical Issues And Dementia

Chapter 15: Consumer Guide To Abnormal Psychology

Introduction To The Consumer Guide��
Becoming A Mental Health Professional��

Types Of Therapists And Quali Cations��
Preparing To Be A Mental Health Professional��

Becoming A Client��
Treatment At The Individual Level��

Active Ingredients Of Treatment��
Process Variables In Treatment��
Does Treatment Work��
Prescriptive Treatment��
Interim Summary��
Review Questions��

Treatment At The Community Level��

Self-help Groups��
Aftercare Services For People With Severe Mental Disorders��
Residential Facilities For People With Developmental Disorders��
Criminal Justice System��
Public Policy And Mental Health��
Interim Summary��
Review Questions��

Limitations And Caveats About Treatment��

Client-therapist Differences��
Cultural Differences��
Managed Care��
Differences Between Clinicians And Researchers��
Quick Fixes��
Misuse Of Research��
Weak Research And How To Judge A Research Article��
Negative Therapist Characteristics��
Lack Of Access To Treatment��

Ethics��

General Principles��
Assessment��
Treatment��
Public Statements��
Research��
Resolving Ethical Issues��
Interim Summary��
Review Questions��

Final Comments��
Thought Questions��
Key Terms��
Special Features

15.1 Focus On Gender: Graduate School And Mentors
Personal Narrative 15.1 Julia Martinez, Graduate Student In Clinical Psychology��
Personal Narrative 15.2 Tiffany S. Borst, M.a., L.P.C.
15.2 Focus On Law And Ethics: Rights Of Those Hospitalized For Mental Disorder
15.3 Focus On Diversity: Lack Of Diversity In Research
Personal Narrative 15.3 Christopher A. Kearney, Ph.D.
15.4 Focus On Law And Ethics: Sexual Intimacy And The Therapeutic Relationship

Appendix: Stress-Related Problems
Glossary��
References��
Name Index��
Subject Index��

1. 2016-12-21T16:33:45+0000
2. Preflight Ticket Signature