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FundamentalsofAbnormalPsycho-RonaldJ.Comer.pdf
Diagnosis of somatic symptom disorder may be given to people who are overly anxious about their medical problems (page 257).
Clinicians no longer need to distin- guish hysteri- cal symptoms from medical symptoms.
People with a
serious medi- cal disease, such as cancer, may receive a psychiatric di- agnosis.
Diagnosis of major depressive disorder may be given to recently bereaved people (page 196).
Clinicians can more quickly spot and treat clini- cal depression among griev- ing people.
People experi-
encing normal grief reactions may receive a psychiatric di- agnosis.
Previous category of
Asperger’s disorder has been eliminated (page 486).
Better alterna- tive diagnoses may now be assigned to people with severe social impairments.
Individu- als may
no longer qual- ify for special educational services if they lose the As- perger’s label.
The new category substance use disorder combines substance abuse and substance dependence into one disorder (page 314).
Patterns of sub- stance abuse and substance dependence were often indistinguish- able.
Sub- stance
abuse and sub- stance depen- dence may re- quire different treatments.
Top DSM-5 DebaTeS Many of the DSM-5 changes have provoked debate. Several have been particularly controversial in some clinical circles.
Who DevelopeD DSM-5?
* World Health Organization ** National Institute of Mental Health
Field Testing DSM-5 From 2010 to 2012, DSM-5 researchers conducted field studies to see how well clinicians could apply the new criteria.
Disorders tested: 23
Clinical participants: 3,646
Clinicians: 879 (APA, 2013; Clarke et al., 2013; Regier et al., 2013)
Two-thirds of the DSM-5 work group members were psychiatrists and one-third were psychologists.
(APA, 2013)
Work groups (pathology groups)
13 160 persons
12 persons per group
Task force (oversight committee)
30 persons
New Categories Hoarding disorder (page 143)
Excoriation disorder (page 143)
Persistent depressive disorder (page 187)
Premenstrual dysphoric disorder (page 209)
Disruptive mood dysregulation disorder (page 472)
Somatic symptom disorder (page 255)
Binge eating disorder (page 288)
Mild neurocognitive disorder (page 511)
WhaT’S NeW iN DSM-5? DSM-5 features a number of changes, new categories, and eliminations. Many of the changes have been controversial.
Name Changes OLD NEW
Mental Retardation
Intellectual Disability (page 489)
Dementia Major Neurocognitive Disorder (page 511)
Hypochondriasis Illness Anxiety Disorder (page 261)
Male Orgasmic Disorder
Delayed Ejaculation (page 355)
Gender Identity Disorder
Gender Dysphoria (page 376)
Dropped Categories Dissociative fugue (page 168)
Asperger’s disorder (page 486)
Sexual aversion disorder (page 348)
Substance abuse (page 314)
Substance dependence (page 314)
CoMpeTiTorS Both within North America and around the world, the DSM faces competition from 2 other diagnostic systems—the International Classification of Disorders
(ICD) and Research Domain Criteria (RDoC).
DSM
ICD
RDoC
Producer Disorders Criteria
APA Psychological Detailed
WHO* Psychological/
medical Brief
NIMH** Psychological Neuro/scanning
Gambling disorder is considered an addiction (page 342).
Excessive gambling and substance addictions often share similar brain dysfunc- tioning.
Many other be-
haviors pursued excessively, such as sex, Internet use, and shopping, could eventually be considered behavioral ad- dictions.
Mild neurocognitive disorder is added as a category (page 515).
This diag-nosis may help clinicians identify early symptoms of Alzheimer’s dis- ease.
People with nor-
mal age-related forgetfulness may receive a psychiatric diag- nosis.
1950
1970
1960
1990
2010
• 1980
book price $32.00
• 1994
book price $49.00
• 2000
book price $75.00
DSM-5 • 2013
book price $199.00
128 diagnoses
• 1952
book price $3.00
• 1987
book price $40.00
DSM-III
DSM-IV
DSM-IV-TR
DSM-I
DSM-III-R
DSM-II • 1968
book price $3.50
193 diagnoses
228 diagnoses
253 diagnoses
383 diagnoses
383 diagnoses
541 diagnoses
DSM-5 vS. ItS PreDeceSSorS The new edition of DSM is bigger and more expensive than all previous editions. It cost the APA $25 million to produce, an amount that was immediately recouped by presales of 150,000 copies (Gorenstein, 2013).
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n 2013, the American Psychiatric Association (APA) published DSM-5, its new edition of the Diagnostic and Statistical Manual of Mental Disorders — the most widely used classification system in North America. DSM-5 is a 947-page manual that lists 541 diagnoses (Blashfield et al., 2014). The production of DSM-5 was a monumental 12-year undertaking, marked by long delays, controversies, and protests (page 95).
Inside DSM-5
Application Area of Use
Practice/research North America
Practice/research Worldwide
Research United States
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Abnormal Psychology Fundamentals of
this page left intentionally blank
Princeton University
Abnormal Psychology
Ronald J. Comer
EIGHTH EDITION
Fundamentals of
New York
Publisher: Rachel Losh Executive Acquisitions Editor: Daniel McDonough Editorial Assistant: Kimberly Morgan Senior Marketing Manager: Lindsay Johnson Marketing Assistant: Allison Greco Executive Media Editor: Rachel Comerford Associate Media Editor: Jessica Lauffer Director, Content Management Enhancement: Tracey Kuehn Managing Editor: Lisa Kinne Senior Project Editor: Jane O’Neill Media Producer: Eve Conte Photo Editor: Jennifer Atkins Permissions Editors: Felicia Ruocco, Melissa Pellerano Permissions Associate: Chelsea Roden Director of Design, Content Management: Diana Blume Cover and Interior Designer: Babs Reingold Layout Designer: Paul Lacy Infographics Artist: Charles Yuen Senior Production Supervisor: Sarah Segal Composition: codeMantra Printing and Binding: RR Donnelley Cover Image: Ed Fairburn
Credits to use previously published material can be found in the Credits section, starting on page C-1.
Library of Congress Control Number: 2015957306
ISBN-13: 978-1-4641-7697-5 ISBN-10: 1-4641-7697-3
© 2016, 2014, 2011, 2008 by Worth Publishers
All rights reserved
Printed in the United States of America
First Printing
Worth Publishers One New York Plaza Suite 4500 New York, NY 10004-1562
http://www.macmillanhighered.com
To Delia and Emmett Comer, The World Awaits
viii
About the Author
Ron ComeR has taught in Princeton University’s Department of Psychology for the past 41 years, serving also as Director of Clinical Psychology Studies and as chair of the university’s Institutional Review Board. His courses—Abnormal Psychology, Theories of Psychotherapy, Childhood Psychopathology, Experimental Psychopathology, and Controversies in Clinical Psychology—have been among the university’s most popular offerings.
Professor Comer has received the President’s Award for Distinguished Teaching at the university. He is also a practicing clinical psychologist and a consultant to Eden Autism Services and to hospitals and family practice residency programs throughout New Jersey.
In addition to writing Fundamentals of Abnormal Psychology, Eighth Edition, Professor Comer is the author of the textbook Abnormal Psychology, now in its ninth edition; coauthor of the introductory psychology textbook Psychology Around Us, Second Edition; and coauthor of Case Studies in Abnormal Psychology, Second Edition. He is the producer of numerous videos for courses in psychology and other fields of education, including The Higher Education Video Library Series, Video Anthology for Abnormal Psychology, Video Segments in Neuroscience, Introduction to Psychology Video Clipboard, and Developmental Psychology Video Clipboard. He also has published journal articles in clinical psychol- ogy, social psychology, and family medicine.
Professor Comer completed his undergraduate studies at the University of Pennsylvania and his graduate work at Clark University. He lives in Lawrenceville, New Jersey, with his wife, Marlene. From there he can keep a close eye on the Philadelphia sports teams with which he grew up. Pa
ul L
. B re
e
ix
Contents in brief Abnormal Psychology in Science and Clinical Practice 1 Abnormal Psychology: Past and Present 1
2 Models of Abnormality 37
3 Clinical Assessment, Diagnosis, and Treatment 77
Problems of Anxiety and Mood 4 Anxiety, Obsessive-Compulsive, and Related Disorders 105
5 Disorders of Trauma and Stress 149
6 Depressive and Bipolar Disorders 183
7 Suicide 221
Problems of the Mind and Body 8 Disorders Featuring Somatic Symptoms 249
9 Eating Disorders 279
10 Substance Use and Addictive Disorders 309
11 Disorders of Sex and Gender 347
Problems of Psychosis 12 Schizophrenia 385
Life-Span Problems 13 Personality Disorders 421
14 Disorders Common Among Children and Adolescents 463
15 Disorders of Aging and Cognition 501
Conclusion 16 Law, Society, and the Mental Health Profession 527
x
Contents
Preface xvii
chapter : 1 Abnormal Psychology: Past and Present 1 What Is Psychological Abnormality? 2
Deviance 3 Distress 3 Dysfunction 4 Danger 4 The elusive nature of Abnormality 4
What Is Treatment? 5
How Was Abnormality Viewed and Treated in the Past? 7
Ancient Views and Treatments 7 Greek and Roman Views and Treatments 8 europe in the middle Ages: Demonology Returns 8 The Renaissance and the Rise of Asylums 9 The nineteenth Century: Reform and
moral Treatment 10 The early Twentieth Century: The Somatogenic
and Psychogenic Perspectives 11
Current Trends 14 How Are People with Severe Disturbances
Cared for? 15 How Are People with Less Severe
Disturbances Treated? 15 A Growing emphasis on Preventing Disorders
and Promoting mental Health 16 multicultural Psychology 17 The Increasing Influence of Insurance Coverage 17 What Are Today’s Leading Theories and Professions? 18 Technology and mental Health 20
What Do Clinical Researchers Do? 22 The Case Study 22 The Correlational method 23 The experimental method 27 What Are the Limits of Clinical Investigation? 31 Protecting Human Participants 32
Putting it together: A Work in Progress 34
Key terms 34
QuicK Quiz 35
LaunchPad 35
PsychWatch Verbal Debuts 2
PsychWatch Marching to a Different Drummer: Eccentrics 6
InfoCentral Happiness 19
MindTech Mental Health Apps Explode in the Marketplace 21
MindTech A Researcher’s Paradise? 24
MediaSpeak Flawed Study, Gigantic Impact 28
chapter : 2 Models of Abnormality 37 The Biological Model 39
How Do Biological Theorists explain Abnormal Behavior? 39
Biological Treatments 42 Assessing the Biological model 44
The Psychodynamic Model 44 How Did Freud explain normal and Abnormal
Functioning? 45 How Do other Psychodynamic explanations Differ
from Freud’s? 47 Psychodynamic Therapies 47 Assessing the Psychodynamic model 49
The Behavioral Model 50 How Do Behaviorists explain Abnormal Functioning? 51 Behavioral Therapies 52 Assessing the Behavioral model 53
The Cognitive Model 54 How Do Cognitive Theorists explain Abnormal
Functioning? 54 Cognitive Therapies 55 Assessing the Cognitive model 56
The Humanistic-Existential Model 58
CONTENTS : xi
Rogers’ Humanistic Theory and Therapy 59 Gestalt Theory and Therapy 60 Spiritual Views and Interventions 61 existential Theories and Therapy 61 Assessing the Humanistic-existential model 63
The Sociocultural Model: Family-Social and Multicultural Perspectives 64
How Do Family-Social Theorists explain Abnormal Functioning? 65
Family-Social Treatments 67 How Do multicultural Theorists explain Abnormal
Functioning? 71 multicultural Treatments 72 Assessing the Sociocultural model 72
Putting it together: integrAtion of the Models 73
Key terms 75
QuicK Quiz 75
LaunchPad 75
InfoCentral Dietary Supplements: An Alternative Treatment 43
PsychWatch Cybertherapy: Surfing for Help 57
MediaSpeak Saving Minds Along with Souls 62
MindTech Have Your Avatar Call My Avatar 67
chapter : 3 Clinical Assessment, Diagnosis, and Treatment 77 Clinical Assessment: How and Why Does the Client Behave Abnormally? 77
Characteristics of Assessment Tools 78 Clinical Interviews 79 Clinical Tests 81 Clinical observations 89
Diagnosis: Does the Client’s Syndrome Match a Known Disorder? 92
Classification Systems 92 DSm-5 93 Is DSm-5 an effective Classification System? 94 Call for Change 95 Can Diagnosis and Labeling Cause Harm? 96
Treatment: How Might the Client Be Helped? 97 Treatment Decisions 98
The effectiveness of Treatment 98
Putting it together: AssessMent And diAgnosis At A CrossroAds 102
Key terms 103
QuicK Quiz 103
LaunchPad 103
MindTech Psychology’s Wiki Leaks? 83
PsychWatch The Truth, the Whole Truth, and Nothing but the Truth 87
MediaSpeak Intelligence Tests Too? eBay and the Public Good 90
InfoCentral Common Factors in Therapy 101
chapter : 4 Anxiety, Obsessive-Compulsive, and Related Disorders 105 Generalized Anxiety Disorder 106
The Sociocultural Perspective: Societal and multicultural Factors 107
The Psychodynamic Perspective 108 The Humanistic Perspective 110 The Cognitive Perspective 111 The Biological Perspective 116
Phobias 119 Specific Phobias 120 Agoraphobia 120 What Causes Phobias? 122 How Are Phobias Treated? 124
Social Anxiety Disorder 127 What Causes Social Anxiety Disorder? 128 Treatments for Social Anxiety
Disorder 130
Panic Disorder 132 The Biological Perspective 133 The Cognitive Perspective 135
Obsessive-Compulsive Disorder 137 What Are the Features of obsessions
and Compulsions? 137 The Psychodynamic Perspective 138 The Behavioral Perspective 139 The Cognitive Perspective 140 The Biological Perspective 141
: CONTENTSxii
obsessive-Compulsive-Related Disorders 143
Putting it together: diAthesis-stress in ACtion 146
cLinicaL choices 146
Key terms 147
QuicK Quiz 147
LaunchPad 147
PsychWatch Fears, Shmears: The Odds Are Usually on Our Side 113
InfoCentral Mindfulness 115
MediaSpeak The Fear Business 121
MindTech Social Media Jitters 129
chapter : 5 Disorders of Trauma and Stress 149 Stress and Arousal: The Fight-or-Flight Response 151
Acute and Posttraumatic Stress Disorders 152 What Triggers Acute and Posttraumatic
Stress Disorders? 154 Why Do People Develop Acute and Posttraumatic
Stress Disorders? 158 How Do Clinicians Treat Acute and Posttraumatic
Stress Disorders? 161
Dissociative Disorders 166 Dissociative Amnesia 167 Dissociative Identity Disorder 170 How Do Theorists explain Dissociative Amnesia
and Dissociative Identity Disorder? 172 How Are Dissociative Amnesia and Dissociative
Identity Disorder Treated? 176 Depersonalization-Derealization Disorder 177
Putting it together: getting A hAndle on trAuMA And stress 179
cLinicaL choices 180
Key terms 181
QuicK Quiz 181
LaunchPad 181
InfoCentral Sexual Assault 156
PsychWatch Adjustment Disorders: A Category of Compromise? 159
MindTech Virtual Reality Therapy: Better Than the Real Thing? 163
PsychWatch Repressed Childhood Memories or False Memory Syndrome? 169
PsychWatch Peculiarities of Memory 175
chapter : 6 Depressive and Bipolar Disorders 183 Unipolar Depression: The Depressive Disorders 184
How Common Is Unipolar Depression? 184 What Are the Symptoms of Depression? 184 Diagnosing Unipolar Depression 187 Stress and Unipolar Depression 187 The Biological model of Unipolar Depression 188 Psychological models of Unipolar Depression 196 The Sociocultural model of Unipolar Depression 205
Bipolar Disorders 211 What Are the Symptoms of mania? 212 Diagnosing Bipolar Disorders 212 What Causes Bipolar Disorders? 214 What Are the Treatments for Bipolar Disorders? 215
Putting it together: MAking sense of All thAt is knoWn 218
cLinicaL choices 218
Key terms 219
QuicK Quiz 219
LaunchPad 219
InfoCentral Sadness 185
PsychWatch Sadness at the Happiest of Times 190
MediaSpeak Immigration and Depression in the 21st Century 199
MindTech Texting: A Relationship Buster? 207
PsychWatch Premenstrual Dysphoric Disorder: Déjá Vu All Over Again 209
PsychWatch Abnormality and Creativity: A Delicate Balance 214
chapter : 7 Suicide 221 What Is Suicide? 222
How Is Suicide Studied? 226 Patterns and Statistics 226
What Triggers a Suicide? 227 Stressful events and Situations 228
CONTENTS : xiii
mood and Thought Changes 228 Alcohol and other Drug Use 229 mental Disorders 229 modeling: The Contagion of Suicide 230
What Are the Underlying Causes of Suicide? 232 The Psychodynamic View 232 Durkheim’s Sociocultural View 233 The Biological View 234
Is Suicide Linked to Age? 235 Children 235 Adolescents 236 The elderly 239
Treatment and Suicide 242 What Treatments Are Used After Suicide
Attempts? 242 What Is Suicide Prevention? 242 Do Suicide Prevention Programs Work? 245
Putting it together: PsyChologiCAl And BiologiCAl insights lAg Behind 246
Key terms 247
QuicK Quiz 247
LaunchPad 247
MediaSpeak Videos of Self-Injury Find an Audience 225
PsychWatch The Black Box Controversy: Do Antidepressants Cause Suicide? 238
InfoCentral The Right to Commit Suicide 240
MindTech Crisis Texting 243
chapter : 8 Disorders Featuring Somatic Symptoms 249 Factitious Disorder 250
Conversion Disorder and Somatic Symptom Disorder 253
Conversion Disorder 253 Somatic Symptom Disorder 255 What Causes Conversion and Somatic
Symptom Disorders? 257 How Are Conversion and Somatic Symptom
Disorders Treated? 260
Illness Anxiety Disorder 261
Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions 262
Traditional Psychophysiological Disorders 262 new Psychophysiological Disorders 267
Psychological Treatments for Physical Disorders 273 Relaxation Training 273 Biofeedback 273 meditation 273 Hypnosis 274 Cognitive Interventions 275 Support Groups and emotion expression 275 Combination Approaches 275
Putting it together: exPAnding the BoundAries of ABnorMAl PsyChology 276
cLinicaL choices 276
Key terms 276
QuicK Quiz 277
LaunchPad 277
PsychWatch Munchausen Syndrome by Proxy 252
MindTech Can Social Media Spread “Mass Hysteria”? 255
InfoCentral Sleep and Sleep Disorders 264
MediaSpeak When Doctors Discriminate 270
chapter : 9 Eating Disorders 279 Anorexia Nervosa 280
The Clinical Picture 281 medical Problems 282
Bulimia Nervosa 282 Binges 284 Compensatory Behaviors 284 Bulimia nervosa Versus Anorexia nervosa 286
Binge-Eating Disorder 288
What Causes Eating Disorders? 289 Psychodynamic Factors: ego Deficiencies 289 Cognitive Factors 290 Depression 290 Biological Factors 291 Societal Pressures 292 Family environment 293 multicultural Factors: Racial and ethnic Differences 295 multicultural Factors: Gender Differences 296
How Are Eating Disorders Treated? 298 Treatments for Anorexia nervosa 298 Treatments for Bulimia nervosa 302
: CONTENTSxiv
Treatments for Binge-eating Disorder 305
Putting it together: A stAndArd for integrAting PersPeCtives 306
cLinicaL choices 306
Key terms 306
QuicK Quiz 307
LaunchPad 307
InfoCentral Body Dissatisfaction 287
MindTech Dark Sites of the Internet 294
PsychWatch The Sugar Plum Fairy 304
chapter : 10 Substance Use and Addictive Disorders 309 Depressants 311
Alcohol 311 Sedative-Hypnotic Drugs 316 opioids 316
Stimulants 319 Cocaine 319 Amphetamines 322 Stimulant Use Disorder 323
Hallucinogens, Cannabis, and Combinations of Substances 323
Hallucinogens 323 Cannabis 326 Combinations of Substances 328
What Causes Substance Use Disorders? 330 Sociocultural Views 330 Psychodynamic Views 330 Cognitive-Behavioral Views 331 Biological Views 332
How Are Substance Use Disorders Treated? 334 Psychodynamic Therapies 335 Behavioral Therapies 335 Cognitive-Behavioral Therapies 337 Biological Treatments 337 Sociocultural Therapies 339
Other Addictive Disorders 342 Gambling Disorder 342 Internet Gaming Disorder: Awaiting official Status 343
Putting it together: neW Wrinkles to A fAMiliAr story 343
cLinicaL choices 344
Key terms 344
QuicK Quiz 345
LaunchPad 345
PsychWatch College Binge Drinking: An Extracurricular Crisis 313
MindTech Neknomination Goes Viral 315
InfoCentral Smoking, Tobacco, and Nicotine 320
PsychWatch Club Drugs: X Marks the (Wrong) Spot 325
MediaSpeak Enrolling at Sober High 336
chapter : 11 Disorders of Sex and Gender 347 Sexual Dysfunctions 348
Disorders of Desire 348 Disorders of excitement 351 Disorders of orgasm 354 Disorders of Sexual Pain 358
Treatments for Sexual Dysfunctions 360 What Are the General Features of Sex Therapy? 360 What Techniques Are Used to Treat Particular
Dysfunctions? 363 What Are the Current Trends in Sex Therapy? 366
Paraphilic Disorders 367 Fetishistic Disorder 369 Transvestic Disorder 370 exhibitionistic Disorder 371 Voyeuristic Disorder 372 Frotteuristic Disorder 372 Pedophilic Disorder 372 Sexual masochism Disorder 374 Sexual Sadism Disorder 375
Gender Dysphoria 376 explanations of Gender Dysphoria 378 Treatments for Gender Dysphoria 378
Putting it together: A PrivAte toPiC drAWs PuBliC Attention 382
cLinicaL choices 382
Key terms 382
QuicK Quiz 383
LaunchPad 383
InfoCentral Sex Throughout the Life Cycle 350
PsychWatch Sexism, Viagra, and the Pill 365
CONTENTS : xv
MindTech “Sexting”: Healthy or Pathological? 368
MediaSpeak A Different Kind of Judgment 380
chapter : 12 Schizophrenia 385 The Clinical Picture of Schizophrenia 387
What Are the Symptoms of Schizophrenia? 387 What Is the Course of Schizophrenia? 391
How Do Theorists Explain Schizophrenia? 392 Biological Views 393 Psychological Views 398 Sociocultural Views 399
How Are Schizophrenia and Other Severe Mental Disorders Treated? 401
Institutional Care in the Past 403 Institutional Care Takes a Turn for the Better 404 Antipsychotic Drugs 406 Psychotherapy 409 The Community Approach 411
Putting it together: An iMPortAnt lesson 418
cLinicaL choices 418
Key terms 419
QuicK Quiz 419
LaunchPad 419
InfoCentral Hallucinations 390
PsychWatch Postpartum Psychosis: The Case of Andrea Yates 394
MindTech Can Computers Develop Schizophrenia? 396
PsychWatch Lobotomy: How Could It Happen? 405
MindTech Putting a Face on Auditory Hallucinations 410
MediaSpeak “Alternative” Mental Health Care 416
chapter : 13 Personality Disorders 421 “Odd” Personality Disorders 424
Paranoid Personality Disorder 425 Schizoid Personality Disorder 427 Schizotypal Personality Disorder 428
“Dramatic” Personality Disorders 431 Antisocial Personality Disorder 431 Borderline Personality Disorder 436
Histrionic Personality Disorder 441 narcissistic Personality Disorder 444
“Anxious” Personality Disorders 447 Avoidant Personality Disorder 447 Dependent Personality Disorder 450 obsessive-Compulsive Personality Disorder 452
Multicultural Factors: Research Neglect 454
Are There Better Ways to Classify Personality Disorders? 455
The “Big Five” Theory of Personality and Personality Disorders 456
“Personality Disorder—Trait Specified”: Another Dimensional Approach 458
Putting it together: disorders of PersonAlity—redisCovered And reConsidered 460
cLinicaL choices 460
Key terms 460
QuicK Quiz 461
LaunchPad 461
PsychWatch Mass Murders: Where Does Such Violence Come From? 434
MediaSpeak The Patient as Therapist 440
MindTech Selfies: Narcissistic or Not? 446
InfoCentral Lying 457
chapter : 14 Disorders Common Among Children and Adolescents 463 Childhood and Adolescence 464
Childhood Anxiety Disorders 465 Separation Anxiety Disorder 467 Treatments for Childhood Anxiety Disorders 468
Childhood Depressive and Bipolar Disorders 469 major Depressive Disorder 469 Bipolar Disorder and Disruptive mood
Dysregulation Disorder 471
Oppositional Defiant Disorder and Conduct Disorder 473
What Are the Causes of Conduct Disorder? 474 How Do Clinicians Treat Conduct Disorder? 474
Elimination Disorders 476 enuresis 476 encopresis 476
: CONTENTSxvi
Neurodevelopmental Disorders 479 Attention-Deficit/Hyperactivity Disorder 479 Autism Spectrum Disorder 483 Intellectual Disability 488
Putting it together: CliniCians DisCover ChilDhooD anD aDolesCenCe 498
CliniCal ChoiCes 498
Key terms 499
QuiCK Quiz 499
launChPad 499
InfoCentral Child and Adolescent Bullying 466
MindTech Parent Worries on the Rise 470
PsychWatch Child Abuse 478
PsychWatch A Special Kind of Talent 485
PsychWatch Reading and ‘Riting and ‘Rithmetic 491
chapter : 15 Disorders of Aging and Cognition 501 Old Age and Stress 502
Depression in Later Life 503
Anxiety Disorders in Later Life 505
Substance Misuse in Later Life 505
Psychotic Disorders in Later Life 508
Disorders of Cognition 509 Delirium 509 Alzheimer’s Disease and Other Neurocognitive
Disorders 511
Issues Affecting the Mental Health of the Elderly 522
Putting it together: CliniCians DisCover the elDerly 524
CliniCal ChoiCes 524
Key terms 525
QuiCK Quiz 525
launChPad 525
PsychWatch The Oldest Old 503
InfoCentral The Aging Population 506
MindTech Remember to Tweet; Tweet to Remember 510
MediaSpeak Focusing on Emotions 521
chapter : 16 Law, Society, and the Mental Health Profession 527 Law and Mental Health 528
How Do Clinicians Influence the Criminal Justice System? 528
How Do the Legislative and Judicial Systems Influence Mental Health Care? 536
In What Other Ways Do the Clinical and Legal Fields Interact? 541
What Ethical Principles Guide Mental Health Professionals? 544
Mental Health, Business, and Economics 546 Bringing Mental Health Services to the Workplace 546 The Economics of Mental Health 546
Technology and Mental Health 548 The Person Within the Profession 550
Putting it together: operating Within a larger system 552
Key terms 553
QuiCK Quiz 553
launChPad 553
PsychWatch Famous Insanity Defense Cases 531
PsychWatch Serial Murderers: Madness or Badness? 543
MindTech New Ethics for a Digital Age 549
InfoCentral Personal and Professional Issues 551
Glossary G-1 References R-1 Credits C-1 Name Index NI-1 Subject Index SI-1
xvii
It was the spring of 1981. Over the previous eight months, the Philadelphia Phillies had won the World Series, and the Eagles, Sixers, and Flyers had made it to the Super Bowl, NBA Finals, and Stanley Cup Finals, respectively. I had two adorable children ages 5 and 3. I had been granted tenure at Princeton. My life was full—or so I thought.
Then, Linda Chaput, at that time an editor at W. H. Freeman and Company and Worth Publishers, walked into my office. During a lively discussion, she and I discovered that we had similar ideas about how abnormal psychology should be presented in a textbook. By the time Linda departed two hours later, we had out- lined the principles that should underlie the “ideal” abnormal psychology textbook. We had, in effect, a deal. All that was left was for me to write the book. A decade later, the first edition of Abnormal Psychology (“the BOOK,” as my family and I had come to call it) was published, followed a few years later by the first edition of Fundamentals of Abnormal Psychology.
As I look back to that fateful day in 1981, I cannot help but note that several things have changed. With a few exceptions, my Philadelphia sports teams have returned to form and have struggled year in, year out. My sons have become ac- complished middle-aged men, and their previous “adorable” tag is now worn by my 2-year-old and 4-year-old grandchildren, Emmett and Delia. I am older, humbler, and a bit more fatigued than the person who met with Linda Chaput 35 years ago.
At the same time, several wonderful things remain the same. I am still at Princeton University. I am still married to the same near-perfect person—Marlene Comer. And I still have the privilege of writing abnormal psychology textbooks— Fundamentals of Abnormal Psychology and Abnormal Psychology. The current version, Fundamentals of Abnormal Psychology, Eighth Edition, represents my eighteenth edi- tion of one or the other of the textbooks.
My textbook journey has been a labor of love, but I also must admit that each edition requires enormous effort, ridiculous pressure, and too many sleepless nights to count. I mention these labors not only because I am a world-class whiner but also to emphasize that I approach each edition as a totally new undertaking rather than as a cut-and-paste update of past editions. I work feverishly to make each edi- tion fresh and to include innovative and enlightening pedagogical techniques.
With this in mind, I have added an enormous amount of new material and many exciting new features for this edition of Fundamentals of Abnormal Psychology—while at the same time retaining the successful themes, material, and techniques that have been embraced enthusiastically by past readers. The result is, I believe, a book that will excite readers and speak to them and their times. I have again tried to convey my passion for the field of abnormal psychology, and I have built on the generous feedback of my colleagues in this undertaking—the students and professors who have used this textbook over the years.
New and expanded Features
In line with the many changes that have occurred over the past several years in the fields of abnormal psychology, education, and publishing, and in the world, I have brought the following new features and changes to the current edition.
•NEW• DSM-5 With the publication of DSM-5, abnormal psychology is clearly a field in transition. To help students appreciate the field’s current status and new
PrefACe
: PREFACExviii
directions, I present, integrate, and analyze DSM-5 material throughout the text- book. Controversy aside, this is now the field’s classification and diagnostic system, and it is important that readers understand and master its categories and criteria, appreciate its strengths and weaknesses, and recognize its assumptions and implica- tions, just as past readers learned about previous DSM editions.
DSM-5, as well as discussions of its implications and controversial nature, is pre- sented in various ways throughout my textbook. First, its new categories, criteria, and information are woven smoothly into the narrative of each and every chapter. Second, reader-friendly pedagogical tools throughout the textbook, including a two-page infographic on the inside front cover and regular short features called Dx Checklist and DSM-5 Controversy, help students fully grasp the DSM-5 mate- rial. Third, special topic boxes highlight DSM-5 issues and controversies, such as Premenstrual Dysphoric Disorder: Déjà Vu All Over Again (page 209) and Mass Murders: Where Does Such Violence Come From? (page 434).
•NEW• TECHNOLOGY AND THE “MindTech” FEATURE The breathtaking rate of technological change that characterizes today’s world has had significant effects on the mental health field. In this edition I cover this impact extensively, including many discussions in the book’s narrative, boxes, photographs, and figures. The book examines, for example, how the Internet, texting, and social networks have become convenient tools for those who wish to bully others or pursue pedophilic desires (pages 373, 465, 466); how social networking may provide a new source for social anxiety (page 129); and how today’s technology has helped create new psychologi- cal disorders such as Internet addiction (page 343). It also looks at dangerous new trends such as the posting of self-cutting videos on the Internet (page 225), and it informs the reader about cybertherapy in its ever-expanding forms—from Skype therapy and avatar therapy to virtual reality treatments (pages 57, 67, 163, 410).
In addition, I have added a new feature throughout the book called MindTech— sections in each chapter that give special attention to particularly provocative tech- nological trends in engaging and enlightening ways. The MindTech features examine the following cutting-edge topics:
• Mental Health Apps Explode in the Marketplace (page 21)
• Social Networking Sites: A Researcher’s Paradise? (page 24)
• Have Your Avatar Call My Avatar (page 67)
• Rorschach on Wikipedia: Psychology’s Wiki Leaks? (page 83)
• Social Media Jitters (page 129)
• Virtual Reality Therapy: Better Than the Real Thing? (page 163)
• Texting: A Relationship Buster? (page 207)
• Crisis Texting (page 243)
• Can Social Media Spread “Mass Hysteria”? (page 255)
• Dark Sites of the Internet (page 294)
• Neknomination Goes Viral (page 315)
• “Sexting”: Healthy or Pathological? (page 368)
• Can Computers Develop Schizophrenia? (page 396)
• Putting a Face on Auditory Hallucinations (page 410)
• Selfies: Narcissistic or Not? (page 446)
• Children Online: Parent Worries on the Rise (page 470)
PREFACE : xix
• Remember to Tweet: Tweet to Remember (page 510)
• New Ethics for a Digital Age (page 549)
•NEW• “INFOCENTRALS” It is impossible to surf the Internet, watch TV, or flip through a magazine without coming across infographics, those graphic representa- tions that present complex data in quick, stimulating, and visually appealing ways. Infographics present information in a way that allows us to easily recognize trends and patterns and make connections between related concepts. With the develop- ment of new digital tools over the past decade, the popularity of infographics has exploded. Readers and viewers like them and learn from them.
Thus Fundamentals of Abnormal Psychology, Eighth Edition, introduces a new fea- ture called InfoCentral—numerous, lively infographics on important topics in the field. The infographics provide visual representations of data related to key topics and concepts in each chapter, repeatedly offering fascinating snippets of informa- tion to spur readers’ interest. I am certain that readers will greatly enjoy these special offerings, while also learning from them.
Every chapter features a full-page InfoCentral, including the following ones:
• Happiness (page 19)
• Dietary Supplements: An Alternative Treatment (page 43)
• Common Factors in Therapy (page 101)
• Mindfulness (page 115)
• Sexual Assault (page 156)
• Sadness (page 185)
• The Right to Commit Suicide (page 240)
• Sleep and Sleep Disorders (page 264)
• Body Dissatisfaction (page 287)
• Smoking and Tobacco Use (page 320)
• Sex Throughout the Life Cycle (page 350)
• Hallucinations (page 390)
• Lying (page 457)
• Bullying (page 466)
• The Aging Population (page 506)
• Personal and Professional Issues (page 551)
•NEW• ADDITIONAL CUTTING-EDGE BOXES I have grouped the book’s other boxes into two categories: PsychWatch boxes examine text topics in more depth, emphasize the effect of culture on mental disorders and treatment, and explore ex- amples of abnormal psychology in movies, the news, and the real world. MediaSpeak boxes offer provocative pieces by news, magazine, and Web writers and bloggers on current issues in abnormal psychology. In addition to updating the PsychWatch and MediaSpeak boxes that have been retained from the previous edition, I have added many new ones. For example, new MediaSpeak boxes include the following:
• Flawed Study, Gigantic Impact (Chapter 1)
• Saving Minds Along with Souls (Chapter 2)
• The Fear Business (Chapter 4)
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• Immigration and Depression in the 21st Century (Chapter 6)
• When Doctors Discriminate (Chapter 8)
•NEW• “CLINICAL CHOICES” INTERACTIVE CASE STUDIES This eighth edi- tion of Fundamentals of Abnormal Psychology includes 11 new interactive case studies (one for each of the disorders chapters), available online through LaunchPad, our online course management system. Through an immersive mix of video, audio, and assessment, each interactive case allows the student to simulate the thought process of a clinician by identifying and evaluating a virtual “client’s” symptoms, gather- ing information about the client’s life situation and family history, determining a diagnosis, and formulating a treatment plan. The student will also answer various questions about each case to help reinforce the chapter material. Each answer will trigger feedback, guidance, and critical thinking in an active learning environment.
•NEW• ADDITIONAL AND EXPANDED TEXT SECTIONS Over the past few years, a number of topics in abnormal psychology have received special attention. In this edition, I have provided new sections on such topics, including the psychology of mass killings (pages 434), the impact of the Affordable Care Act (pages 17, 547), the growing role of IRBs (pages 32–33), dimensional diagnoses (pages 94, 456–459), new treatments in the field (pages 30, 57, 410), spirituality and mental health (pages 61, 62), overuse of certain diagnoses (pages 471, 492), the psychological price of celebrity (pages 200, 231), transgen- der issues (pages 376, 381), alternative views of personality disorders (pages 455–459), self-injury (pages 224, 437), the pro-Ana movement (page 294), poor medical treatment for people with psychological disorders (page 270), ethics and psychology (pages 544–546), culture and abnormality (pages 71, 454), race and the clinical field (pages 107–108), and sexism in the clinical field (pages 209, 365).
•NEW• ADDITIONAL CASE MATERIAL One of the hallmarks of my textbooks is the inclusion of numerous and culturally diverse clinical examples that bring theoretical and clinical issues to life. In my continuing quest for relevance to the reader and to today’s world, I have replaced or revised more than one-third of the clinical material in this edition. The new clinical material includes the cases of Franco, major depressive disorder (pages 77, 79); Tonya, Munchausen syndrome by proxy (page 252); Meri, major depressive disorder (page 183); Eduardo, paranoid personality disorder (page 425); Luisa, dissociative personality disorder (page 170); Kay, bipolar disorder (page 216); Shani, anorexia nervosa (page 279); Ricky, ADHD (page 463); Lucinda, histrionic personality disorder (pages 441–442); Jonah, separa- tion anxiety disorder (pages 467–468); and many others.
•NEW• CRITICAL THOUGHT QUESTIONS A very stimulating and popular feature of my previous edition of Fundamentals of Abnormal Psychology was the “critical thought questions”—questions that pop up within the text narrative, asking stu- dents to pause at precisely the right moment and think critically about the material they have just read. Given the enthusiastic response to this feature by professors and readers alike, I have added many new critical thought questions throughout the textbook, including ones in the MindTech and MediaSpeak features.
•NEW• “BETWEEN THE LINES” The textbook not only retains but also expands a fun and thought-provoking feature from past editions that has been very popu- lar among students and professors—reader-friendly elements called “Between the Lines,” consisting of text-relevant tidbits, surprising facts, current events, historical notes, interesting trends, enjoyable lists, and stimulating quotes.
•NEW• THOROUGH UPDATE In this edition I present the most current theories, research, and events, including more than 2,000 new references from the years 2013–2015, as well as hundreds of new photos, tables, and figures.
PREFACE : xxi
•EXPANDED COVERAGE• PREVENTION AND MENTAL HEALTH PROMOTION In accord with the clinical field’s growing emphasis on prevention, positive psychol- ogy, and psychological wellness, I have increased the textbook’s attention to these important approaches (for example, pages 16–17, 19, 524).
•EXPANDED COVERAGE• MULTICULTURAL ISSUES Over the past 30 years, clinical theorists and researchers increasingly have become interested in ethnic, racial, gen- der, and other cultural factors, and my previous editions of Fundamentals of Abnormal Psychology certainly have included these important factors. The study of such factors has, appropriately, been elevated to a broad perspective in recent years—the multicul- tural perspective. Consistent with this clinical movement, the current edition includes yet additional multicultural material and research throughout the text. Even a quick look through the pages of this textbook will reveal that it truly reflects the diversity of our society and of the field of abnormal psychology.
•EXPANDED COVERAGE• “NEW-WAVE” COGNITIVE AND COGNITIVE- BEHAVIORAL THEORIES AND TREATMENTS The current edition of Abnormal Psychology has expanded its coverage of the “new-wave” cognitive and cognitive- behavioral theories and therapies, including mindfulness-based cognitive therapy and Acceptance and Commitment Therapy (ACT), presenting their propositions, techniques, and research in chapters throughout the text (for example, pages 56, 114, 115, 410).
•EXPANDED COVERAGE• NEUROSCIENCE The clinical field continues to witness the growth and impact of remarkable brain-imaging techniques, genetic map- ping strategies, and other neuroscience approaches, all of which are expanding our understanding of the brain. Correspondingly, the new edition of Fundamentals of Abnormal Psychology has further expanded its coverage of how biochemical factors, brain structure, brain function, and genetic factors contribute to abnormal behavior (for example, pages 39, 116, 118, 393).
continuing Strengths
As I noted earlier, in this edition I have also retained the themes, material, and techniques that have worked successfully and have been embraced enthusiastically by past readers.
BREADTH AND BALANCE The field’s many theories, studies, disorders, and treat- ments are presented completely and accurately. All major models—psychological, biological, and sociocultural—receive objective, balanced, up-to-date coverage, without bias toward any single approach.
INTEGRATION OF MODELS Discussions throughout the text, particularly those headed “Putting It Together,” help students better understand where and how the various models work together and how they differ.
EMPATHY The subject of abnormal psychology is people—very often people in great pain. I have tried therefore to write always with empathy and to impart this awareness to students.
INTEGRATED COVERAGE OF TREATMENT Discussions of treatment are pre- sented throughout the book. In addition to a complete overview of treatment in the opening chapters, each of the pathology chapters includes a full discussion of relevant treatment approaches.
RICH CASE MATERIAL As I mentioned earlier, the textbook features hundreds of culturally diverse clinical examples to bring theoretical and clinical issues to life.
: PREFACExxii
More than 25 percent of the clinical material in this edition is new or revised significantly.
MARGIN GLOSSARY Hundreds of key words are defined in the margins of pages on which the words appear. In addition, a traditional glossary is available at the back of the book.
ROLLING SUMMARIES Instead of waiting until the end of a chapter for a summary, SUMMING UP sections appear throughout each chapter, at the completion of each major section, helping students to better retain the material under discussion.
“PUTTING IT TOGETHER” A section toward the end of each chapter, “Putting It Together,” asks whether competing models can work together in a more integrated approach and also summarizes where the field now stands and where it may be going.
FOCUS ON CRITICAL THINKING The textbook provides tools for thinking criti- cally about abnormal psychology. As I mentioned earlier, in this edition, “critical thought” questions appear at carefully selected locations within the text discussions. The questions ask readers to stop and think critically about the material they have just read.
CHAPTER-ENDING KEY TERMS AND QUICK QUIZ SECTIONS These sections, keyed to appropriate pages in the chapter for easy reference, allow students to re- view and test their knowledge of chapter materials.
STRIKING PHOTOS AND STIMULATING ILLUSTRATIONS Concepts, disorders, treatments, and applications are brought to life for the reader with stunning photo- graphs, diagrams, graphs, and anatomical figures—all reflecting the most up-to-date data available. The photos range from historical to today’s world to pop culture. They do more than just illustrate topics: they touch and move readers.
ADAPTABILITY Chapters are self-contained, so they can be assigned in any order that makes sense to the professor.
MeDIA and other Supplements
I have been delighted by the enthusiastic responses of both professors and students to the supplements that accompany my textbooks. This edition offers those supple- ments once again, revised and enhanced, and adds a number of exciting new ones.
FOR PROFESSORS
WORTH VIDEO COLLECTION FOR ABNORMAL PSYCHOLOGY Produced and edited by Ronald J. Comer, Princeton University, and Gregory Comer, Princeton Academic Resources. Faculty Guide included. This incomparable video series offers 128 clips that depict disorders, show historical footage, and illustrate clinical topics, pathologies, treatments, experiments, and dilemmas. Videos are available in LaunchPad and on the Video Collection for Abnormal Psychology Flash Drive. I also have written an ac- companying guide that fully describes and discusses each video clip, so that profes- sors can make informed decisions about the use of the segments in lectures.
INSTRUCTOR’S RESOURCE MANUAL by Charlie Harris, Clayton State University and Danielle Gunraj, SUNY Binghamton. This comprehensive guide ties together the ancillary package for professors and teaching assistants. The manual includes de- tailed chapter summaries, lists of principal learning objectives, topic overviews, ideas for lectures, lecture outlines, discussion launchers, classroom activities, extra credit
PREFACE : xxiii
projects, and DSM criteria for each of the disorders discussed in the text. It also offers strategies for using the accompanying media, including the video collection. Finally, it includes a comprehensive set of valuable materials that can be obtained from outside sources—items such as relevant feature films, documentaries, teaching references, and Internet sites related to abnormal psychology.
• Lecture Slides available at http://www.macmillanhighered.com/Catalog/product/ fundamentalsofabnormalpsychology-eighthedition-comer. These slides focus on key concepts and themes from the text and can be used as-is or customized to fit a professor’s needs.
• Illustration Slides available at http://www.macmillanhighered.com/Catalog/product/ fundamentalsofabnormalpsychology-eighthedition-comer. These slides featuring all chap- ter photos and illustrations can be used as is or customized to fit a professor’s needs.
• Chapter Figures, Photos, and Tables available at http://www. macmillanhighered. com/Catalog/product/fundamentalsofabnormalpsychology-eighthedition-comer. This col- lection gives professors access to all of the photographs, illustrations, and tables from Fundamentals of Abnormal Psychology, Eighth Edition.
ASSESSMENT TOOLS
TEST BANK by Chrysalis Wright, University of Central Florida. A comprehensive test bank offers more than 2,200 multiple-choice, fill-in-the-blank, and essay questions. Each question is graded according to difficulty, the Bloom’s level is identified, and keyed to the topic and page in the text where the source information appears.
DIPLOMA ONLINE COMPUTERIZED TEST BANK Available for both Windows and Macintosh at http://www.macmillanhighered.com/Catalog/product/fundamentalsofab- normalpsychology-eighthedition-comer. This downloadable Test Bank guides professors step-by-step through the process of creating a test and allows them to add an un- limited number of questions, edit or scramble questions, format a test, and include pictures and multimedia links. The accompanying grade book enables them to record students’ grades throughout the course and includes the capacity to sort student records and view detailed analyses of test items, curve tests, generate re- ports, add weights to grades, and more. These Test Bank files also provide tools for converting the Test Bank into a variety of useful formats as well as Blackboard- and WebCT-formatted versions of the Test Bank for Fundamentals of Abnormal Psychology, Eighth Edition.
FOR STUDENTS
CASE STUDIES IN ABNORMAL PSYCHOLOGY, SECOND EDITION, by Ethan E. Gorenstein, Behavioral Medicine Program, New York–Presbyterian Hospital, and Ronald J. Comer, Princeton University. This new edition of our popular case study book pro- vides 20 case histories—all of them updated and several of them brand new—each going beyond DSM diagnoses to describe the individual’s history and symptoms, a theoretical discussion of treatment, a specific treatment plan, and the actual treat- ment conducted. The casebook also provides three cases without diagnoses or treatment, so that students can identify disorders and suggest appropriate therapies. Wonderful case material, particularly for somatic symptom disorder, hoarding dis- order, and gender dysphoria, has been added for this edition by Danae Hudson and Brooke Whisenhunt, professors at Missouri State University.
LAUNCHPAD with LearningCurve Quizzing—Multimedia to Support Teaching and Learning Available at www.launchpadworks.com.
A comprehensive Web resource for teaching and learning psychology, Launch- Pad combines Worth Publishers’ award-winning media with an innovative platform
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for easy navigation. For students, it is the ultimate online study guide with rich interactive tutorials, videos, e-Book, and the LearningCurve adaptive quizzing sys- tem. For instructors, LaunchPad is a full-course space where class documents can be posted, quizzes are easily assigned and graded, and students’ progress can be assessed and recorded. Whether you are looking for the most effective study tools or a robust platform for an online course, LaunchPad is a powerful way to enhance your class.
LaunchPad to Accompany Fundamentals of Abnormal Psychology, Eighth Edition, can be previewed at www.launchpadworks.com.
Fundamentals of Abnormal Psychology, Eighth Edition, and LaunchPad can be or- dered together with:
ISBN-10: 1-319-06179-6 ISBN-13: 978-1-319-06179-1
LaunchPad for Fundamentals of Abnormal Psychology, Eighth Edition, includes the fol- lowing resources:
• The LearningCurve quizzing system was designed based on the latest findings from learning and memory research. It combines adaptive question selection, immediate and valuable feedback, and a gamelike interface to engage students in a learning experience that is unique to them. Each LearningCurve quiz is fully integrated with other resources in LaunchPad through the Personalized Study Plan, so students will be able to review with Worth’s extensive library of videos and activities. And state-of-the-art question analysis reports allow instructors to track the progress of individual students as well as their class as a whole.
• An interactive e-Book allows students to highlight, bookmark, and make their own notes, just as they would with a printed textbook.
• Clinical Choices, authored by Taryn Myers, of Virginia Wesleyan College. In these 11 interactive case studies in LaunchPad, students simulate the role of clinical psychologist, engaging with virtual clients to identify psychological disorders (based on DSM-5 criteria) and think critically about diagnosis and treatment options.
• Abnormal Psychology Video Activities, produced and edited by Ronald J. Comer, Princeton University, and Gregory Comer, Princeton Academic Resources. These in- triguing video cases run three to seven minutes each and focus on persons affected by disorders discussed in the text. Students first view a video case and then answer a series of thought-provoking questions about it.
• Deep integration is available between LaunchPad products and Blackboard, Brightspace by D2Learn, Canvas, and Moodle. These deep integrations offer educators single sign-on and gradebook sync, now with auto-refresh. Also, these best-in-class integrations offer deep linking to all Macmillan digital content at the chapter and asset level, giving professors ultimate flexibility and customiza- tion capability within their learning management system.
Acknowledgments
I am very grateful to the many people who have contributed to writing and pro- ducing this book. I particularly thank Marlene Comer for her usual outstanding work on the manuscript. In addition, I am indebted to Marlene Glissmann for her fast, furious, and fantastic work on the references. And I sincerely appreciate the superb work of the book’s assistants—actually collaborators—Greg Comer and Jon Comer.
PREFACE : xxv
I am indebted greatly to those outstanding academicians and clinicians who have provided feedback on this new edition of Fundamentals of Abnormal Psychology, along with that of its partner, Abnormal Psychology, and have commented with great insight and wisdom on its clarity, accuracy, and completeness. Their collective knowledge has in large part shaped the current edition: David Alfano, Community College of Rhode Island; Jeffrey Armstrong, Northampton Community College; Wendy Bartkus, Albright College; Jennifer Bennett, University of New Mexico; Christine Browning, Victory University; Megan Davies, NOVA-Woodbridge Campus; Pernella Deams, Grambling State University; Frederick Ernst, University of Texas Pam America; Jessica Goodwin Jolly, Gloucester County College; Abby Hill, Trinity International University; Tony Hoffman, University of California, Santa Cruz; Craig Knapp, College of St. Joseph; Sally Kuhlenschmidt, Western Kentucky University; Paul Lewis, Bethel College; Gregory Mallis, University of Indianapolis; Taryn Myers, Virginia Wesleyan College; Edward O'Brien, Marywood University; Mary Pelton- Cooper, Northern Michigan University; Ginger Pope, South Piedmont Community College; Lisa Riley, Southwest Wisconsin Technical College; Ty Schepis, Texas State University; and Elizabeth Seebach, Saint Mary’s University of Minnesota.
Earlier I also received valuable feedback from academicians and clinicians who reviewed portions of the previous editions of Fundamentals of Abnormal Psychology and Abnormal Psychology. Certainly their collective knowledge has also helped shape this new edition, and I gratefully acknowledge their important contributions: Christopher Adams, Fitchburg State University; Dave W. Alfano, Community College of Rhode Island; Alisa Aston, University of North Florida; Kent G. Bailey, Virginia Commonwealth University; Stephanie Baralecki, Chestnut Hill College; Sonja Barcus, Rochester College; Marna S. Barnett, Indiana University of Pennsylvania; Jillian Bennett, University of Massachusetts Boston; Otto A. Berliner, Alfred State College; Allan Berman, University of Rhode Island; Douglas Bernstein, University of Toronto, Mississauga; Sarah Bing, University of Maryland Eastern Shore; Greg Bolich, Cleveland Community College; Stephen Brasel, Moody Bible Institute; Conrad Brombach, Christian Brothers University; Barbara Brown, Georgia Perimeter College; Jeffrey A. Buchanan, Minnesota State University, Mankato; Gregory M. Buchanan, Beloit College; Laura Burlingame-Lee, Colorado State University; Loretta Butehorn, Boston College; Glenn M. Callaghan, San Jose State University; E. Allen Campbell, University of St. Francis; Julie Carboni, San Jose College and National University; David N. Carpenter, Southwest Texas University; Marc Celentana, The College of New Jersey; Edward Chang, University of Michigan; Daniel Chazin, Rutgers University; Sarah Cirese, College of Marin; June Madsen Clausen, University of San Francisco; Victor B. Cline, University of Utah; E. M. Coles, Simon Fraser University; Michael Connor, California State University, Long Beach; Frederick L. Coolidge, University of Colorado, Colorado Springs; Patrick J. Courtney, Central Ohio Technical College; Charles Cummings, Asheville Buncombe Technical Community College; Dennis Curtis, Metropolitan Community College; Timothy K. Daugherty, Missouri State University; Lauren Doninger, Gateway Community College; Mary Dosier, University of Delaware; S. Wayne Duncan, University of Washington, Seattle; Anne Duran, California State University Bakersfield; Morris N. Eagle, York University; Miriam Ehrenberg, John Jay College of Criminal Justice; Jon Elhai, University of Toledo; Daniella K. C. Errett, Pennsylvania Highlands Community College; Carlos A. Escoto, Eastern Connecticut State University; William Everist, Pima Community College; Jennifer Fiebig, Loyola University Chicago; David M. Fresco, Kent State University; Anne Fisher, University of Southern Florida; William E. Flack Jr., Bucknell University; John Forsyth, State University of New York, Albany; Alan Fridlund, University of California, Santa Barbara; Stan Friedman, Southwest Texas State University; Dale Fryxell, Chaminade University; Lawrence L. Galant,
: PREFACExxvi
Gaston College; Kathryn E. Gallagher, Georgia State University; Rosemarie B. Gilbert, Brevard Community College; Karla Gingerich, Colorado State University; Nicholas Greco, College of Lake County; Jane Halonen, University of West Florida; James Hansell, University of Michigan; Neth Hansjoerg, Rensselaer Polytechnic Institute; David Harder, Tufts University; Morton G. Harmatz, University of Massachusetts; Jinni A. Harrigan: California State University, Fullerton; Jumi Hayaki, College of the Holy Cross; RaNae Healy, Gateway Community College; Anthony Hermann, Kalamazoo College; Paul Hewitt, University of British Columbia; David A. Hoffinan, University of California, Santa Cruz; Art Hohmuth, The College of New Jersey; Art Houser, Fort Scott Community College; Danae Hudson, Missouri State University; William G. Iacono, University of Minnesota; Ashleigh E. Jones, University of Illinois at Urbana-Champaign; Ricki E. Kantrowitz, Westfield State University; Barbara Kennedy, Brevard Community College; Lynn M. Kernen, Hunter College; Audrey Kim, University of California, Santa Cruz; Guadalupe Vasquez King, Milwaukee Area Technical College; Tricia Z. King, Georgia State University; Bernard Kleinman, University of Missouri, Kansas City; Futoshi Kobayashi, Northern State University; Alan G. Krasnoff, University of Missouri, St. Louis; Robert D. Langston, University of Texas, Austin; Kimberlyn Leary, University of Michigan; Harvey R. Lerner, Kaiser-Permanente Medical Group; Arnold D. LeUnes, Texas A&M University; Michael P. Levin, Kenyon College; Barbara Lewis, University of West Florida; Mary Margaret Livingston, Louisiana Technical University; Karsten Look, Columbus State Community College; Joseph LoPiccolo, University of Missouri, Columbia; L. E. Lowenstein, Southern England Psychological Services; Jerald J. Marshall, University of Central Florida; Toby Marx, Union County College; Janet R. Matthews, Loyola University; Robert J. McCaffrey, State University of New York, Albany; Rosemary McCullough, Ave Maria University; E. Dudley McGlynn, Auburn University; Tara McKee, Hamilton College; Lily D. McNair, University of Georgia; Mary W. Meagher, Texas A&M University; Dorothy Mercer, Eastern Kentucky University; Michele Metcalf, Coconino Community College; Joni L. Mihura, University of Toledo; Andrea Miller, Georgia Southwestern State University; Antoinette Miller, Clayton State University; Regina Miranda, Hunter College; John Mitchell, Lycoming College; Robin Mogul, Queens University; Linda M. Montgomery, University of Texas, Permian Basin; Jeri Morris, Roosevelt University; Karen Mottarella, University of Central Florida; Maria Moya, College of Southern Nevada; Karla Klein Murdock, University of Massachusetts, Boston; Sandy Naumann, Delaware Technical & Community College; David Nelson, Sam Houston State University; Paul Neunuebel, Sam Houston State University; Ryan Newell, Oklahoma Christian University; Katherine M. Nicolai, Rockhurst University; Susan A. Nolan, Seton Hall University; Fabian Novello, Purdue University; Ryan O’Loughlin, Nazareth College; Mary Ann M. Pagaduan, American Osteopathic Association; Crystal Park, University of Connecticut; Dominic J. Parrott, Georgia State University; Daniel Paulson, Carthage College; Paul A. Payne, University of Cincinnati; David V. Perkins, Ball State University; Julie C. Piercy, Central Virginia Community College; Lloyd R. Pilkington, Midlands Technical College; Harold A. Pincus, chair, DSM-IV, University of Pittsburgh, Western Psychiatric Institute and Clinic; Chris Piotrowski, University of West Florida; Debbie Podwika, Kankakee Community College; Norman Poppel, Middlesex County College; David E. Powley, University of Mobile; Laura A. Rabin, Brooklyn College; Max W. Rardin, University of Wyoming, Laramie; Lynn P. Rehm, University of Houston; Leslie A. Rescorla, Bryn Mawr College; R. W. Rieber, John Jay College, CUNY; George Esther Rothblum, University of Vermont; Vic Ryan, University of Colorado, Boulder; Randall Salekin, Florida International University; Edie Sample, Metropolitan Community College; Jackie Sample, Central Ohio Technical College; A. A. Sappington, University of Alabama, Birmingham; Martha Sauter, McLennan Community College; Laura Scaletta, Niagara County Community College; George W. Shardlow, City College of San
PREFACE : xxvii
Francisco; Shalini Sharma, Manchester Community College; Roberta S. Sherman, Bloomington Center for Counseling and Human Development; Wendy E. Shields, University of Montana; Sandra T. Sigmon, University of Maine, Orono; Susan J Simonian, College of Charleston; Janet A. Simons, Central Iowa Psychological Services; Jay R. Skidmore, Utah State University; Rachel Sligar, James Madison University; Katrina Smith, Polk Community College; Robert Sommer, University of California, Davis; Jason S. Spiegelman, Community College of Baltimore County; John M. Spores, Purdue University, South Central; Caroline Stanley, Wilmington College; Wayne Stein, Brevard Community College; Arnit Steinberg, Tel Aviv University; David Steitz, Nazareth College; B. D. Stillion, Clayton College and State University; Deborah Stipp, Ivy Tech College; Joanne H. Stohs, California State University, Fullerton; Jaine Strauss, Macalester College; Mitchell Sudolsky, University of Texas at Austin; John Suler, Rider University; Sandra Todaro, Bossier Parish Community College; Terry Trepper, Purdue University Calumet; Thomas A. Tutko, San Jose State University; Arthur D. VanDeventer, Thomas Nelson Community College; Maggie VandeVelde, Grand Rapids Community College; Jennifer Vaughn, Metropolitan Community College; Norris D. Vestre, Arizona State University; Jamie Walter, Roosevelt University; Steve Wampler, Southwestern Community College; Eleanor M. Webber, Johnson State College; Lance L. Weinmann, Canyon College; Doug Wessel, Black Hills State University; Laura Westen, Emory University; Brook Whisenhunt, Missouri State University; Joseph L. White, University of California, Irvine; Justin Williams, Georgia State University; Amy C. Willis, Veterans Administration Medical Center, Washington, DC; James M. Wood, University of Texas, El Paso; Lisa Wood, University of Puget Sound; Lucinda E. Woodward, Indiana University Southeast; Kim Wright, Trine University; David Yells, Utah Valley State College; Jessica Yokely, University of Pittsburgh; Carlos Zalaquett, University of South Florida; and Anthony M. Zoccolillo, Rutgers University.
I would also like to thank a small group of talented professors who provided valu- able feedback that shaped the development of our new, exciting interactive case studies, Clinical Choices, in this new edition: David Berg, Community College of Philadelphia; Christopher J. Dyszelski, Madison Area Technical College; Paul Deal, Missouri State University; Urminda Firlan, Kalamazoo Valley Community College; Julie Hanauer, Suffolk County Community College; Sally Kuhlenschmidt, Western Kentucky University; Erica Musser, Florida International University; Garth Neufeld, Highline Community College; and Jeremy Pettit, Florida International University.
A special thank you to the authors of the book’s supplements package for doing splen- did jobs with their respective supplements: Chrysalis Wright, University of Central Florida (Test Bank); Charlie Harris, Clayton State University, and Danielle Gunraj, SUNY Binghamton (Instructor’s Resource Manual); Taryn Myers, Virginia Wesleyan College (Clinical Choices); Mallory Malkin, Mississippi University for Women (Research Exercises); Jennifer Bennett, University of New Mexico (Chapter Quizzes); Ann Brandt- Williams, Glendale Community College; Elaine Cassel, Marymount University and Lord Fairfax Community College; Danae L. Hudson, Missouri State University; John Schulte, Cape Fear Community College and University of North Carolina; and Brooke L. Whisenhunt, Missouri State University (additional Web site materials).
I also extend my deep appreciation to the core team of professionals at Worth Publishers and W. H. Freeman and Company who have worked so closely with me to produce this edition and many previous editions. The team consists of truly extraor- dinary people—each extremely talented, each committed to excellence, each dedi- cated to the education of readers, each bound by a remarkable work ethic, and each a wonderful person. It is accurate to say that these members of the core team were once again my co-authors and co-teachers in this enterprise, and I am in their debt.
: PREFACExxviii
They are Rachel Losh, publisher; Daniel McDonough, executive acquisitions editor; Mimi Melek, senior development editor; Tracey Kuehn, director, content manage- ment enhancement; Jane O’Neill, senior project editor; Sarah Segal, senior produc- tion supervisor; Paul Lacy, layout designer; Jennifer Atkins, photo editor; Rachel Comerford, executive media editor; Jessica Lauffer, associate media editor; Eve Conte, media producer; Babs Reingold, cover and interior designer; Blake Logan, design manager; Diana Blume, director of design, content management; and Chuck Yuen, infographics designer.
I also am indebted to Kevin Feyen, vice president, digital product development, and Catherine Woods, vice president, content management, who have been so closely involved with my books for many years. In addition, still other professionals at Worth and at W. H. Freeman to whom I am indebted are Lisa Kinne, managing editor; Chuck Linsmeier, vice president editorial, sciences and social sciences; Todd Elder, director of advertising; Kimberly Morgan, editorial assistant; Hilary Newman, director of rights and permissions; Melissa Pellerano and Felicia Ruocco, permissions editors; Chelsea Roden, permissions associate; Michele Kornegay, copy editor; Tina Hastings, proofreader; Ellen Brennan and Marlene Glissmann, indexers; and John Philp, for his outstanding work on the video supplements for professors and students. Not to be overlooked are the superb professionals at Worth and at Freeman who continuously work with great passion, skill, and judgment to bring my books to the attention of professors across the world: Kate Nurre, executive marketing manager; Lindsay Johnson, senior marketing manager; Allison Greco, marketing assistant; Craig Bleyer, national sales manager; and the company’s wonderful sales representatives. Thank you so much.
One final note. As I mentioned in the prefaces of the past few editions, with each passing year I have become increasingly aware of just how fortunate I am. So, once again, at the risk of sounding like a walking cliché, let me say with a clarity that at my current age is sharper and better informed than at earlier points in my life, how appreciative I am that I have the opportunity each day to work with so many interesting and stimulating students during this important and exciting stage of their lives. Similarly, I am grateful beyond words for my extraordinary family, particularly my wonderful sons, Greg and Jon; my fantastic daughters-in-law, Emily and Jami; my perfect grandchildren, Delia and Emmett; and my truly magnificent wife, Marlene.
Ron Comer Princeton University
January 2016
Abnormal Psychology Fundamentals of
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J ohanne cries herself to sleep every night. She is certain that the future holds nothing but misery. Indeed, this is the only thing she does feel certain about. “I’m going to suffer and suffer and suffer, and my daughters will suffer as well. We’re doomed. The world is ugly. I hate every moment of my life.” She has great
trouble sleeping. She is afraid to close her eyes. When she does, the hopelessness of her life—and the ugly future that awaits her daughters—becomes all the clearer to her. When she drifts off to sleep, her dreams are nightmares filled with terrible images—bodies, decay, death, destruction.
Some mornings Johanne even has trouble getting out of bed. The thought of fac- ing another day overwhelms her. She wishes that she and her daughters were dead. “Get it over with. We’d all be better off.” She feels paralyzed by her depression and anxiety, overwhelmed by her sense of hopelessness, and filled with fears of becoming ill, too tired to move, too negative to try anymore. On such mornings, she huddles her daughters close to her and sits away the day in the cramped tent she shares with them. She feels she has been deserted by the world and left to rot. She is both furious at life and afraid of it at the same time.
During the past year Alberto has been hearing mysterious voices that tell him to quit his job, leave his family, and prepare for the coming invasion. These voices have brought tremendous confusion and emotional turmoil to Alberto’s life. He believes that they come from beings in distant parts of the universe who are somehow wired to him. Although it gives him a sense of purpose and specialness to be the cho- sen target of their communications, the voices also make him tense and anxious. He does all he can to warn others of the coming apocalypse. In accordance with instructions from the voices, he identifies online articles that seem to be filled with foreboding signs, and he posts comments that plead with other readers to recog- nize the articles’ underlying messages. Similarly, he posts long, rambling YouTube videos that describe the invasion to come. The online comments and feedback that he receives typically ridicule and mock him. If he rejects the voices’ instructions and stops his online commentary and videos, then the voices insult and threaten him and turn his days into a waking nightmare.
Alberto has put himself on a sparse diet as protection against the possibility that his enemies may be contaminating his food. He has found a quiet apartment far from his old haunts, where he has laid in a good stock of arms and ammunition. After witnessing the abrupt and troubling changes in his behavior and watching his rant- ing and rambling videos, his family and friends have tried to reach out to Alberto, to understand his problems, and to dissuade him from the disturbing course he is taking. Every day, however, he retreats further into his world of mysterious voices and imagined dangers.
Most of us would probably consider Johanne’s and Alberto’s emotions, thoughts, and behaviors psychologically abnormal. They are the result of a state some- times called psychopathology, maladjustment, emotional disturbance, or mental illness (see PsychWatch on the next page). These terms have been applied to the many problems that seem closely tied to the human brain or mind. Psychologi- cal abnormality affects the famous and the unknown, the rich and the poor. Celebrities, writers, politicians, and other public figures of the present and the past have struggled with it. Psychological problems can bring great suffering, but they can also be the source of inspiration and energy.
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T O P I C O V E R V I E W
What Is Psychological Abnormality? Deviance Distress Dysfunction Danger The Elusive Nature of Abnormality
What Is Treatment?
How Was Abnormality Viewed and Treated in the Past? Ancient Views and Treatments Greek and Roman Views and Treatments Europe in the Middle Ages The Renaissance and the Rise of Asylums The Nineteenth Century The Early Twentieth Century
Current Trends How Are People with Severe Disturbances Cared For? How Are People with Less Severe Disturbances Treated? A Growing Emphasis on Preventing Disorders and Promoting Mental Health Multicultural Psychology The Increasing Influence of Insurance Coverage What Are Today’s Leading Theories and Professions? Technology and Mental Health
What Do Clinical Researchers Do? The Case Study The Correlational Method The Experimental Method What Are the Limits of Clinical Investigations? Protecting Human Participants
Putting It Together: A Work in Progress
Abnormal Psychology: Past and Present
: chapter 12
Because they are so common and so personal, these problems capture the interest of us all. Hundreds of novels, plays, films, and television programs have explored what many people see as the dark side of human nature, and self-help books flood the market. Mental health experts are popular guests on both television and radio, and some even have their own shows, Web sites, and blogs.
The field devoted to the scientific study of the problems we find so fascinating is usually called abnor- mal psychology. As in any science, workers in this field, called clinical scientists, gather information system- atically so that they can describe, predict, and explain the phenomena they study. The knowledge that they acquire is then used by clinical practitioners, whose role is to detect, assess, and treat abnormal patterns of functioning.
What Is Psychological Abnormality? Although their general goals are similar to those of other scientific professionals, clinical scientists and practitioners face problems that make their work especially difficult. One of the most troubling is that psychological abnormality is very hard to define. Consider once again Johanne and Alberto. Why are we so ready to call their responses abnormal?
While many definitions of abnormality have been proposed over the years, none has won total acceptance (Bergner & Bunford, 2014). Still, most of the definitions have certain features in common, often called “the four Ds”: deviance, distress, dysfunction, and danger. That is, patterns of psychological abnormality are typically deviant (different, extreme, unusual, perhaps even bizarre), distressing (unpleasant and upsetting to the person), dysfunctional (interfering with the person’s ability to con- duct daily activities in a constructive way), and possibly dangerous. This definition offers a useful starting point from which to explore the phenomena of psychological abnormality. As you will see, however, it has limitations.
PsychWatch
debut in print as expressions of psycho- logical dysfunctioning? The Oxford English Dictionary offers the following dates.
Verbal Debuts
time not that long ago when these terms did not exist. When did these and similar words (including slang terms) make their We use words like “abnormal” and “mental disorder” so often that it is easy to forget that there was a
unstable
madness
1200 1300 1400 1500 1600 1700 1800 1900 2000
“crazy” (slang)
“nuts” (slang)
mentally handicapped deviant
mental illness
psychological
dysfunctional impaired
insanity distressed disturbed unbalanced
abnormal psychopathology psychiatric maladjustment
Why do actors who
portray characters
with psychological dis-
orders tend to receive
more awards for their
performances?
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In Their Words “I became insane, with long intervals of horrible sanity.”
edgar allen poe
Abnormal Psychology: Past and Present : 3
Deviance Abnormal psychological functioning is deviant, but deviant from what? Johanne’s and Alberto’s behaviors, thoughts, and emotions are different from those that are considered normal in our place and time. We do not expect people to cry themselves to sleep each night, hate the world, wish themselves dead, or obey voices that no one else hears.
In short, abnormal behavior, thoughts, and emotions are those that differ markedly from a society’s ideas about proper function- ing. Each society establishes norms—stated and unstated rules for proper conduct. Behavior that breaks legal norms is consid- ered to be criminal. Behavior, thoughts, and emotions that break norms of psychological functioning are called abnormal.
Judgments of abnormality vary from society to society. A society’s norms grow from its particular culture—its history, values, institutions, habits, skills, technology, and arts. A society that values competition and assertiveness may accept aggressive behavior, whereas one that emphasizes cooperation and gentleness may consider aggressive behavior unacceptable and even abnormal. A society’s values may also change over time, causing its views of what is psychologically abnormal to change as well. In Western society, for example, a woman seeking the power of running a major corporation or indeed of leading the country would have been considered inappropriate and even delusional a hundred years ago. Today the same behavior is valued.
Judgments of abnormality depend on specific circumstances as well as on cultural norms. What if, for example, we were to learn that Johanne is a citizen of Haiti and that her desperate unhappiness began in the days, weeks, and months follow- ing the massive earthquake that struck her country, already the poorest country in the Western hemisphere, on January 12, 2010? The quake, one of the worst natural disasters in history, killed 250,000 Haitians and left 1.5 million homeless. Half of Haiti’s homes and buildings were immediately turned into rubble, and its electricity and other forms of power disappeared. Tent cities replaced homes for most people (Granitz, 2014; Wilkinson, 2011).
In the weeks and months that followed the earthquake, Johanne came to accept that she wouldn’t get all of the help she needed and that she might never again see the friends and neighbors who had once given her life so much meaning. As she and her daughters moved from one temporary tent or hut to another throughout the country, always at risk of developing serious diseases, she gradually gave up all hope that her life would ever return to normal. In this light, Johanne’s reactions do not seem quite so inappropriate. If anything is abnormal here, it is her situation. Many human experiences produce intense reactions—financial ruin, large-scale catastro- phes and disasters, rape, child abuse, war, terminal illness, chronic pain ( Janssen et al., 2015). Is there an “appropriate” way to react to such things? Should we ever call reactions to such experiences abnormal?
Distress Even functioning that is considered unusual does not necessarily qualify as abnor- mal. According to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they can be labeled abnormal. Consider the Ice Breakers, a group of people in Michigan who go swimming in lakes throughout the state every weekend from November through February. The colder the weather, the better they like it. One man, a member of the group for 17 years, says he loves the challenge of human against nature. A 37-year-old lawyer believes that the weekly shock is good for her health. “It cleanses me,” she says. “It perks me up and gives me strength.”
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Dealing with deviance Each culture identifies and deals with deviant behavior in its own way. For example, uncom- fortable with the deviant appearance of young punk rockers—mohawks, tattoos, nose pierc- ings, tight jeans, and chains—shari‘a police in Aceh province on Sumatra Island in Indonesia arrested 60 such youth in 2011 and made them undergo a 10-day “moral rehabilitation” camp. There the rockers were forced to have their heads shaved, bathe in a lake, wear traditional clothes, remove their piercings, and pray.
▶▶ abnormal psychology The scientific study of abnormal behavior undertaken to describe, predict, explain, and change abnormal patterns of functioning.
▶▶ norms A society’s stated and unstated rules for proper conduct.
▶▶ culture A people’s common history, values, institutions, habits, skills, technology, and arts.
: chapter 14
Certainly these people are different from most of us, but is their behavior abnormal? Far from experiencing distress, they feel energized and challenged. Their positive feelings must cause us to hesitate before we decide that they are functioning abnormally.
Should we conclude, then, that feelings of distress must always be present before a person’s functioning can be con- sidered abnormal? Not necessarily. Some people who func- tion abnormally maintain a positive frame of mind. Consider once again Alberto, the young man who hears mysterious voices. What if he enjoyed listening to the voices, felt hon- ored to be chosen, loved sending out warnings on the Inter- net, and looked forward to saving the world? Shouldn’t we still regard his functioning as abnormal?
Dysfunction Abnormal behavior tends to be dysfunctional; that is, it inter- feres with daily functioning (Bergner & Bunford, 2014). It so upsets, distracts, or confuses people that they cannot care for
themselves properly, participate in ordinary social interactions, or work productively. Alberto, for example, has quit his job, left his family, and prepared to withdraw from the productive life he once led. Because our society holds that it is important to carry out daily activities in an effective manner, Alberto’s behavior is likely to be regarded as abnormal and undesirable. In contrast, the Ice Breakers, who continue to perform well in their jobs and enjoy fulfilling relationships, would probably be considered simply unusual.
Danger Perhaps the ultimate in psychological dysfunctioning is behavior that becomes dan- gerous to oneself or others. Individuals whose behavior is consistently careless, hostile, or confused may be placing themselves or those around them at risk. Alberto, for example, seems to be endangering both himself, with his diet, and others, with his buildup of arms and ammunition.
Although danger is often cited as a feature of abnormal psychological function- ing, research suggests that it is actually the exception rather than the rule (Stuber et al., 2014). Most people struggling with anxiety, depression, and even bizarre thinking pose no immediate danger to themselves or to anyone else.
The Elusive Nature of Abnormality Efforts to define psychological abnormality typi- cally raise as many questions as they answer. Ulti- mately, a society selects general criteria for defining abnormality and then uses those criteria to judge particular cases. One clinical theorist, Thomas Szasz (1920–2012), placed such emphasis on society’s role that he found the whole concept of mental illness to be invalid, a myth of sorts (Szasz, 2011, 1963, 1960). According to Szasz, the deviations that society calls abnormal are simply “problems in living,” not signs of something wrong within the person.
Even if we assume that psychological abnormality is a valid concept and that it can indeed be defined, we may be unable to apply our definition consistently. If a behavior—excessive use of alcohol among college students, say—is familiar enough,
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Context is key On the morning after Japan’s devastating earthquake and tsunami in 2011, Reiko Kikuta (right) and her husband Takeshi watch workers try to attach ropes to their home and pull it ashore. Anxiety and depression were common and seemingly nor- mal reactions in the wake of this extraordinary disaster, rather than being clear symptoms of psychopathology.
▶▶ treatment A systematic procedure designed to change abnormal behavior into more normal behavior. Also called therapy.
What behaviors fit
the criteria of deviant,
distressful, dysfunc-
tional, or dangerous
but would not be
considered abnormal
by most people?
Abnormal Psychology: Past and Present : 5
the society may fail to recognize that it is deviant, distressful, dysfunctional, and dangerous. Thousands of college students throughout the United States are so dependent on alcohol that it interferes with their personal and academic lives, causes them great discomfort, jeopardizes their health, and often endangers them and the people around them (Merrill et al., 2014). Yet their problem often goes unnoticed and undiagnosed. Alcohol is so much a part of the college subculture that it is easy to overlook drinking behavior that has become abnormal.
Conversely, a society may have trouble separating an abnormality that requires intervention from an eccentricity, an unusual pattern with which others have no right to interfere. From time to time we see or hear about people who behave in ways we consider strange, such as a man who lives alone with two dozen cats and rarely talks to other people. The behavior of such people is deviant, and it may well be distressful and dysfunctional, yet many professionals think of it as eccentric rather than abnormal (see PsychWatch on the next page).
In short, while we may agree to define psychological abnormalities as patterns of functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that these criteria are often vague and subjective. In turn, few of the current categories of abnormal- ity that you will meet in this book are as clear-cut as they may seem, and most continue to be debated by clinicians.
➤ Summing Up WHAT IS PSYCHOLOGICAL ABNORMALITY? The field devoted to the scientific study of abnormal behavior is called abnormal psychology. Abnormal func- tioning is generally considered to be deviant, distressful, dysfunctional, and dangerous. Behavior must also be considered in the context in which it occurs, however, and the concept of abnormality depends on the norms and values of the society in question.
What Is Treatment? Once clinicians decide that a person is indeed suffering from some form of psycho- logical abnormality, they seek to treat it. Treatment, or therapy, is a procedure designed to change abnormal behavior into more normal behavior; it, too, requires careful definition. For clinical scientists, the problem is closely related to defining abnormality. Consider the case of Bill:
February: He cannot leave the house; Bill knows that for a fact. Home is the only place where he feels safe—safe from humiliation, danger, even ruin. If he were to go to work, his coworkers would somehow reveal their contempt for him. A pointed remark, a quizzical look—that’s all it would take for him to get the message. If he were to go shopping at the store, before long everyone would be staring at him. Surely others would see his dark mood and thoughts; he wouldn’t be able to hide them. He dare not even go for a walk alone in the woods—his heart would probably start racing again, bringing him to his knees and leaving him breathless, incoherent, and unable to get home. No, he’s much better off staying in his room, trying to get
Changing times Just decades ago, a woman’s love for race car driving would have been considered strange, perhaps even abnormal. Today, Danica Patrick (right) is one of America’s finest race car drivers. The size difference between her first-place trophy at the Indy Japan 300 auto race and that of second-place male driver Hélio Castroneves symbolizes just how far women have come in this sport.
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: chapter 16
through another evening of this curse called life. Thank goodness for the Internet. Were it not for his reading of news sites and blog posts and online forums, he would, he knows, be cut off from the world altogether.
July: Bill’s life revolves around his circle of friends: Bob and Jack, whom he knows from the office, where he was recently promoted to director of customer relations, and Frank and Tim, his weekend tennis partners. The gang meets for dinner every week at someone’s house, and they chat about life, politics, and their jobs. Particularly special in Bill’s life is Janice. They go to movies, restaurants, and shows together. She thinks Bill’s just terrific, and Bill finds himself beaming whenever she’s around. Bill looks forward to work each day and to his one-on-one dealings with customers. He is taking part in many activities and relationships and more fully enjoying life.
Bill’s thoughts, feelings, and behavior interfered with all aspects of his life in February. Yet most of his symptoms had disappeared by July. All sorts of factors may have contributed to Bill’s improvement—advice from friends and family members, a new job or vacation, perhaps a big change in his diet or exercise regimen. Any or all of these things may have been useful to Bill, but they could not be considered treat- ment or therapy. Those terms are usually reserved for special, systematic procedures
PsychWatch
ness, unusual eating and living habits, disinterest in others’ opinions or company, mischievous sense of humor, nonmar- riage, eldest or only child, and poor spelling skills.
Weeks suggests that eccentrics do not typically suffer from mental disorders. Whereas the unusual behavior of per- sons with mental disorders is thrust upon them and usually causes them suffering, eccentricity is chosen freely and provides pleasure. In short, “Eccentrics know they’re different and glory in it” (Weeks & James, 1995, p. 14). Similarly, the thought processes of eccentrics are not severely disrupted and do not leave these persons dysfunctional. In fact, Weeks found that eccentrics in his study actually had fewer emotional problems than individuals in the general population. Perhaps being an “original” is good for mental health.
Marching to a Different Drummer: Eccentrics pinpointed 15 characteristics common to the eccentrics in his study: nonconfor- mity, creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being different, high intel- ligence, outspokenness, noncompetitive-
➤ Writer James Joyce always carried a tiny pair of lady’s bloomers, which he waved in the air to show approval.
➤ Benjamin Franklin took “air baths” for his health, sitting naked in front of an open window.
➤ Alexander Graham Bell covered the windows of his house to keep out the rays of the full moon. He also tried to teach his dog how to talk.
➤ Writer D. H. Lawrence enjoyed remov- ing his clothes and climbing mulberry trees.
These famous persons have been called eccentrics. The dictionary defines an eccentric as a person who deviates from common behavior patterns or displays odd or whimsical behavior. But how can we separate a psychologically healthy person who has unusual habits from a person whose oddness is a symptom of psychopathology? Little research has been done on eccentrics, but a few studies offer some insights (Stares, 2005; Pickover, 1999; Weeks & James, 1995).
Researcher David Weeks studied 1,000 eccentrics and estimated that as many as 1 in 5,000 persons may be “classic, full-time eccentrics.” Weeks
Musical eccentric Pop superstar Lady Gaga is known far and wide for her eccentric behav- ior, outrageous sense of fashion, and unusual performing style. Her millions of fans enjoy her unusual persona every bit as much as the lyrics and music that she writes and sings.La
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Abnormal Psychology: Past and Present : 7
for helping people overcome their psychological difficulties. According to clinical theorist Jerome Frank, all forms of therapy have three key features:
1. A sufferer who seeks relief from the healer. 2. A trained, socially accepted healer, whose expertise is accepted by the suf-
ferer and his or her social group. 3. A series of contacts between the healer and the sufferer, through which the
healer . . . tries to produce certain changes in the sufferer’s emotional state, attitudes, and behavior.
(Frank, 1973, pp. 2–3)
Despite this straightforward definition, clinical treatment is surrounded by con- flict and confusion. Carl Rogers, a pioneer in the modern clinical field (you will meet him in Chapter 2), noted that “therapists are not in agreement as to their goals or aims. . . . They are not in agreement as to what constitutes a successful outcome of their work. They cannot agree as to what constitutes a failure. It seems as though the field is completely chaotic and divided.”
Some clinicians view abnormality as an illness and so consider therapy a procedure that helps cure the illness. Others see abnormality as a problem in living and therapists as teachers of more functional behavior and thought. Clinicians even differ on what to call the person who receives therapy: those who see abnormality as an illness speak of the “patient,” while those who view it as a problem in living refer to the “client.” Because both terms are so common, this book will use them interchangeably.
Despite their differences, most clinicians do agree that large numbers of people need therapy of one kind or another. Later you will encounter evidence that therapy is indeed often helpful.
➤ Summing Up WHAT IS TREATMENT? Therapy is a systematic process for helping people overcome their psychological difficulties. It typically requires a patient, a thera- pist, and a series of therapeutic contacts.
How Was Abnormality Viewed and Treated in the Past? In any given year, as many as 30 percent of the adults and 19 percent of the chil- dren and adolescents in the United States display serious psychological disturbances and are in need of clinical treatment (Merikangas et al., 2013; Kessler et al., 2012, 2009). The rates in other countries are similarly high. It is tempting to conclude that something about the modern world is responsible for these many emotional problems—perhaps rapid technological change, the growing threat of terrorism, or a decline in religious, family, or other support systems (Paslakis et al., 2015; Gelkopf et al., 2013). But every society, past and present, has witnessed psychological abnormality. Perhaps, then, the proper place to begin our examination of abnormal behavior and treatment is in the past.
Ancient Views and Treatments Historians who have examined the unearthed bones, artwork, and other remnants of ancient societies have concluded that these societies probably regarded abnor- mal behavior as the work of evil spirits. People in prehistoric societies apparently
Therapy . . . not Recently, a hotel in Spain that was about to undergo major renovations invited members of the public to relieve their stress by destroying the rooms on one floor of the hotel. This activity may indeed have been therapeutic for some, but it was not therapy. It lacked, among other things, a “trained healer” and a series of systematic contacts between healer and sufferer.
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believed that all events around and within them resulted from the actions of magical, sometimes sinister, beings who controlled the world. In particular, they viewed the
human body and mind as a battleground between external forces of good and evil. Abnormal behavior was typically interpreted as a victory by evil spirits, and the cure for such behavior was to force the demons from a victim’s body.
This supernatural view of abnormality may have begun as far back as the Stone Age, a half-million years ago. Some skulls from that period recovered in Europe and South America show evidence of an operation called trephina- tion, in which a stone instrument, or trephine, was used to cut away a circular section of the skull (Heeramun-Aubeeluck & Lu, 2013). Some historians have concluded that this early operation was performed as a treatment for severe
abnormal behavior—either hallucinations, in which people saw or heard things not actually present, or melancholia, characterized by extreme sadness and immobility. The purpose of opening the skull was to release the evil spirits that were supposedly causing the problem (Selling, 1940).
Later societies also explained abnormal behavior by pointing to pos- session by demons. Egyptian, Chinese, and Hebrew writings all account for
psychological deviance this way, and the Bible describes how an evil spirit from the Lord affected King Saul and how David pre- tended to be mad to convince his enemies that he was visited by divine forces.
The treatment for abnormality in these early societies was often exorcism. The idea was to coax the evil spirits to leave or to make the person’s body an uncomfortable place in which to live. A shaman, or priest, might recite prayers, plead with the evil spirits, insult the spirits, perform magic, make loud noises, or have the person drink bitter potions. If these techniques failed, the shaman performed a more extreme form of exorcism, such as whipping or starving the person.
Greek and Roman Views and Treatments In the years from roughly 500 b.c. to 500 a.d., when the Greek and Roman civi- lizations thrived, philosophers and physicians often offered different explanations and treatments for abnormal behaviors. Hippocrates (460–377 b.c.), often called the father of modern medicine, taught that illnesses had natural causes. He saw abnormal behavior as a disease arising from internal physical problems. Specifically, he believed that some form of brain pathology was the culprit and that it resulted—like all other forms of disease, in his view—from an imbalance of four fluids, or humors, that flowed through the body: yellow bile, black bile, blood, and phlegm (Wolters, 2013). An excess of yellow bile, for example, caused frenzied activity; an excess of black bile was the source of unshakable sadness.
To treat psychological dysfunctioning, Hippocrates sought to correct the under- lying physical pathology. He believed, for instance, that the excess of black bile underlying sadness could be reduced by a quiet life, a diet of vegetables, exercise, celibacy, and even bleeding. Hippocrates’ focus on internal causes for abnormal behavior was shared by the great Greek philosophers Plato (427–347 b.c.) and Aristotle (384–322 b.c.) and by influential Greek and Roman physicians.
Europe in the Middle Ages: Demonology Returns The enlightened views of Greek and Roman physicians and scholars were not enough to shake ordinary people’s belief in demons. And with the decline of Rome, demonological views and practices became popular once again. A growing distrust of science spread throughout Europe.
What demonological
explanations or treatments,
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Expelling evil spirits The two holes in this skull recovered from ancient times indi- cate that the person underwent trephination, possibly for the purpose of releasing evil spir- its and curing mental dysfunctioning.
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▶▶ trephination An ancient operation in which a stone instrument was used to cut away a circular section of the skull, perhaps to treat abnormal behavior.
▶▶ humors According to the Greeks and Romans, bodily chemicals that influence mental and physical functioning.
Abnormal Psychology: Past and Present : 9
From 500 to 1350 a.d., the period known as the Middle Ages, the power of the clergy increased greatly throughout Europe. In those days the church rejected scien- tific forms of investigation, and it controlled all education. Religious beliefs, which were highly superstitious and demonological, came to dominate all aspects of life. Deviant behavior, particularly psychological dys- functioning, was seen as evidence of Satan’s influence.
The Middle Ages were a time of great stress and anxiety—of war, urban uprisings, and plagues. People blamed the devil for these troubles and feared being possessed by him (Sluhovsky, 2011). Abnormal behavior apparently increased greatly during this period. In addition, there were outbreaks of mass madness, in which large numbers of people apparently shared absurd false beliefs and imagined sights or sounds. In one such disorder, tarantism (also known as Saint Vitus’ dance), groups of people would suddenly start to jump, dance, and go into convulsions (Prochwicz & Sobczyk, 2011; Sigerist, 1943). All were convinced that they had been bitten and possessed by a wolf spider, now called a tarantula, and they sought to cure their dis- order by performing a dance called a tarantella. In another form of mass madness, lycanthropy, people thought they were possessed by wolves or other animals. They acted wolflike and imagined that fur was growing all over their bodies.
Not surprisingly, some of the earlier demonological treatments for psychological abnormality reemerged during the Middle Ages. Once again the key to the cure was to rid the person’s body of the devil that possessed it. Exorcisms were revived, and clergymen, who generally were in charge of treatment during this period, would plead, chant, or pray to the devil or evil spirit (Sluhovsky, 2011, 2007). If these tech- niques did not work, they had others to try, some amounting to torture.
It was not until the Middle Ages drew to a close that demonology and its methods began to lose favor. Towns throughout Europe grew into cities, and government officials gained more power and took over nonreligious activities. Among their other responsibilities, they began to run hospitals and direct the care of people suffering from mental disorders. Medical views of abnormality gained favor once again, and many people with psychological disturbances received treatment in medical hospitals, such as the Trinity Hospital in England (Allderidge, 1979).
The Renaissance and the Rise of Asylums During the early part of the Renaissance, a period of flourishing cultural and scientific activity from about 1400 to 1700, demonological views of abnormality continued to decline. German physician Johann Weyer (1515–1588), the first phy- sician to specialize in mental illness, believed that the mind was as susceptible to sickness as the body was. He is now considered the founder of the modern study of psychopathology.
The care of people with mental disorders improved in this atmosphere. In England, such individuals might be kept at home while their families were aided financially by the local parish. Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders. Perhaps the best known of these shrines was at Gheel in Belgium. Beginning in the fifteenth century, people came to Gheel from all over the world for psychic healing. Local residents welcomed these pilgrims into their homes, and many stayed on to form the world’s first “colony” of mental patients. Gheel was the forerunner of today’s community mental health programs (Guarnieri, 2009; Aring, 1975, 1974). Many patients still live in foster homes there, interacting with other residents, until they recover.
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Bewitched or bewildered? A great fear of witchcraft swept Europe beginning in the 1300s and extending through the “enlight- ened” Renaissance. Tens of thousands of people, mostly women, were thought to have made a pact with the devil. Some appear to have had mental disorders, which caused them to act strangely (Zilboorg & Henry, 1941). This woman is being “dunked” repeat- edly until she confesses to witchery.
how might twitter, text mes-
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: chapter 110
Unfortunately, these improvements in care began to fade by the mid- sixteenth century. Government officials discovered that private homes and community residences could house only a small percentage of those with severe mental disorders and that medical hospitals were too few and too small. More and more, they converted hospitals and monasteries into asylums, institutions whose primary purpose was to care for people with mental illness. These institutions were begun with the intention that they would provide good care (Kazano, 2012). Once the asylums started to overflow, however, they became virtual prisons where patients were held in filthy conditions and treated with unspeakable cruelty.
In 1547, for example, Bethlehem Hospital was given to the city of London by Henry VIII for the sole purpose of confining the mentally ill. In this asylum, patients bound in chains cried out for all to hear. The hospital even became a popular tourist attraction; people were eager to pay to look at the howling and gibbering inmates. The hospital’s name, pronounced “Bedlam” by the local people, has come to mean a chaotic uproar (Selling, 1940).
The Nineteenth Century: Reform and Moral Treatment Historians usually point to La Bicêtre, an asylum in Paris for male patients, as the first site of asylum reform. In 1793, during the French Revolution, Philippe Pinel (1745–1826) was named the chief physician there. He argued that the patients were sick people whose illnesses should be treated with sympathy and kindness rather than chains and beatings (Yakushev & Sidorov, 2013). He allowed them to move freely about the hospital grounds; replaced the dark dungeons with sunny, airy rooms; and offered support and advice. Pinel’s approach proved remarkably suc- cessful. Many patients who had been shut away for decades improved greatly over a short period of time and were released. Pinel later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière.
Meanwhile, an English Quaker named William Tuke (1732–1819) was bringing similar reforms to northern England. In 1796 he founded the York Retreat, a rural estate where about 30 mental patients lived as guests in quiet country houses and were treated with a combination of rest, talk, prayer, and manual work (Kibria & Metcalfe, 2014).
The Spread of Moral Treatment The methods of Pinel and Tuke, called moral treatment because they emphasized moral guidance and humane and respectful techniques, caught on throughout Europe and the United States. Patients
with psychological problems were increasingly perceived as potentially productive human beings who deserved individual care, including discussions of their problems, useful activities, work, companionship, and quiet.
The person most responsible for the early spread of moral treatment in the United States was Benjamin Rush (1745– 1813), an eminent physician at Pennsylvania Hospital who is now considered the father of American psychiatry. Limiting his practice to mental illness, Rush developed humane approaches to treatment (Grossman, 2013; Rush, 2010). For example, he required that the hospital hire intelligent and sensitive atten- dants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients now and then.
Rush’s work was influential, but it was a Boston school- teacher named Dorothea Dix (1802–1887) who made humane Da
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The “crib” Outrageous devices and techniques, such as the “crib,” were used in asylums, and some continued to be used even during the reforms of the nineteenth century.
Dance in a madhouse A popular feature of moral treatment was the “lunatic ball.” Hos- pital officials would bring patients together to dance and enjoy themselves. One such ball is shown in this painting, Dance in a Madhouse, by George Bellows.
Abnormal Psychology: Past and Present : 11
care a public and political concern in the United States. From 1841 to 1881, Dix went from state legislature to state legislature and to Congress speaking of the hor- rors she had observed at asylums and calling for reform. Dix’s campaign led to new laws and greater government funding to improve the treatment of people with men- tal disorders (Davidson et al., 2010). Each state was made responsible for developing effective public mental hospitals, or state hospitals, all of which were intended to offer moral treatment. Similar hospitals were established throughout Europe.
The Decline of Moral Treatment By the 1850s, a number of mental hos- pitals throughout Europe and America reported success using moral approaches. By the end of that century, however, several factors led to a reversal of the moral treat- ment movement (Kazano, 2012). One factor was the speed with which the move- ment had spread. As mental hospitals multiplied, severe money and staffing shortages developed, recovery rates declined, and overcrowding in the hospitals became a major problem. Another factor was the assumption behind moral treatment that all patients could be cured if treated with humanity and dignity. For some, this was indeed sufficient. Others, however, needed more effective treatments than any that had yet been developed. An additional factor contributing to the decline of moral treatment was the emergence of a new wave of prejudice against people with mental disorders. The public came to view them as strange and dangerous, undeserving of donations or government funds. Moreover, many of the patients entering public mental hospitals in the United States in the late nineteenth century were poor for- eign immigrants, whom the public had little interest in helping.
By the early years of the twentieth century, the moral treatment movement had ground to a halt in both the United States and Europe. Public mental hospitals were providing only custodial care and ineffective medical treatments and were becom- ing more overcrowded every year. Long-term hospitalization became the rule once again.
The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives As the moral movement was declining in the late 1800s, two opposing perspectives emerged and began to compete for the attention of clinicians: the somatogenic perspective, the view that abnormal psychological functioning has physical causes, and the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. These perspectives came into full bloom during the twentieth century.
The Somatogenic Perspective The somatogenic perspective has at least a 2,400-year history—remember Hippocrates’ view that abnormal behavior resulted from brain disease and an imbalance of humors? Not until the late 1800s, however, did this perspective make a triumphant return and begin to gain wide acceptance.
Two factors were responsible for this rebirth. One was the work of a distinguished German researcher, Emil Kraepelin (1856–1926). In 1883, Kraepelin published an influential textbook arguing that physical factors, such as fatigue, are responsible for mental dysfunction. In addition, as you will see in Chapter 3, he developed the first modern system for classifying abnormal behaviors, listing their physical causes and discussing their course (Hoff, 2015; Jäger et al., 2013).
New biological discoveries also triggered the rise of the somatogenic perspec- tive. One of the most important discoveries was that an organic disease, syphilis, led to general paresis, an irreversible disorder that featured both mental symptoms such as delusions of grandeur and physical ones like paralysis (Hogebrug et al., 2013). In 1897, German neurologist Richard von Krafft-Ebing (1840–1902) injected matter from syphilis sores into patients suffering from general paresis and found that none
▶▶ asylum A type of institution that first became popular in the sixteenth century to provide care for persons with mental disorders. Most became virtual prisons.
▶▶ moral treatment A nineteenth- century approach to treating people with mental dysfunction that emphasized moral guidance and humane and respectful treatment.
▶▶ state hospitals State-run public mental institutions in the United States.
▶▶ somatogenic perspective The view that abnormal psychological functioning has physical causes.
▶▶ psychogenic perspective The view that the chief causes of abnormal functioning are psychological.
B e t W e e n t h e L i n e s
Early Asylums Most of the patients in Middle Age asylums, from all classes and circum stances, were women.
The first asylum in colonial America was established in Williamsburg, Virginia, in 1773.
(faqs.org, 2014; Barton, 2004)
: chapter 112
of the patients developed symptoms of syphilis. Their immunity could have been caused only by an earlier case of syphilis. Since all of his patients with general paresis were now immune to syphilis, Krafft-Ebing theorized that syphilis had been the cause of their general paresis. The work of Kraepelin and the new understanding of general paresis led many researchers and practitioners to suspect that physical factors were responsible for many mental disorders, perhaps all of them.
Despite the general optimism, biological approaches yielded mostly disappoint- ing results throughout the first half of the twentieth century. Although many medi- cal treatments were developed for patients in mental hospitals during that time, most of the techniques failed to work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy (alternating hot and cold baths), and lobotomy, a surgical cutting of certain nerve fibers in the brain. Even worse, biological views and claims led, in some circles, to proposals for immoral solutions such as eugenic sterilization, the elimination (through medical or other means) of individuals’ ability to reproduce (see Table 1-1). Not until the 1950s, when a number of effective medications were finally discovered, did the somatogenic perspective truly begin to pay off for patients.
The Psychogenic Perspective The late 1800s also saw the emergence of the psychogenic perspective, the view that the chief causes of abnormal functioning are often psychological. This view, too, had a long history, but it did not gain much of a following until studies of hypnotism demonstrated its potential.
Hypnotism is a procedure in which a person is placed in a trancelike mental state during which he or she becomes extremely suggestible. It was used to help treat psychological disorders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734–1815) set up a clinic in Paris. His patients suffered from hysterical disorders, mysterious bodily ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room filled with music; then he
table: 1-1
Eugenics and Mental Disorders
Year Event 1896 Connecticut became the first state in the United States to prohibit
persons with mental disorders from marrying.
1896–1933 Every state in the United States passed a law prohibiting marriage by persons with mental disorders.
1907 Indiana became the first state to pass a bill calling for people with mental disorders, as well as criminals and other “defectives,” to undergo sterilization.
1927 The U.S. Supreme Court ruled that eugenic sterilization was constitutional.
1907–1945 Approximately 45,000 Americans were sterilized under eugenic sterilization laws; 21,000 of them were patients in state mental hospitals.
1929–1932 Denmark, Norway, Sweden, Finland, and Iceland passed eugenic sterilization laws.
1933 Germany passed a eugenic sterilization law, under which 375,000 people were sterilized by 1940.
1940 Nazi Germany began to use “proper gases” to kill people with mental disorders; 70,000 or more people were killed in less than 2 years.
Information from: Fischer, 2012; Whitaker, 2002.
▶▶ psychoanalysis Either the theory or the treatment of abnormal mental func- tioning that emphasizes unconscious psychological forces as the cause of psychopathology.
B e t W e e n t h e L i n e s
Famous Psych Lines from the Movies “Crying helps me slow down and obsess over the weight of life’s problems.” (Inside Out, 2015)
“Do you have any idea how crazy you are?” (No Country for Old Men, 2007)
“Are you talkin’ to me?” (Taxi Driver, 1976)
“Mother’s not herself today.” (Psycho, 1960)
“Dave, my mind is going. I can feel it.” (2001: A Space Odyssey, 1968)
“I’m not going to be ignored!” (Fatal Attraction, 1987)
Abnormal Psychology: Past and Present : 13
appeared, dressed in a colorful costume, and touched the troubled area of each patient’s body with a special rod. A surprising number of patients seemed to be helped by this treatment, called mesmerism (Musikantow, 2011; Dingfelder, 2010). Their pain, numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients and that this state was causing their symptoms to disappear. The treatment was so controversial, however, that eventually Mesmer was banished from Paris.
It was not until years after Mesmer died that many researchers had the courage to investigate his procedure, later called hypnotism (from hypnos, the Greek word for “sleep”), and its effects on hysterical disorders. The experiments of two physicians practicing in the city of Nancy in France, Hippolyte-Marie Bernheim (1840–1919) and Ambroise-Auguste Liébault (1823–1904), showed that hysterical disorders could actually be induced in otherwise normal people while they were under the influence of hypnotism. That is, the physicians could make normal people experience deafness, paralysis, blindness, or numbness by means of hypnotic suggestion—and they could remove these artificial symptoms by the same means. Thus they established that a mental process—hypnotic suggestion—could both cause and cure even a physical dysfunction. Leading scien- tists concluded that hysterical disorders were largely psychological in origin, and the psychogenic perspective rose in popularity.
Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer (1842–1925) of Vienna. Breuer, a physician, discovered that his patients sometimes awoke free of hysterical symptoms after speaking openly under hypnosis about past upsetting events. During the 1890s, Breuer was joined in his work by another Viennese physician, Sigmund Freud (1856–1939). As you will see in Chap- ter 2, Freud’s work eventually led him to develop the theory of psychoanalysis, which holds that many forms of abnormal and normal psychological functioning are psychogenic. In particular, Freud believed that unconscious psychological pro- cesses are at the root of such functioning.
Freud also developed the technique of psychoanalysis, a form of discussion in which clinicians help troubled people gain insight into their unconscious psycho- logical processes. He believed that such insight, even without hypnotic procedures, would help the patients overcome their psychological problems. Freud and his
The more things change . . . Patients at a modern-day mental hospital in Bangladesh eat their lunch off of the floor of their ward. Such conditions are similar to those that existed in some state hospitals throughout the United States well into the twentieth century.Q.
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Hypnotism update Hypnotism, the procedure that opened the door for the psy- chogenic perspective, continues to influence many areas of modern life, including the fields of psychotherapy, entertainment, and law enforcement. Here a forensic clinician uses hypnosis to help a witness recall the details of a crime. Recent research has clarified, how- ever, that hypnotic procedures are as capable of creating false memories as they are of uncovering real memories.
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followers offered treatment to patients in their offices for sessions of approximately an hour—a format now known as outpatient therapy. By the early twentieth century, psychoanalytic theory and treatment were widely accepted throughout the Western world (Messias, 2014).
➤ Summing Up HOW WAS ABNORMALITY VIEWED AND TREATED IN THE PAST? The history of psychological disorders stretches back to ancient times. Prehistoric societies apparently viewed abnormal behavior as the work of evil spirits. There is evi- dence that Stone Age cultures used trephination, a primitive form of brain sur- gery, to treat abnormal behavior. People of early societies also sought to drive out evil spirits by exorcism.
Physicians of the Greek and Roman empires offered more enlightened expla- nations of mental disorders. Hippocrates believed that abnormal behavior was caused by an imbalance of the four bodily fluids, or humors.
Unfortunately, throughout history each period of enlightened thinking about psychological functioning has been followed by a period of backward think- ing. In the Middle Ages, for example, Europeans returned to demonological explanations of abnormal behavior. The clergy was very influential and held that mental disorders were the work of the devil. As the Middle Ages drew to a close, such explanations and treatments began to decline, and care of people with mental disorders improved during the early part of the Renaissance. Certain religious shrines became dedicated to the humane treatment of such individuals. Unfortunately, this enlightened approach was short-lived, and by the middle of the sixteenth century persons with mental disorders were being warehoused in asylums.
Care of people with mental disorders started to improve again in the nine- teenth century. In Paris, Philippe Pinel started the movement toward moral treatment. In the United States, Dorothea Dix spearheaded a movement to ensure legal rights and protection for people with mental disorders and to establish state hospitals for their care. Unfortunately, the moral treatment move- ment disintegrated by the late nineteenth century, and mental hospitals again became warehouses where inmates received minimal care.
The turn of the twentieth century saw the return of the somatogenic perspec- tive, the view that abnormal psychological functioning is caused primarily by physical factors. The same period saw the rise of the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. Sig- mund Freud’s psychogenic approach, psychoanalysis, eventually gained wide acceptance and influenced future generations of clinicians.
Current Trends It would hardly be accurate to say that we now live in a period of great enlight- enment about or dependable treatment of mental disorders. In fact, surveys have found that 43 percent of respondents believe that people bring mental disorders on themselves, and 35 percent consider such disorders to be caused by sinful behavior (Stuber et al., 2014; NMHA, 1999). Nevertheless, there have been major changes over the past 50 years in the ways clinicians understand and treat abnormal function- ing. There are more theories and types of treatment, more research studies, more information, and—perhaps because of those increases—more disagreements about abnormal functioning today than at any time in the past.
B e t W e e n t h e L i n e s
All About Freud Freud’s parents often favored Sigmund over his siblings.
Freud’s fee for one session of therapy was $20.
For almost 40 years, Freud treated patients 10 hours per day, 5 or 6 days per week.
Freud’s four sisters died in Nazi concentration camps.
Freud was nominated for the Nobel Prize in 12 different years, but never won.
(Nobel Media, 2014; cherry, 2010; hess, 2009; Gay, 2006, 1999; Jacobs, 2003)
B e t W e e n t h e L i n e s
Lunar Myths Although it is popularly believed that a full moon is regularly accompanied by significant increases in crime, strange and abnormal behaviors, and admis sions to mental hospitals, decades of research have failed to support this notion.
(Bakalar, 2013, 2011; Schafer et al., 2010; McLay et al., 2006)
Abnormal Psychology: Past and Present : 15
How Are People with Severe Disturbances Cared for? In the 1950s, researchers discovered a number of new psychotropic medications— drugs that primarily affect the brain and reduce many symptoms of mental dysfunc- tioning. They included the first antipsychotic drugs, which correct extremely confused and distorted thinking; antidepressant drugs, which lift the mood of depressed people; and antianxiety drugs, which reduce tension and worry.
When given these drugs, many patients who had spent years in mental hospitals began to show signs of improvement. Hospi- tal administrators, encouraged by these results and pressured by a growing public outcry over the terrible conditions in public mental hospitals, began to discharge patients almost immediately.
Since the discovery of these medications, mental health pro- fessionals in most of the developed nations of the world have followed a policy of deinstitutionalization, releasing hundreds of thousands of patients from public mental hospitals. On any given day in 1955, close to 600,000 people were confined in public mental institutions across the United States (see Figure 1-1). Today the daily patient population in the same kinds of hospitals is less than 40,000 (Althouse, 2010).
In short, outpatient care has now become the primary mode of treatment for people with severe psychological disturbances as well as for those with more moderate problems. When severely disturbed people do need institutionalization these days, they are usually hospitalized for a short period of time. Ideally, they are then provided with outpatient psycho- therapy and medication in community programs and residences (Stein et al., 2015).
Chapters 2 and 12 will look more closely at this recent emphasis on community care for people with severe psychological disturbances—a philosophy called the com- munity mental health approach. The approach has been helpful for many patients, but too few community programs are available to address current needs in the United States (Dixon & Schwarz, 2014). As a result, hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets. At least 100,000 people with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons (Kooyman & Walsh, 2011; Althouse, 2010). Their abandonment is truly a national disgrace.
How Are People with Less Severe Disturbances Treated? The treatment picture for people with moderate psychological disturbances has been more positive than that for people with severe disorders. Since the 1950s, out- patient care has continued to be the preferred mode of treatment for them, and the number and types of facilities that offer such care have expanded to meet the need.
Before the 1950s, outpatient care exclusively took the form of private psychotherapy, in which individuals seek out a self-employed therapist for coun- seling services. Since the 1950s, most health insurance plans have expanded coverage to include private psychotherapy, so that it is now widely available to people of all incomes. Today, outpatient therapy is also offered in a number of less expensive set- tings, such as community mental health centers, crisis intervention centers, family service centers, and other social service agencies. Surveys suggest that nearly one of every six adults in the United States receives outpatient treatment for psychological disorders in the course of a year (NIMH, 2010).
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figure 1-1 The impact of deinstitutionalization The number of patients (fewer than 40,000) now hospitalized in public mental hospitals in the United States is a small fraction of the number hospitalized in 1955. (Information from: Althouse, 2010; Torrey, 2001; Lang, 1999.)
▶▶ psychotropic medications Drugs that mainly affect the brain and reduce many symptoms of mental dysfunctioning.
▶▶ deinstitutionalization The practice, begun in the 1960s, of releasing hundreds of thousands of patients from public mental hospitals.
▶▶ private psychotherapy An arrangement in which a person directly pays a therapist for counseling services.
: chapter 116
Outpatient treatments are also becoming available for more and more kinds of problems. When Freud and his colleagues first began to practice, most of their patients suffered from anxiety or depression. Almost half of today’s clients suffer from those same problems, but people with other kinds of disorders are also receiv- ing therapy. In addition, at least 20 percent of clients enter therapy because of milder problems in living—problems with marital, family, job, peer, school, or community relationships (Ten Have et al., 2013; Druss & Bornemann, 2010).
Yet another change in outpatient care since the 1950s has been the develop- ment of programs devoted exclusively to one kind of psychological problem. We now have, for example, suicide prevention centers, substance abuse programs, eating disorder programs, phobia clinics, and sexual dysfunction programs. Clinicians in these programs have the kind of expertise that can be acquired only by concentra- tion in a single area.
A Growing Emphasis on Preventing Disorders and Promoting Mental Health Although the community mental health approach has often failed to address the needs of people with severe disorders, it has given rise to an important principle of mental health care—prevention (Grill & Monsell, 2014). Rather than wait for psy- chological disorders to occur, many of today’s community programs try to correct the social conditions that underlie psychological problems (poverty or violence in the community, for example) and to help individuals who are at risk for developing emotional problems (for example, teenage mothers or the children of people with severe psychological disorders). As you will see later, community prevention programs are not always successful, but they have grown in num- ber, offering great promise as the ultimate form of intervention.
Prevention programs have been further energized in the past few years by the field of psychology’s ever-growing interest in positive psychology (Ramirez et al., 2014; Seligman & Fowler, 2011). Positive psychology is the study and promotion of positive feelings such as optimism and happiness, positive traits like hard work and
From Juilliard to the streets Nathaniel Ayers, subject of the book and movie The Soloist, plays his violin on the streets of Los Angeles while living as a homeless person in 2005. Once a promising musical student at the Juilliard School in New York, Ayers developed schizophrenia and eventually found himself without treatment and without a home.
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Green spaces and mental health A young woman soaks in the green environment at Battersea Park in London. Recent positive psychology research has found that people who live in urban areas feel less distress and more life satisfaction if they reside in greener areas of their cities (White et al., 2013). Small wonder that Londoners with easy access to parks and green spaces report having a better quality of life than those living without it.
Why do you think it has
taken psychologists so long
to start studying positive
behaviors?
Abnormal Psychology: Past and Present : 17
wisdom, positive abilities, and group-directed virtues, including altruism and toler- ance (see InfoCentral on page 19).
While researchers study and learn more about positive psychology in the labora- tory, clinical practitioners with this orientation are teaching people coping skills that may help protect them from stress and encouraging them to pursue psychological wellness, meaningful activities, and enriching relationships—thus preventing mental disorders (Sergeant & Mongrain, 2014).
Multicultural Psychology We are, without question, a society of multiple cultures, races, and languages. Mem- bers of racial and ethnic minority groups in the United States collectively make up 35 percent of the population, a percentage that is expected to grow to more than 50 percent in the coming decades (Santa-Cruz, 2010; U.S. Census Bureau, 2010). This change is partly because of shifts in immigration trends and partly because of higher birth rates among minority groups in the United States (NVSR, 2010).
In response to this growing diversity, a new area of study called multicultural psychology has emerged. Multicultural psychologists seek to understand how cul- ture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders may differ psychologically (Alegría et al., 2013, 2010). As you will see throughout this book, the field of multicultural psychology has begun to have a powerful effect on our understanding and treatment of abnormal behavior.
The Increasing Influence of Insurance Coverage So many people now seek therapy that insurance companies have changed their coverage for mental health patients. Today the dominant form of coverage is the managed care program—a program in which the insurance company deter- mines such key issues as which therapists its clients may choose, the cost of sessions, and the number of sessions for which a client may be reimbursed (Domino, 2012; Glasser, 2010).
At least 75 percent of all privately insured persons in the United States are currently enrolled in managed care programs (Deb et al., 2006). The coverage for mental health treatment under such programs follows the same basic principles as coverage for medical treatment, including a limited pool of practitioners from which patients can choose, preapproval of treatment by the insurance company, strict stan- dards for judging whether problems and treatments qualify for reimbursement, and ongoing reviews. In the mental health realm, both therapists and clients typically dislike managed care programs (Lustig et al., 2013). They fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments whose results are not always lasting (for example, drug therapy), pose a special hardship for those with severe mental disorders, and result in treatments determined by insurance companies rather than by therapists (Turner, 2013).
A key problem with insurance coverage—both managed care and other kinds of insurance programs—is that reimbursements for mental disorders tend to be lower than those for medical disorders. This places persons with psychological difficulties at a distinct disadvantage (Sipe et al., 2015). Thus, in 2008 the U.S. Congress passed a federal parity law that directed insurance companies to provide equal coverage for mental and medical problems, and in 2014 the mental health provisions of the Affordable Care Act (the ACA)—referred to colloquially as “Obamacare”—went into effect and extended the reach of the earlier law. The ACA designates mental health care as 1 of 10 types of “essential health benefits” that must be provided by all insurers (SAMHSA, 2014; Pear, 2013). It also requires all health plans to provide preventive mental health services at no additional cost (for example, free screenings
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Positive psychology in action Often positive psychology and multicultural psy- chology work together. Here, for example, two young girls come together as one at the end of a “slave reconciliation” walk by 400 people in Maryland. The walk was intended to promote racial understanding and to help Americans overcome the lasting psychological effects of slavery.
▶▶ prevention Interventions aimed at deterring mental disorders before they can develop.
▶▶ positive psychology The study and enhancement of positive feelings, traits, and abilities.
▶▶ multicultural psychology The field that examines the impact of culture, race, ethnicity, and gender on behaviors and thoughts and focuses on how such factors may influence the origin, nature, and treatment of abnormal behavior.
▶▶ managed care program Health care coverage in which the insurance company largely controls the nature, scope, and cost of medical or psychological services.
: chapter 118
for depressive disorders) and to allow membership to individuals who have preexist- ing mental conditions. It is not yet clear whether such provisions will in fact result in better treatment for people with psychological problems.
What Are Today’s Leading Theories and Professions? One of the most important developments in the clinical field has been the growth of numerous theoretical perspectives that now coexist in the field. Before the 1950s, the psychoanalytic perspective, with its emphasis on unconscious psychological problems as the cause of abnormal behavior, was dominant. Since then, additional influential perspectives have emerged, particularly the biological, behavioral, cognitive, humanistic-existential, and sociocultural schools of thought. At present, no single view- point dominates the clinical field as the psychoanalytic perspective once did. In fact, the perspectives often conflict and compete with one another.
In addition, a variety of professionals now offer help to people with psychologi- cal problems. Before the 1950s, psychotherapy was offered only by psychiatrists, phy- sicians who complete three to four additional years of training after medical school (a residency) in the treatment of abnormal mental functioning. After World War II, however, with millions of soldiers returning home to countries throughout North America and Europe, the demand for mental health services expanded so rapidly that other professional groups had to step in to fill the need.
Among those other groups are clinical psychologists—professionals who earn a doctorate in clinical psychology by completing four to five years of graduate training in abnormal functioning and its treatment and also complete a one-year internship in a mental health setting. Psychotherapy is also provided by counseling psychologists, educational and school psychologists, psychiatric nurses, marriage therapists, family therapists, and—the largest group—psychiatric social workers (see Table 1-2). Each of these specialties has its own graduate training program. Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the various spe- cialties often use similar techniques.
A related development in the study and treatment of mental disorders since World War II has been a growing appreciation of the need for effective research. Clinical researchers have tried to determine which concepts best explain and predict abnor- mal behavior, which treatments are most effective, and what kinds of changes may be required. Well-trained clinical researchers conduct studies in universities, medical schools, laboratories, mental hospitals, mental health centers, and other clinical set- tings throughout the world. Their work has produced important discoveries and has changed many of our ideas about abnormal psychological functioning.
table: 1-2
Profiles of Mental Health Professionals in the United States
Degree Began to Practice
Current Number
Average Annual Salary
Percent Female
Psychiatrists MD, DO 1840s 50,000 $144,020 25
Psychologists PhD, PsyD, EdD Late 1940s 174,000 $63,000 52
Social workers MSW, DSW Early 1950s 607,000 $43,040 77
Counselors Various Early 1950s 475,000 $47,530 90
Information from: Cherry, 2014; U.S. Bureau of Labor Statistics, 2014, 2011, 2002; AMA, 2011; Carey, 2011; Weissman, 2000.
B e t W e e n t h e L i n e s
Gender Shift 28% Psychologists in 1978 who were
female
52% Psychologists today who are female
77% Current undergraduate psychol ogy majors who are female
72% Current psychology graduate students who are female
(cherry, 2014; carey, 2011; cynkar, 2007; Barber, 1999)
InfoCentral
HAPPINESS Positive psychology is the study of positive feelings, traits, and abilities. A better understanding of constructive function- ing enables clinicians to better promote psychological wellness. Happiness is the positive psychology topic currently receiving the
most attention. Many, but far from all, people are happy. In fact, only one-third of adults declare themselves “very happy.” Let’s take a look at some of today’s leading facts, figures, and notions about happiness.
The Pursuit of Happiness People tend to pursue a happy life. For some, that means pursuit of a pleasant life – filled with as many pleasures as possible. Others pursue an engaging life, characterized by satisfaction in work, parenting, love, and leisure. Still others pursue a meaningful life – recognizing and using their strengths in the service of others. (Seligman, 2002)
Work and Happiness Certain jobs have a higher percentage of happy people than others.
Garage and service station attendants
Clergy 67%
Firefighters 57%
Special-education teachers 53%
Actors and directors 51%
House cleaners 23%
Restaurant kitchen workers 21%
Construction laborers 19%
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Social Contact and Happiness The more social contact, the happier we are – up to a point!
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WHO Is “Very Happy?”
WHAT Do Happy People Do? Engage in social
relationships and activities
Bounce back from failures (resilience)
Devote time to charity and giving
Allow themselves to lose track of time
Try to listen
Experience spirituality/ mindfulness
Exercise
Get enough sleep
(Harris Interactive, 2013)
0
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2
3
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Currently married 3.4
Always single 3.2
Currently divorced 2.9
Currently widowed 2.9
Marriage and Happiness Married people are, on average, a bit happier than people with a different marital status.
(Brooks, 2013)
(Bratskeir, 2013)
(Crabtree, 2011)
(Mann, 2009; Smith 2007)
)310 2 ,oluaPeD(
Politically conservative people Politically liberal people
Unashamed people Guilt-ridden people
Peaceful people Angry people
Extroverts Introverts
Regular church attenders Church nonattenders
(Brooks, 2013; DePaulo, 2013; The Economist, 2010)
Happiness Building Blocks Are people born with a happy disposition? Or do their surroundings and life circumstances make them more or less happy? Researchers of this nature-versus-nurture question have learned that both sets of factors interact to determine one’s degree of happiness. But the factors have different degrees of impact.
Who Tends to Be Happier?
Values (family, friends, community, work) 12%
Life events 40%
Genes 48%
19
: chapter 120
Technology and Mental Health The breathtaking rate of technological change that characterizes today’s world has begun to have significant effects—both positive and negative—on the mental health field, and it will undoubtedly affect the field even more in the coming years. Let’s consider just a small sample of these effects.
Our digital world provides new triggers for abnormal behavior. As you’ll see in Chapter 10, for example, many individuals who grapple with gambling disorder have found the ready availability of Internet gambling to be all too inviting. Simi- larly, the Internet, text messaging, and social media have become convenient tools for those who wish to stalk or bully others, express sexual exhibitionism, or pursue pedophilic desires (Aboujaoude et al., 2015). Likewise, some clinicians believe that violent video games may contribute to the development of antisocial behavior (Zhuo, 2010). And, in the opinion of many clinicians, constant text messaging, tweeting, and Internet browsing may contribute to shorter attention spans and establish a foundation for attention problems (Richtel, 2010).
A number of clinicians also worry that social networking can contribute to psy- chological dysfunctioning in certain cases. On the positive side, research indicates that, on average, social media users are particularly likely to maintain close rela-
tionships, receive social support, be trusting, and lead active lives (Hampton et al., 2011; Rainie et al., 2011). On the negative side, however, is research suggesting that social networking sites may increase peer pressure and social anxiety in some adolescents (Charles, 2011; Hampton et al., 2011). The sites may, for example, cause some people to develop fears that others in their network will exclude them socially. Similarly, there is clinical concern that sites such as Facebook may facilitate shy people’s withdrawal from valuable face-to-face relationships.
In addition, the face of clinical treatment is con- stantly changing in our fast-moving digital world. The use of cybertherapy, for example, is growing by leaps and bounds as a treatment option (Blanken et al., 2015; Pope & Vasquez, 2011). As you’ll see in Chapter 2, cybertherapy takes such forms as long- distance therapy between clients and therapists using
Skype, therapy offered by computer programs, treatment enhanced by the use of video game–like avatars and other virtual reality experiences, and Internet-based support groups. Similarly, countless Web sites offer a wealth of mental health infor- mation. And literally thousands of apps are devoted to relaxing people, cheering them up, or otherwise improving their psychological states (see MindTech on the next page).
Unfortunately, as you’ll also see throughout the book, the cybertherapy move- ment is not without its problems. Along with the body of mental health informa- tion now available online comes an enormous amount of misinformation about psychological problems and their treatments, offered by persons and sites that are far from knowledgeable. Similarly, the issue of quality control is a major problem for Internet-based therapy, support groups, and the like. Moreover, there are now numerous anti-treatment Web sites that try to guide people away from seeking help for their psychological problems (Davey, 2010). In Chapters 3, 7, and 9, for example, you will read about the growing phenomenon of pro-anorexia and pro-suicide Web sites and their dangerous effects on vulnerable people. Clearly, the impact of tech- nological change presents formidable challenges for clinicians and researchers alike.
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“We don’t go to therapists—we just watch them on TV.”
▶▶ cybertherapy The use of computer technology, such as Skype or avatars, to provide therapy.
Abnormal Psychology: Past and Present : 21
➤ Summing Up CURRENT TRENDS In the 1950s, researchers discovered a number of new psychotropic medications, drugs that mainly affect the brain and reduce many symptoms of mental dysfunctioning. Their success contributed to a policy of deinstitutionalization, under which hundreds of thousands of patients were released from public mental hospitals. In addition, outpatient treatment has become the primary approach for most people with mental disorders, both mild and severe; prevention programs are growing in number and influence; the field of multicultural psychology has begun to influence how clinicians view and treat abnormality; and insurance coverage is having a significant impact on the way treatment is conducted.
It is also the case that a variety of perspectives and professionals have come to operate in the field of abnormal psychology, and many well-trained clinical researchers now investigate the field’s theories and treatments. And finally, the remarkable technological advances of recent times have affected the mental health field.
MindTech
Mental Health Apps Explode in the Marketplace About a decade ago, some clinicians and researchers began using text messages to help track the behaviors, thoughts, and emotions of clients with psychological
problems (Bauer, 2003). That pioneering work has mushroomed into an industry of smartphone apps that often help provide mental health assistance to consumers (Sifferlin, 2013). There are, in fact, now thousands of such apps in the marketplace— many of them free, the rest low in cost (Saedi, 2012).
Many of these apps provide individuals with mental health education and resources; others help users to keep track of their shifting moods, thoughts, and bodily changes (called bio- metrics); still others are interactive and are designed to serve as co-therapists or even substitute therapists, offering reminders, advice, and exercises in response to the needs and input of users. Some of today’s more popular apps include My Mood Tracker, MindShift, PTSD Coach, Moody Me, Live Happy, Optimism, Moodscope, and Mood 24/7 (Kiume, 2013; Szalavitz, 2013; Landau, 2012; Saedi, 2012).
Many of today’s apps are promising (Konrath, 2013) and have increasingly been recommended by therapists and mental health researchers, even by the National Institutes of Health. But be aware: most of them are unregulated. Only in the past year has the FDA announced its intention to systematically regulate smart- phone apps that monitor health and mental health (Alter, 2013). In the meantime, in the absence of regulation and proper research, consumers and therapists alike would be wise to investigate the reputation, manufacturer, content, and therapeutic principles of apps that they are considering (Sifferlin, 2013).
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What kinds of problems
might result from the growing
availability and use of mental
health apps in today’s world?
: chapter 122
What Do Clinical Researchers Do? Research is the key to accuracy in all fields of study; it is particularly important in abnormal psychology because a wrong belief in this field can lead to great suffering. At the same time, clinical researchers, also called clinical scientists, face certain chal- lenges that make their work very difficult. They must, for example, figure out how to measure such elusive concepts as private thoughts, mood changes, and human potential. They must consider the different cultural backgrounds, races, and genders of the people they choose to study. And they must always ensure that the rights of their research participants, both human and animal, are not violated. Let us examine the leading methods used by today’s researchers.
Clinical researchers try to discover broad laws, or principles, of abnormal psy- chological functioning. They search for a general, or nomothetic, understanding of the nature, causes, and treatments of abnormality. They do not typically assess, diagnose, or treat individual clients; that is the job of clinical practitioners. To gain a broad insight, clinical researchers, like scientists in other fields, use the scientific method—that is, they collect and evaluate information through careful observa- tions. These observations in turn enable them to pinpoint and explain relationships between variables.
Simply stated, a variable is any characteristic or event that can vary, whether from time to time, from place to place, or from person to person. Age, sex, and race are human variables. So are eye color, occupation, and social status. Clinical researchers are interested in variables such as childhood upsets, present life experiences, moods, social functioning, and responses to treatment. They try to determine whether two or more such variables change together and whether a change in one variable causes a change in another. Will the death of a parent cause a child to become depressed? If so, will a given treatment reduce that depression?
Such questions cannot be answered by logic alone because scientists, like all human beings, frequently make errors in thinking. Thus, clinical researchers must depend mainly on three methods of investigation: the case study, which typically is focused on one individual, and the correlational method and experimental method, approaches that are usually used to gather information about many individuals. Each is best suited to certain kinds of circumstances and questions. As a group, these methods enable sci- entists to form and test hypotheses, or hunches, that certain variables are related in certain ways—and to draw broad conclusions as to why. More properly, a hypothesis is a tentative explanation offered to provide a basis for an investigation.
The Case Study A case study is a detailed description of a person’s life and psychological prob- lems. It describes the person’s history, present circumstances, and symptoms. It may also include speculation about why the problems developed, and it may describe the person’s treatment (Yin, 2013). As you will see in Chapter 5, one of the field’s best-known case studies, called The Three Faces of Eve, describes a woman with three alternating personalities, each having a distinct set of memories, preferences, and personal habits (Thigpen & Cleckley, 1957).
Most clinicians take notes and keep records in the course of treating their patients, and some further organize such notes into a formal case study to be shared with other professionals. The clues offered by a case study may help a clinician bet- ter understand or treat the person under discussion (Yin, 2013). In addition, case studies may play nomothetic roles that go far beyond the individual clinical case.
How Are Case Studies Helpful? Case studies can be a source of new ideas about behavior and “open the way for discoveries” (Bolgar, 1965). Freud’s theory of psychoanalysis was based mainly on the patients he saw in private practice. In
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Case study, Hollywood style Case studies often find their way into the arts or media and capture the public’s attention. Unfortunately, as this movie poster of The Three Faces of Eve illustrates, the studies may be trivialized or sensationalized in those ventures.
Abnormal Psychology: Past and Present : 23
addition, a case study may offer tentative support for a theory. Freud used case studies in this way as well, regarding them as evidence for the accuracy of his ideas. Con- versely, case studies may serve to challenge a theory’s assumptions (Yin, 2013).
Case studies may also show the value of new therapeutic techniques. And finally, case studies may offer opportunities to study unusual problems that do not occur often enough to permit a large number of observations (Goodwin & Goodwin, 2012). Investigators of problems such as personality disorder once relied entirely on case studies for information.
What Are the Limitations of Case Studies? Case studies also have limitations (Yin, 2013). First, they are reported by biased observers, that is, by therapists who have a personal stake in seeing their treatments succeed. These therapists must choose what to include in a case study, and their choices may at times be self-serving. Second, case studies rely on subjective evidence. Is a client’s problem really caused by the events that the therapist or client says are responsible? After all, those are only a
fraction of the events that may be contributing to the situation. Finally, case studies provide little basis for generalization. Events or treatments that seem important in one case may be of no help at all in efforts to understand or treat others.
The limitations of the case study are largely addressed by two other methods of investigation: the correlational method and the experimental method.
These methods do not offer the rich details that make case studies so interesting, but they do help investigators draw broad conclusions about abnormality in the popu- lation at large. Thus they are now the preferred methods of clinical investigation.
Three features of the correlational and experimental methods enable clinical investigators to gain general insights: (1) The researchers typically observe many individuals (see MindTech on the next page). (2) The researchers apply procedures uniformly and can thus repeat, or replicate, their investigations. And (3) the research- ers use statistical tests to analyze the results of a study.
The Correlational Method Correlation is the degree to which events or characteristics vary with each other. The correlational method is a research procedure used to determine this “co- relationship” between variables. This method can be used, for example, to answer the question, “Is there a correlation between the amount of stress in people’s lives and the degree of depression they experience?” That is, as people keep experiencing stressful events, are they increasingly likely to become depressed?
To test this question, researchers have collected life stress scores (for example, the number of threatening events experienced during a certain period of time) and depression scores (for example, scores on a depression survey) from individuals and have correlated these scores. The people who are chosen for a study are its subjects, or participants, the term preferred by today’s investigators. Typically, investigators have found that life stress and depression variables do indeed increase or decrease together (Monroe et al., 2014). That is, the greater someone’s life stress score, the higher his or her score on the depression scale. When variables change the same way, their correlation is said to have a positive direction and is referred to as a positive correlation. Alternatively, correlations can have a negative rather than a positive direction. In a negative correlation, the value of one variable increases as the value of the other variable decreases. Researchers have found, for example, a
▶▶ scientific method The process of systematically gathering and evaluating information through careful observations to understand a phenomenon.
▶▶ hypothesis A hunch or prediction that certain variables are related in certain ways.
▶▶ case study A detailed account of a person’s life and psychological problems.
▶▶ correlation The degree to which events or characteristics vary along with each other.
▶▶ correlational method A research procedure used to determine how much events or characteristics vary along with each other.
Why do case studies and
other anecdotal offerings
influence people so much,
often more than system-
atic research does?
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Twins, correlation, and inheritance These healthy twin sisters are participating in a twin cultural festival at Honglingjin Park in Beijing, China. Correlational studies of many pairs of twins have suggested a link between genetic factors and certain psychological disorders. Identical twins (who have identi- cal genes) display a higher correlation for some disorders than do fraternal twins (whose genetic makeup is not identical).
: chapter 124
negative correlation between depression and activity level. The greater one’s depres- sion, the lower the number of one’s activities.
There is yet a third possible outcome for a correlational study. The variables under study may be unrelated, meaning that there is no consistent relationship between them. As the measures of one variable increase, those of the other variable
MindTech
A Researcher’s Paradise? Two of the biggest problems for researchers are finding enough participants for their studies and obtaining a sufficient range of participants. Until recent years, undergraduates were the most common participants in behavioral
research—even clinical research (Gosling, 2011). This was largely a matter of con- venience. Undergraduates are, after all, just down the hall, often in need of money, and typically interested in joining research studies. Moreover, at many universities, undergraduates are required to participate in research studies.
On the downside, undergraduates are a pretty homogeneous group whose behaviors and emotions do not always generalize to other groups in society (Phillips, 2011). Thus, it is probably good that the face of research recruitment is now changing. More and more researchers are turning to social networking sites— Facebook, Twitter, Tumblr, Instagram, and others—and their ready-to-be-studied users (Kosinski, Stillwell, & Graepel, 2013; Phillips, 2011). These sites provide an enormous pool of potential participants. Facebook, for example, has 1 billion monthly visitors and Twitter has 500 million (eBizMBA, 2015). And the sites’ users are diverse—persons of all races, ages, incomes, and education lev- els (Pew Research, 2013).
One recent study demonstrates the power and potential of social media participant pools (Kosinski et al., 2013). In this investiga- tion, 58,000 Facebook subscribers allowed the researchers access to their list of “likes,” and the subscribers further filled out online personality tests. The study found that information about a par- ticipant’s likes could predict with considerable accuracy his or her
personality traits, level of happiness, use of addictive substances, and level of intel- ligence, among other variables. Similarly, other social media site studies have tested various psychological theories “about relationships, identity, self-esteem, popularity, collective action, race, and political engagement” (Rosenbloom, 2007).
What a great resource, right? Not so fast. The studies above asked social media users whether they were willing to participate, but in a number of other studies, the users do not know that their posted information is being examined and tested. Inasmuch as posted information is publicly available, some researchers believe it is ethical to study that information without informing users that they are indeed being studied.
Facebook and most other social media sites do not have policies prohibiting scholars from studying user profiles without permission (Rosenbloom, 2007). In contrast, many research institutes have concluded that postings on social networking sites should be considered private, and they require their researchers at their institu- tions to obtain explicit permission from social media users when network informa- tion is being examined. While this technology-driven question of what’s public and what’s private is under debate, it is probably best that posters follow a new version of that most sacred rule of consumerism—“poster beware.”
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People Who Purchased This Participant Also Purchased . . . Leave it to Amazon. More and more researchers are now finding study par ticipants on Amazon Mechanical Turk, an Amazon site that helps investigators and prospective participants find each other. Researchers post their studies on this Internet marketplace, and par ticipants choose which ones to sign up for. Upon completion of the online study, participants receive payment via an Amazon.com gift certificate, and Amazon receives 10 percent of their reimbursement.
Abnormal Psychology: Past and Present : 25
sometimes increase and sometimes decrease. Studies have found that depression and intelligence are unrelated, for example.
In addition to knowing the direction of a correlation, researchers need to know its magnitude, or strength. That is, how closely do the two variables correspond? Does one always vary along with the other, or is their relationship less exact? When two variables are found to vary together very closely in person after person, the correlation is said to be high, or strong.
The direction and magnitude of a correlation are often cal- culated numerically and expressed by a statistical term called the correlation coefficient. The correlation coefficient can vary from +1.00, which indicates a perfect positive correlation between two variables, down to –1.00, which represents a perfect nega- tive correlation. The sign of the coefficient (+ or –) signifies the direction of the correlation; the number represents its magnitude. The closer the correlation is to .00, the weaker, or lower in magnitude, it is. Thus correlations of +.75 and –.75 are of equal magnitude and equally strong, whereas a correlation of +.25 is weaker than either.
Everyone’s behavior is changeable, and many human responses can be measured only approximately. Most correlations found in psychological research, therefore, fall short of perfect positive or negative correlation. For example, one early study of life stress and depression, with a sample of 68 adults, found a correlation of +.53 (Miller, Ingham, & Davidson, 1976). Although hardly perfect, a correlation of this magnitude is considered large in psychological research.
When Can Correlations Be Trusted? Scientists must decide whether the correlation they find in a given sample of participants accurately reflects a real correlation in the general population. Could the observed correlation have occurred by mere chance? They can test their conclusions with a statistical analysis of their data, using principles of probability. In essence, they ask how likely it is that the study’s particular findings have occurred by chance. If the statistical analysis indicates that chance is unlikely to account for the correlation they found, researchers may con- clude that their findings reflect a real correlation in the general population.
What Are the Merits of the Correlational Method? The correla- tional method has certain advantages over the case study (see Table 1-3). Because researchers measure their variables, observe many participants, and apply statistical analyses, they are in a better position to generalize their correlations to people beyond the ones they have studied. Furthermore, researchers can easily repeat correlational studies using new samples of participants to check the results of earlier studies.
Stress and depression In Norcross, Geor- gia, friends and workers bring all of this family’s possessions to the curb after their bank has foreclosed on their mortgage, another casu- alty of the subprime loan crisis and economic downturn. Researchers have found that the stress produced by the loss of one’s home is often accompanied by the onset of depression and other psychological symptoms.
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Relative Strengths and Weaknesses of Research Methods
Provides Individual Information
Provides General Information
Provides Causal Information
Statistical Analysis Possible Replicable
Case study Yes No No No No
Correlational method
No Yes No Yes Yes
Experimental method
No Yes Yes Yes Yes
: chapter 126
Although correlations allow researchers to describe the relationship between two variables, they do not explain the relation- ship ( Jackson, 2012). When we look at the positive correlation found in many life stress studies, we may be tempted to conclude that increases in recent life stress cause people to feel more depressed. In fact, however, the two variables may be corre- lated for any one of three reasons: (1) Life stress may cause depression. (2) Depression may cause people to experience more life stress (for example, a depressive approach to life may cause people to perform poorly at work or may interfere with social relationships). (3) Depres- sion and life stress may each be caused by a third variable, such as financial problems (Gutman & Nemeroff, 2011).
Although correlations say nothing about causation, they can still be of great use to clinicians. Clinicians know, for example, that suicide attempts increase as people become more depressed. Thus, when they work with severely depressed clients, they stay on the lookout for signs of suicidal thinking. Perhaps depression directly causes suicidal behav-
ior, or perhaps a third variable, such as a sense of hopelessness, causes both depression and suicidal thoughts. Whatever the cause, just knowing that there is a correlation may enable clinicians to take measures (such as hospitalization) to help save lives.
Special Forms of Correlational Research Epidemiological studies and longitudinal studies are two kinds of correlational research used widely by clinical investigators. Epidemiological studies reveal the incidence and prevalence of a disorder in a particular population. Incidence is the number of new cases that emerge during a given period of time. Prevalence is the total number of cases in the population during a given period; prevalence includes both existing and new cases.
Over the past 40 years, clinical researchers throughout the United States have worked on one of the largest epidemiological studies of mental disorders ever conducted, called the Epidemiologic Catchment Area Study (Ramsey et al., 2013). They have interviewed more than 20,000 people in five cities to determine the prevalence of many psychological disorders and the treatment programs used. Two other large-scale epidemiological studies in the United States, the National Comor- bidity Survey and the National Comorbidity Survey Replication, have questioned more than 9,000 individuals (Martin, Neighbors, & Griffith, 2013). All these studies have been further compared with epidemiological studies of specific groups, such as Hispanic and Asian American populations, or with epidemiological studies con- ducted in other countries, to see how rates of mental disorders and treatment pro- grams vary from group to group and from country to country ( Jimenez et al., 2010).
Such epidemiological studies have helped researchers identify groups at risk for particular disorders. Women, it turns out, have a higher rate of anxiety disorders and depression than men, while men have a higher rate of alcoholism than women. Elderly people have a higher rate of suicide than young people. Hispanic Americans experience posttraumatic stress disorder more than other racial and ethnic groups in the United States. And persons in some countries have higher rates of certain mental disorders than those in other countries. Eating disorders such as anorexia nervosa, for example, appear to be more common in Western countries than in non-Western ones.
In longitudinal studies, correlational studies of another kind, researchers observe the same individuals on many occasions over a long period of time. In sev- eral such studies, investigators have observed the progress over the years of normally functioning children whose mothers or fathers suffered from schizophrenia (Rasic et al., 2014; Mednick, 1971). The researchers have found, among other things, that
▶▶ epidemiological study A study that measures the incidence and prevalence of a disorder in a given population.
▶▶ longitudinal study A study that observes the same participants on many occasions over a long period of time.
▶▶ experiment A research procedure in which a variable is manipulated and the effect of the manipulation is observed.
▶▶ independent variable The variable in an experiment that is manipulated to determine whether it has an effect on another variable.
▶▶ dependent variable The variable in an experiment expected to change as the independent variable is manipulated.
▶▶ confound In an experiment, a variable other than the independent variable that is also acting on the dependent variable.
▶▶ control group In an experiment, a group of participants who are not exposed to the independent variable.
▶▶ experimental group In an experiment, the participants who are exposed to the independent variable under investigation.
can you think of
other correlations
in life that are inter-
preted mistakenly
as causal?
“Recalculating . . . recalculating . . .”
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Abnormal Psychology: Past and Present : 27
the children of the parents with the most severe cases of schizophrenia were par- ticularly likely to develop a psychological disorder and to commit crimes at later points in their development.
The Experimental Method An experiment is a research procedure in which a variable is manipulated and the manipulation’s effect on another variable is observed. The manipulated variable is called the independent variable and the variable being observed is called the dependent variable.
To examine the experimental method more fully, let’s consider a question that is often asked by clinicians (Toth et al., 2014): “Does a particular therapy relieve the symptoms of a particular disorder?” Because this question is about a causal relation- ship, it can be answered only by an experiment (see Table 1-4). That is, experiment- ers must give the therapy in question to people who are suffering from a disorder and then observe whether they improve. Here the therapy is the independent vari- able, and psychological improvement is the dependent variable.
As with correlational studies, investigators who conduct experiments must do a statistical analysis on their data and find out how likely it is that the observed improvement is due to chance. Again, if that likelihood is very low, the improvement is considered to be statistically significant, and the experimenter may conclude with some confidence that it is due to the independent variable.
If the true cause of changes in the dependent variable cannot be separated from other possible causes, then an experiment gives very little information. Thus, experimenters must try to eliminate all confounds from their studies—variables other than the indepen- dent variable that may also be affecting the dependent variable. When there are confounds in an experiment, they, rather than the independent variable, may be causing the observed change.
For example, situational variables, such as the loca- tion of the therapy office (say, a quiet country setting) or soothing background music in the office, may have a therapeutic effect on participants in a therapy study. Or perhaps the participants are unusually motivated or have high expectations that the therapy will work, fac- tors that thus account for their improvement. To guard against confounds, researchers should include three important features in their experiments—a control group, random assignment, and a blind design (see MediaSpeak on the next page).
The Control Group A control group is a group of research participants who are not exposed to the independent variable under investigation but whose experience is similar to that of the experimen- tal group, the participants who are exposed to the independent variable. By comparing the two groups, an experimenter can better determine the effect of the independent variable.
To study the effectiveness of a particular therapy, for example, experimenters typically divide partici- pants into two groups. The experimental group may come into an office and receive the therapy for an hour, while the control group may simply come into
table: 1-4
Most Investigated Questions in Clinical Research Most Common Correlational Questions Are stress and onset of mental disorders related?
Is culture (or gender or race) generally linked to mental disorders?
Are income and mental disorders related?
Are social skills tied to mental disorders?
Is social support tied to mental disorders?
Are family conflict and mental disorders related?
Is treatment responsiveness tied to culture?
Which symptoms of a disorder appear together?
How common is a disorder in a particular population?
Most Common Causal Questions Does factor X cause a disorder?
Is cause A more influential than cause B?
How does family communication and structure affect family members?
How does a disorder affect the quality of a person’s life?
Does treatment X alleviate a disorder?
Is treatment X more helpful than no treatment at all?
Is treatment A more helpful than treatment B?
Why does treatment X work?
Can an intervention prevent abnormal functioning?
: chapter 128
75%10:00 AM
MediaSpeak Flawed Study, Gigantic Impact
By David DiSalvo, Forbes, May 19, 2012
In 2001, Dr. Robert L. Spitzer, psychiatrist and professor emeritus of Columbia University, presented a paper at a meeting of the American Psychiatric Association about something called “reparative therapy” [also known as “conversion therapy”] for gay men and women. By undergoing reparative therapy, the paper claimed, gay men and women could change their sexual orientation. Spitzer had interviewed 200 allegedly former- homosexual men and women that he claimed had shown varying degrees of such change; all of the participants provided Spitzer with self reports of their experience with the therapy.
Spitzer, now 79 years old, was no stranger to the controversy surrounding his chosen subject. Thirty years earlier, he had played a leading role in removing homo- sexuality from the list of mental disorders in the association’s diagnostic manual [DSM-III]. Clearly, his interest in the topic was more than a passing aca- demic curiosity. . . .
Fast forward to 2012, and Spitzer is of quite a different mind. Last month he told a re- porter with The American Pros- pect that he regretted the 2001 study and the effect it had on the gay community, and that he owed the community an apol- ogy. And this month he sent a letter to the Archives of Sexual Behavior, which published his work in 2003, asking that the journal retract his paper.
Spitzer’s mission to clean the slate is commendable, but the effects of his work have been coursing through the homo- sexual community like acid since it made headlines a decade ago. His study was seized upon by
anti-homosexual activists and therapists who held up Spitzer’s paper as proof that they could “cure” patients of their sexual orientation.
Spitzer didn’t invent reparative therapy, and he isn’t the only researcher to have conducted studies claiming that it works, but as an influential psychiatrist from a prestigious university, his words carried a lot of weight.
In his recantation of the study, he says that it contained at least two fatal flaws: the self reports from those he surveyed were not verifiable, and he didn’t include a control group of men and women who didn’t undergo the therapy for comparison. Self reports are notoriously unreliable. . . . Lacking a control group is a fundamental no-no in social science research across
the board. The conclusion is in- escapable—Spitzer’s study was simply bad science. . . .
The object lesson worth draw- ing from this story is that just one instance of bad science given the blessing of recognized experts can lead to years of damaging lies that snowball out of control. Spitzer cannot be held solely responsible for what happened after his paper was published, but he’d probably agree now that the study should never have been presented in the first place. At the very least, his example may help prevent future episodes of the same.
May 19, 2012, “How One Flawed Study Spawned a Decade of Lies” by David DiSalvo. From Forbes, 5/19/2012 © 2012 Forbes LLC. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmis- sion of this content without express written permission is prohibited.
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Protesting reparative therapy Protestors from a gay rights group in Hong Kong hold up a banner outside a social welfare department in 2011 to protest the department’s endorse- ment of reparative therapy.
Abnormal Psychology: Past and Present : 29
the office for an hour. If the experimenters find later that the people in the experimental group improve more than the people in the control group, they may conclude that the therapy was effective, above and beyond the effects of time, the office setting, and any other confounds. To guard against confounds, exper- imenters try to provide all participants, both control and experimental, with experiences that are identical in every way—except for the independent variable.
Random Assignment Researchers must also watch out for differences in the makeup of the exper- imental and control groups since those differences may also confound a study’s results. In a therapy study, for example, the experimenter may unintentionally put wealthier participants in the experimental group and poorer ones in the control group. This difference, rather than their therapy, may be the cause of the greater improvement later found among the experimental participants. To reduce the effects of preexisting differences, experimenters typically use random assign- ment. This is the general term for any selection procedure that ensures that every participant in the experiment is as likely to be placed in one group as the other. Researchers might, for example, assign people to groups by flipping a coin or pick- ing names out of a hat.
Blind Design A final confound problem is bias. Participants may bias an experi- ment’s results by trying to please or help the experimenter. In a therapy experiment, for example, if those participants who receive the treatment know the purpose of the study and which group they are in, they might actually work harder to feel bet- ter or fulfill the experimenter’s expectations. If so, subject, or participant, bias rather than therapy could be causing their improvement.
To avoid this bias, experimenters can prevent participants from finding out which group they are in. This experimental strategy is called a blind design because the individuals are blind as to their assigned group. In a therapy study, for
example, control participants could be given a placebo (Latin for “I shall please”), some- thing that looks or tastes like real therapy but has none of its key ingredients. This “imitation” therapy is called placebo therapy. If the experimental (true therapy) participants
improve more than the control (placebo therapy) participants, experimenters have more confidence that the true therapy has caused their improvement.
An experiment may also be confounded by experimenter bias—that is, experi- menters may have expectations that they unintentionally transmit to the participants in their studies. In a drug therapy study, for example, the experimenter might smile and act confident while providing real medications to the experimental participants but frown and appear hesitant while offering placebo drugs to the control partici- pants. This kind of bias is sometimes referred to as the Rosenthal effect, after the psychologist who first identified it (Rosenthal, 1966). Experimenters can eliminate their own bias by arranging to be blind themselves. In a drug therapy study, for example, an aide could make sure that the real medication and the placebo drug look identical. The experimenter could then administer treatment without knowing which participants were receiving true medications and which were receiving false medications. While either the participants or the experimenter may be kept blind in
Is animal companionship a form of therapy? A patient (right) and therapist (left) feed ring-tailed lemurs at Serengeti Park near Hodenhagen, Germany, as part of a monthly program called “Psychiatric Animal Days.” The program is based on the assumption that animals have a calming and therapeutic effect on people. An experimental design is needed to determine whether this or any other form of treatment actually causes clients to improve.
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▶▶ random assignment A selection procedure that ensures that participants are randomly placed either in the control group or in the experimental group.
▶▶ blind design An experiment in which participants do not know whether they are in the experimental or the control condition.
Why might sugar pills or other
kinds of placebo treatments
help some people feel better?
: chapter 130
an experiment, it is best that both be blind—a research strategy called a double-blind design. In fact, most medication experiments now use double-blind designs to test promising drugs (Pratley, Fleck, & Wilson, 2014).
Alternative Experimental Designs Clinical researchers must often settle for experimental designs that are less than ideal (Manton et al., 2014). The most common such variations are the quasi-experimental design, the natural experiment, the analogue experiment, and the single-subject experiment.
In quasi-experiments, or mixed designs, investigators do not randomly assign participants to control and experimental groups but instead make use of groups that already exist in the world at large (Girden & Kabacoff, 2011). Consider, for example, research into the effects of child abuse. Because it would be unethical for investigators of this issue to actually abuse a randomly chosen group of children, they must instead compare children who already have a history of abuse with chil- dren who do not. To make this comparison as valid as possible, they may further use matched control participants. That is, they match the experimental participants with control participants who are similar in age, sex, race, number of children in the family, socioeconomic status, type of neighborhood, or other characteristics. When the data from studies of this kind show that abused children are typically sadder and have lower self-esteem than matched control participants who have not been abused, the investigators can conclude with some confidence that abuse is causing the differences (Lindert et al., 2013).
In natural experiments, nature itself manipulates the independent variable, and the experimenter observes the effects. Natural experiments must be used for studying the psychological effects of unusual and unpredictable events, such as floods, earthquakes, plane crashes, and fires. Because the participants in these studies are selected by an accident of fate rather than by the investigators’ design, natural experiments are actually a kind of quasi-experiment.
On December 26, 2004, an earthquake occurred beneath the Indian Ocean off the coast of Sumatra, Indonesia. The earthquake triggered a series of massive tsu-
namis that flooded the ocean’s coastal communities, killed more than 225,000 people, and injured and left millions of survivors homeless, particularly in Indonesia, Sri Lanka, India, and Thailand. Within months of this disaster, researchers conducted natural experiments in which they collected data from hundreds of sur- vivors and from control groups of people who lived in areas not directly affected by the tsunamis. The disaster survivors scored sig- nificantly higher on anxiety and depression measures (dependent variables) than the controls did. The survivors also experienced more sleep problems, feelings of detachment, arousal, difficulties concentrating, startle responses, and guilt feelings than the controls did (Musa et al., 2014; Heir et al., 2010). Over the past several years, other natural experiments have focused on survivors of the 2010 Haitian earthquake, the massive earthquake and tsunami in Japan in 2011, the Northeast’s Superstorm Sandy in 2012, and the unprecedented Oklahoma tornados in 2013. These studies have also revealed lingering psychological symptoms among survivors of those disasters (Iwadare et al., 2013).
Experimenters often run analogue experiments. Here they induce laboratory participants to behave in ways that seem to resemble real-life abnormal behavior and then conduct experi- ments on the participants in the hope of shedding light on the real-life abnormality. For example, as you’ll see in Chapter 6, inves- tigator Martin Seligman, in a classic body of work, has produced
Natural experiments In this famous photograph, a woman carries her daughter to safety after a massive tornado carved its way through Moore, Oklahoma, in 2013, leveling the town, killing 25 people, and injuring 377 others. Natural experiments conducted in the aftermath of such catastrophes have found that many survivors experience lingering feelings of anxiety and depression.
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Animal Research Approximately 101 million animals are used in biomedical research each year. Fewer than 1 percent of them are dogs, cats, or primates.
(U.S. Department of agriculture, 2014; Speaking of Research, 2011)
Abnormal Psychology: Past and Present : 31
depression-like symptoms in laboratory participants—both animals and humans— by repeatedly exposing them to negative events (shocks, loud noises, task failures) over which they have no control. In these “learned helplessness” analogue studies, the participants seem to give up, lose their initiative, and become sad—suggesting to some clinicians that human depression itself may indeed be caused by loss of control over the events in one’s life.
Finally, scientists sometimes do not have the luxury of experimenting on many participants. They may, for example, be investigating a disorder so rare that few participants are available. Experimentation is still possible, however, with a single-subject experimental design. Here a single participant is observed both before and after the manipulation of an independent variable (Richards, Taylor, & Ramasamy, 2014).
For example, using a particular kind of single-subject design, called an ABAB, or reversal, design, one researcher sought to determine whether the systematic use of rewards would reduce a teenage boy’s habit of disrupting his special education class with loud talk (Deitz, 1977). He rewarded the boy, who suffered from intel- lectual disability (previously called mental retardation), with extra teacher time whenever he went 55 minutes without interrupting the class more than three times. In condition A, the student was observed prior to receiving any reward, and he was found to disrupt the class frequently with loud talk. In condition B, the boy was given a series of teacher reward sessions (introduction of the independent variable); as expected, his loud talk decreased dramatically. Next, the rewards from the teacher were stopped (condition A again), and the student’s loud talk increased once again. Apparently the independent variable had indeed been the cause of the improvement. To be still more confident about this conclusion, the researcher had the teacher apply reward sessions yet again (condition B again). Once again the student’s behavior improved.
What Are the Limits of Clinical Investigations? We began this section by noting that clinical scientists look for general laws that will help them understand, treat, and prevent psychological disorders. As we have seen, however, circumstances can interfere with their progress.
Each method of investigation that we have observed addresses some of the problems involved in studying human behavior, but no one approach overcomes
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Similar enough? Celebrity chimpanzee Cheetah, age 59, does some painting along with her friend and trainer. Chimps and human beings share more than 90 percent of their genetic material, but their brains and bodies are very different, as are their perceptions and experiences. Thus, abnormal-like behavior produced in animal analogue experiments may differ from the human abnormality under investigation.
▶▶ quasi-experiment An experiment in which investigators make use of control and experimental groups that already exist in the world at large. Also called a mixed design.
▶▶ natural experiment An experiment in which nature, rather than an experimenter, manipulates an independent variable.
▶▶ analogue experiment A research method in which the experimenter pro- duces abnormal-like behavior in labo- ratory participants and then conducts experiments on the participants.
▶▶ single-subject experimental design A research method in which a sin- gle participant is observed and measured both before and after the manipulation of an independent variable.
: chapter 132
them all. Thus it is best to view each research method as part of a team of approaches that together may shed light on abnormal human functioning. When more than one method has been used to investigate a disorder, it is important to ask whether all the results seem to point in the same direction. If they do, clinical scientists are probably making progress toward understand- ing and treating that disorder. Conversely, if the various methods seem to produce conflicting results, the scientists must admit that knowledge in that particular area is still limited.
Protecting Human Participants Human research participants have needs and rights that must be respected. In fact, researchers’ primary obligation is to avoid harming the human par- ticipants in their studies—physically or psychologically.
The vast majority of researchers are conscientious about fulfilling this obligation. They try to conduct studies that test their hypotheses and fur- ther scientific knowledge in a safe and respectful way. But there have been some notable exceptions to this over the years, particularly several infamous studies conducted in the mid-1900s. Partly because of such exceptions, the
government and the institutions in which research is conducted now take careful measures to ensure that the safety and rights of human research participants are properly protected.
Who, beyond researchers themselves, might directly watch over the rights and safety of human participants? For the past few decades, that responsibility has been given to Institutional Review Boards, or IRBs. Each research facility has an IRB—a committee of five or more members who review and monitor every study conducted at that institution, starting when the studies are first proposed. The insti- tution may be a university, medical school, psychiatric or medical hospital, private research facility, mental health center, or the like. If research is conducted there, the institution must have an IRB, and that IRB has the responsibility and power to require changes in a proposed study as a condition of approval. If acceptable changes are not made by the researcher, then the IRB can disapprove the study altogether. Similarly, if, over the course of the study, the safety or rights of the participants are placed in jeop- ardy, the IRB must intervene and can even stop the study if necessary. These powers are granted to IRBs (or similar ethics committees) by nations around the world. In the United States, for example, IRBs are empow- ered by two agencies of the federal government—the Office for Human Research Protections and the Food and Drug Administration.
It turns out that protecting the rights and safety of human research participants is a complex undertaking. Thus, IRBs often are forced to conduct a kind of risk- benefit analysis in their reviews. They may, for example, approve a study that poses minimal or slight risks to participants if that “acceptable” level of risk is offset by the study’s potential benefits to society. In general, IRBs try to ensure that each study grants the following rights to its participants (NIJ, 2010):
➤ The participants enlist voluntarily. ➤ Before enlisting, the participants are adequately informed about what the study entails (“informed consent”).
➤ The participants can end their participation in the study at any time. ➤ The benefits of the study outweigh its costs/risks. ➤ The participants are protected from physical and psychological harm.
▶▶ Institutional Review Board (IRB) An ethics committee in a research facility that is empowered to protect the rights and safety of human research participants.
A national disgrace In a 1997 White House ceremony, President Bill Clinton offers an offi- cial apology to 94-year-old Herman Shaw and other African American men whose syphilis went untreated by government doctors and researchers in the Tuskegee Syphilis Study, a research undertaking conducted from 1932 to 1972, prior to the emergence of Institutional Review Boards. In this infamous study, 399 par- ticipants were not informed that they had the disease, and they continued to go untreated even after it was discovered that penicillin is an effective intervention for syphilis.
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Abnormal Psychology: Past and Present : 33
➤ The participants have access to information about the study. ➤ The participants’ privacy is protected by principles such as confi- dentiality or anonymity.
Unfortunately, even with IRBs on the job, these rights can be in jeopardy. Consider, for example, the right of informed consent. To help ensure that participants understand what they are getting into when they enlist for a study, IRBs typically require that the individuals read and sign an “informed consent form” that spells out everything they need to know. But how clear are such forms? Not very, according to some investigations (Albala, Doyle, & Appelbaum, 2010; Mathew & McGrath, 2002).
It turns out that most such forms—the very forms deemed accept- able by IRBs—are written at an advanced college level, making them incomprehensible to a large percentage of participants. In fact, fewer than half of all participants may fully understand the informed con- sent forms they are signing. Still other investigations indicate that only around 10 percent of human participants carefully read the informed consent forms before signing them, and only 30 percent ask questions of the researchers during the informed consent phase of their studies (CISCRP, 2013).
In short, the IRB system is flawed, much like the research undertakings it oversees. There are various reasons for this. One is that ethical principles are subtle and elusive notions that do not always translate into simple regulations and guidelines. Another reason is that ethical decisions—whether by IRB members or by researchers—are subject to differences in perspective, interpretation, decision- making style, and the like. Despite such problems and limitations, most observers agree that the creation and work of IRBs have helped improve the rights and safety of human research participants over the years. The boards may reflect an imperfect system, but they play a necessary and important role in monitoring the quality and appropriateness of research undertakings.
➤ Summing Up WHAT DO CLINICAL RESEARCHERS DO? Researchers use the scientific method to uncover nomothetic principles of abnormal psychological functioning. They attempt to identify and examine relationships between variables and depend primarily on three methods of investigation: the case study, the correlational method, and the experimental method.
A case study is a detailed account of a person’s life and psychological problems.
Correlational studies are used to systematically observe the degree to which events or characteristics vary together. This method allows researchers to draw broad conclusions about abnormality in the population at large. Two widely used forms of the correlational method are epidemiological studies and longi- tudinal studies.
In experiments, researchers manipulate suspected causes to see whether expected effects will result. This method allows researchers to determine the causes of various conditions or events. Clinical experimenters must often settle for experimental designs that are less than ideal, including the quasi- experiment, the natural experiment, the analogue experiment, and the single- subject experiment.
Each research facility has an Institutional Review Board (IRB) that has the power and responsibility to protect the rights and safety of human participants in all studies conducted at that facility. Members of the IRB review each study
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Making a point The rights of animal subjects must also be considered. Here, members of an organization called In Defense of Animals wear monkey masks and sit in locked cages in front of the University of California, San Francisco, to protest the use of monkeys in research.
B e t W e e n t h e L i n e s
Predictions Made Without Research
“Websites will never replace newspapers.”
Newsweek, 1995
“Next Christmas, the iPod will be dead.” amstrad (electronics company), 2005
“Guitar music is on the way out.” Decca records company, 1964
“The cloning of mammals . . . is biologically impossible.”
James McGrath and Davor Solter, genetic researchers, 1984
“The ‘telephone’ has too many short comings to be seriously considered as a means of communication.”
Western Union, 1876
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: chapter 134
during the planning stages and can require changes in the proposed study before granting approval for the undertaking. If the required changes are not made, the IRB has the authority to disapprove the study. Among the impor- tant participant rights that the IRB protects is the right of informed consent, an acceptable risk/benefit balance, and privacy (confidentiality or anonymity).
PUTTING IT...together A Work in Progress Since ancient times, people have tried to explain, treat, and study abnormal behavior. By examining the responses of past societies to such behaviors, we can better under- stand the roots of our present views and treatments. In addition, a look backward helps us appreciate just how far we have come—how humane our present views are, how impressive our recent discoveries are, and how important our current emphasis on research is.
At the same time, we must recognize the many problems in abnormal psychology today. The field has yet to agree on one definition of abnormality. It is currently made up of conflicting schools of thought and treatment whose members are often unim- pressed by the claims and accomplishments of the others. Clinical practice is car- ried out by a variety of professionals trained in different ways. And current research methods each have flaws that limit our knowledge and use of clinical information.
As you travel through the topics in this book, keep in mind the field’s current strengths and weaknesses, the progress that has been made, and the journey that lies ahead. Perhaps the most important lesson to be learned from our look at the his- tory of this field is that our current understanding of abnormal behavior represents a work in progress. The clinical field stands at a crossroads, with some of the most important insights, investigations, and changes yet to come.
KEY TERMS abnormal psychology, p. 2
deviance, p. 3
norms, p. 3
culture, p. 3
distress, p. 3
dysfunction, p. 4
danger, p. 4
treatment, p. 5
trephination, p. 8
humors, p. 8
asylum, p. 10
moral treatment, p. 10
state hospitals, p. 11
somatogenic perspective, p. 11
psychogenic perspective, p. 11
general paresis, p. 11
hypnosis, p. 13
psychoanalysis, p. 13
psychotropic medications, p. 15
deinstitutionalization, p. 15
private psychotherapy, p. 15
prevention, p. 16
positive psychology, p. 16
multicultural psychology, p. 17
managed care program, p. 17
cybertherapy, p. 20
scientific method, p. 22
hypothesis, p. 22
case study, p. 22
correlation, p. 23
correlational method, p. 23
epidemiological study, p. 26
incidence, p. 26
prevalence, p. 26
longitudinal study, p. 26
experiment, p. 27
independent variable, p. 27
dependent variable, p. 27
confound, p. 27
control group, p. 27
experimental group, p. 27
random assignment, p. 29
blind design, p. 29
placebo therapy, p. 29
double-blind design, p. 30
quasi-experiment, p. 30
natural experiment, p. 30
analogue experiment, p. 30
single-subject experimental design, p. 31
Institutional Review Board (IRB), p. 32
informed consent, p. 32
B e t W e e n t h e L i n e s
Famous Psych Lines from from the Movies: Take 2 “She wore the gloves all the time, so I just thought, maybe she has a thing about dirt.” (Frozen, 2013)
“I just want to be perfect.” (Black Swan, 2010)
“Take baby steps.” (What About Bob? 1991)
“I see dead people.” (The Sixth Sense, 1999)
“I love the smell of napalm in the morning.” (Apocalypse Now, 1979)
“I begged you to get some therapy.” (Tootsie, 1982)
Abnormal Psychology: Past and Present : 35
QuickQuiz
1. What features are common to abnormal psychological functioning? pp. 2–5
2. Name two forms of past treatments that reflect a demonological view of abnormal behavior. pp. 7–9
3. Give examples of the somatogenic view of psychological abnormality from Hippocrates, the Renaissance, the nine- teenth century, and the recent past. pp. 8–12
4. Describe the role of hypnotism and
hysterical disorders in the development of the psychogenic view. pp. 12–14
5. How did Sigmund Freud come to develop the theory and technique of psychoanalysis? pp. 13–14
6. Describe the major changes that have occurred since the 1950s in the treat- ment of people with mental disorders. pp. 14–21
7. What are the advantages and disadvan- tages of the case study, correlational
method, and experimental method? pp. 22–31
8. What techniques do researchers include in experiments to guard against the influence of confounds? pp. 27–31
9. Describe four alternative kinds of experiments that researchers often use. pp. 30–31
10. What are Institutional Review Boards, and what are their responsibilities and goals? pp. 32–33
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the ebook, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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P hilip Berman, a 25-year-old single unemployed former copy editor for a large publishing house . . . had been hospitalized after a suicide attempt in which he deeply gashed his wrist with a razor blade. He described [to the therapist] how he had sat on the bathroom floor and watched the blood drip into the bathtub
for some time before he [contacted] his father at work for help. He and his father went to the hospital emergency room to have the gash stitched, but he convinced himself and the hospital physician that he did not need hospitalization. The next day when his father suggested he needed help, he knocked his dinner to the floor and angrily stormed to his room. When he was calm again, he allowed his father to take him back to the hospital.
The immediate precipitant for his suicide attempt was that he had run into one of his former girlfriends with her new boyfriend. The patient stated that they had a drink together, but all the while he was with them he could not help thinking that “they were dying to run off and jump in bed.” He experienced jealous rage, got up from the table, and walked out of the restaurant. He began to think about how he could “pay her back.”
Mr. Berman had felt frequently depressed for brief periods during the previous several years. He was especially critical of himself for his limited social life and his inability to have managed to have sexual intercourse with a woman even once in his life. As he related this to the therapist, he lifted his eyes from the floor and with a sarcastic smirk said, “I’m a 25-year-old virgin. Go ahead, you can laugh now.” He has had several girlfriends to date, whom he described as very attractive, but who he said had lost interest in him. On further questioning, however, it became apparent that Mr. Berman soon became very critical of them and demanded that they always meet his every need, often to their own detriment. The women then found the rela- tionship very unrewarding and would soon find someone else.
During the past two years Mr. Berman had seen three psychiatrists briefly, one of whom had given him a drug, the name of which he could not remember, but that had precipitated some sort of unusual reaction for which he had to stay in a hospital overnight. . . . Concerning his hospitalization, the patient said that “It was a dump,” that the staff refused to listen to what he had to say or to respond to his needs, and that they, in fact, treated all the patients “sadistically.” The referring doctor corrobo- rated that Mr. Berman was a difficult patient who demanded that he be treated as special, and yet was hostile to most staff members throughout his stay. After one angry exchange with an aide, he left the hospital without [permission], and subse- quently signed out against medical advice.
Mr. Berman is one of two children of a middle-class family. His father is 55 years old and employed in a managerial position for an insurance company. He perceives his father as weak and ineffectual, completely dominated by the patient’s overbearing and cruel mother. He states that he hates his mother with “a passion I can barely con- trol.” He claims that his mother used to call him names like “pervert” . . . when he was growing up, and that in an argument she once “kicked me in the balls.” Together, he sees his parents as rich, powerful, and selfish, and, in turn, thinks that they see him as lazy, irresponsible, and a behavior problem. When his parents called the therapist to discuss their son’s treatment, they stated that his problem began with the birth of his younger brother, Arnold, when Philip was 10 years old. After Arnold’s birth Philip apparently became [a disagreeable] child who cursed a lot and was difficult to discipline. Philip recalls this period only vaguely. He reports that his mother once was hospitalized for depression, but that now “she doesn’t believe in psychiatry.”
Mr. Berman had graduated from college with average grades. Since graduating he had worked at three different publishing houses, but at none of them for more than one year. He always found some justification for quitting. He usually sat around his house doing very little for two or three months after quitting a job, until his parents
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T o P i c o v e r v i e w
The Biological Model How Do Biological Theorists Explain Abnormal Behavior? Biological Treatments Assessing the Biological Model
The Psychodynamic Model How Did Freud Explain Normal and Abnormal Functioning? How Do Other Psychodynamic Explanations Differ from Freud’s? Psychodynamic Therapies Assessing the Psychodynamic Model
The Behavioral Model How Do Behaviorists Explain Abnormal Functioning? Behavioral Therapies Assessing the Behavioral Model
The Cognitive Model How Do Cognitive Theorists Explain Abnormal Functioning? Cognitive Therapies Assessing the Cognitive Model
The Humanistic-Existential Model Rogers’ Humanistic Theory and Therapy Gestalt Theory and Therapy Spiritual Views and Interventions Existential Theories and Therapy Assessing the Humanistic-Existential Model
The Sociocultural Model: Family- Social and Multicultural Perspectives How Do Family-Social Theorists Explain Abnormal Functioning? Family-Social Treatments How Do Multicultural Theorists Explain Abnormal Functioning? Multicultural Treatments Assessing the Sociocultural Model
Putting It Together: Integration of the Models
Models of Abnormality
: chapter 238
Philip Berman is clearly a troubled person, but how did he come to be that way? How do we explain and correct his many problems? To answer these questions, we must first look at the wide range of complaints we are trying to understand: Philip’s depression and anger, his social failures, his lack of employment, his distrust of those around him, and the problems within his family. Then we must sort through all kinds of potential causes—internal and external, biological and interpersonal, past and present.
Although we may not realize it, we all use theoretical frameworks as we read about Philip. Over the course of our lives, each of us has developed a perspective that helps us make sense of the things other people say and do. In science, the per- spectives used to explain events are known as models, or paradigms. Each model spells out the scientist’s basic assumptions, gives order to the field under study, and sets guidelines for its investigation (Kuhn, 1962). It influences what the investiga- tors observe as well as the questions they ask, the information they seek, and how they interpret this information. To understand how a clinician explains or treats a specific set of symptoms, such as Philip’s, we must know his or her preferred model of abnormal functioning.
Until recently, clinical scientists of a given place and time tended to agree on a single model of abnormality—a model greatly influenced by the beliefs of their cul- ture. The demonological model that was used to explain abnormal functioning during the Middle Ages, for example, borrowed heavily from medieval society’s concerns with religion, superstition, and warfare. Medieval practitioners would have seen the devil’s guiding hand in Philip Berman’s efforts to commit suicide and his feelings of depression, rage, jealousy, and hatred. Similarly, their treatments for him—from prayers to whippings—would have sought to drive foreign spirits from his body.
Today several models are used to explain and treat abnormal functioning. This variety has resulted both from shifts in values and beliefs over the past half-century and from improvements in clinical research. At one end of the spectrum is the bio- logical model, which sees physical processes as key to human behavior. In the middle are four models that focus on more psychological and personal aspects of human functioning: the psychodynamic model looks at people’s unconscious internal processes and conflicts, the behavioral model emphasizes behavior and the ways in which it is learned, the cognitive model concentrates on the thinking that underlies behavior, and the humanistic-existential model stresses the role of values and choices. At the far end of the spectrum is the sociocultural model, which looks to social and cultural forces as the keys to human functioning. This model includes the family-social perspective, which focuses on an individual’s family and social interactions, and the multicultural perspective, which emphasizes an individual’s culture and the shared beliefs, values, and history of that culture.
Given their different assumptions and principles, the models are sometimes in conflict. Those who follow one perspective often scoff at the “naïve” interpretations,
prodded him into getting a new one. He described innumerable interactions in his life with teachers, friends, and employers in which he felt offended or unfairly treated . . . and frequent arguments that left him feeling bitter . . . and [he] spent most of his time alone, “bored.” He was unable to commit himself to any person, he held no strong convictions, and he felt no allegiance to any group.
The patient appeared as a very thin, bearded . . . young man with pale skin who maintained little eye contact with the therapist and who had an air of angry bitter- ness about him. Although he complained of depression, he denied other symptoms of the depressive syndrome. He seemed preoccupied with his rage at his parents, and seemed particularly invested in conveying a despicable image of himself. . . .
Spitzer et al., 1983, pp. 59–61
▶▶ model A set of assumptions and con- cepts that helps scientists explain and interpret observations. Also called a paradigm.
▶▶ neuron A nerve cell.
▶▶ synapse The tiny space between the nerve ending of one neuron and the dendrite of another.
▶▶ neurotransmitter A chemical that, released by one neuron, crosses the syn- aptic space to be received at receptors on the dendrites of neighboring neurons.
B e t w e e n t h e L i n e s
In Their Words “Mental illness is so much more complicated than any pill that any mortal could invent.”
elizabeth Wurtzel, Prozac Nation
Models of Abnormality : 39
investigations, and treatment efforts of the others. Yet none of the models is com- plete in itself. Each focuses mainly on one aspect of human functioning, and none can explain all aspects of abnormality.
The Biological Model Philip Berman is a biological being. His thoughts and feelings are the results of biochemical and bioelectrical processes throughout his brain and body. Proponents of the biological model believe that a full understanding of Philip’s thoughts, emotions, and behavior must therefore include an understanding of their biological basis. Not surprisingly, then, they believe that the most effective treatments for Philip’s prob- lems will be biological ones.
How Do Biological Theorists Explain Abnormal Behavior? Adopting a medical perspective, biological theorists view abnor- mal behavior as an illness brought about by malfunctioning parts of the organism. Typically, they point to problems in brain anat- omy or brain chemistry as the cause of such behavior.
Brain Anatomy and Abnormal Behavior The brain is made up of approximately 100 billion nerve cells, called neurons, and thousands of billions of support cells, called glia (from the Greek word for “glue”). Within the brain large groups of neurons form distinct areas, or brain regions. Toward the top of the brain, for example, is a cluster of regions, collectively referred to as the cerebrum, which includes the cortex, corpus callosum, basal ganglia, hippocampus, and amygdala (see Figure 2-1). The neurons in each of these brain regions control important functions. The cortex is the outer layer of the brain, the corpus callosum connects the brain’s two cerebral hemispheres, the basal ganglia plays a crucial role in planning and producing movement, the hippocampus helps regulate emo- tions and memory, and the amygdala plays a key role in emotional memory. Clinical researchers have discovered connections between certain psychological disorders and problems in specific areas of the brain. One such disorder is Huntington’s disease, a disorder marked by violent emotional outbursts, memory loss, suicidal thinking, involuntary body movements, and absurd beliefs. This disease has been traced to a loss of cells in the basal ganglia and cortex.
Brain Chemistry and Abnormal Behavior Biological researchers have also learned that psychological disorders can be related to problems in the transmis- sion of messages from neuron to neuron. Information is communicated throughout the brain in the form of electrical impulses that travel from one neuron to one or more others. An impulse is first received by a neuron’s dendrites, antenna-like extensions located at one end of the neuron. From there it travels down the neu- ron’s axon, a long fiber extending from the neuron’s body. Finally, it is transmitted through the nerve ending at the end of the axon to the dendrites of other neurons (see Figure 2-2).
But how do messages get from the nerve ending of one neuron to the dendrites of another? After all, the neurons do not actually touch each other. A tiny space, called the synapse, separates one neuron from the next, and the message must some- how move across that space. When an electrical impulse reaches a neuron’s ending, the nerve ending is stimulated to release a chemical, called a neurotransmitter, that
Amygdala
Hippocampus
Cerebral cortex
Corpus callosum
Basal ganglia
figure 2-1 The cerebrum Some psychological disor- ders can be traced to abnormal functioning of neurons in the cerebrum, which includes brain structures such as the cerebral cortex, corpus callosum, basal ganglia, hippocampus, and amygdala.
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travels across the synaptic space to receptors on the dendrites of the neighboring neurons. After binding to the receiving neuron’s receptors, some neurotransmitters give a message to receiving neurons to “fire,” that is, to trigger their own electrical impulse. Other neurotransmitters carry an inhibitory message; they tell receiving neurons to stop all firing. As you can see, neurotransmitters play a key role in mov- ing information through the brain.
Researchers have identified dozens of neurotransmitters in the brain, and they have learned that each neuron uses only certain kinds. Studies indicate that abnor- mal activity by certain neurotransmitters can lead to specific mental disorders. Depression, for example, has been linked to low activity of the neurotransmitters serotonin and norepinephrine. Perhaps low serotonin activity is partly responsible for Philip Berman’s pattern of depression and rage.
In addition to focusing on neurons and neurotransmitters, researchers have learned that mental disorders are sometimes related to abnormal chemical activity in the body’s endocrine system. Endocrine glands, located throughout the body, work along with neurons to control such vital activities as growth, reproduction, sexual activity, heart rate, body temperature, energy, and responses to stress. The glands release chemicals called hormones into the bloodstream, and these chemicals then propel body organs into action. During times of stress, for example, the adrenal glands, located on top of the kidneys, secrete the hormone cortisol to help the body deal with the stress. Abnormal secretions of this chemical have been tied to anxiety and mood disorders.
Sources of Biological Abnormalities Why do some people have brain structures or biochemical activities that differ from the norm? Three factors have received particular attention in recent years—genetics, evolution, and viral infections.
GENETICS AND ABNORMAL BEHAVIOR Abnormalities in brain anatomy or chemistry are sometimes the result of genetic inheritance. Each cell in the human brain and body contains 23 pairs of chromosomes, with each chromosome in a pair inherited from one of the person’s parents. Every chromosome contains numerous genes— segments that control the characteristics and traits a person inherits. Altogether, each cell contains around 30,000 genes (NIH, 2015; Emig et al., 2013). Scientists have known for years that genes help determine such physical characteristics as hair color, height, and eyesight. Genes can make people more prone to heart disease, cancer, or diabetes and perhaps to possessing artistic or musical skill. Studies suggest that
Dendrites
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Axon
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Neurotransmitters
Release of neurotransmitters
Receptor sites on receiving neuron Receptor sites on receiving neuron
Synapse
figure 2-2 A neuron communicating information A message in the form of an electrical impulse travels down the sending neuron’s axon to its nerve ending, where neurotransmitters are released and carry the message across the synaptic space to the dendrites of a receiving neuron.
▶▶ receptor A site on a neuron that receives a neurotransmitter.
▶▶ hormones The chemicals released by endocrine glands into the bloodstream.
▶▶ gene Chromosome segments that control the characteristics and traits we inherit.
Models of Abnormality : 41
inheritance also plays a part in mood disorders, schizophrenia, and other mental disorders. It appears that in most cases, several genes combine to help produce our actions and reactions, both functional and dysfunctional.
The precise contributions of various genes to mental disorders have become clearer in recent years, thanks in part to the completion of the Human Genome Project in 2000. In this major undertaking, sci- entists used the tools of molecular biology to map, or sequence, all of the genes in the human body in great detail. With this information in hand, researchers hope eventually to be able to prevent or change genes that help cause medical or psychological disorders.
EVOLUTION AND ABNORMAL BEHAVIOR Genes that contribute to mental disorders are typically viewed as unfortunate occurrences— almost mistakes of inheritance. The responsible gene may be a muta- tion, an abnormal form of the appropriate gene that emerges by accident. Or the problematic gene may be inherited by an individual after it has initially entered the family line as a mutation. According to some theorists, however, many of the genes that contribute to abnormal functioning are actually the result of normal evolutionary principles (Sipahi et al., 2014; Fábrega, 2010).
In general, evolutionary theorists argue that human reactions and the genes responsible for them have survived over the course of time because they have helped individuals to thrive and adapt. Ancestors who had the ability to run fast, for example, or the craftiness to hide were most able to escape their enemies and to reproduce. Thus, the genes responsible for effective walking, running, or problem solving were particularly likely to be passed on from generation to generation to the present day.
Similarly, say evolutionary theorists, the capacity to experience fear was, and in many instances still is, adaptive. Fear alerted our ancestors to dangers, threats, and losses so that persons could avoid or escape potential problems. People who were particularly sensitive to danger—those with greater fear responses—were more likely to survive catastrophes, battles, and the like and to reproduce and pass on their fear genes. Of course, in today’s world, pressures are more numerous, subtle, and complex than they were in the past, condemning many individuals with such genes to a near-endless stream of fear and arousal. That is, the very genes that helped their ancestors to survive and reproduce might now leave these individuals particularly prone to fear reactions, anxiety disorders, or related psychological disorders.
The evolutionary perspective is controversial in the clinical field and has been rejected by many theorists. Imprecise and at times impossible to research, this expla- nation requires leaps of faith that many scientists find unacceptable.
VIRAL INFECTIONS AND ABNORMAL BEHAVIOR Another possible source of abnor- mal brain structure or biochemical dysfunctioning is viral infections. As you will see in Chapter 14, for example, research suggests that schizophrenia, a disorder marked by delusions, hallucinations, or other departures from reality, may be related to exposure to certain viruses during childhood or before birth (Liu et al., 2014; Arias et al., 2012). Studies have found that the mothers of many individuals with this disorder contracted influenza or related viruses during their pregnancy. This and related pieces of circumstantial evidence suggest that a damaging virus may enter the fetus’ brain and remain dormant there until the individual reaches ado- lescence or young adulthood. At that time, the virus may produce the symptoms of schizophrenia. During the past decade, researchers have sometimes linked viruses to anxiety, depressive, and bipolar disorders, as well as to psychotic disorders (Liu et al., 2014).
More than coincidence? Identical twins Ronde and Tiki Barber, shown here at the 2006 NFL Pro Bowl, each had a successful football career—Ronde with the Tampa Bay Buccaneers and Tiki with the New York Giants. Studies of twins suggest that some aspects of behavior and personality are influenced by genetic factors. Many identical twins, like the Barbers, have similar tastes, behave in similar ways, and make similar life choices. Some even develop similar abnormal behaviors.
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In Their Words “My brain? That’s my second favorite organ.”
Woody allen
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Biological Treatments Biological practitioners look for certain kinds of clues when they try to understand abnormal behavior. Does the person’s family have a history of that behavior, and hence a possible genetic predisposition to it? (Philip Berman’s case history mentions that his mother was once hospitalized for depression.) Is the behavior produced by events that could have had a physiological effect? (Philip was having a drink when he flew into a jealous rage at the restaurant.)
Once the clinicians have pinpointed physical sources of dysfunctioning, they are in a better position to choose a biological course of treatment. The three leading kinds of biological treatments used today are drug therapy, electroconvulsive therapy, and psychosurgery. Drug therapy is by far the most common of these approaches.
In the 1950s, researchers discovered several effective psychotropic medica- tions, drugs that mainly affect emotions and thought processes. These drugs have greatly changed the outlook for a number of mental disorders and today are used widely, either alone or with other forms of therapy. However, the psychotropic drug revolution has also produced some major problems. Many people believe, for example, that the drugs are overused. Moreover, while drugs are effective in many cases, they do not help everyone. Thus many people seek out a biological alternative
to drug therapy—the enormously popular herbal supplements (see InfoCentral on the next page).
Four major psychotropic drug groups are used in therapy: antianxiety, antidepressant, antibipolar, and antipsychotic drugs. Antianxiety drugs, also called minor tranquilizers or anxiolyt- ics, help reduce tension and anxiety. Antidepressant drugs help improve the mood of people who are depressed. Antibipolar drugs, also called mood stabilizers, help steady the moods of
those with a bipolar disorder, a condition marked by mood swings from mania to depression. And antipsychotic drugs help reduce the confusion, hallucinations, and delusions of psychotic disorders, disorders (such as schizophrenia) marked by a loss of contact with reality.
Psychotropic drugs, like all medications, reach the marketplace only after system- atic research and careful review. It takes an average of 12 years and hundreds of mil- lions of dollars for a pharmaceutical company in the United States to bring a newly identified chemical compound to market. Along the way, the drug is vigorously tested in study after study—first on animals and then on humans—to determine its efficacy, safety, dosage, and side effects, until finally it receives approval by the U.S. Food and Drug Administration. Only 3 percent of newly discovered chemical compounds make it to animal testing, only 2 percent of animal-tested compounds reach human testing, and only 21 percent of human-tested drugs are eventually
approved (FDA, 2014). A second form of biological treatment, used primarily on depressed
patients, is electroconvulsive therapy (ECT). Two electrodes are attached to a patient’s forehead, and an electrical current of 65 to 140 volts is passed briefly through the brain. The current causes a brain seizure that lasts up to a few minutes. After seven to nine ECT ses- sions, spaced two or three days apart, many patients feel considerably less depressed. The treatment is used on tens of thousands of depressed persons annually, particularly those whose depression fails to respond to other treatments (Dukart et al., 2014).
A third form of biological treatment is psychosurgery, or neuro- surgery, brain surgery for mental disorders. It is thought to have roots as far back as trephining, the prehistoric practice of chipping a hole in the skull of a person who behaved strangely. Modern procedures are derived from a technique first developed in the late 1930s by a
The ultimate brain The human brain increasingly has captured the attention of both neuroscientists and the public at large. This image, taken from a screenshot of a popular iPad app, shows brain tissue from the renowned physicist Albert Einstein.
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▶▶ psychotropic medications Drugs that primarily affect the brain and reduce many symptoms of mental dysfunctioning.
▶▶ electroconvulsive therapy (ECT) A biological treatment in which a brain seizure is triggered as an electric current passes through electrodes attached to the patient’s forehead.
▶▶ psychosurgery Brain surgery for men- tal disorders. Also called neurosurgery.
InfoCentral
DIETARY SUPPLEMENTS: AN ALTERNATIVE TREATMENT Dietary supplements, also known as nutraceuticals, are non- pharmaceutical and nonfood substances that people may take to supplement their diets, often to help prevent or treat psychological
or physical ailments. Depression is the psychological problem for which nutraceuticals are used most often.
NUTRACEUTICALS ARE. . .
0 10 20 30 40 50 60 70 80
undisclosed to physicians self-prescribed taken for depression taken along with conventional medication
75%
60%
34%
13%
POPULAR NUTRACEUTICALS FOR DEPRESSION
Nutraceuticals do not appear to be helpful for people with severe depression. However, accord- ing to research, several types of supplements are effective for mild or moderate depression.
(Qureshi & Al-Bedah, 2013; Howland, 2012; Lakhan & Vieira, 2008)
Depressed people take nutraceuticals because... • they are not helped by conventional treatments
• they developed major side effects to antidepressant drugs
• they cannot afford conventional treatments
• they dislike modern medications
• they prefer more natural treatments
(Qureshi & Al-Bedah, 2013)
20-39 40-59 >60
Age
White American
African American
Hispanic American
Race/ethnicity
Low Moderate High
Income
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0
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20
30
40
50
60
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10
20
30
40
50
60
34.2%
50.8%
67.4% 53.8%
37.8% 33.3% 36.6%
46.9%
58.9%
Herbal supplements (plant-derived substances) St. John’s wort Rhodiola rosea
Nutrients (essential nourishing ingredients found in food)
Omega-3 fatty acids Vitamin B Vitamin D
Folate
Natural hormones/amino acids (substances identical to hormones or amino acids normally produced by the human body)
s-adenosylmethionine (SAM-e) L-Tryptophan
Melatonin
WHO CONSUMES NUTRACEUTICALS?
NUTRACEUTICALS AND CONVENTIONAL MEDICATIONS To receive approval for a conventional drug, its manufacturer must prove it safe and effective through a testing process that costs hundreds of millions of dollars.
The 1994 Dietary Supplement Health and Edu- cation Act states that dietary supplements are not bound by the same legal requirements as conventional medications. Since then more than 4,000 manufacturers have rushed supplements to market, typically without research and often with extraordinary claims about their healing powers.
• Nutraceuticals are assumed to be safe unless the FDA can prove them harmful.
• Nutraceuticals can be potent, and even interact dangerously with conventional medications (NIH, 2011; Magee, 2007).
• Patients are often misinformed by friends or the Internet and may take nutraceuticals incorrectly.
• Many patients are reluctant to discuss their use of supplements with their therapists or physi- cians (Niv et al., 2010; Kessler, 2002).
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Portuguese neuropsychiatrist, António Egas Moniz. In that procedure, known as a lobotomy, a surgeon would cut the connections between the brain’s frontal lobes and the lower regions of the brain. Today’s psychosurgery procedures are much more precise than the lobotomies of the past. Even so, they are considered experimental and are used only after certain severe disorders have continued for years without responding to any other form of treatment.
Assessing the Biological Model Today the biological model enjoys considerable respect. Biological research con- stantly produces valuable new information. And biological treatments often bring great relief when other approaches have failed. At the same time, this model has its shortcomings. Some of its proponents seem to expect that all human behavior can be explained in biological terms and treated with biological methods. This view can limit rather than enhance our understanding of abnormal functioning. Our mental life is an interplay of biological and nonbiological factors, and it is important to understand that interplay rather than to focus on biological variables alone.
Another shortcoming is that several of today’s biological treatments are capa- ble of producing significant undesirable effects. Certain antipsychotic drugs, for example, may produce movement problems such as severe shaking, bizarre-looking contractions of the face and body, and extreme restlessness. Clearly such costs must be addressed and weighed against the drug’s benefits.
➤ Summing Up THE BIOLOGICAL MODEL Biological theorists look at the biological processes of human functioning to explain abnormal behavior, pointing to anatomical or biochemical problems in the brain and body. Such abnormalities are sometimes the result of genetic inheritance, evolution, or viral infections. Biological thera- pists use physical and chemical methods to help people overcome their psy- chological problems. The leading methods are drug therapy, electroconvulsive therapy, and, on rare occasions, psychosurgery.
The Psychodynamic Model The psychodynamic model is the oldest and most famous of the modern psychological models. Psychodynamic theorists believe that a person’s behavior, whether normal or abnormal, is determined largely by underlying psychological forces of which he or she is not consciously aware. These internal forces are described as dynamic—that is, they interact with one another—and their interaction gives rise to behavior, thoughts, and emotions. Abnormal symptoms are viewed as the result of conflicts between these forces.
Psychodynamic theorists would view Philip Berman as a person in conflict. They would want to explore his past experiences because, in their view, psychologi- cal conflicts are tied to early relationships and to traumatic experiences that occurred during childhood. Psychodynamic theories rest on the deterministic assumption that no symptom or behavior is “accidental”: All behavior is determined by past experi- ences. Thus Philip’s hatred for his mother, his memories of her as cruel and over- bearing, the weakness of his father, and the birth of a younger brother when Philip was 10 may all be important to the understanding of his current problems.
The psychodynamic model was first formulated by Viennese neurologist Sigmund Freud (1856–1939) at the turn of the twentieth century. After studying
▶▶ id According to Freud, the psychologi- cal force that produces instinctual needs, drives, and impulses.
▶▶ ego According to Freud, the psycho- logical force that employs reason and operates in accordance with the reality principle.
▶▶ ego defense mechanisms Accord- ing to psychoanalytic theory, strategies developed by the ego to control unac- ceptable id impulses and to avoid or reduce the anxiety they arouse.
B e t w e e n t h e L i n e s
Big Dates in Drug Approval 1954 Thorazine (first antipsychotic)
1955 Ritalin (first ADHD drug)
1958 MAO inhibitors (first antidepressant)
1960 Librium (first benzodiazepine antianxiety drug)
1961 Elavil (first tricyclic antidepressant)
1963 Valium (second benzodiazepine antianxiety drug)
1970 Lithium (first mood stabilizer/ antibipolar drug)
1987 Prozac (first SSRI antidepressant)
1998 Viagra (first erectile disorder drug)
Models of Abnormality : 45
hypnosis, Freud developed the theory of psychoanalysis to explain both normal and abnormal psychological functioning as well as a corresponding method of treatment, a conversational approach also called psychoanalysis. During the early 1900s, Freud and several of his colleagues in the Vienna Psychoanalytic Society—including Carl Gustav Jung (1875–1961)—became the most influential clinical theorists in the Western world.
How Did Freud Explain Normal and Abnormal Functioning? Freud believed that three central forces shape the personality—instinctual needs, rational thinking, and moral standards. All of these forces, he believed, operate at the unconscious level, unavailable to immediate awareness; he further believed these forces to be dynamic, or interactive. Freud called the forces the id, the ego, and the superego.
The Id Freud used the term id to denote instinctual needs, drives, and impulses. The id operates in accordance with the pleasure principle; that is, it always seeks gratification. Freud also believed that all id instincts tend to be sexual, noting that from the very earliest stages of life a child’s pleasure is obtained from nursing, defecating, masturbating, or engaging in other activities that he considered to have sexual ties. He further suggested that a person’s libido, or sexual energy, fuels the id.
The Ego During our early years we come to recognize that our envi- ronment will not meet every instinctual need. Our mother, for example, is not always available to do our bidding. A part of the id separates off and becomes the ego. Like the id, the ego unconsciously seeks gratification, but it does so in accordance with the reality principle, the knowledge we acquire through experience that it can be unacceptable to express our id impulses outright. The ego, employing reason, guides us to know when we can and cannot express those impulses.
The ego develops basic strategies, called ego defense mechanisms, to control unacceptable id impulses and avoid or reduce the anxiety they arouse. The most basic defense mechanism, repression, prevents unaccept- able impulses from ever reaching consciousness. There are many other ego defense mechanisms, and each of us tends to favor some over others (see Table 2-1 on the next page).
Freud takes a closer look at Freud Sigmund Freud, founder of psychoanalytic theory and therapy, contemplates a sculptured bust of himself in 1931 at his village home in Potzlein, near Vienna. As Freud and the bust go eyeball to eyeball, one can only imagine what conclusions each is drawing about the other.AP
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The Superego The superego grows from the ego, just as the ego grows out of the id. This personality force operates by the morality principle, a sense of what is right and what is wrong. As we learn from our parents that many of our id impulses are unacceptable, we unconsciously adopt our parents’ values. Judging ourselves by their standards, we feel good when we uphold their values; conversely, when we go against them, we feel guilty. In short, we develop a conscience.
According to Freud, these three parts of the personality—the id, the ego, and the superego—are often in some degree of conflict. A healthy personality is one in which an effective working relationship, an acceptable compromise, has formed among the three forces. If the id, ego, and superego are in excessive conflict, the person’s behavior may show signs of dysfunction.
Freudians would therefore view Philip Berman as someone whose personality forces have a poor working relationship. His ego and superego are unable to control his id impulses, which lead him repeatedly to act in impulsive and often dangerous ways—suicidal gestures, jealous rages, job resignations, outbursts of temper, frequent arguments.
Developmental Stages Freud proposed that at each stage of development, from infancy to maturity, new events challenge individuals and require adjustments in their id, ego, and superego. If the adjustments are successful, they lead to per- sonal growth. If not, the person may become fixated, or stuck, at an early stage of development. Then all subsequent development suffers, and the individual may well be headed for abnormal functioning in the future. Because parents are the key figures during the early years of life, they are often seen as the cause of improper development.
The Defense Never Rests: Defense Mechanisms to the Rescue
Defense Operation Example Repression Person avoids anxiety by simply not allowing An executive’s desire to run amok and attack his boss and painful or dangerous thoughts to become colleagues at a board meeting is denied access to his conscious. awareness.
Denial Person simply refuses to acknowledge the You are not prepared for tomorrow’s final exam, but you existence of an external source of anxiety. tell yourself that it’s not actually an important exam and that there’s no good reason not to go to a movie tonight.
Projection Person attributes own unacceptable impulses, The executive who repressed his destructive desires may motives, or desires to other individuals. project his anger onto his boss and claim that it is actually the boss who is hostile.
Rationalization Person creates a socially acceptable reason A student explains away poor grades by citing the for an action that actually reflects importance of the “total experience” of going to college unacceptable motives. and claiming that too much emphasis on grades would actually interfere with a well-rounded education.
Displacement Person displaces hostility away from a After a perfect parking spot is taken by a person who cuts dangerous object and onto a safer substitute. in front of your car, you release your pent-up anger by starting an argument with your roommate.
Intellectualization Person represses emotional reactions in favor A woman who has been beaten and raped gives a of overly logical response to a problem. detached, methodical description of the effects that such attacks may have on victims.
Regression Person retreats from an upsetting conflict to an A boy who cannot cope with the anger he feels toward early developmental stage at which no one is his rejecting mother regresses to infantile behavior, soiling expected to behave maturely or responsibly. his clothes and no longer taking care of his basic needs.
table: 2-1
▶▶ superego According to Freud, the psychological force that represents a per- son’s values and ideals.
▶▶ fixation According to Freud, a condi- tion in which the id, ego, and superego do not mature properly and are frozen at an early stage of development.
▶▶ free association A psychodynamic technique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.
Models of Abnormality : 47
Freud named each stage of development after the body area that he considered most important to the child at that time. For example, he referred to the first 18 months of life as the oral stage. During this stage, children fear that the mother who feeds and comforts them will disappear. Children whose mothers consistently fail to gratify their oral needs may become fixated at the oral stage and display an “oral character” throughout their lives, one marked by extreme dependence or extreme mistrust. Such persons are particularly prone to develop depression. As you will see in later chapters, Freud linked fixations at the other stages of development—anal (18 months to 3 years of age), phallic (3 to 5 years), latency (5 to 12 years), and genital (12 years to adulthood)—to yet other kinds of psychological dysfunction.
How Do Other Psychodynamic Explanations Differ from Freud’s? Personal and professional differences between Freud and his colleagues led to a split in the Vienna Psychoan- alytic Society early in the twentieth century. Carl Jung and others developed new theories. Although the new theories departed from Freud’s ideas in important ways, each held on to Freud’s belief that human functioning is shaped by dynamic (interacting) psychological forces. Thus all such theories, including Freud’s, are referred to as psychodynamic.
Three of today’s most influential psychodynamic theories are ego theory, self theory, and object relations theory. Ego theorists emphasize the role of the ego and consider it a more independent and powerful force than Freud did (Sharf, 2015). Self theorists, in contrast, give the greatest attention to the role of the self—the unified personality. They believe that the basic human motive is to strengthen the wholeness of the self (Dunn, 2013; Kohut, 2001, 1977). Object relations theorists propose that people are motivated mainly by a need to have relationships with others and that severe problems in the relationships between children and their caregivers may lead to abnormal development (Yun et al., 2013; Kernberg, 2005, 1997).
Psychodynamic Therapies Psychodynamic therapies range from Freudian psychoanalysis to modern thera- pies based on self theory or object relations theory. Psychodynamic therapists seek to uncover past traumas and the inner conflicts that have resulted from them. They try to help clients resolve, or settle, those conflicts and to resume personal development.
According to most psychodynamic therapists, therapists must subtly guide ther- apy discussions so that the patients discover their underlying problems for them- selves. To aid in the process, the therapists rely on such techniques as free association, therapist interpretation, catharsis, and working through.
Free Association In psychodynamic therapies, the patient is responsible for starting and leading each discussion. The therapist tells the patient to describe any thought, feeling, or image that comes to mind, even if it seems unimportant. This practice is known as free association. The therapist expects that the patient’s associations will eventually uncover unconscious events. In the following excerpts from a famous psychodynamic case, notice how free association helps a woman to discover threatening impulses and conflicts within herself:
“Luke, I am your father.” This light saber fight between Luke Skywalker and Darth Vader highlights the most famous, and contentious, father–son relationship in movie history. According to Sigmund Freud, however, all fathers and sons have significant tensions and conflicts that they must work through, even in the absence of the special pressures faced by Luke and his father in the Star Wars series.
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Patient: So I started walking, and walking, and decided to go behind the museum and walk through [New York’s] Central Park. So I walked and went through a back field and felt very excited and wonderful. I saw a park bench next to a clump of bushes and sat down. There was a rustle behind me and I got frightened. I thought of men concealing themselves in the bushes. I thought of the sex perverts I read about in Central Park. I wondered if there was someone behind me exposing himself. The idea is repulsive, but exciting too. I think of father now and feel excited. I think of an erect penis. This is connected with my father. There is some- thing about this pushing in my mind. I don’t know what it is, like on the border of my memory. (Pause)
Therapist: Mm-hmm. (Pause) On the border of your memory? Patient: (The patient breathes rapidly and seems to be under great tension.) As
a little girl, I slept with my father. I get a funny feeling. I get a funny feel- ing over my skin, tingly-like. It’s a strange feeling, like a blindness, like not seeing something. My mind blurs and spreads over anything I look at. I’ve had this feeling off and on since I walked in the park. My mind seems to blank off like I can’t think or absorb anything.
(Wolberg, 2005, 1967, p. 662)
Therapist Interpretation Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative conclusions, and sharing interpre- tations when they think the patient is ready to hear them. Interpretations of three phenomena are particularly important—resistance, transference, and dreams.
Patients are showing resistance, an unconscious refusal to participate fully in therapy, when they suddenly cannot free associate or when they change a subject to avoid a painful discussion. They demonstrate transference when they act and feel toward the therapist as they did or do toward important persons in their lives, especially their parents, siblings, and spouses. Consider again the woman who walked in Central Park. As she continues talking, the therapist helps her to explore her transference:
Patient: I get so excited by what is happening here. I feel I’m being held back by needing to be nice. I’d like to blast loose sometimes, but I don’t dare.
Therapist: Because you fear my reaction? Patient: The worst thing would be that you wouldn’t like me. You wouldn’t speak
to me friendly; you wouldn’t smile; you’d feel you can’t treat me and dis- charge me from treatment. But I know this isn’t so, I know it.
Therapist: Where do you think these attitudes come from? Patient: When I was nine years old, I read a lot about great men in history. I’d
quote them and be dramatic. I’d want a sword at my side; I’d dress like an Indian. Mother would scold me. Don’t frown, don’t talk so much. Sit on your hands, over and over again. I did all kinds of things. I was a naughty child. She told me I’d be hurt. Then at fourteen I fell off a horse and broke my back. I had to be in bed. Mother told me on the day I went riding not to, that I’d get hurt because the ground was frozen. I was a stubborn, self-willed child. Then I went against her will and suffered an accident that changed my life, a fractured back. Her attitude was, “I told you so.” I was put in a cast and kept in bed for months.
(Wolberg, 2005, 1967, p. 662)
▶▶ resistance An unconscious refusal to participate fully in therapy.
▶▶ transference According to psychody- namic theorists, the redirection toward the psychotherapist of feelings associ- ated with important figures in a patient’s life, now or in the past.
▶▶ dream A series of ideas and images that form during sleep.
▶▶ catharsis The reliving of past repressed feelings in order to settle internal conflicts and overcome problems.
▶▶ working through The psychoanalytic process of facing conflicts, reinterpreting feelings, and overcoming one’s problems.
Models of Abnormality : 49
Finally, many psychodynamic therapists try to help patients interpret their dreams (Russo, 2014) (see Table 2-2). Freud (1924) called dreams the “royal road to the unconscious.” He believed
that repression and other defense mechanisms operate less completely during sleep and that dreams, if cor- rectly interpreted, can reveal uncon- scious instincts, needs, and wishes. Freud identified two kinds of dream content—manifest and latent. Mani-
fest content is the consciously remembered dream; latent content is its symbolic meaning. To interpret a dream, therapists must translate its manifest content into its latent content.
Catharsis Insight must be an emotional as well as an intellectual process. Psychodynamic therapists believe that patients must expe- rience catharsis, a reliving of past repressed feelings, if they are to settle internal conflicts and overcome their problems.
Working Through A single episode of interpretation and catharsis will not change the way a person functions. The patient and therapist must examine the same issues over and over in the course of many sessions, each time with greater clarity. This process, called working through, usually takes a long time, often years.
Current Trends in Psychodynamic Therapy The past 40 years have witnessed significant changes in the way many psychodynamic therapists con- duct sessions. An increased demand for focused, time-limited psychotherapies has resulted in efforts to make psychodynamic therapy more efficient and affordable. Two current psychodynamic approaches that illustrate this trend are short-term psy- chodynamic therapies and relational psychoanalytic therapy.
SHORT-TERM PSYCHODYNAMIC THERAPIES In several short versions of psychody- namic therapy, patients choose a single problem—a dynamic focus—to work on, such as difficulty getting along with other people (Frederickson, 2013). The therapist and patient focus on this problem throughout the treatment and work only on the psychodynamic issues that relate to it (such as unresolved oral needs). Only a limited number of studies have tested the effectiveness of these short-term psychodynamic therapies, but their findings do suggest that the approaches are sometimes quite helpful to patients (Knekt et al., 2015; Wolitzky, 2011).
RELATIONAL PSYCHOANALYTIC THERAPY Whereas Freud believed that psychody- namic therapists should take on the role of a neutral, distant expert during a treatment session, a contemporary school of psychodynamic therapy referred to as relational psy- choanalytic therapy argues that therapists are key figures in the lives of patients—figures whose reactions and beliefs should be included in the therapy process (Ringstrom, 2014; Luborsky et al., 2011). Thus, a key principle of relational therapy is that thera- pists should also disclose things about themselves, particularly their own reactions to patients, and try to establish more equal relationships with patients.
Assessing the Psychodynamic Model Freud and his followers have helped change the way abnormal functioning is understood. Largely because of their work, a wide range of theorists today look for answers outside of biological processes. Psychodynamic theorists have also helped us to understand that abnormal functioning may be rooted in the same processes
table: 2-2
Percent of Research Participants Who Have Had Common Dreams Men Women Being chased or pursued, not injured 78% 83%
Sexual experiences 85 73
Falling 73 74
School, teachers, studying 57 71
Arriving too late, e.g., for a train 55 62
Trying to do something repeatedly 55 53
Flying or soaring through the air 58 44
Failing an examination 37 48
Being physically attacked 40 44
Being frozen with fright 32 44
Information from: Robert & Zadra, 2014; Copley, 2008; Kantrowitz & Springen, 2004.
why do you think most
people try to interpret
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own dreams?
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In Their Words “Fortunately, analysis is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist.”
Karen horney, Our Inner Conflicts, 1945
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as normal functioning. Psychological con- flict is a common experience; it leads to abnormal functioning only if the conflict becomes excessive.
Freud and his many followers have also had a monumental impact on treatment. They were the first to apply theory system- atically to treatment. They were also the first to demonstrate the potential of psychological, as opposed to biological, treat- ment, and their ideas have served as starting points for many other psychological treatments.
At the same time, the psychodynamic model has its shortcomings. Its concepts are hard to research (Prochaska & Norcross, 2013; Levy et al., 2012). Because pro- cesses such as id drives, ego defenses, and fixation are abstract and supposedly operate at an unconscious level, there is no way of knowing for certain if they are occurring. Not surprisingly, then, psychodynamic explanations and treatments have received limited research support over the years, and psychodynamic theorists rely largely on evidence provided by individual case studies. Nevertheless, recent research evidence suggests that long-term psychodynamic therapy may be helpful for many persons with long-term complex disorders (Lorentzen et al., 2015; Kunst, 2014), and 18 per- cent of today’s clinical psychologists identify themselves as psychodynamic therapists (Prochaska & Norcross, 2013, 2010).
➤ Summing Up THE PSYCHODYNAMIC MODEL Psychodynamic theorists believe that an indi- vidual’s behavior, whether normal or abnormal, is determined by underlying psychological forces. They consider psychological conflicts to be rooted in early parent–child relationships and traumatic experiences. The psychodynamic model was formulated by Sigmund Freud, who said that three dynamic forces—the id, ego, and superego—interact to produce thought, feeling, and behavior. Other psychodynamic theories are ego theory, self theory, and object relations theory.
Psychodynamic therapists help people uncover past traumas and the inner conflicts that have resulted from them. They use a number of techniques, including free association and interpretations of psychological phenomena such as resistance, transference, and dreams. The leading contemporary psychody- namic approaches include short-term psychodynamic therapies and relational psychoanalytic therapy.
The Behavioral Model Like psychodynamic theorists, behavioral theorists believe that our actions are determined largely by our experiences in life. However, the behavioral model concen- trates on behaviors, the responses an organism makes to its environment. Behaviors can be external (going to work, say) or internal (having a feeling or thought). In turn, behavioral theorists base their explanations and treatments on principles of learn- ing, the processes by which these behaviors change in response to the environment.
Many learned behaviors help people to cope with daily challenges and to lead happy, productive lives. However, abnormal behaviors also can be learned. Behav- iorists who try to explain Philip Berman’s problems might view him as a man who has received improper training: he has learned behaviors that offend others and repeatedly work against him.
what are some of the ways that
Freud’s theories have affected
literature, film and television,
child rearing, and education in
western society?
▶▶ conditioning A simple form of learning.
▶▶ operant conditioning A process of learning in which behavior that leads to satisfying consequences is likely to be repeated.
▶▶ modeling A process of learning in which an individual acquires responses by observing and imitating others.
▶▶ classical conditioning A process of learning in which two events that repeat- edly occur close together in time become fused in a person’s mind and produce the same response.
A cultural phenomenon The history and practice of psychoanalysis have been very popular subjects in the arts over the years. For example, the critically acclaimed 2011 film A Dangerous Method portrays complex personal and professional reasons for the col- lapse of Sigmund Freud’s relationship with his close colleague and friend, Carl Jung.
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Whereas the psychodynamic model had its beginnings in the clinical work of physicians, the behavioral model began in laboratories where psychologists were running experiments on conditioning, simple forms of learning. The researchers manipulated stimuli and rewards, then observed how their manipulations affected the responses of their research participants.
During the 1950s, many clinicians became frustrated with what they viewed as the vagueness and slowness of the psychodynamic model. Some of them began to apply the principles of learning to the study and treatment of psychological prob- lems. Their efforts gave rise to the behavioral model of abnormality.
How Do Behaviorists Explain Abnormal Functioning? Learning theorists have identified several forms of conditioning, and each may produce abnormal behavior as well as normal behavior. In operant conditioning, for example, humans and animals learn to behave in certain ways as a result of receiving rewards—consequences of one kind or another—whenever they do so. In modeling, individuals learn responses simply by observing other individuals and repeating their behaviors.
In a third form of conditioning, classical conditioning, learning occurs when two events repeatedly occur close together in time. The events become fused in a person’s mind, and before long the person responds in the same way to both events. If one event produces a response of joy, the other brings joy as well; if one event brings feelings of relief, so does the other. A closer look at this form of conditioning illustrates how the behavioral model can account for abnormal functioning.
Ivan Pavlov (1849–1936), a famous Russian physiologist, first demonstrated classical conditioning with animal studies. He placed a bowl of meat powder before a dog, producing the natural response that all dogs have to meat: They start to salivate (see Figure 2-3). Next Pavlov added a step: Just before presenting the dog with meat powder, he sounded a bell. After several such pairings of bell tone and presentation of meat powder, Pavlov noted that the dog began to salivate as soon as it heard the bell. The dog had learned to salivate in response to a sound.
In the vocabulary of classical conditioning, the meat in this demonstration is an unconditioned stimulus (US). It elicits the uncon- ditioned response (UR) of salivation, that is, a natural response with
figure 2-3 Working for Pavlov In Ivan Pavlov’s experi- mental device, the dog’s saliva was collected in a tube as it was secreted, and the amount was recorded on a revolving cylinder. The experimenter observed the dog through a one-way glass window.
Conditioning for entertainment and profit Animals can be taught a wide assort- ment of tricks by using the principles of conditioning. Here, Susie, an Asian elephant, performs a trick called “the living statue” as she acknowledges the crowd at a circus in Atlanta, Georgia. In recent years, animal welfare groups have protested the training procedures used on circus elephants, leading one major circus chain to remove all Asian elephants from their shows.
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which the dog is born. The sound of the bell is a conditioned stimulus (CS), a previ- ously neutral stimulus that comes to be linked with meat in the dog’s mind. As such, it too produces a salivation response. When the salivation response is produced by the conditioned stimulus rather than by the unconditioned stimulus, it is called a conditioned response (CR).
Before Conditioning After Conditioning CS: Tone → No response CS: Tone → CR: Salivation US: Meat → UR: Salivation US: Meat → UR: Salivation
Classical conditioning explains many familiar behaviors. The romantic feelings a young man experiences when he smells his girlfriend’s perfume, say, may represent a conditioned response. Initially, this perfume may have had little emotional effect on him, but because the fragrance was present during several romantic encounters, it came to elicit a romantic response.
Abnormal behaviors, too, can be acquired by classical conditioning. Consider a young boy who is repeatedly frightened by a neighbor’s large German shepherd dog. Whenever the child walks past the neighbor’s front yard, the dog barks loudly and lunges at him, stopped only by a rope tied to the porch. In this unfortunate situation, the boy’s parents are not surprised to discover that he develops a fear of dogs. They are stumped, however, by another intense fear the child displays, a fear of sand. They cannot understand why he cries whenever they take him to the beach and screams in fear if sand even touches his skin.
Where did this fear of sand come from? Classical conditioning. It turns out that a big sandbox is set up in the neighbor’s front yard for the dog to play in. Every time the dog barks and lunges at the boy, the sandbox is there too. After repeated pairings of this kind, the child comes to fear sand as much as he fears the dog.
Behavioral Therapies Behavioral therapists aim to identify the behaviors that are causing a person’s prob- lems and then try to replace them with more appropriate ones by applying the principles of classical conditioning, operant conditioning, or modeling (Antony, 2014). The therapist’s attitude toward the client is that of teacher rather than healer.
Classical conditioning treatments, for example, may be used to change abnormal reactions to particular stimuli. Systematic desensitization is one such method, often applied in cases of phobia—a specific and unreasonable fear. In this step-by-step procedure, clients learn to react calmly instead of with intense fear to the objects or situations they dread (Tellez et al., 2015; Wolpe, 1997, 1995, 1990). First, they are taught the skill of relaxation over the course of several sessions. Next, they construct a fear hierarchy, a list of feared objects or situations, starting with those that are less
See and do Modeling may account for some forms of abnormal behavior. A well-known study by Albert Bandura and his colleagues (1963) demonstrated that children learned to abuse a doll by observing an adult hit it. Children who had not been exposed to the adult model did not mistreat the doll.
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▶▶ systematic desensitization A behavioral treatment in which clients with phobias learn to react calmly instead of with intense fear to the objects or situa- tions they dread.
Models of Abnormality : 53
feared and ending with the ones that are most dreaded. Here is the hierarchy devel- oped by a man who was afraid of dogs:
1. Read the word “dog” in a book. 2. Hear a neighbor’s barking dog. 3. See photos of small dogs. 4. See photos of large dogs. 5. See a movie in which a dog is prominently featured. 6. Be in the same room with a quiet, small dog. 7. Pet a small, cuddly dog. 8. Be in the same room with a large dog. 9. Pet a big, frisky dog. 10. Play roughhouse with a dog.
Desensitization therapists next have their clients either imagine or actually confront each item on the hierarchy while in a state of relaxation. In step-by-step pairings of feared items and relaxation, clients move up the hierarchy until at last they can face every one of the items without experiencing fear. As you will read in Chapter 4, research has shown systematic desensitization and other classical condi- tioning techniques to be effective in treating phobias (Antony, 2014).
Assessing the Behavioral Model The behavioral model has become a powerful force in the clinical field. Various behavioral theories have been proposed over the years, and many treatment techniques have been developed. As you can see in Figure 2-4, approximately 15 per- cent of today’s clinical psychologists report that their approach is mainly behavioral (Prochaska & Norcross, 2013).
Perhaps the greatest appeal of the behavioral model is that it can be tested in the laboratory, whereas psychodynamic theories generally cannot. The behaviorists’ basic concepts— stimulus, response, and reward—can be observed and measured. Experimenters have, in fact, successfully used the principles of learning to create clinical symptoms in laboratory participants, suggesting that psychological disorders may indeed develop in the same way. In addition, research has found that behavioral treatments can be helpful to people with specific fears, compulsive behavior, social deficits, mental retardation, and other problems (Antony, 2014).
At the same time, research has also revealed weaknesses in the model. Certainly behavioral researchers have produced specific symptoms in participants. But are these symptoms ordinarily acquired in this way? There is still no indisputable evi- dence that most people with psychological disorders are victims of improper con- ditioning. Similarly, behavioral therapies have limitations. The improvements noted in the therapist’s office do not always extend to real life. Nor do they necessarily last without continued therapy.
Finally, some critics hold that the behavioral view is too simplistic, that its concepts fail to account for the complexity of human functioning. In 1977 Albert Bandura, a leading behaviorist, argued that in order to feel happy and function effectively people must develop a positive sense of self-efficacy. That is, they must know that they can master and perform needed behaviors whenever necessary. Other behaviorists of the 1960s and 1970s similarly recognized that human beings engage in cognitive processes, such as anticipating or interpreting—ways of thinking that until then had been largely ignored in behavioral theory and therapy. These
figure 2-4 Theoretical orientations of today’s clinical psychologists In one survey, 22 percent of clinical psychologists labeled their approach as “eclectic,” 31 percent considered their model “cognitive,” and 18 percent called their orientation “psychodynamic.” (Informa- tion from: Prochaska & Norcross, 2013.)
Behavioral 15%
Interpersonal 4%
Family systems 2%
Existential 1%
Other 3%
Client-centered 2%
Gestalt 1%
Psychodynamic 18%
Eclectic 22%
Cognitive 31% Multicultural 1%
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individuals developed cognitive-behavioral explanations that took both behaviors and unseen cognitions into account and cognitive-behavioral therapies that helped clients to change both counterproductive behaviors and dysfunctional ways of thinking (Redding, 2014; Meichenbaum, 1993; Goldiamond, 1965). Cognitive-behavioral theorists and therapists bridge the behavioral model and the cognitive model, the view to which we turn next.
➤ Summing Up THE BEHAvIORAL MODEL Behaviorists focus on behaviors and propose that they develop in accordance with the principles of learning. These theorists hold that three types of conditioning—classical conditioning, operant conditioning, and modeling—account for all behavior, whether normal or dysfunctional. The goal of the behavioral therapies is to identify the client’s problematic behaviors and replace them with more appropriate ones, using techniques based on one or more of the principles of learning. The classical conditioning approach of systematic desensitization, for example, has been effective in treating phobias.
The Cognitive Model Philip Berman, like the rest of us, has cognitive abilities—special intellectual capaci- ties to think, remember, and anticipate. These abilities can help him accomplish a great deal in life. Yet they can also work against him. As he thinks about his experi- ences, Philip may misinterpret them in ways that lead to poor decisions, maladaptive responses, and painful emotions.
In the early 1960s two clinicians, Albert Ellis (1962) and Aaron Beck (1967), pro- posed that cognitive processes are at the center of behaviors, thoughts, and emotions and that we can best understand abnormal functioning by looking to cognition—a perspective known as the cognitive model. Ellis and Beck claimed that clinicians must ask questions about the assumptions and attitudes that color a client’s perceptions, the thoughts running through that person’s mind, and the conclusions to which they are leading. Other theorists and therapists soon embraced and expanded these ideas and techniques.
How Do Cognitive Theorists Explain Abnormal Functioning? According to cognitive theorists, abnormal functioning can result from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes that are disturbing and inaccurate (Beck & Weishaar, 2014; Ellis, 2014). Philip Berman, for example, often seems to assume that his past history has locked him in his pres- ent situation. He believes that he was victimized by his parents and that he is now forever doomed by his past. He seems to approach all new experiences and relation- ships with expectations of failure and disaster.
Illogical thinking processes are another source of abnormal functioning, according to cognitive theorists. Beck, for example, has found that some people consistently think in illogical ways and keep arriving at self-defeating conclusions (Beck & Weishaar, 2014). As you will see in Chapter 6, he has identified a number of illogi- cal thought processes regularly found in depression, such as overgeneralization, the drawing of broad negative conclusions on the basis of a single insignificant event.
B e t w e e n t h e L i n e s
In Their Words “The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind.”
William James (1842–1910)
Models of Abnormality : 55
One depressed student couldn’t remember the date of Columbus’ third voyage to America during a history class. Overgeneralizing, she spent the rest of the day in despair over her wide-ranging ignorance.
Cognitive Therapies According to cognitive therapists, people with psychological dis- orders can overcome their problems by developing new, more functional ways of thinking. Because different forms of abnor- mality may involve different kinds of cognitive dysfunctioning, cognitive therapists have developed a number of strategies. Beck, for example, has developed an approach that is widely used, par- ticularly in cases of depression (Beck & Weishaar, 2014).
In Beck’s approach, called simply cognitive therapy, thera- pists help clients recognize the negative thoughts, biased inter- pretations, and errors in logic that dominate their thinking and, according to Beck,
cause them to feel depressed. Therapists also guide clients to challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply the new ways of thinking in their daily lives. As you will see in Chapter 6, people with depression who are treated with Beck’s approach improve much more than those who receive no treatment.
In the excerpt that follows, a cognitive therapist guides a depressed 26-year-old graduate student to see the link between the way she interprets her experiences and the way she feels and to begin questioning the accuracy of her interpretations:
Therapist: How do you understand it? Patient: I get depressed when things go wrong. Like when I fail a test. Therapist: How can failing a test make you depressed? Patient: Well, if I fail I’ll never get into law school. Therapist: So failing the test means a lot to you. But if failing a test could drive
people into clinical depression, wouldn’t you expect everyone who failed the test to have a depression? . . . Did everyone who failed get depressed enough to require treatment?
Patient: No, but it depends on how important the test was to the person. Therapist: Right, and who decides the importance? Patient: I do. Therapist: And so, what we have to examine is your way of viewing the test (or the
way that you think about the test) and how it affects your chances of getting into law school. Do you agree?
Patient: Right. . . . Therapist: Now what did failing mean? Patient: (Tearful) That I couldn’t get into law school. Therapist: And what does that mean to you? Patient: That I’m just not smart enough. Therapist: Anything else? Patient: That I can never be happy. Therapist: And how do these thoughts make you feel? Patient: Very unhappy.
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▶▶ cognitive therapy A therapy developed by Aaron Beck that helps people recognize and change their faulty thinking processes.
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Therapist: So it is the meaning of failing a test that makes you very unhappy. In fact, believing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals “I can never be happy.”
(Beck et al., 1979, pp. 145–146)
Assessing the Cognitive Model The cognitive model has had very broad appeal. In addition to a large number of cognitive-behavioral clinicians who apply both cognitive and learning principles in their work, many cognitive clinicians focus exclusively on client interpretations, attitudes, assumptions, and other cognitive processes. Altogether approximately 31 percent of today’s clinical psychologists identify their approach as cognitive (Prochaska & Norcross, 2013).
The cognitive model is popular for several reasons. First, it focuses on a process unique to human beings—the process of human thought—and many theorists from varied backgrounds find themselves drawn to a model that considers thought to be the primary cause of normal and abnormal behavior.
Cognitive theories also lend themselves to research. Investigators have found that people with psychological disorders often make the kinds of assumptions and errors in thinking the theorists claim (Ingram et al., 2007). Yet another rea- son for the popularity of this model is the impressive performance of cognitive and cognitive-behavioral therapies in formats ranging from individual and group therapy to cybertherapy (see PsychWatch on the next page). They have proved very effective for treating depression, panic disorder, social phobia, and sexual dysfunc- tions, for example (Barlow, 2014; Zu et al., 2014).
Nevertheless, the cognitive model, too, has its drawbacks. First, although dis- turbed cognitive processes are found in many forms of abnormality, their precise role has yet to be determined. The cognitions seen in psychologically troubled people could well be a result rather than a cause of their difficulties. Second, although cog- nitive and cognitive-behavioral therapies are clearly of help to many people, they do not help everyone. Is it enough simply to change cognitions? Can such changes make a general and lasting difference in the way people feel and behave? A grow- ing body of research suggests that it is not always possible to achieve the kinds of cognitive changes proposed by Beck and other cognitive therapists (Sharf, 2015).
In response to such limitations, a new group of cognitive and cognitive- behavioral therapies, sometimes called the new wave of cognitive therapies, has emerged in recent years (Prochaska & Norcross, 2013). These new approaches, such as the widely used Acceptance and Commitment Therapy (ACT), help clients to accept many of their problematic thoughts rather than judge them, act on them, or try fruitlessly to change them (Levin et al., 2015; Hayes & Lillis, 2012). The hope is that by recog- nizing such thoughts for what they are—just thoughts—clients will eventually be able to let them pass through their awareness without being particularly troubled by them.
As you will see in Chapter 4, ACT and other new-wave cognitive therapies often employ mindfulness-based techniques to help clients achieve such acceptance. These techniques borrow heavily from a form of meditation called mindful- ness meditation, which teaches individuals to pay attention to the thoughts and feelings that are flowing through their minds during meditation and to accept such thoughts in a
“What did I tell you about destroying Mommy’s inner balance?”
B e t w e e n t h e L i n e s
In Their Words “I am so clever that sometimes I don’t understand a single word of what I am saying.”
Oscar Wilde, The Happy Prince and Other Stories
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nonjudgmental way. Early research indicates that ACT and other new-wave cogni- tive therapies are often helpful in the treatment of anxiety and depression (A-Tjak et al., 2015; Swain et al., 2013).
A final drawback of the cognitive model is that, like the other models you have read about, it is narrow in certain ways. Although cognition is a very special human dimension, it is still only one part of human functioning. Aren’t human beings more than the sum of their thoughts, emotions, and behaviors? Shouldn’t explanations of human functioning also consider broader issues, such as how people approach life, what value they extract from it, and how they deal with the question of life’s meaning? This is the position of the humanistic-existential model.
PsychWatch
A s you read in Chapter 1, computer-based treatment, or cybertherapy, has come to complement, and in some instances replace, traditional face- to-face therapy over the past few decades (Ringwood, 2013). The clinical field’s first journey into the digital world took the form of computer software therapy pro- grams (Harklute, 2010; Tantam, 2006). These programs, which continue to be popular, are designed to reduce emotional distress through typed conversations between human “clients” and their com- puters. One software program, for exam- ple, helps people state their problems in “if–then” statements, a technique similar to that used by cognitive therapists. As
you will see later in this chapter, a number of software therapy programs also have users interact with avatars, on-screen virtual human figures (Reamer, 2013). Advocates of software therapy programs argue that many people find it easier to disclose sensitive personal information to a computer than to a therapist, and indeed research indicates that some of the programs are helpful to a degree (Emmelkamp, 2011; Harklute, 2010).
Another form of cybertherapy, e-mail therapy, has exploded in popularity over the past decade. Thousands of therapists have set up online services that invite people with problems to e-mail their ques- tions and concerns (Murphy et al., 2011;
Mulhauser, 2010). However, services of this kind have raised concerns about the quality of care and about confidentiality (Fenichel, 2011). Many e-mail therapists do not even have advanced clinical training.
Also on the rise is visual e-therapy (Khatri, 2014; Hoffman, 2011), which more closely mimics the conventional therapy experience. A client sets up an appoint- ment with a therapist, and, with the aid of Skype or a webcam, the two proceed to have a face-to-face session. The advan- tage? Clients can receive counseling con- veniently while sitting at home or in their office, and they can have access to a coun- selor who is located even thousands of miles away. The key disadvantage? Once again, quality control (Fenichel, 2011).
Still more common than either e-mail therapy or visual e-therapies are Internet chat groups and “virtual” sup- port groups. Tens of thousands of these groups are currently “in session” around the clock for everything from depression to substance abuse, anxiety, sexual dys- functions, and eating disorders (Hucker & McCabe, 2014; Moskowitz, 2008, 2001). Like in-person self-help groups, the online chat groups provide opportunities for people with similar problems to commu- nicate with one another and freely trade information, advice, and empathy.
Cybertherapy is still being developed, and its effectiveness has yet to be fully determined. At the same time, the rapid growth of this approach serves as a reminder of digital technology’s increasing impact on the mental health field.
Cybertherapy: Surfing for Help
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Meeting at your place . . . and mine Colorado psychiatrist Robert Chalfant and his office administrator demonstrate the simple digital setup that enables him to conduct treat- ment with many distant clients each week.
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➤ Summing Up THE COGNITIvE MODEL According to the cognitive model, we must under- stand human thought to understand human behavior. When people display abnormal patterns of functioning, cognitive theorists point to cognitive prob- lems, such as maladaptive assumptions and illogical thinking processes. Cogni- tive therapists try to help people recognize and change their faulty ideas and thinking processes. In addition to traditional cognitive therapies, such as Beck’s cognitive therapy, a new wave of cognitive and cognitive-behavioral therapies has emerged in recent years. The new therapies teach clients to be mindful of and accept many of their problematic thoughts.
The Humanistic-Existential Model Philip Berman is more than the sum of his psychological conflicts, learned behaviors, or cognitions. Being human, he also has the ability to pursue philosophical goals such as self-awareness, strong values, a sense of meaning in life, and freedom of choice. According to humanistic and existential theorists, Philip’s problems can be under- stood only in the light of such complex goals. Humanistic and existential theorists are often grouped together—in an approach known as the humanistic-existential model— because of their common focus on these broader dimensions of human existence. At the same time, there are important differences between them.
Humanists, the more optimistic of the two groups, believe that human beings are born with a natural tendency to be friendly, cooperative, and constructive. People, these theorists propose, are driven to self-actualize—that is, to fulfill this potential for goodness and growth. They can do so, however, only if they honestly recognize and accept their weaknesses as well as their strengths and establish satisfying personal values to live by. Humanists further suggest that self-actualization leads naturally to a concern for the welfare of others and to behavior that is loving, courageous, spontaneous, and independent (Maslow, 1970).
Existentialists agree that human beings must have an accurate awareness of them- selves and live meaningful—they say “authentic”—lives in order to be psychologi- cally well adjusted. These theorists do not believe, however, that people are naturally inclined to live positively. They believe that from birth we have total freedom, either to face up to our existence and give meaning to our lives or to shrink from that responsibility. Those who choose to “hide” from responsibility and choice will view themselves as helpless and may live empty, inauthentic, and dysfunctional lives as a result.
The humanistic and existential views of abnormality both date back to the 1940s. At that time Carl Rogers (1902–1987), often considered the pioneer of the humanistic perspective, developed client-centered therapy, a warm and support- ive approach that contrasted sharply with the psychodynamic techniques of the day. He also proposed a theory of personality that paid little attention to irrational instincts and conflicts.
The existential view of personality and abnormality appeared during this same period. Many of its principles came from the ideas of nineteenth-century European existential philosophers who held that human beings are constantly defining and so giving meaning to their existence through their actions (Yalom, 2014).
The humanistic and existential theories, and their uplifting implications, were extremely popular during the 1960s and 1970s, years of considerable soul-searching and social upheaval in Western society. They have since lost some of their popularity, but they continue to influence the ideas and work of many clinicians. In particular,
Actualizing the self Humanists suggest that self-actualized people show concern for the welfare of humanity. This 89-year-old social services volunteer (right), one of 65 million Americans who perform volunteer work each year (CNCS, 2013), has participated for the past 20 years as a companion to elderly persons with intellectual disability and developmental disabilities.
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▶▶ self-actualization The humanistic process by which people fulfill their potential for goodness and growth.
▶▶ client-centered therapy The humanistic therapy developed by Carl Rogers in which clinicians try to help cli- ents by conveying acceptance, accurate empathy, and genuineness.
Models of Abnormality : 59
humanistic principles are apparent throughout positive psychology (the study and enhancement of positive feelings, traits, abilities, and selfless virtues), an area of psychology that, as you read in Chapter 1, has gained much momentum in recent years (see pages 16–17).
Rogers’ Humanistic Theory and Therapy According to Carl Rogers, the road to dysfunction begins in infancy (Raskin, Rogers, & Witty, 2014; Rogers, 1987, 1951). We all have a basic need to receive posi- tive regard from the important people in our lives (primarily our parents). Those who receive unconditional (nonjudgmental) positive regard early in life are likely to develop unconditional self-regard. That is, they come to recognize their worth as persons, even while recognizing that they are not perfect. Such people are in a good position to actualize their positive potential.
Unfortunately, some children repeatedly are made to feel that they are not worthy of positive regard. As a result, they acquire conditions of worth, standards that tell them they are lovable and acceptable only when they conform to certain guidelines. To maintain positive self-regard, these people have to look at themselves very selectively, denying or distorting thoughts and actions that do not measure up to their conditions of worth. They thus acquire a distorted view of themselves and their experiences. They do not know what they are truly feeling, what they genuinely need, or what values and goals would be meaningful for them. Problems in functioning are then inevitable.
Rogers might view Philip Berman as a man who has gone astray. Rather than striving to fulfill his positive human potential, he drifts from job to job and relation- ship to relationship. In every interaction he is defending himself, trying to interpret events in ways he can live with, usually blaming his problems on other people. Nevertheless, his basic negative self-image continually reveals itself. Rogers would probably link this problem to the critical ways Philip was treated by his mother throughout his childhood.
Clinicians who practice Rogers’ client-centered therapy try to create a support- ive climate in which clients feel able to look at themselves honestly and accept- ingly (Raskin et al., 2014). The therapist must display three important qualities throughout the therapy—unconditional positive regard (full and warm acceptance for
Unconditional positive regard Carl Rogers argued that clients must receive unconditional positive regard in order to feel better about themselves and to overcome their problems. In this spirit, a number of organizations now arrange for individuals to have close relationships with gentle and nonjudgmental animals. Here a Bosnian child hugs her horse during rehabilitation therapy at the Therapeutic and Leisure Center in Kakrinje, near Sarajevo.AP
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Charitable Acts $308 billion Amount contributed to
charities each year in the United States
83% Percentage of Americans who have made charitable contributions in the last year
33% Percentage of charitable donations contributed to religious organizations
67% Percentage of donations directed to education, human services, health, and the arts
(Gallup, 2013; american association of Fundraising counsel, 2010)
: chapter 260
the client), accurate empathy (skillful listening and restating), and genuineness (sincere communication). In the following classic case, the therapist uses all these qualities to move the client toward greater self-awareness:
Client: Yes, I know I shouldn’t worry about it, but I do. Lots of things—money, people, clothes. In classes I feel that everyone’s just waiting for a chance to jump on me. . . . When I meet somebody I wonder what he’s actually thinking of me. Then later on I wonder how I match up to what he’s come to think of me.
Therapist: You feel that you’re pretty responsive to the opinions of other people. Client: Yes, but it’s things that shouldn’t worry me. Therapist: You feel that it’s the sort of thing that shouldn’t be upsetting, but they
do get you pretty much worried anyway. Client: Just some of them. Most of those things do worry me because they’re
true. The ones I told you, that is. But there are lots of little things that aren’t true. . . . Things just seem to be piling up, piling up inside of me. . . . It’s a feeling that things were crowding up and they were going to burst.
Therapist: You feel that it’s a sort of oppression with some frustration and that things are just unmanageable.
Client: In a way, but some things just seem illogical. I’m afraid I’m not very clear here but that’s the way it comes.
Therapist: That’s all right. You say just what you think.
(Snyder, 1947, pp. 2–24)
In such an atmosphere, clients are expected to feel accepted by their therapists. They then may be able to look at themselves with honesty and acceptance. They begin to value their own emotions, thoughts, and behaviors, and so they are freed from the insecurities and doubts that prevent self-actualization.
Client-centered therapy has not fared very well in research (Prochaska & Norcross, 2013). Although some studies show that participants who receive this therapy improve more than control participants, many other studies have failed to find any such advantage. All the same, Rogers’ therapy has had a positive influence on clinical practice (Raskin et al., 2014). It was one of the first major alternatives to psychodynamic therapy, and it helped open up the clinical field to new approaches. Rogers also helped pave the way for psychologists to practice psychotherapy, which had previously been considered the exclusive territory of psychiatrists. And his commitment to clinical research helped promote the systematic study of treat- ment. Approximately 2 percent of today’s clinical psychologists, 1 percent of social workers, and 3 percent of counseling psychologists report that they employ the client-centered approach (Prochaska & Norcross, 2013).
Gestalt Theory and Therapy Gestalt therapy, another humanistic approach, was developed in the 1950s by a charismatic clinician named Frederick (Fritz) Perls (1893–1970). Gestalt therapists, like client-centered therapists, guide their clients toward self-recognition and self- acceptance (Yontef & Jacobs, 2014). But unlike client-centered therapists, they often try to achieve this goal by challenging and even frustrating their clients. Some of Perls’ favorite techniques were skillful frustration, role playing, and employing numerous rules and exercises.
In the technique of skillful frustration, gestalt therapists refuse to meet their clients’ expectations or demands. This use of frustration is meant to help people see how
“Just remember, son, it doesn’t matter whether you win or lose—unless you
want Daddy’s love.”
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▶▶ gestalt therapy The humanistic therapy developed by Fritz Perls in which clinicians actively move clients toward self-recognition and self-acceptance by using techniques such as role playing and self-discovery exercises.
Models of Abnormality : 61
often they try to manipulate others into meeting their needs. In the technique of role playing, the therapists instruct clients to act out various roles. A person may be told to be another person, an object, an alternative self, or even a part of the body. Role playing can become intense, as individuals are encouraged to express emotions fully. Many cry out, scream, kick, or pound. Through this experience they may come to “own” (accept) feelings that previously made them uncomfortable.
Perls also developed a list of rules to ensure that clients will look at themselves more closely. In some versions of gestalt therapy, for example, clients may be required to use “I” language rather than “it” language. They must say, “I am fright- ened” rather than “The situation is frightening.” Yet another common rule requires clients to stay in the here and now. They have needs now, are hiding their needs now, and must observe them now.
Approximately 1 percent of clinical psychologists and other kinds of clinicians describe themselves as gestalt therapists (Prochaska & Norcross, 2013). Because they believe that subjective experiences and self-awareness cannot be measured objec- tively, proponents of gestalt therapy have not often performed controlled research on this approach (Yontef & Jacobs, 2014; Leung, Leung, & Ng, 2013).
Spiritual Views and Interventions For most of the twentieth century, clinical scientists viewed religion as a negative—or at best neutral—factor in mental health (Bonelli & Koenig, 2013; Van Praag, 2011). In the early 1900s, for example, Freud argued that religious beliefs were defense mechanisms, “born from man’s need to make his helplessness tolerable” (1961, p. 23). This negative view of religion now seems to be ending, however. During the past decade, many articles and books linking spiritual issues to clinical treatment have been published, and the ethical codes of psychologists, psychiatrists, and counselors
have each concluded that religion is a type of diversity that mental health professionals must respect (Peteet, Lu, & Narrow, 2011).
Researchers have learned that spirituality does, in fact, often correlate with psychological health. In particular, studies have examined the mental health of people who are devout and
who view God as warm, caring, helpful, and dependable. Repeatedly, these indi- viduals are found to be less lonely, pessimistic, depressed, or anxious than people without any religious beliefs or those who view God as cold and unresponsive (Koenig, 2015; Day, 2010; Loewenthal, 2007). Such people also seem to cope better with major life stressors—from illness to war—and to attempt suicide less often. In addition, they are less likely to abuse drugs.
Do such correlations indicate that spirituality helps produce greater mental health? Not necessarily. As you’ll recall from Chapter 1, correlations do not indicate causation. It may be, for example, that a sense of optimism leads to more spirituality and that, independently, optimism contributes to greater mental health. Whatever the proper interpretation, many therapists now make a point of including spiritual issues when they treat religious clients, and some further encourage clients to use their spiritual resources to help them cope with current stressors (Gonçalves et al., 2015; Koenig, 2015). Similarly, a number of religious institutions offer counseling services to their members (see MediaSpeak on the next page).
Existential Theories and Therapy Like humanists, existentialists believe that psychological dysfunctioning is caused by self-deception; existentialists, however, are talking about a kind of self-deception in which people hide from life’s responsibilities and fail to recognize that it is up
Beating the blues Gestalt therapists often guide clients to express their needs and feelings in their full intensity by banging on pillows, crying out, kicking, or pounding things. Building on these techniques, a new approach, drum therapy, teaches clients, such as this woman, how to beat drums in order to help release traumatic memories, change beliefs, and feel more liberated.
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75%10:00 AM
MediaSpeak Saving Minds Along with Souls
By T. M. Luhrmann, The New York Times, April 18, 2014
A few weeks ago, one year after his son took his life while struggling with depression, [Rick] Warren, the founding pastor of Saddleback Church, one of the na- tion’s largest evangelical churches, teamed up with his local Roman Catholic Diocese and the National Alliance on Mental Illness for an event that announced a new initiative to involve the church in the care of serious mental illness.
Their goal is not only to reduce stigma for people with schizophrenia, bipolar disorder, depression and the like, though that is an important part of it. “We are all broken,” Mr. Warren said in his remarks. . . . “We’re all a little bit mentally ill.”
The larger goal is to get the church directly in- volved with the care of people with serious psychiatric illness by training administrators and pastors to handle psychiatric crises, to set up groups within the church for people with serious mental illness and to estab- lish services within the church for people who need them. . . .
. . . The public mental health system is a woe- fully underfunded crazy-quilt of uncoordinated agencies. . . . It can be hideously difficult to navigate even for someone who is not hearing hallucinated voices. . . . [And] many psychiatric clients hate the idea of being forcibly medicated.
But they do often go to church. . . . In an urban Chicago neighborhood where I did many months of research with homeless psychotic women, I found that these women often refused psychiatric care. . . . But fully half of them said that they had a church and that they went to that church at least twice each month, and over 80 percent of them said that God was their best friend—some, that he was their only friend.
Mr. Warren’s . . . interest in training the ordinary people who work in church offices and hold prayer circles to be actively involved in mental health care . . . can sound a little alarming. But in fact . . . a study just published in The Lancet demonstrated that this [kind of] community care [sometimes] produced modestly better outcomes for patients with schizophrenia than care in the psychiatric facility.
. . . Psychiatrists are the least religious of all physi- cians, and the new initiative may leave them cold. But Mr. Warren has made an impact before: His initiative on H.I.V.-AIDS was partially responsible for generating George W. Bush’s President’s Emergency Plan for AIDS Relief. If this works, it could have a real impact on the mental health system.
We’re desperately in need of something that does.
(T. M. Lurhman is a professor of anthropology at Stanford University.)
April 19, 2014, “Contributing Op-Ed Writer: Saving Minds Along with Souls” by T. M. L uhrmann. From New York Times, 4/19/2014, © 2014 The New York Times. All rights reserved. Used by permis- sion and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmission of this content without express written permission is prohibited.
Actualizing the self A few years ago, Tibetan spiritual leader the Dalai Lama (right) met with professor of psychiatry Zindel Segal (left) and other mental health researchers at a conference examining possible ties between science, mental health, and spirituality.
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to them to give meaning to their lives. According to existentialists, many people become overwhelmed by the pressures of present-day society and so look to others for explanations, guidance, and authority. They overlook their personal freedom of choice and avoid responsibility for their lives and decisions (Yalom, 2014). Such people are left with empty, inauthentic lives. Their dominant emotions are anxiety, frustration, boredom, alienation, and depression.
Existentialists might view Philip Berman as a man who feels overwhelmed by the forces of society. He sees his parents as “rich, powerful, and selfish,” and he perceives teachers, acquaintances, and employers as oppressing. He fails to appreci- ate his choices in life and his capacity for finding meaning and direction. Quitting becomes a habit with him—he leaves job after job, ends every romantic relationship, and flees difficult situations.
In existential therapy, people are encouraged to accept responsibility for their lives and for their problems. Therapists try to help clients recognize their freedom so that they may choose a different course and live with greater meaning (Yalom, 2014; van Deurzen, 2012; Schneider & Krug, 2010). The precise techniques used in existential therapy vary from clinician to clinician. At the same time, most existential therapists place great emphasis on the relationship between therapist and client and try to create an atmosphere of honesty, hard work, and shared learning and growth.
Patient: I don’t know why I keep coming here. All I do is tell you the same thing over and over. I’m not getting anywhere.
Doctor: I’m getting tired of hearing the same thing over and over, too. Patient: Maybe I’ll stop coming. Doctor: It’s certainly your choice. Patient: What do you think I should do? Doctor: What do you want to do? Patient: I want to get better. Doctor: I don’t blame you. Patient: If you think I should stay, ok, I will. Doctor: You want me to tell you to stay? Patient: You know what’s best; you’re the doctor. Doctor: Do I act like a doctor?
(Keen, 1970, p. 200)
Existential therapists do not believe that experimental methods can adequately test the effectiveness of their treatments. To them, research dehumanizes individu- als by reducing them to test measures. Not surprisingly, then, very little controlled research has been devoted to the effectiveness of this approach (Vos et al., 2015; Schneider & Krug, 2010). Nevertheless, around 1 percent of today’s clinical psychol- ogists use an approach that is primarily existential (Prochaska & Norcross, 2013).
Assessing the Humanistic-Existential Model The humanistic-existential model appeals to many people in and out of the clini- cal field. In recognizing the special challenges of human existence, humanistic and existential theorists tap into an aspect of psychological life that typically is missing from the other models (Watson et al., 2011). Moreover, the factors that they say are essential to effective functioning—self-acceptance, personal values, personal mean- ing, and personal choice—are certainly lacking in many people with psychological disturbances.
▶▶ existential therapy A therapy that encourages clients to accept responsibil- ity for their lives and to live with greater meaning and value.
B e t w e e n t h e L i n e s
Is Niceness in the Genes? Research suggests that people with particular versions of the receptor genes for two hormones, oxytocin and vasopressin, are consistently nicer than people without such gene versions.
(poulin, homan, & Buffone, 2012)
: chapter 264
The optimistic tone of the humanistic-existential model is also an attraction. Such optimism meshes quite well with the goals and principles of positive psy- chology (Rashid & Seligman, 2014). Theorists who follow the principles of the humanistic-existential model offer great hope when they assert that, despite past and present events, we can make our own choices, determine our own destiny, and accomplish much. Still another attractive feature of the model is its emphasis on health. Unlike clinicians from some of the other models who see individuals as patients with psychological illnesses, humanists and existentialists view them simply as people who have yet to fulfill their potential.
At the same time, the humanistic-existential focus on abstract issues of human fulfillment gives rise to a major problem from a scientific point of view: these issues are difficult to research. In fact, with the notable exception of Rogers, who tried to investigate his clinical methods carefully, humanists and existentialists have tradi- tionally rejected the use of empirical research. This antiresearch position is just now beginning to change among some humanistic and existential researchers—a change that may lead to important insights about the merits of this model in the coming years (Vos et al., 2015; Schneider & Krug, 2010; Strumpfel, 2006).
➤ Summing Up THE HuMANISTIC-ExISTENTIAL MODEL The humanistic-existential model focuses on the human need to successfully deal with philosophical issues such as self-awareness, values, meaning, and choice.
Humanists believe that people are driven to self-actualize. When this drive is interfered with, abnormal behavior may result. One group of humanistic thera- pists, client-centered therapists, tries to create a very supportive therapy climate in which people can look at themselves honestly and acceptingly, thus opening the door to self-actualization. Another group, gestalt therapists, uses more active techniques to help people recognize and accept their needs. Recently the role of religion as an important factor in mental health and in psychotherapy has caught the attention of researchers and clinicians.
According to existentialists, abnormal behavior results from hiding from life’s responsibilities. Existential therapists encourage people to accept responsibility for their lives, to recognize their freedom to choose a different course, and to choose to live with greater meaning.
The Sociocultural Model: Family-Social and Multicultural Perspectives Philip Berman is also a social and cultural being. He is surrounded by people and by institutions, he is a member of a family and a cultural group, he participates in social relationships, and he holds cultural values. Such forces are always operating upon Philip, setting rules and expectations that guide or pressure him, helping to shape his behaviors, thoughts, and emotions.
According to the sociocultural model, abnormal behavior is best understood in light of the broad forces that influence an individual. What are the norms of the individual’s society and culture? What roles does the person play in the social envi- ronment? What kind of family structure or cultural background is the person a part of? And how do other people view and react to him or her? In fact, the sociocultural model is composed of two major perspectives—the family-social perspective and the multicultural perspective.
B e t w e e n t h e L i n e s
In Their Words “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
Maya angelou
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Pressures of Poverty 94 Number of victims of violent
crime per 1,000 impoverished people
50 Number of victims per 1,000 middle-income people
40 Number of victims per 1,000 wealthy people
(U.S. Bureau of Justice Statistics, 2011)
Models of Abnormality : 65
How Do Family-Social Theorists Explain Abnormal Functioning? Proponents of the family-social perspective argue that clinical theorists should concentrate on those broad forces that operate directly on an individual as he or she moves through life—that is, family relationships, social interactions, and community events. They believe that such forces help account for both normal and abnormal behavior, and they pay particular attention to three kinds of factors: social labels and roles, social networks, and family structure and communication.
Social Labels and Roles Abnormal functioning can be influenced greatly by the labels and roles assigned to troubled people (Rüsch et al., 2014; Yap et al., 2013). When people stray from the norms of their society, the society calls them deviant and, in many cases, “mentally ill.” Such labels tend to stick. Moreover, when people are viewed in particular ways, reacted to as “crazy,” and perhaps even encouraged to act sick, they gradually learn to accept and play the assigned social role. Ultimately the label seems appropriate.
A famous study called “On Being Sane in Insane Places” by clinical investigator David Rosenhan (1973) supports this position. Eight normal people, actually col- leagues of Rosenhan, presented themselves at various mental hospitals, complaining that they had been hearing voices say the words “empty,” “hollow,” and “thud.” On the basis of this complaint alone, each was diagnosed as having schizophrenia and admitted.
Moreover, the pseudopatients had a hard time convinc- ing others that they were well once they had been given the diagnostic label. Their hospitalizations ranged from 7 to 52 days, even though they behaved normally and stopped reporting symptoms as soon as they were admitted. In addi- tion, the label “schizophrenia” kept influencing the way the staff viewed and dealt with them. For example, one pseudopatient who paced the corridor out of boredom was, in clinical notes, described as “nervous.” For their part, the pseudopatients came to feel powerless, invisible, and bored.
Social Connections and Supports Family-social theorists are also concerned with the social environments in which people operate, including their social and professional relationships. How well do they communicate with others? What kind of signals do they send to or receive from oth- ers? Researchers have often found ties between deficiencies in social networks and a person’s functioning (Schwarzbach et al., 2013; Paykel, 2008, 2006, 2003). They have observed, for example, that people who are isolated and lack social support or intimacy in their lives are more likely to become depressed when under stress and to remain depressed longer than are people with supportive spouses or warm friendships.
Some clinical theorists believe that people who are unwilling or unable to com- municate and develop relationships in their everyday lives will often find adequate social contacts online, using social networking sites like Facebook. Although this may be true for some such individuals, research suggests that people’s online rela- tionships tend to parallel their offline relationships (Dolan, 2011). One survey of 172 college students, for example, found that those students with the most friends on Facebook also were particularly social offline, while those who were less willing to communicate with other people offline also tended to initiate far fewer relationships on Facebook (Sheldon, 2008).
Are friends more influential than relatives? Yes, according to the work of researchers Jerome Micheletta and Bridget Waller. Their studies indicate that macaque monkeys, such as those shown here, are more responsive to and more likely to imitate the behaviors of friends than relatives.
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Family Structure and Communication Of course, one of the important social networks for an individual is his or her family. According to family systems theory, the family is a system of interacting parts—the family members—who interact with one another in consistent ways and follow rules unique to each family (Goldenberg, Goldenberg, & Pelavin, 2014). Family systems theorists believe that the structure and communication patterns of some families actually force individual members to behave in a way that otherwise seems abnormal. If the members were to behave normally, they would severely strain the family’s usual manner of opera- tion and would actually increase their own and their family’s turmoil.
Family systems theory holds that certain family systems are particularly likely to produce abnormal functioning in individual members. Some families, for example, have an enmeshed structure in which the members are grossly overinvolved in one another’s activities, thoughts, and feelings. Children from this kind of family may have great difficulty becoming independent in life (Santiseban et al., 2001). Some
families display disengagement, which is marked by very rigid bound- aries between the members. Children from these families may find it hard to function in a group or to give or request support (Corey, 2012, 2004).
Philip Berman’s angry and impulsive personal style might be seen as the product of a disturbed family structure. According to family systems theorists, the whole family—Philip’s mother, father, and brother, and Philip himself—relate in such a way as to maintain
Philip’s behavior. Family theorists might be particularly interested in the conflict between Philip’s mother and father and the imbalance between their parental roles. They might see Philip’s behavior as both a reaction to and stimulus for his parents’ behaviors. With Philip acting out the role of the misbehaving child, or scapegoat, his parents may have little need or time to question their own relationship.
Family systems theorists would also seek to clarify the precise nature of Philip’s relationship with each parent. Is he enmeshed with his mother and/or disengaged from his father? They would look too at the rules governing the sibling relationship in the family, the relationship between Philip’s parents and brother, and the nature of parent–child relationships in previous generations of the family.
Today’s TV families Unlike television viewers of the 1950s, when problem-free families like the Nelsons (of Ozzie & Harriet) and the Andersons (of Father Knows Best) ruled the airwaves, today’s viewers prefer more complex, sometimes dysfunctional, families, like the Pritchetts, whose trials and tribulations are on display in ABC’s popular series Modern Family. Da nn
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▶▶ family systems theory A theory that views the family as a system of inter- acting parts whose interactions exhibit consistent patterns and unstated rules.
▶▶ group therapy A therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.
Models of Abnormality : 67
Family-Social Treatments The family-social perspective has helped spur the growth of several treatment approaches, including group, family, and couple therapy and community treatment. Thera- pists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models (see MindTech below). However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.
Group Therapy Thousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. One survey of clinical psychologists showed that almost one-third of them devoted some portion of their practice to group therapy (Norcross & Goldfried, 2005). Typically, members of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights,
MindTech
Have Your Avatar Call My Avatar The sociocultural model holds that abnormal behavior is best understood and treated in a social context. Thus, some proponents of this perspective are particularly interested in a relatively new feature in cybertherapy—the
use of avatars, three-dimensional graphical representa- tions of the users and/or other key persons in their lives (Reamer, 2013; Pagliari et al., 2012; Carey, 2010). A growing number of computer software therapy programs have users interact with on-screen virtual human figures who ask questions such as “What kinds of things do you dislike about yourself?”, who nod sympathetically when users offer self-criticisms, and who reinforce certain user statements with smiles or encouraging words.
In another use of avatars, some real-life therapists guide their clients to enter virtual environments on their computers, acquire virtual bodies, and interact with animated figures who resemble their parents, bosses, or friends—in situations that can feel very real. Theoretically, experiences in virtual worlds of this kind can help clients change their reactions in the real world (Reamer, 2013).
In one highly publicized case, for exam- ple, a woman with agoraphobia—a fear of leaving the house—was guided by her thera- pist to adopt an avatar and enter into a vir- tual world of other avatars, a journey that eventually enabled her to venture outside into the real world (Smith, 2008). Similarly, therapists have used avatar therapy to help
individuals who suffer from social anxiety, trauma aftereffects, substance abuse, and even hallucinations—often with considerable success (Leff et al., 2014, 2013; Kedmey, 2013).
clients know they are entering
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Being Social Most people text faster when texting persons they like.
For most people, silence becomes awkward after about four seconds.
The maximum number of in-person relationships/friendships one can maintain is between 50 and 150.
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: chapter 268
build social skills, strengthen feelings of self-worth, and share useful information or advice (Corey, 2016). Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.
Research suggests that group therapy is of help to many cli- ents, often as helpful as individual therapy (Green et al., 2015). The group format also has been used for purposes that are edu- cational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.
A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (for example, bereavement, substance abuse, illness, unemploy-
ment, or divorce) come together to help and support one another without the direct leadership of a professional clinician (Lake, 2014; Mueller et al., 2007). According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by as many as 3 to 4 percent of the population. In addition, numerous self-help chat groups have emerged on the Internet.
Family Therapy Family therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change its ways (Goldenberg et al., 2014). Here, the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:
Tommy sat motionless in a chair gazing out the window. He was fourteen and a bit small for his age. . . . Sissy was eleven. She was sitting on the couch between her Mom and Dad with a smile on her face. Across from them sat Ms. Fargo, the family therapist.
Ms. Fargo spoke. “Could you be a little more specific about the changes you have seen in Tommy and when they came about?”
Mrs. Davis answered first. “Well, I guess it was about two years ago. Tommy started getting in fights at school. When we talked to him at home he said it was
why might group therapy
actually be more helpful to
some people with psycholog-
ical problems than individual
therapy would be?
Sharing and supporting Clients often benefit from group therapy and self-help groups. Many such groups focus on particular client populations, such as bereaved persons, abused spouses, or people with social skills deficits.
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Models of Abnormality : 69
none of our business. He became moody and disobedient. He wouldn’t do anything that we wanted him to. He began to act mean to his sister and even hit her.”
“What about the fights at school?” Ms. Fargo asked. This time it was Mr. Davis who spoke first. “Ginny was more worried about them
than I was. I used to fight a lot when I was in school and I think it is normal. . . . But I was very respectful to my parents, especially my Dad. If I ever got out of line he would smack me one.”
“Have you ever had to hit Tommy?” Ms. Fargo inquired softly. “Sure, a couple of times, but it didn’t seem to do any good.” All at once Tommy seemed to be paying attention, his eyes riveted on his father.
“Yeah, he hit me a lot, for no reason at all!” “Now, that’s not true, Thomas.” Mrs. Davis has a scolding expression on her face.
“If you behaved yourself a little better you wouldn’t get hit. Ms. Fargo, I can’t say that I am in favor of the hitting, but I understand sometimes how frustrating it may be for Bob.”
“You don’t know how frustrating it is for me, honey.” Bob seemed upset. “You don’t have to work all day at the office and then come home to contend with all of this. Sometimes I feel like I don’t even want to come home.”
Ginny gave him a hard stare. “You think things at home are easy all day? I could use some support from you. You think all you have to do is earn the money and I will do everything else. Well, I am not about to do that anymore.” . . . [She] began to cry. “I just don’t know what to do anymore. Things just seem so hopeless. Why can’t people be nice in this family anymore? I don’t think I am asking too much, am I?”
Ms. Fargo . . . looked at each person briefly and was sure to make eye contact. “There seems to be a lot going on . . . . I think we are going to need to understand a lot of things to see why this is happening.”
(Sheras & Worchel, 1979, pp. 108–110)
Family therapists may follow any of the major theoretical models, but many of them adopt the principles of family systems theory (Riina & McHale, 2014). Today 2 percent of all clinical psychologists, 5 percent of counseling psychologists, and 14 percent of social workers identify themselves mainly as family systems therapists (Prochaska & Norcross, 2013).
As you read earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, structural family therapy, therapists try to change the family power structure, the roles each person plays, and the relation- ships between members (Goldenberg et al., 2014; Minuchin, 2007, 1987, 1974). In another, conjoint family therapy, therapists try to help members recognize and change harmful patterns of communication (Sharf, 2015; Satir, 1987, 1967, 1964).
Family therapies of various kinds are often helpful to individuals, although research has not yet clarified how helpful (Goldenberg et al., 2014; Nichols, 2013). Some studies have found that as many as 65 percent of individuals treated with fam- ily approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others (Bitter, 2013; Alexander et al., 2002).
Couple Therapy In couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns in the relationship (Baucom et al., 2015, 2010, 2009). A couple approach may also be used when a child’s psychological problems are traced to problems in the parents’ relationship.
▶▶ self-help group A group made up of people with similar problems who help and support one another without the direct leadership of a clinician. Also called a mutual help group.
▶▶ family therapy A therapy format in which the therapist meets with all members of a family and helps them to change in therapeutic ways.
▶▶ couple therapy A therapy format in which the therapist works with two people who share a long-term relationship. Also called marital therapy.
B e t w e e n t h e L i n e s
Shifting Family Values 59% Percentage of adults who say
their families have fewer family dinners than when they were growing up
10 Average number of weekly hours today’s fathers spend doing housework, compared with 4 hours a half-century ago
18 Average number of weekly hours today’s mothers spend doing housework, compared with 32 hours a half-century ago
(harris Interactive, 2013; pew research center, 2013)
: chapter 270
Although some degree of conflict exists in any long-term relationship, many couples in our society have serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate. Many couples who live together without marrying apparently have similar levels of dif- ficulty (Martins et al., 2014).
Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Cognitive-behavioral couple therapy, for example, uses many techniques from the cognitive and behavioral perspectives (Baucom & Boeding, 2013; Becvar & Becvar, 2012). Therapists help spouses recognize and change problem behaviors largely by teaching specific problem-solving and communication skills. A broader, more sociocultural version, called integrative couple therapy, further helps part- ners accept behaviors that they cannot change and embrace the whole relationship nevertheless (Christensen et al., 2014, 2010). Partners are asked to see such behaviors as an understandable result of basic differences between them.
Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who do not receive treatment, but no one form of couple therapy stands out as superior to others (Christensen et al., 2014, 2010). Although marital functioning improved in two-thirds of treated couples by the end of therapy, fewer than half of those who are treated achieve “distress free” or “happy” relationships. One-fourth of all treated couples eventually separate or divorce.
Community Treatment Community mental health treatment programs allow clients to receive treatment in nearby social surroundings as they try to recover. Such community-based treatments, including community day programs and residential services, seem to be of special value to people with severe mental disor- ders (Stein et al., 2015; Cuddeback et al., 2013). A number of other countries have launched similar community movements over the past several decades.
As you read in Chapter 1, a key principle of commu- nity treatment is prevention. This involves clinicians actively reaching out to clients rather than waiting for them to seek treatment. Research suggests that such efforts are often very successful (Urben et al., 2015; Beardslee et al., 2013) Community workers recognize three types of prevention, which they call primary, secondary, and tertiary.
Primary prevention consists of efforts to improve com- munity attitudes and policies. Its goal is to prevent psy- chological disorders altogether. Community workers may, for example, consult with a local school board, offer public workshops on stress reduction, or construct Web sites on how to cope effectively.
Secondary prevention consists of identifying and treat- ing psychological disorders in the early stages, before they become serious. Community workers may work with teachers, ministers, or police to help them recognize the
early signs of psychological dysfunction and teach them how to help people find treatment. Similarly, hundreds of mental health Web sites provide this same kind of information to family members, teachers, and the like.
The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Community agencies across the United States successfully offer tertiary care for mil- lions of people with moderate psychological problems, but, as you read in Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances (Althouse, 2010). One of the reasons for this failure is lack of funding, an issue that you will read about in later chapters.
The community way At the Queens Com- munity Center, a program in New York City funded by Catholic Charities, counselors such as the man on the right teach computer and broader life skills to people with mental health challenges or developmental disabilities.
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▶▶ community mental health treatment A treatment approach that emphasizes community care.
▶▶ multicultural perspective The view that each culture within a larger society has a particular set of values and beliefs, as well as special external pressures, that help account for the behavior and functioning of its members. Also called culturally diverse perspective.
Models of Abnormality : 71
How Do Multicultural Theorists Explain Abnormal Functioning? Culture refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next (Matsumoto & Hwang, 2012, 2011; Matsumoto, 2007, 2001). We are, without question, a soci- ety of multiple cultures. Indeed, by the year 2050, the number of racial and ethnic minority group members in the United States will collectively equal or surpass the number of white Americans (U.S. Census Bureau, 2014; Kaiser Family Foundation, 2010).
Partly in response to this growing diversity, the multicultural, or culturally diverse, perspective has emerged (Leong, 2014, 2013). Multicultural psychologists seek to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders dif- fer psychologically (Alegría et al., 2014, 2012, 2007). Today’s multicultural view is different from past—less enlightened—cultural perspectives: it does not imply that members of racial, ethnic, and other minority groups are in some way inferior or culturally deprived in comparison with a majority population. Rather, the model holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of that individual’s unique cultural context, from the values of that culture to the special external pressures faced by members of the culture.
The groups in the United States that have received the most attention from multicultural researchers are ethnic and racial minority groups (African American, Hispanic American, American Indian, and Asian American groups) and groups such as economically disadvantaged persons, gays and lesbians, and women (although women are not technically a minority group). Each of these groups is subjected to special pressures in American society that may contribute to feelings of stress and, in some cases, to abnormal functioning. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is indeed more common among poorer people than among wealthier people (Wittayanukorn, 2013; Sareen et al., 2011) (see Figure 2-5). Perhaps the pressures of poverty explain this relationship.
Of course, membership in these various groups overlaps. Many members of minority groups, for example, also live in poverty. The higher rates of crime, unem- ployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities typically available to poor people may place great stress on many members of such minority groups (Alegria et al., 2014; Miller et al., 2011).
Multicultural researchers have also noted that the prejudice and discrimination faced by many minority groups may contribute to various forms of abnormal functioning (McDonald et al., 2014; Guimón, 2010). Women in Western society receive diagnoses of anxiety disorders and of depression at least twice as often as men (NIMH, 2015). Similarly, African Americans, Hispanic Amer- icans, and American Indians are more likely than white Americans to experience serious psychological distress or extreme sadness. American Indians also have exceptionally high alcoholism and suicide rates (Maza, 2015; Horwitz, 2014). Although many factors may combine to produce these differences, prejudice based on race and sexual orientation, and the prob- lems such prejudice poses, may contribute to abnor- mal patterns of tension, unhappiness, low self-esteem, and escape (Guimón, 2010).
27%
10% 9%
2%
19%
6% 5%
0.3%
Severe depression
Severe anxiety
Posttraumatic stress disorder
Disorder
Psychosis
Percentage of people with disorder
Annual income below $20,000
Annual income above $70,000
figure 2-5 Poverty and mental health Recent sur- veys in the United States find that people with low annual incomes have a greater risk of experiencing mental disorders than do those with higher incomes. For example, 10 percent of low-income people have persistent symp- toms of anxiety, compared with 6 percent of higher-income people. (Information from: Sareen et al., 2011.)
B e t w e e n t h e L i n e s
Gender Bias in the Workplace Women today earn $0.79 for every $1 earned by a man.
Around 60 percent of young adult women believe that women have to outperform men at work to get the same rewards; 48 percent of young adult men agree.
(pew research, 2013, 2010; Bureau of Labor Statistics, 2011; Yin, 2002)
: chapter 272
Multicultural Treatments Studies conducted throughout the world have found that members of ethnic and racial minority groups tend to show less improvement in clinical treatment, make less use of mental health services, and stop therapy sooner than members of majority groups (Cook et al., 2014; Comas-Diaz, 2012, 2011).
A number of studies suggest that two features of treatment can increase a thera- pist’s effectiveness with minority clients: (1) greater sensitivity to cultural issues and (2) inclusion of cultural morals and models in treatment, especially in therapies for children and adolescents (Comas-Diaz, 2014; Inman & DeBoer, 2013). Given such findings, some clinicians have developed culture-sensitive therapies, approaches that are designed to help address the unique issues faced by members of cultural minority groups. Therapies geared to the pressures of being female, called gender- sensitive, or feminist, therapies, follow similar principles (Sharf, 2015).
Culture-sensitive approaches typically include the following elements (Prochaska & Norcross, 2013; Wyatt & Parham, 2007):
1. Special cultural instruction for therapists in their graduate training program 2. The therapist’s awareness of a client’s cultural values 3. The therapist’s awareness of the stress, prejudices, and stereotypes to which
minority clients are exposed 4. The therapist’s awareness of the hardships faced by the children of
immigrants 5. Helping clients recognize the impact of both their own culture and the
dominant culture on their self-views and behaviors 6. Helping clients identify and express suppressed anger and pain 7. Helping clients achieve a bicultural balance that feels right for them 8. Helping clients raise their self-esteem—a sense of self-worth that has often
been damaged by generations of negative messages
Assessing the Sociocultural Model The family-social and multicultural perspectives have added greatly to the under- standing and treatment of abnormal functioning. Today most clinicians take family, cultural, social, and societal issues into account, factors that were overlooked just 35 years ago. In addition, clinicians have become more aware of the impact of clinical and social roles. Finally, the treatment formats offered by the sociocultural model sometimes succeed where traditional approaches have failed.
At the same time, the sociocultural model has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Indeed, research may reveal a relationship between certain family or cultural factors and a particular dis- order yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not necessarily mean that family dysfunction causes schizophrenia. It is equally possible that family func- tioning is disrupted by the tension and conflict created by the psychotic behavior of a family member.
Another limitation of the sociocultural model is its inability to predict abnor- mality in specific individuals. If, for example, social conditions such as prejudice and discrimination are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?
Given these limitations, most clinicians view the family-social and multicul- tural explanations as operating in conjunction with the biological or psychologi- cal explanations. They agree that family, social, and cultural factors may create a
An unacceptable difference Dressed in traditional American Indian clothing, a high school student from the Mescalero Apache Reservation in New Mexico testifies before Congress on “The Preventable Epidemic: Youth Suicides and the Urgent Need for Mental Health Care Resources in Indian Country.”
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B e t w e e n t h e L i n e s
Who Is Discriminated Against? 35% Percentage of African Americans
who report being treated unfairly because of their race in the past year
20% Percentage of Hispanic Americans who report being treated unfairly because of their race in the past year
10% Percentage of white Americans who report being treated unfairly because of their race in the past year
(pew research center, 2013)
Models of Abnormality : 73
climate favorable to the development of certain disorders. They believe, however, that biological or psychological conditions—or both—must also be present for the disorders to evolve.
➤ Summing Up THE SOCIOCuLTuRAL MODEL One sociocultural perspective, the family-social perspective, looks outward to three kinds of factors: social labels and roles, social connections and supports, and the family system. Practitioners from the family-social perspective may practice group, family, or couple therapy or com- munity treatment.
The multicultural perspective, another perspective from the sociocultural model, holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of his or her unique cultural context, including the values of that culture and the special external pressures faced by members of that culture. Practitioners of this perspective may practice culture- sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups.
PUTTING IT...together Integration of the Models Today’s leading models vary widely (see Table 2-3 on the next page), and none of the models has proved consistently superior. Each helps us appreciate a key aspect of human functioning, and each has important strengths as well as serious limitations.
With all their differences, the conclusions and techniques of the various models are often compatible. Certainly our understanding and treatment of abnormal behav- ior are more complete if we appreciate the biological, psychological, and sociocultural aspects of a person’s problem rather than only one of them. Not surprisingly, a grow- ing number of clinicians favor explanations of abnormal behavior that consider more
Community mental health: Argentine style Staff members and patients from Borda Neuropsychiatric Hospital in Buenos Aires set up a laptop and begin broadcasting on the popular radio station Radio La Colifata (colifa is slang for “crazy one”). The station was started more than 20 years ago to help patients pur- sue therapeutic activities and reach out to the community.AP
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▶▶ culture-sensitive therapies Approaches that are designed to help address the unique issues faced by members of cultural minority groups.
▶▶ gender-sensitive therapies Approaches geared to the pressures of being a woman in Western society. Also called feminist therapies.
: chapter 274
than one kind of cause at a time. These explanations, sometimes called biopsychosocial theories, state that abnormality results from the interaction of genetic, biological, developmental, emotional, behavioral, cognitive, social, cultural, and societal influences (Calkins & Dollar, 2014). A case of depression, for example, might best be explained by pointing collectively to an individual’s inheritance of unfavorable genes, traumatic losses during childhood, negative ways of thinking, and social isolation.
Some biopsychosocial theorists favor a diathesis-stress explanation of how the various factors work together to cause abnormal functioning (“diathesis” means a predisposed tendency). According to this theory, people must first have a biological, psychological, or sociocultural predisposition to develop a disorder and must then be subjected to episodes of severe stress. In a case of depression, for example, we might find that unfavorable genes and related biochemical abnormalities predispose the indi- vidual to develop the disorder, while the loss of a loved one actually triggers its onset.
In a similar quest for integration, many therapists are now combining treatment techniques from several models (Norcross & Beutler, 2014). In fact, 22 percent of today’s clinical psychologists, 34 percent of counseling psychologists, and 26 percent of social workers describe their approach as “eclectic” or “integrative” (Prochaska & Norcross, 2013). Studies confirm that clinical problems often respond better to com- bined approaches than to any one therapy alone. For example, as you will see, drug therapy combined with cognitive therapy is sometimes the most effective treatment for depression.
Given the recent rise in biopsychosocial theories and combination treatments, our examinations of abnormal behavior throughout this book will take two direc- tions. As different disorders are presented, we will look at how today’s models explain each disorder, how clinicians who endorse each model treat people with the disorder, and how well these explanations and treatments are supported by research. Just as important, however, we will also be observing how the explanations and treatments may build upon and strengthen one another, and we will examine current efforts toward integration of the models.
table: 2-3
Comparing the Models
Family- Biological Psychodynamic Behavioral Cognitive Humanistic Existential Social Multicultural
Cause of Biological Underlying Maladaptive Maladaptive Self-deceit Avoidance of Family or External dysfunction malfunction conflicts learning thinking responsibility social pressures or stress cultural conflicts
Research Strong Modest Strong Strong Weak Weak Moderate Moderate support
Consumer Patient Patient Client Client Patient or Patient Client Client designation client or client
Therapist Doctor Interpreter Teacher Persuader Observer Collaborator Family/ Cultural role social advocate/ facilitator teacher
Key therapy Biological Free Conditioning Reasoning Reflection Varied Family/ Culture- technique intervention association and social sensitive interpretation intervention intervention
Therapy Biological Broad Functional Adaptive Self- Authentic Effective Cultural goal repair psychological behaviors thinking actualization life family or awareness change social and comfort system
B e t w e e n t h e L i n e s
In Their Words “Help! I’m being held prisoner by my heredity and environment.”
Dennis allen
Models of Abnormality : 75
KEY TERMS model, p. 38
neuron, p. 39
synapse, p. 39
neurotransmitter, p. 39
receptors, p. 40
endocrine system, p. 40
hormone, p. 40
gene, p. 40
psychotropic medication, p. 42
electroconvulsive therapy (ECT), p. 42
psychosurgery, p. 42
unconscious, p. 45
id, p. 45
ego, p. 45
ego defense mechanism, p. 45
superego, p. 46
fixation, p. 46
object relations theory, p. 47
free association, p. 47
resistance, p. 48
transference, p. 48
dream, p. 49
catharsis, p. 49
working through, p. 49
short-term psychodynamic therapies, p. 49
relational psychoanalytic therapy, p. 49
conditioning, p. 51
operant conditioning, p. 51
modeling, p. 51
classical conditioning, p. 51
systematic desensitization, p. 52
self-efficacy, p. 53
cognitive therapy, p. 55
self-actualization, p. 58
client-centered therapy, p. 58
gestalt therapy, p. 60
existential therapy, p. 63
family systems theory, p. 66
group therapy, p. 67
self-help group, p. 68
family therapy, p. 68
couple therapy, p. 69
community mental health treatment, p. 70
multicultural perspective, p. 71
culture-sensitive therapy, p. 72
gender-sensitive therapy, p. 72
biopsychosocial theories, p. 74
diathesis-stress explanation, p. 74
QuickQuiz
1. What are the key regions of the brain, and how do messages travel throughout the brain? Describe the biological treatments for psychological disorders. pp. 39–44
2. Identify the models associated with learned responses (p. 50), values (p. 58), responsibility (p. 63), spirituality (p. 61), underlying conflicts (p. 44), and maladaptive assumptions (p. 54).
3. Identify the treatments that use unconditional positive regard (p. 59), free association (p. 47), classical condi- tioning (p. 52), skillful frustration (p. 60), and dream interpretation (p. 49).
4. What are the key principles of the psy- chodynamic (pp. 44–50), behavioral
(pp. 50–54), cognitive (pp. 54–58), and humanistic- existential (pp. 58–64) models?
5. According to psychodynamic theorists, what roles do the id, ego, and super- ego play in the development of both normal and abnormal behavior? What are the key techniques used by psycho- dynamic therapists? pp. 45–49
6. What forms of conditioning do behav- iorists rely on in their explanations and treatments of abnormal behaviors? pp. 51–53
7. What kinds of cognitive dysfunction- ing can lead to abnormal behavior, and which treatment approaches are used
to address such cognitive dysfunctions? pp. 54–58
8. How do humanistic theories and therapies differ from existential ones? pp. 58–63
9. How might societal labels and roles, social connections, family factors, and culture relate to psychological function- ing? pp. 64–66, 71
10. What are the key features of culture- sensitive therapy, group therapy, family therapy, couple therapy, and commu- nity treatment? How effective are these various approaches? pp. 67–73
visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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F ranco started seeing a therapist at the urging of his friend Jesse. It had been almost four months since Franco broke up with his girlfriend, and he still seemed unable to pull himself together. He had totally stopped playing sports and attending concerts, things he normally did on a regular basis. When he
finally returned Jesse’s calls, he mentioned several serious and avoidable mistakes that he had made at work recently, but he barely seemed to care. He also confided to his friend that he felt very tired and was unable to touch his food. Jesse suspected that Franco was clinically depressed, but, then again, he was not a therapist.
Feelings of despondency led Franco to make an appointment with a therapist at a local counseling center. His clinician’s first step was to learn as much as possible about Franco and his disturbance. Who is he, what is his life like, and what are his symptoms? The answers might help to reveal the causes and probable course of his present dysfunction and suggest what kinds of strategies would be most likely to help him. Treatment could then be tailored to Franco’s needs and particular pattern of abnormal functioning.
In Chapters 1 and 2 you read about how researchers in abnormal psychol- ogy build a general understanding of abnormal functioning. Clinical practi- tioners apply this broad information in their work, but their main focus when faced with new clients is to gather idiographic, or individual, information about them (Zheng et al., 2015). To help a client overcome problems, clini- cians must fully understand the client and his or her particular difficulties. To gather such individual information, clinicians use the procedures of assessment and diagnosis. Then they are in a position to offer treatment.
Clinical Assessment: How and Why Does the Client Behave Abnormally? Assessment is simply the collecting of relevant information in an effort to reach a conclusion. It goes on in every realm of life. We make assessments when we decide what cereal to buy or which presidential candidate to vote for. College admissions officers, who have to select the “best” of the students applying to their college, depend on academic records, recommendations, achievement test scores, interviews, and application forms to help them decide. Employers, who have to predict which applicants are most likely to be effective workers, collect informa- tion from résumés, interviews, references, and perhaps on-the-job observations.
Clinical assessment is used to determine whether, how, and why a person is behaving abnormally and how that person may be helped. It also enables clinicians to evaluate people’s progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity.
3
T o p i c o v e r v i e w
Clinical Assessment: How and Why Does the Client Behave Abnormally? Characteristics of Assessment Tools Clinical Interviews Clinical Tests Clinical Observations
Diagnosis: Does the Client’s Syndrome Match a Known Disorder? Classification Systems DSM-5 Is DSM-5 an Effective Classification System? Call for Change Can Diagnosis and Labeling Cause Harm?
Treatment: How Might the Client Be Helped? Treatment Decisions The Effectiveness of Treatment
Putting It Together: Assessment and Diagnosis at a Crossroads
Clinical Assessment, Diagnosis, and Treatment
: chapter 378
Characteristics of Assessment Tools All clinicians must follow the same procedures when they use a particular type of assessment tool. To standardize such a tool is to set up common steps to be fol- lowed whenever it is administered. Similarly, clinicians must standardize the way they interpret the results of an assessment tool in order to be able to understand what a particular score means. They may standardize the scores of a test, for example,
by first administering it to a group of research participants whose performance will then serve as a common standard, or norm, against which later individual scores can be measured. The group that initially takes the test must be typical of the larger population for whom the test is intended. If an aggres- siveness test meant for the public at large were standardized on a group of Marines, for example, the resulting “norm” might turn out to be misleadingly high (Hogan, 2014).
Reliability refers to the consistency of assessment mea- sures. A good assessment tool will always yield similar results in the same situation (Dehn, 2013). An assessment tool has high test–retest reliability, one kind of reliability, if it yields similar results every time it is given to the same people. If a woman’s responses on a particular test indicate that she is generally a heavy drinker, the test should produce a similar result when she takes it again a week later. To measure test– retest reliability, participants are tested on two occasions and
the two scores are correlated (Holden & Bernstein, 2013). The higher the correla- tion (see Chapter 1), the greater the test’s reliability.
An assessment tool shows high interrater (or interjudge) reliability, another kind of reliability, if different judges independently agree on how to score and interpret it. True–false and multiple-choice tests yield consistent scores no matter who evaluates them, but other tests require that the evaluator make a judgment. Consider a test that requires the person to draw a copy of a picture, which a judge then rates for accuracy. Different judges may give different ratings to the same drawing.
Finally, an assessment tool must have validity: it must accurately measure what it is supposed to measure (Dehn, 2013). Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those readings are not valid, or accurate.
A given assessment tool may appear to be valid simply because it makes sense and seems reasonable. However, this sort of validity, called face validity, does not by itself mean that the instrument is trustworthy. A test for depression, for example, might include questions about how often a person cries. Because it makes sense that depressed people would cry, these test questions have face validity. It turns out, however, that many people cry a great deal for reasons other than depression, and some extremely depressed people do not cry at all. Thus an assessment tool should not be used unless it has high predictive validity or concurrent validity (Dehn, 2013).
Predictive validity is a tool’s ability to predict future characteristics or behavior. Let’s say that a test has been developed to identify elementary schoolchildren who are likely to take up cigarette smoking in high school. The test gathers informa- tion about the children’s parents—their personal characteristics, smoking habits, and attitudes toward smoking—and on that basis identifies high-risk children. To establish the test’s predictive validity, investigators could administer it to a group of elementary school students, wait until they were in high school, and then check to see which children actually did become smokers.
Concurrent validity is the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques. Participants’ scores on a new test designed to measure anxiety, for example, should correlate
Reliable assessments Former National Basketball Association stars Clyde Drexler, James Worthy, Brent Barry, Dominique Wilkins, and Julius Erving served as judges at the 2011 All‑Star slam dunk contest. Holding up their scores after each dunk, they displayed high interrater reliability and showed they still know a great dunk when they see one.
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Clinical Assessment, Diagnosis, and Treatment : 79
highly with their scores on other anxiety tests or with their behavior during clinical interviews.
Before any assessment technique can be fully useful, it must meet the requirements of standardization, reliability, and validity. No
matter how insightful or clever a technique may be, clinicians cannot profitably use its results if they are uninterpretable, inconsistent, or inaccurate. Unfortunately, more than a few clinical assessment tools fall short, suggesting that at least some clinical assessments, too, miss their mark.
Clinical Interviews Most of us feel instinctively that the best way to get to know people is to meet with them face to face. Under these circumstances, we can see them react to what we do and say, observe as well as listen as they answer, and generally get a sense of who they are. A clinical interview is just such a face-to-face encounter (Miller, 2015; Goldfinger & Pomerantz, 2014). If during a clinical interview a man looks as happy as can be while describing his sadness over the recent death of his mother, the clinician may suspect that the man actually has conflicting emotions about this loss.
Conducting the Interview The interview is often the first contact between client and clinician. Clinicians use it to collect detailed information about the per- son’s problems and feelings, lifestyle and relationships, and other personal history. They may also ask about the person’s expectations of therapy and motives for seek- ing it. The clinician who worked with Franco began with a face-to-face interview:
Franco arrived for his appointment in gray sweatpants and a T-shirt. His stubble suggested that he had not shaved, and the many food stains on his shirt indicated he had not washed it for quite some time. Franco spoke without emotion. He slouched into the chair, sending signals that he did not want to be there.
When pressed, he talked about his two-year relationship with Maria, who, at 25, was 13 years younger than he was. Franco had believed that he had met his future wife, but Maria’s domineering mother was unhappy about the age difference and kept telling her daughter that she could find someone better. Franco wanted Maria to stand up to her mother and to move in with him, but this was not easy for her to do. Believing that Maria’s mother had too much influence over her and frustrated that she would not commit to him, he had broken up with Maria during a fight. He soon realized that he had acted impulsively, but Maria refused to take him back.
When asked about his childhood, Franco described his father’s death in a gruesome car crash on his way to pick up 12-year-old Franco from soccer practice. Initially, his father had told Franco that he could not come get him from practice, but Franco “threw a tantrum” and his father agreed to rearrange his schedule. Franco believed himself responsible for his father’s death.
Franco stated that, over the years, his mother had encouraged this feeling of self- blame by complaining that she had been forced to “give up her life” to raise Franco alone. She was always nasty to Franco and nasty to every woman he later dated. She even predicted that Franco would “die alone.”
Franco described being very unhappy throughout his school years. He hated school and felt less smart than the other kids. On occasion, a teacher’s critique— meant as encouragement—left him unable to do his homework for days, and his grades suffered. He truly believed he was stupid. Similarly, later in life, he inter- preted his rise to a position as bank manager as due entirely to hard work. “I know I’m not as smart as the others there.”
how reliable and valid are the
tests you take in school? What
about the tests you see online
and in print magazines?
▶▶ idiographic understanding An understanding of a particular individual.
▶▶ assessment The process of collect- ing and interpreting relevant information about a client or research participant.
▶▶ standardization The process in which a test is administered to a large group of people whose performance then serves as a standard or norm against which any individual’s score can be measured.
▶▶ reliability A measure of the consis- tency of test or research results.
▶▶ validity A measure of the accuracy of a test’s or study’s results.
(continues on the next page)
B e t W e e n t h e L i n e s
The Stigma Continues 33% Americans who would not seek
counseling for fear of being labeled “mentally ill”
67% Americans who would not tell their employer that they were seeking mental health treatment
37% Americans who would be reluctant to seek treatment because of confidentiality concerns
(Opinion research corporation, 2011, 2004)
: chapter 380
Franco explained that since the breakup with Maria, he had experienced more unhappiness than ever before. He often spent all night watching television. At the same time, he could barely pay attention to what was happening on the screen. He said that some days he actually forgot to eat. He had no wish to see his friends. At work, the days blurred into one another, distinguished only by a growing number of reprimands from his bank supervisors. He attributed these work problems to his basic lack of ability. His supervisors had simply figured out that he had not been good enough for the job all along.
Beyond gathering basic background data of this kind, clinical interviewers give special attention to those topics they consider most important (Miller, 2015; Segal, June, & Marty, 2010). Psychodynamic interviewers try to learn about the person’s needs and memories of past events and relationships. Behavioral interviewers try to pinpoint information about the stimuli that trigger responses and their conse- quences. Cognitive interviewers try to discover assumptions and interpretations that influence the person. Humanistic clinicians ask about the person’s self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments.
Interviews can be either unstructured or structured. In an unstructured interview, the clinician asks mostly open-ended questions, perhaps as simple as “Would you tell me about yourself?” The lack of structure allows the interviewer to follow leads and explore relevant topics that could not be anticipated before the interview.
In a structured interview, clinicians ask prepared—mostly specific—questions. Sometimes they use a published interview schedule—a standard set of questions designed for all interviews. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client’s awareness, orientation with regard to time and place, attention span, memory, judg- ment and insight, thought content and processes, mood, and appearance (Sommers- Flanagan & Sommers-Flanagan, 2013). A structured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals.
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Military concerns U.S. Army troops await their turn for psychological assessment at the Soldier Readiness Processing Center at Fort Hood, Texas. Many soldiers have developed significant psychological problems in recent years as a result of their repeated deployments to Iraq and Afghanistan, leading the Army to conduct assessments that might predict which individuals are particularly vulnerable to such reactions.
B e t W e e n t h e L i n e s
A New Employment Screening Tool More than 40 percent of companies use social networking sites to help screen job candidates. Why? To see whether candidates present themselves profes- sionally (65%), are good fits for the company’s culture (51%), are qualified (45%), and/or are well rounded (35%).
(careerBuilder, 2012)
Clinical Assessment, Diagnosis, and Treatment : 81
Although most clinical interviews have both unstructured and structured portions, many clinicians favor one kind over the other. Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by behavioral and cognitive clinicians, who need to pinpoint behav- iors, attitudes, or thinking processes that may underlie abnormal behavior (Segal & Hersen, 2010).
What Are the Limitations of Clinical Interviews? Although interviews often produce valuable information about people, there are limits to what they can accomplish. One problem is that they sometimes lack validity, or accuracy (Sommers-Flanagan & Sommers-Flanagan, 2013). Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discuss- ing embarrassing topics (Gold & Castillo, 2010). Or people may be unable to give an accurate report in their interviews. Individuals who suffer from depression, for example, take a pessimistic view of themselves and may describe themselves as poor workers or inad- equate parents when that isn’t the case at all.
Interviewers too may make mistakes in judgments that slant the information they gather (Clinton, Fernandez, & Alicea, 2010). They usually rely too heavily on first impressions, for example, and give too much weight to unfavorable informa- tion about a client (Wu & Shi, 2005). Interviewer biases, including gender, race, and age biases, may also influence the interviewers’ interpretations of what a client says (Ungar et al., 2006).
Interviews, particularly unstructured ones, may also lack reliability (Sommers- Flanagan & Sommers-Flanagan, 2013). People respond differently to different inter- viewers, providing, for example, less information to a cold interviewer than to a warm and supportive one (Quas et al., 2007). Similarly, a clinician’s race, gender, age, and appearance may influence a client’s responses (Davis et al., 2010; Springman, Wherry, & Notaro, 2006).
Because different clinicians can obtain different answers and draw different con- clusions even when they ask the same questions of the same person, some research- ers believe that interviewing should be discarded as a tool of clinical assessment. As you’ll see, however, the two other kinds of clinical assessment methods also have serious limitations.
Clinical Tests Clinical tests are devices for gathering information about a few aspects of a per- son’s psychological functioning, from which broader information about the person can be inferred. On the surface, it may look easy to design an effective test. Every month, magazines and Web sites present new tests that supposedly tell us about our personalities, relationships, sex lives, reactions to stress, or ability to succeed. Such tests might sound convincing, but most of them lack reliability, validity, and stan- dardization. That is, they do not yield consistent, accurate information or say where we stand in comparison with others.
More than 500 clinical tests are currently in use throughout the United States. Clinicians use six kinds most often: projective tests, personality inventories, response inven- tories, psychophysiological tests, neurological and neuropsychological tests, and intelligence tests.
Projective Tests Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as “Draw a person.” Theoretically, when clues and instructions are so general, people will “project” aspects of their personality into the task (Cherry, 2015; Hogan, 2014).
“I’ll say a normal word, then you say the first sick thing that pops into your head.”
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▶▶ mental status exam A set of interview questions and observations designed to reveal the degree and nature of a client’s abnormal functioning.
▶▶ clinical test A device for gathering information about a few aspects of a person’s psychological functioning from which broader information about the per- son can be inferred.
▶▶ projective test A test consisting of ambiguous material that people interpret or respond to.
: chapter 382
Projective tests are used primarily by psychodynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning (Baer & Blais, 2010). The most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence-completion tests, and drawings.
RoRschach TesT In 1911 Hermann Rorschach, a Swiss psychiatrist, experi- mented with the use of inkblots in his clinical work. He made thousands of blots by dropping ink on paper and then folding the paper in half to create a symmetrical but wholly accidental design, such as the one shown in Fig- ure 3-1. Rorschach found that everyone saw images in these blots. In addition, the images a viewer saw seemed to correspond in important ways with his or her psychologi- cal condition. People diagnosed with schizo- phrenia, for example, tended to see images that differed from those described by people expe- riencing depression.
Rorschach selected 10 inkblots and pub- lished them in 1921 with instructions for their
use in assessment. This set was called the Rorschach Psychodynamic Inkblot Test. Rorschach died just 8 months later, at the age of 37, but his work was continued by others, and his inkblots took their place among the most widely used projective tests of the twentieth century (see MindTech on the next page).
Clinicians administer the “Rorschach,” as it is commonly called, by presenting one inkblot card at a time and asking respondents what they see, what the ink- blot seems to be, or what it reminds them of. In the early years, Rorschach testers paid special attention to the themes and images that the inkblots brought to mind (Butcher, 2010). Testers now also pay attention to the style of the responses: Do the clients view the design as a whole or see specific details? Do they focus on the blots or on the white spaces between them?
ThemaTic appeRcepTion TesT The Thematic Apperception Test (TAT) is a pictorial projective test (Aronow, Weiss, & Reznikoff, 2011; Morgan & Murray, 1935). People who take the TAT are commonly shown 30 cards with black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each
card. They must tell what is happening in the picture, what led up to it, what the characters are feeling and thinking, and what the outcome of the situation will be.
Clinicians who use the TAT believe that people always identify with one of the characters on each card. The stories are thought to reflect the individuals’ own circumstances, needs, and emotions. For example, a female client seems to be revealing her own feelings when telling this story about a TAT picture similar to the image shown in Figure 3-2:
This is a woman who has been quite troubled by memories of a mother she was resentful toward. She has feelings of sorrow for the way she treated her mother, her memories of her mother plague her. These feel- ings seem to be increasing as she grows older and sees her children treating her the same way that she treated her mother.
(Aiken, 1985, p. 372)
senTence-compleTion TesT In the sentence-completion test, first developed in the 1920s (Payne, 1928), the test-taker completes a series of unfinished sentences, such as “I wish . . .” or “My father. . . .” The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore.
figure 3-1 An inkblot similar to those used in the Rorschach test. In this test, individuals view and react to a total of 10 inkblot images.
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Despite its limitations,
just about everyone has
heard of the rorschach.
Why do you think it is
so famous and popular?
figure 3-2 A picture similar to one used in the Thematic Apperception Test.
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Clinical Assessment, Diagnosis, and Treatment : 83
DRawings On the assumption that a drawing tells us something about its creator, clinicians often ask clients to draw human figures and talk about them (McGrath & Carroll, 2012). Evaluations of these drawings are based on the details and shape of the drawing, the solidity of the pencil line, the location of the drawing on the paper, the size of the figures, the features of the figures, the use of background, and comments made by the respondent during the drawing task. In the Draw-a-Person (DAP) test, the most popular of the drawing tests, individuals are first told to draw “a person” and then are instructed to draw a person of the other sex.
MindTech
Psychology’s Wiki Leaks? In 2009, an emergency room physician posted the images of all 10 Rorschach cards, along with common responses to each card, on Wikipedia, the online encyclopedia. The publisher of the test, Hogrefe Publishing, immediately
threatened to take Wikipedia to court, saying that the encyclopedia’s willingness to post the images was “unbelievably reckless” (Cohen, 2009). However, no legal actions took place, and to this day, the 10 cards remain on Wikipedia for the entire world to see.
Many psychologists have criticized the Wikipedia posting, arguing that the Rorschach test responses of patients who have previously seen the test on Wikipedia cannot be trusted. In support of their concerns, a recent study found that reading the Wikipedia Rorschach test article did indeed help many individuals perform more positively on the test itself (Schultz & Brabender, 2012). These clinical concerns are consistent with the long-standing positions of the British, Canadian, and American Psychological Associations, who hold that nonprofessional publications of psychological test answers are wrong and potentially harmful to patients (CPA, 2009; BPS, 2007; APA, 1996).
Still other critics point out that the online publication of the Rorschach cards jeopardizes the usefulness of thousands of published studies—studies that have tried to link patients’ Rorschach responses to particular psychological disorders (Cohen, 2009). These studies were conducted on first-time inkblot observers, not on people
who had already viewed the cards online. On the other hand, more than a few test skeptics
seem very pleased by the online posting, hoping that it will lower the public’s regard for the test and lessen its clinical use (Radford, 2009). In fact, one recent study suggests that the Rorschach–Wikipedia debate has already led to unfavorable opinions of the test among many individuals (Schultz & Loving, 2012).
It appears that this debate is actually leading to an increase—rather than a decrease—in the distribution of psychological tests. Several newspapers reporting on the controversy have themselves published photos of the Rorschach cards (Simple, 2009; White, 2009). And as you will read later in this chapter, intelligence tests, among the most widely used of all psychological tests, are now available—on eBay of all places—to anyone who is willing to pay the price.
Why do you think this
rorschach debate has
led to an increase in
the distribution of
psychological tests?
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Drawing test Drawing tests are commonly used to assess the functioning of children. One is the Kinetic Family Drawing test, in which chil‑ dren draw their household members performing some activity (“kinetic” means “active”).
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: chapter 384
whaT aRe The meRiTs of pRojecTive TesTs? Until the 1950s, projective tests were the most commonly used method for assessing personality. In recent years, how- ever, clinicians and researchers have relied on them largely to gain “supplementary” insights (McGrath & Carroll, 2012). One reason for this shift is that practitioners who follow the newer models have less use for the tests than psychodynamic clini- cians do. Even more important, the tests have not consistently shown much reli- ability or validity (Hogan, 2014).
In reliability studies, different clinicians have tended to score the same person’s projective test quite differently. Similarly, in validity studies, when clinicians try to describe a client’s personality and feelings on the basis of responses to projective tests, their conclusions often fail to match the self-report of the client, the view of the psychotherapist, or the picture gathered from an extensive case history (Cherry, 2015; Bornstein, 2007).
Another validity problem is that projective tests are sometimes biased against minority ethnic groups (Costantino et al., 2007) (see Table 3-1). For example, peo- ple are supposed to identify with the characters in the TAT when they make up stories about them, yet no members of minority groups are in the TAT pictures. In response to this problem, some clinicians have developed other TAT-like tests with African American or Hispanic figures (Costantino et al., 2007, 1992).
Personality Inventories An alternative way to collect information about individuals is to ask them to assess themselves. Respondents to a personality inventory answer a wide range of questions about their behavior, beliefs, and feel- ings. In the typical personality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person’s personality and psychological functioning (Hogan, 2014; Watson, 2012).
By far the most widely used personality inventory is the Minnesota Multiphasic Personality Inventory (MMPI) (Butcher, 2011). Two adult versions are available—the original test, published in 1945, and the MMPI-2, a 1989 revision that was itself revised in 2001. There is also a streamlined version of the inventory called the MMPI-2-Restructured Form and a special version of the test for adolescents called the MMPI-A (Williams & Butcher, 2011).
The MMPI consists of more than 500 self-statements, to be labeled “true,” “false,” or “cannot say.” The statements cover issues ranging from physical concerns to mood, sexual behaviors, and social activities. Altogether the statements make up 10 clinical scales, on each of which an individual can score from 0 to 120. When people score above 70 on a scale, their functioning on that scale is considered devi- ant. When the 10 scale scores are considered side by side, a pattern called a profile takes shape, indicating the person’s general personality. The 10 scales on the MMPI measure the following:
Hypochondriasis Items showing abnormal concern with bodily functions (“I have chest pains several times a week.”)
Depression Items showing extreme pessimism and hopelessness (“I often feel hope- less about the future.”)
Hysteria Items suggesting that the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities (“My heart frequently pounds so hard I can feel it.”)
Psychopathic deviate Items showing a repeated and gross disregard for social cus- toms and an emotional shallowness (“My activities and interests are often criticized by others.”)
Masculinity-femininity Items that are thought to separate male and female respon- dents (“I like to arrange flowers.”)
The art of assessment In the spirit of pro‑ jective tests, the sometimes bizarre cat portraits of early‑twentieth‑century artist Louis Wain have been interpreted as reflections of the psy‑ chosis with which he struggled for many years.
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Clinical Assessment, Diagnosis, and Treatment : 85
Paranoia Items that show abnormal suspiciousness and delusions of grandeur or persecution (“There are evil people trying to influence my mind.”)
Psychasthenia Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness (“I save nearly everything I buy, even after I have no use for it.”)
Schizophrenia Items that show bizarre or unusual thoughts or behavior (“Things around me do not seem real.”)
Hypomania Items that show emotional excitement, overactivity, and flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent reason.”)
Social introversion Items that show shyness, little interest in people, and insecurity (“I am easily embarrassed.”)
The MMPI and other personality inventories have several advantages over projective tests (Cherry, 2015; Hogan, 2014). Because they are computerized or paper-and-pencil tests, they do not take much time to administer, and they are objectively scored. Most of them are standardized, so one person’s scores can be compared with those of many others. Moreover, they often display greater test– retest reliability than projective tests. For example, people who take the MMPI a second time after a period of less than 2 weeks receive approximately the same scores (Graham, 2014, 2006).
table: 3-1
Multicultural Hot Spots in Assessment and Diagnosis
Cultural Hot Spot Effect on Assessment or Diagnosis
• Immigrant Client • Dominant-Culture Assessor Homeland culture may differ from current country’s dominant culture May misread culture‑bound reactions as pathology
May have left homeland to escape war or oppression May overlook client’s vulnerability to posttraumatic stress
May have weak support systems in this country May overlook client’s heightened vulnerability to stressors
Lifestyle (wealth and occupation) in this country may fall below May overlook client’s sense of loss and frustration lifestyle in homeland
May refuse or be unable to learn dominant language May misunderstand client’s assessment responses, or may overlook or misdiagnose client’s symptoms
• Ethnic-Minority Client • Dominant-Culture Assessor May reject or distrust members of dominant culture, including May experience little rapport with client, or may assessor misinterpret client’s distrust as pathology
May be uncomfortable with dominant culture’s values May view client as unmotivated (e.g., assertiveness, confrontation) and so find it difficult to apply clinician’s recommendations
May manifest stress in culture‑bound ways (e.g., somatic May misinterpret symptom patterns symptoms such as stomachaches)
May hold cultural beliefs that seem strange to dominant culture May misinterpret cultural responses as pathology (e.g., belief in communication with dead) (e.g., a delusion)
May be uncomfortable during assessment May overlook and feed into client’s discomfort
• Dominant-Culture Assessor • Ethnic-Minority Client May be unknowledgeable or biased about ethnic‑minority culture Cultural differences may be pathologized, or symptoms may be overlooked
May nonverbally convey own discomfort to ethnic‑minority client May become tense and anxious
Information from: Rose et al., 2011; Bhattacharya et al., 2010; Dana, 2005, 2000; Westermeyer, 2004, 2001, 1993; López & Guarnaccia, 2005, 2000; Kirmayer, 2003, 2002, 2001; Sue & Sue, 2003; Tsai et al., 2001; Thakker & Ward, 1998.
▶▶ personality inventory A test, designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either character- istic or uncharacteristic of them.
: chapter 386
Personality inventories also appear to have more valid- ity, or accuracy, than projective tests (Cherry, 2015; Butcher, 2011, 2010). However, they can hardly be considered highly valid. When clinicians have used these tests alone, they have not regularly been able to judge a respondent’s personality accurately (Braxton et al., 2007). One problem is that the personality traits that the tests seek to measure cannot be examined directly. How can we fully know a person’s char- acter, emotions, and needs from self-reports alone?
Another problem is that despite the use of more diverse standardization groups by the MMPI-2 designers, this and other personality tests continue to have certain cultural limi- tations. Responses that indicate a psychological disorder in one culture may be normal responses in another (Butcher, 2010; Dana, 2005, 2000). In Puerto Rico, for example, where it is common to practice spiritualism, it would be normal to answer “true” to the MMPI item “Evil spirits possess me at times.” In other populations, that response could indicate psychopathology (Rogler et al., 1989).
Despite such limits in validity, personality inventories continue to be popular. Research indicates that they can
help clinicians learn about people’s personal styles and disorders as long as they are used in combination with interviews or other assessment tools.
Response Inventories Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning (Wang & Gorenstein, 2013; Vaz et al., 2013; Watson, 2012). For example, one such test may measure affect (emotion), another social skills, and still another cognitive processes. Clinicians can use the inventories to determine the role such factors play in a person’s disorder.
Affective inventories measure the severity of such emotions as anxiety, depression, and anger. In one of the most widely used affective inventories, the Beck Depres- sion Inventory, people rate their level of sadness and its effect on their functioning. For social skills inventories, used particularly by behavioral and family-social clinicians, respondents indicate how they would react in a variety of social situations. Cognitive inventories reveal a person’s typical thoughts and assumptions and can help uncover counterproductive patterns of thinking. They are, not surprisingly, often used by cognitive therapists and researchers.
Both the number of response inventories and the number of clinicians who use them have increased steadily in the past 30 years. At the same time, however, these inventories have major limitations. With the notable exceptions of the Beck Depression Inventory and a few others, many of the tests have not been subjected to careful standardization, reliability, and validity procedures (Blais & Baer, 2010). Often they are created as a need arises, without being tested for accuracy and consistency.
Psychophysiological Tests Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychologi- cal problems (Daly et al., 2014). This practice began three decades ago, after several studies suggested that states of anxiety are regularly accompanied by physiological changes, particularly increases in heart rate, body temperature, blood pressure, skin reactions (galvanic skin response), and muscle contractions. The measuring of physi- ological changes has since played a key role in the assessment of certain psychologi- cal disorders.
One psychophysiological test is the polygraph, popularly known as a lie detec- tor (Bhutta et al., 2015; Rosky, 2013). Electrodes attached to various parts of a
“We’re going to run some tests: blood work, a cat-scan, and the S.A.T.’s.”
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Blink of the eye Before entering combat duty, this Marine takes an eyeblink test—a psychophysiological test in which sensors are attached to the eyelid and other parts of the face. The test tries to detect physical indicators of tension and anxiety and to predict which Marines might be particularly susceptible to posttraumatic stress disorder.
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Clinical Assessment, Diagnosis, and Treatment : 87
person’s body detect changes in breathing, perspiration, and heart rate while the person answers questions. The clinician observes these functions while the person answers “yes” to control questions—questions whose answers are known to be yes, such as “Are both your parents alive?” Then the clinician observes the same physi- ological functions while the person answers test questions, such as “Did you commit
this robbery?” If breathing, perspiration, and heart rate suddenly increase, the person is suspected of lying.
Like other kinds of clinical tests, psy- chophysiological tests have their drawbacks (Rusconi & Mitchener-Nissen, 2013). Many require expensive equipment that must be
carefully tuned and maintained. In addition, psychophysiological measurements can be inaccurate and unreliable (see PsychWatch below). The laboratory equipment itself—elaborate and sometimes frightening—may arouse a participant’s nervous system and thus change his or her physical responses. Physiological responses may also change when they are measured repeatedly in a single session. Galvanic skin responses, for example, often decrease during repeated testing.
PsychWatch
In movies, criminals being grilled by the police reveal their guilt by sweating, shaking, cursing, or twitching. When they are hooked up to a polygraph (a lie detector), the needles bounce all over the paper. This image has been with us since World War I, when some clinicians developed the theory that people who
are telling lies display systemic changes in their breathing, perspiration, and heart rate (Marston, 1917).
The danger of relying on polygraph tests is that, according to researchers, they do not work as well as we would like (Rosky, 2015, 2013; Rusconi & Mitchener‑ Nissen, 2013; Meijer & Verschuere, 2010).
The public did not pay much attention to this inconvenient fact until the mid‑1980s, when the American Psychological Asso‑ ciation officially reported that polygraphs were often inaccurate and the U.S. Con‑ gress voted to restrict their use in criminal prosecution and employment screening (Krapohl, 2002). Research indicates that 8 out of 100 truths, on average, are called lies in polygraph testing (Grubin, 2010; Raskin & Honts, 2002; MacLaren, 2001). Imagine, then, how many innocent people might be convicted of crimes if polygraph findings were taken as valid evidence in criminal trials.
Given such findings, polygraphs are less trusted and less popular today than they once were. For example, few courts now admit results from such tests as evidence of criminal guilt (Grubin, 2010; Daniels, 2002). Polygraph testing has by no means disappeared, however. The FBI uses it extensively, parole boards and probation offices routinely use it to help decide whether to release convicted offenders, and in public‑sector hiring (such as for police officers), the use of polygraph screening may actually be on the increase (Meijer & Verschuere, 2010; Kokish et al., 2005).
The Truth, the whole Truth, and Nothing but the Truth
All the rage A student learns to administer polygraph exams at the Latin American Polygraph Institute in Bogota, Colombia. Despite evidence that these tests are often invalid, they are widely used by businesses in Colombia, where deception by employ‑ ees has become a major problem.
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Why might an innocent person
“fail” a lie detector test? how
might a guilty person manage
to “pass” the test?
▶▶ response inventories Tests that measure a person’s responses in one spe- cific area of functioning, such as affect, social skills, or cognitive processes.
▶▶ psychophysiological test A test that measures physical responses (such as heart rate and muscle tension) as possi- ble indicators of psychological problems.
: chapter 388
Neurological and Neuropsychological Tests Some problems in personality or behavior are caused primar- ily by damage to the brain or by changes in brain activity. Head injuries, brain tumors, brain malfunctions, alcoholism, infections, and other disorders can all cause such impairment. If a psychological dysfunction is to be treated effectively, it is important to know whether its primary cause is a physical abnormality in the brain.
A number of techniques may help pinpoint brain abnor- malities. Some procedures, such as brain surgery, biopsy, and X ray, have been used for many years. More recently, scien- tists have developed a number of neurological tests, which are designed to measure brain structure and activity directly. One neurological test is the electroencephalogram (EEG), which
records brain waves, the electrical activity that takes place within the brain as a result of neurons firing. In an EEG, electrodes placed on the scalp send brain-wave impulses to a machine that records them.
Other neurological tests actually take “pictures” of brain structure or brain activ- ity. These tests, called neuroimaging, or brain scanning, techniques, include computerized axial tomography (CAT scan or CT scan), in which X rays of the brain’s structure are taken at different angles and combined; positron emission tomography (PET scan), a computer-produced motion picture of chemical activity throughout the brain; and magnetic resonance imaging (MRI ), a procedure that uses the magnetic property of certain hydrogen atoms in the brain to create a detailed picture of the brain’s structure.
One version of the MRI, functional magnetic resonance imaging ( fMRI ), converts MRI pictures of brain structures into detailed pictures of neuron activity, thus offering a picture of the functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer than PET scan images, the fMRI has produced enormous enthusiasm among brain researchers since it was first devel- oped in 1990.
Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks; clinicians interpret abnormal performances as an indicator of underlying brain problems (Hogan, 2014). Brain damage is espe- cially likely to affect visual perception, memory, and visual-motor coordination,
Traditional scanning The most widely used neuroimaging techniques in clinical practice— the MRI (bottom), CAT, and PET—take pictures of the living brain. Here, an MRI scan (above left) reveals a large tumor, colored in orange; a CAT scan (above center) reveals a mass of blood within the brain; and a PET scan (above right) shows which areas of the brain are active (those colored in red, orange, and yellow) when an individual is being stimulated.
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Clinical Assessment, Diagnosis, and Treatment : 89
so neuropsychological tests focus particu- larly on these areas. The famous Bender Visual-Motor Gestalt Test, for example, consists of nine cards, each displaying a simple geometrical design. Patients look at the designs one at a time and copy each one on a piece of paper. Later they try to redraw the designs from memory. Notable errors in accuracy by individuals older than 12 are thought to reflect organic brain impairment. Clinicians often use a battery, or series, of neuropsychological tests, each targeting a specific skill area (Flanagan et al., 2013; Reitan & Wolfson, 2005, 1996).
Intelligence Tests An early definition of intelligence described it as “the capacity to judge well, to reason well, and to comprehend well” (Binet & Simon, 1916, p. 192). Because intelligence is an inferred quality rather than a specific physi- cal process, it can be measured only indirectly. In 1905, French psychologist Alfred Binet and his associate Théodore Simon produced an intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills. The general score derived from this and later intelligence tests is termed an intelligence quotient (IQ). There are now more than 100 intelligence tests available. As you will see in Chapter 14, intelligence tests play a key role in the diagnosis of intellec- tual disability (mental retardation), and they can also help clinicians identify other problems (Hogan, 2014; Mishak, 2014).
Intelligence tests are among the most carefully produced of all clinical tests (Bowden et al., 2011). Because they have been standardized on large groups of people, clinicians have a good idea how each individual’s score compares with the performance of the population at large. These tests have also shown very high reliability: people who repeat the same IQ test years later receive approximately
the same score. Finally, the major IQ tests appear to have fairly high validity: children’s IQ scores often correlate with their perfor- mance in school, for example.
Nevertheless, intelligence tests have some key shortcomings. Factors that have nothing to do with intelligence, such as low motivation or high anxiety, can greatly influence test perfor-
mance (Chaudhry & Ready, 2012) (see MediaSpeak on the next page). In addition, IQ tests may contain cultural biases in their language or tasks that place people of one background at an advantage over those of another (Goldfinger & Pomerantz, 2014). Similarly, members of some minority groups may have little experience with this kind of test, or they may be uncomfortable with test examiners of a majority ethnic background. Either way, their performances may suffer.
Clinical Observations In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe cli- ents in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self-monitoring, clients are instructed to observe themselves.
The EEG Electrodes pasted to the scalp help measure the brain waves of this baby boy.
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▶▶ neurological test A test that directly measures brain structure or activity.
▶▶ neuroimaging techniques Neuro- logical tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain scans.
▶▶ neuropsychological test A test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.
▶▶ intelligence test A test designed to measure a person’s intellectual ability.
▶▶ intelligence quotient (IQ) An over- all score derived from intelligence tests.
: chapter 390
Naturalistic and Analog Observations Naturalistic clinical observa- tions usually take place in homes, schools, institutions such as hospitals and prisons, or community settings. Most of them focus on parent–child, sibling–sibling, or teacher–child interactions and on fearful, aggressive, or disruptive behavior (Hughes et al., 2014; Lindhiem et al., 2011). Often such observations are made by participant observers—key people in the client’s environment—and reported to the clinician.
When naturalistic observations are not practical, clinicians may resort to analog observations, often aided by special equipment such as a video camera or one-way mirror. Analog observations often have focused on children interacting with their parents, married couples attempting to settle a disagreement, speech-anxious people giving a speech, and fearful people approaching an object they find frightening.
Although much can be learned from actually witnessing behavior, clinical obser- vations have certain disadvantages. For one thing, they are not always reliable. It is possible for various clinicians who observe the same person to focus on different aspects of behavior, assess the person differently, and arrive at different conclusions (Meersand, 2011). Careful training of observers and the use of observer checklists can help reduce this problem.
75%10:00 AM
intelligence tests . . . are for sale on eBay Inc.’s online auction site, and the test maker is worried they will be misused.
The series of Wechsler intelligence tests, made by San Antonio‑based Harcourt Assessment, Inc., are sup‑ posed to be sold to and administered by only clinical psychologists and trained professionals.
Given more than a million times a year nationwide, according to Harcourt, the intelligence tests often are among numerous tests ordered by prosecutors and de‑ fense attorneys to determine the mental competence of criminal defendants. A low IQ, for example, can be used to argue leniency in sentencing.
Schools use the tests to determine whether to place a student in a special program, whether for gifted or struggling students. Harcourt officials say they fear the tests for sale on eBay will be misused for coaching by lawyers or parents.
But eBay has denied their request to restrict the sale of the tests. eBay officials say there is nothing illegal about selling the tests, and it can‑ not monitor every possible misuse of items sold through its network of 248 million buyers and sellers. [The tests continue to be available on eBay as of 2015.] Five of the tests were listed for sale . . . for
MediaSpeak intelligence Tests Too? eBay and the public Good
Michelle Roberts, Associated Press
about $175 to $900. The latest edition of the adult test, which retails for $939, was offered on eBay for $249.99.
“In order for it to maintain its integ‑ rity, there needs to be limited availabil‑ ity,” said [a] Harcourt spokesman. . . . “Misinterpreting the results [of questions and tasks on the tests], even without malicious intent, could lead to mistakes in assessing a child’s intelligence. . . .”
IQ Tests for Sale on eBay by Michelle Roberts, The Associated Press, 12/18/2007. Used with permission of The Associated Press Copyright © 2014. All rights reserved.
When free enterprise
principles conflict with
psychological well-being,
how should the matter
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The Wechsler Adult Intelligence Scale-Revised (WAIS-R) This widely used intelligence test has 11 subtests, which cover such areas as factual information, memory, vocab‑ ulary, arithmetic, design, and eye–hand coordination.
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Clinical Assessment, Diagnosis, and Treatment : 91
Similarly, observers may make errors that affect the validity, or accuracy, of their observations (Wilson et al., 2010). The observer may suffer from overload and be unable to see or record all of the important behaviors and events. Or the observer may experience observer drift, a steady decline in accuracy as a result of fatigue or of a gradual unintentional change in the standards used when an observation continues for a long period of time. Another possible problem is observer bias—the observer’s judgments may be influenced by information and expectations he or she already has about the person (Hróbjartsson et al., 2014).
A client’s reactivity may also limit the validity of clinical observations; that is, his or her behavior may be affected by the very presence of the observer (Antal et al., 2015). If schoolchildren are aware that someone special is watching them, for example, they may change their usual class- room behavior, perhaps in the hope of creating a good impression (Lane et al., 2011).
Finally, clinical observations may lack cross-situational validity. A child who behaves aggressively in school is not necessarily aggressive at home or with friends after school. Because behavior is often specific to particular situations, observations in one setting cannot always be applied to other settings (Kagan, 2007).
Self-Monitoring As you saw earlier, personality and response inven- tories are tests in which individuals report their own behaviors, feelings, or cognitions. In a related assessment procedure, self-monitoring, people observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time (Newcomb & Mustanski, 2014; Huh et al., 2013). How frequently, for instance, does a drug user have an urge for drugs or a headache sufferer have a headache? Self-monitoring is especially useful in assessing behavior that occurs so infrequently that it is unlikely to be seen during other kinds of observations. It is also useful for behaviors that occur so frequently that any other method of observing them in detail would be impossible—for example, smoking, drinking, or other drug use. Finally, self-monitoring may be the only way to observe and measure private thoughts or perceptions.
Like all other clinical assessment procedures, however, self-monitoring has draw- backs (Huh et al., 2013). Here too validity is often a problem. People do not always manage or try to record their observations accurately. Furthermore, when people monitor themselves, they may change their behaviors unintentionally. Smokers, for example, often smoke fewer cigarettes than usual when they are monitoring themselves, and teachers give more positive and fewer negative comments to their students.
➤ Summing Up CLINICAL ASSESSMENT Clinical practitioners are interested primarily in gather‑ ing individual information about each client. They seek an understanding of the specific nature and origins of a client’s problems through clinical assessment.
To be useful, assessment tools must be standardized, reliable, and valid. Most clinical assessment methods fall into three general categories: clinical inter‑ views, tests, and observations. A clinical interview may be either unstructured or structured. Types of clinical tests include projective, personality, response, psychophysiological, neurological, neuropsychological, and intelligence tests. Types of observation include naturalistic observation, analog observation, and self‑monitoring.
An ideal observation Using a one‑way mir‑ ror, a clinical observer is able to view a mother interacting with her child without distracting the duo or influencing their behaviors.
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In Their Words “You can observe a lot just by watching.”
Yogi Berra
: chapter 392
Diagnosis: Does the Client’s Syndrome Match a Known Disorder? Clinicians use the information from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client’s distur- bance, a construction sometimes known as a clinical picture (Goldfinger & Pomerantz, 2014). Clinical pictures also may be influenced to a degree by the clinician’s theoretical orientation (Garb, 2010, 2006). The psychologist who worked with Franco held a cognitive-behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Franco’s expectations, assumptions, and interpretations:
Franco’s mother had reinforced his feelings of insecurity and his belief that he was unintelligent and inferior. When teachers tried to encourage and push Franco, his mother actually called him “an idiot.” Although he was the only one in his family to attend college and did well there, she told him he was too inadequate to succeed in the world. When he received a B in a college algebra course, his mother told him, “You’ll never have money.” She once told him, “You’re just like your father, dumb as a post,” and railed against “the dumb men I got stuck with.”
As a child Franco had watched his parents argue. Between his mother’s self- serving complaints and his father’s rants about his backbreaking work to provide for his family, Franco had decided that life would be unpleasant. He believed it was natural for couples to argue and blame each other. Using his parents as models, Franco believed that when he was displeased with a girlfriend—Maria or a prior girlfriend—he should yell at her. At the same time, he was confused that several of his girlfriends had complained about his temper.
He took the termination of his relationship with Maria as proof that he was “stupid.” He felt foolish to have broken up with her. He interpreted his behavior and the break-up as proof that he would never be loved and that he would never find happiness. In his mind, all he had to look forward to from here on out was a lifetime of problematic relationships, fights, and getting fired from lesser and lesser jobs. This hopelessness fed his feelings of depression and also made it hard for him to try to make himself feel better.
With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis—that is, a determination that a person’s psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client’s pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person’s problem and the treatments that are likely to be helpful.
Classification Systems The principle behind diagnosis is straightforward. When certain symptoms occur together regularly— a cluster of symptoms is called a syndrome—and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder (see Table 3-2). If people display this particular pattern of symptoms,
Why do you think many
clinicians prefer the
label “person with
schizophrenia” over
“schizophrenic person”?
▶▶ diagnosis A determination that a person’s problems reflect a particular disorder.
▶▶ syndrome A cluster of symptoms that usually occur together.
▶▶ classification system A list of disorders, along with descriptions of symptoms and guidelines for making appropriate diagnoses.
B e t W e e n t h e L i n e s
What Is a Nervous Breakdown? The term “nervous breakdown” is used by laypersons, not clinicians. Most people use it to refer to a sudden psychological disturbance that incapacitates a person, perhaps requiring hospitalization (Hall-Flavin, 2011; Padwa, 1996).
Clinical Assessment, Diagnosis, and Treatment : 93
diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system.
In 1883, Emil Kraepelin developed the first mod- ern classification system for abnormal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic and Statistical Manual of Mental Disorders (DSM ), the classification system currently written by the Ameri- can Psychiatric Association (APA, 2013). The DSM is the most widely used classification system in North America. Most other countries rely primarily on a system called the International Classification of Diseases (ICD), devel- oped by the World Health Organization, which lists both medical and psychological disorders.
The content of the DSM has been changed sig- nificantly over time. The current edition, called DSM-5, was published in 2013. It features a number of changes from the previous edition, DSM-IV-TR, and the edi- tions prior to that.
DSM-5 DSM-5 lists more than 500 mental disorders (see Figure 3-3). Each entry describes the criteria for diagnosing the disorder and the key clinical features of the disorder. The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by background information such as research findings; age, culture, or gender trends; and each disorder’s prevalence, risk, course, complications, predisposing factors, and family patterns.
DSM-5 requires clinicians to provide both categorical and dimensional infor- mation as part of a proper diagnosis. Categorical information refers to the name of the particular category (disorder) indicated by the client’s symptoms. Dimensional information is a rating of how severe a client’s symptoms are and how dysfunctional the client is across various dimensions of personality.
Categorical Information First, the clinician must decide whether the person is displaying one of the hundreds of psychological disorders listed in the manual. Some of the most frequently diagnosed disorders are the anxiety disorders and depressive disorders.
anxieTy DisoRDeRs People with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder); fears of specific situations, objects, or activities (phobias); anxiety about social situations (social anxiety disorder); repeated outbreaks of panic (panic disorder); or anxiety about being separated from one’s parents or other key individuals (separation anxiety disorder).
DepRessive DisoRDeRs People with depressive disorders may expe- rience an episode of extreme sadness and related symptoms (major depressive disorder), persistent and chronic sadness (persistent depressive disorder), or severe premenstrual sadness and related symptoms (pre- menstrual dysphoric disorder).
Although people may receive just one diagnosis from the DSM-5 list, they often receive more than one. Franco would likely receive
table: 3-2
Mental Health Awareness Dates January Mental Wellness Month
March Developmental Disabilities Awareness Month National Self‑Injury Awareness Month
April Alcohol Awareness Month National Autism Awareness Month National Stress Awareness Month
May Children’s Mental Health Awareness Week National Anxiety and Depression Awareness Week Schizophrenia Awareness Week
June Panic Awareness Day (June 17) Posttraumatic Stress Disorder Awareness Day (June 27)
September World Suicide Prevention Day (September 10)
October National Depression Awareness Month World Mental Health Day (October 10) National Bipolar Awareness Day (October 10) OCD Awareness Week ADHD Awareness Month
November National Alzheimer’s Disease Awareness Month
Information from: Disabled World, 2014.
53.6% No disorders
17.3% Three or more disorders
18.7% One disorder
10.4% Two disorders
figure 3-3 How many people in the United States qualify for a DSM diagnosis during their lives? Almost half, according to some surveys. Some people even experience two or more different disorders, which is known as comorbidity. (Information from: Greenberg, 2011; Kessler et al., 2005.)
: chapter 394
a diagnosis of major depressive disorder. In addition, let’s suppose the clinician judged that Franco’s worries about his teachers’ opinions of him and his later concerns that supervisors at work would discover his inadequate skills were really but two examples of a much broader, persistent pattern of excessive worry, concern, and avoidance. He might then receive an additional diagnosis of generalized anxiety disorder. Alternatively, if Franco’s anxiety symptoms did not rise to the level of generalized anxiety disorder, his diagnosis of major depressive disorder might simply specify that he is experiencing some features of anxiety (major depressive disorder with anxious distress).
Dimensional Information In addition to deciding what disorder a client is displaying, diagnosticians assess the current sever- ity of the client’s disorder—that is, how much the symptoms impair the client. For each disorder, the framers of DSM-5 have suggested various rating scales that may prove useful for evaluating the severity of the particular disorder (APA, 2013). In cases of major depressive disorder, for example, two scales are suggested by DSM-5: the Cross- Cutting Symptom Measure and the Emotional Distress– Depression Scale. The former scale indicates the current frequency of general negative feelings and behaviors (for example, “I do not know what I want out of life”), and the latter indicates the frequency of depression-specific feelings and behaviors (for example, “I feel worthless”). Using scores from these scales, the diagnostician then rates the client’s depression
as “mild,” moderate,” or “severe.” Based on his clinical interview, tests, and obser- vations, Franco might warrant a rating of moderate depression from his therapist. DSM-5 is the first edition of the DSM to consistently seek both categorical and dimensional information as equally important parts of the diagnosis, rather than categorical information alone.
Additional Information Clinicians also may include other useful informa- tion when making a diagnosis. They may, for example, indicate special psychosocial problems the client has. Franco’s recent breakup with his girlfriend might be noted as relationship distress. Altogether, Franco might receive the following diagnosis:
Diagnosis: Major depressive disorder with anxious distress Severity: Moderate Additional information: Relationship distress
Each diagnostic category also has a numerical code that clinicians must state—a code listed in ICD-10, the current edition of the international classification system mentioned earlier. Thus if Franco were assigned the DSM-5 diagnosis indicated above, his clinician would also state a numerical code of F32.1—the code corre- sponding to major depressive disorder, moderate severity.
Is DSM-5 an Effective Classification System? A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were at best moderately reliable (Regier et al., 2011). In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, independently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement. Because all four clinicians were experienced diag- nosticians, their failure to agree suggested deficiencies in the classification system.
The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would have greater reliability than
“Am I a happy man or just an asymptomatic one?”
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By the Numbers 1 Number of categories of
psychological dysfunctioning listed in the 1840 U.S. census (“idiocy/insanity”)
60 Number of categories listed in DSM-I in 1952
541 Number of categories listed in DSM-5
Clinical Assessment, Diagnosis, and Treatment : 95
the previous DSMs (APA, 2013). For example, they conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. In addition, they gathered input from a wide range of experienced cli- nicians and researchers. They then developed a number of new diagnostic criteria and categories, expecting that the new criteria and categories were in fact reliable. Despite such efforts, some critics continue to have concerns about the procedures used in the development of DSM-5 (Wakefield, 2015; Brown et al., 2014; Frances, 2013). They worry, for example, that the framers failed to run a sufficient number of their own studies—in particular, field studies that test the merits of the new criteria and categories. In turn, the critics fear that DSM-5 may have retained several of the reliability problems that were on display in the past DSMs.
The validity of a classification system is the accuracy of the information that its diagnostic categories provide. Categories are of most use to clinicians when they demonstrate predictive validity—that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or excessive sleep. When clinicians give Franco a diagnosis of major depressive disorder, they expect that he may eventually develop sleep problems even if none are present now. In addition, they expect him to respond to treatments that are effective for other depressed persons. The more often such predictions are accurate, the greater a category’s predictive validity.
DSM-5’s framers tried to also ensure the validity of this new edition by conducting extensive reviews of research and consulting with numerous clinical advisors. As a result, its crite- ria and categories may have stronger validity than those of the earlier versions of the DSM. But, again, many clinical theorists worry that at least some of the criteria and categories in DSM-5 are based on weak research and that others may reflect gender or racial bias (Koukopoulos & Sani, 2014; Rhebergen & Graham, 2014). In fact, one important organization, the National Insti- tute of Mental Health (NIMH), has already concluded that the validity of DSM-5 is sorely lacking and is acting accordingly (Insel & Lieberman, 2013; Lane, 2013). The world’s largest funding agency for mental health research, NIMH has announced that it will no longer give financial support to clinical studies that rely exclusively on DSM-5 criteria.
Call for Change The effort to produce DSM-5 took more than a decade. After years of preliminary work, a DSM-5 task force and numerous work groups were formed in 2006, seeking to develop a DSM that addressed the limitations of previous DSM editions. Finally, in 2013, DSM-5, the new diagnostic and classification system, was published. The categories and criteria of DSM-5 are featured throughout this textbook (APA, 2013).
Some of the key changes in DSM-5 are the following:
➤ Adding a new category, “autism spectrum disorder,” that combines certain past categories such as “autistic disorder” and “Asperger’s syndrome” (see Chapter 14).
➤ Viewing “obsessive-compulsive disorder” as a problem that is different from the anxiety disorders and grouping it instead along with other obsessive- compulsive-like disorders such as “hoarding disorder,” “body dysmorphic disorder,” “trichotillomania” (hair-pulling disorder), and “excoriation (skin- picking) disorder” (see Chapter 4).
➤ Viewing “posttraumatic stress disorder” as a problem that is distinct from the anxiety disorders (see Chapter 5).
Wave of criticism Although researchers are still conducting studies to sort out the merits and problems of DSM‑5, many clinical theorists have already voiced criticism regard‑ ing its new categories, diagnostic criteria, and possible validity problems. Two outspoken and respected critics, clinicians Gary Greenberg and Allen Frances, have written the books The Book of Woe and Saving Normal.
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➤ Adding new categories, “disruptive mood dysregulation disorder,” “persistent depressive disorder,” and “premenstrual dysphoric disorder,” and grouping them with other kinds of depressive disorders (see Chapter 6).
➤ Adding a new category, “somatic symptom disorder” (see Chapter 8). ➤ Replacing the term “hypochondriasis” with the new term “illness anxiety disorder” (see Chapter 8).
➤ Adding a new category, “binge eating disorder” (see Chapter 9). ➤ Adding a new category, “substance use disorder,” that combines past categories “substance abuse” and “substance dependence” (see Chapter 10).
➤ Viewing “gambling disorder” as a problem that should be grouped as an addictive disorder alongside the substance use disorders (see Chapter 10).
➤ Replacing the term “gender identity disorder” with the new term “gender dysphoria” (see Chapter 11).
➤ Replacing the term “mental retardation” with the new term “intellectual disability” (see Chapter 14).
➤ Adding a new category, “specific learning disorder,” that combines past categories “reading disorder,” “mathematics disorder,” and “disorder of written expression” (see Chapter 14).
➤ Replacing the term “dementia” with the new term “neurocognitive disorder” (see Chapter 15).
➤ Adding a new category, “mild neurocognitive disorder” (see Chapter 15).
Can Diagnosis and Labeling Cause Harm? Even with trustworthy assessment data and reliable and valid classification catego- ries, clinicians will sometimes arrive at a wrong conclusion (Faust & Ahern, 2012; Trull & Prinstein, 2012). Like all human beings, they are flawed information pro- cessors. Studies show that they may be overly influenced by information gathered early in the assessment process. In addition, they may pay too much attention to certain sources of information, such as a parent’s report about a child, and too little to others, such as the child’s point of view. Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status, to
The power of labeling When looking at this late‑nineteenth‑century photograph of a base‑ ball team at the State Homeopathic Asylum for the Insane in Middletown, New York, most observers assume that the players are patients. As a result, they tend to “see” depression or confusion in the players’ faces and posture. In fact, the players are members of the asylum staff, some of whom even sought their jobs for the express purpose of playing for the hospital team. Eli
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New Pop Psychology Labels • “Online disinhibition effect” The ten-
dency of people to show less restraint when on the Internet (Sitt, 2013; Suler, 2004).
• “Drunkorexia” A diet fad, particularly among young women, in which the individual restricts food intake during the day so that she can party and get drunk at night without gaining weight from the alcohol (Archer, 2013).
Clinical Assessment, Diagnosis, and Treatment : 97
name just a few. Given the limitations of assessment tools, assessors, and classifica- tion systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals (Mitchell, 2010; Vickrey et al., 2010).
Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. As you read in Chapter 2, for example, many family-social theorists believe that diagnos- tic labels can become self- fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be perceived and reacted to correspond-
ingly. If others expect them to take on a sick role, they may begin to consider them- selves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Hansson et al., 2014). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relation- ships. Once a label has been applied, it may stick for a long time.
Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classifica- tion and diagnosis are critical to understanding and treating people in distress.
➤ Summing Up DIAgNOSIS After collecting assessment information, clinicians form a clinical picture and decide upon a diagnosis. The diagnosis is chosen from a classifica‑ tion system. The system used most widely in North America is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The most recent version of the DSM, known as DSM‑5, lists more than 500 disorders. DSM‑5 contains numerous additions and changes to the diagnostic categories, criteria, and organization found in past editions of the DSM. The reliability and validity of this revised diagnostic and classification system are currently receiving clinical review and, in some circles, criticism.
Even with trustworthy assessment data and reliable and valid classification categories, clinicians will not always arrive at the correct conclusion. They are human and so fall prey to various biases, misconceptions, and expectations. Another problem related to diagnosis is the prejudice that labels arouse, which may be damaging to the person who is diagnosed.
Treatment: How Might the Client Be Helped? Over the course of 10 months, Franco was treated for depression and related symp- toms. He improved considerably during that time, as the following report describes:
During therapy, Franco’s debilitating depression relented. Increasingly, he came to appreciate that his mother’s accusations against him—and his self-accusations—were not accurate. He also started to consider the possibility that Maria’s reluctance to commit to him had been more about where she was in her life than a sign that he was a terrible or inadequate person. Eventually, Maria and Franco talked again, al- though they did not renew their relationship. Franco felt better realizing that she did not hate him. She even told him that her mother had said some kind things about him after their breakup.
(continues on the next page)
B e t W e e n t h e L i n e s
Bands with Psychological Labels Pavlov’s Dog
Pink Freud
Alcoholics Unanimous
Widespread Panic
Madness
Obsession
Bad Brains
Placebo
Fear Factory
Mood Elevator
Neurosis
10,000 Maniacs
Grupo Mania
Unsane
Why are medical diagnoses
usually valued, while the use
of psychological diagnoses
is often criticized?
: chapter 398
Franco also managed to straighten out his problems at work. He explained his recent difficulties to his immediate supervisor at the bank and committed himself to improving his recent performance. His supervisor, with whom he had been friendly before his recent struggles, said she was glad that he was communicating openly and emphasized that he would be given the opportunity to improve his perfor- mance. He was surprised to hear how highly he had been regarded over the years, although as she put it, “Why would you have been promoted otherwise?”
Over the course of therapy, Franco also forced himself to spend more time hav- ing fun with his friends. He found his mood on the upswing as a result of these reestablished relationships. In addition, he began dating a woman he met through Jesse. He often considered the lessons he learned in treatment, trying to handle this new relationship in ways different from the destructive patterns of his past.
Clearly, treatment helped Franco, and by its conclusion he was a happier, more functional person than the man who had first sought help 10 months earlier. But how did his therapist decide on the treatment program that proved to be so helpful?
Treatment Decisions Franco’s therapist began, like all therapists, with assessment information and diagnostic decisions. Knowing the specific details and background of Franco’s problem (idiographic data) and combining this individual information with broad information about the nature and treatment of depression, the clinician arrived at a treatment plan for him.
Yet therapists may be influenced by additional factors when they make treat- ment decisions. Their treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy (Sharf, 2015). As therapists apply a favored model in case after case, they become more and more familiar with its prin- ciples and treatment techniques and tend to use them in work with still other clients.
Current research may also play a role. Most clinicians say that they value research as a guide to practice (Beutler et al., 1995). However, not all of them actually read research articles, so they cannot be directly influenced by them (Rivett, 2011; Stewart & Chambless, 2007). In fact, according to surveys, therapists gather much of their informa- tion about the latest developments in the field from colleagues, professional newsletters, workshops, conferences, Web sites, books, and the like (Simon, 2011; Corrie & Callanan, 2001). Unfortunately, the accuracy and usefulness of these sources vary widely.
To help clinicians become more familiar with and apply research findings, there is an ever-growing movement in North America, the United Kingdom, and else- where toward empirically supported, or evidence-based, treatment (Holt et al., 2015; Pope & Wedding, 2014). Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such information to clinicians. Critics of the movement worry that such efforts have thus far been simplistic, biased, and at times misleading ( Jager & Leek, 2013; Nairn, 2012). However, the empirically supported treatment movement has been gaining considerable momentum over the past decade.
The Effectiveness of Treatment Altogether, more than 400 forms of therapy are currently practiced in the clinical field (Wedding & Corsini, 2014). Naturally, the most important question to ask about each of them is whether it does what it is supposed to do. Does a particular treatment really help people overcome their psychological problems? On the sur- face, the question may seem simple. In fact, it is one of the most difficult questions for clinical researchers to answer.
▶▶ empirically supported treatment Therapy that has received clear research support for a particular disorder and has corresponding treatment guidelines. Also known as evidence-based treatment.
B e t W e e n t h e L i n e s
Famous Movie Clinicians Dr. Benjamin (Still Alice, 2014)
Dr. Banks (Side Effects, 2013)
Dr. Patel (Silver Linings Playbook, 2012)
Dr. Cawley (Shutter Island, 2010)
Dr. Steele (Changeling, 2008)
Dr. Rosen (A Beautiful Mind, 2001)
Dr. Crowe (The Sixth Sense, 1999)
Dr. Maguire (Good Will Hunting, 1997)
Dr. Lecter (The Silence of the Lambs, 1991)
Dr. Marvin (What About Bob?, 1991)
Dr. Sayer (Awakenings, 1990)
Dr. Sobel (Analyze This, 1999)
Dr. Berger (Ordinary People, 1980)
Dr. Dysart (Equus, 1977)
Nurse Ratched (One Flew Over the Cuckoo’s Nest, 1975)
Clinical Assessment, Diagnosis, and Treatment : 99
The first problem is how to define “success.” If, as Franco’s therapist implies, he still has much progress to make at the conclusion of therapy, should his recovery be considered suc- cessful? The second problem is how to measure improvement (Hunsley & Lee, 2014; Lambert, 2010). Should researchers give equal weight to the reports of clients, friends, relatives, thera- pists, and teachers? Should they use rating scales, inventories, therapy insights, observations, or some other measure?
Perhaps the biggest problem in determining the effective- ness of treatment is the variety and complexity of the treatments currently in use. People differ in their problems, personal styles, and motivations for therapy. Therapists differ in skill, experience, orientation, and personality. And therapies differ in theory, for- mat, and setting. Because an individual’s progress is influenced by all these factors and more, the findings of a particular study will not always apply to other clients and therapists.
Proper research procedures address some of these problems. By using control groups, random assignment, matched research participants, and the like, clinicians can draw certain conclu- sions about various therapies. Even in studies that are well designed, however, the variety and complexity of treatment limit the conclusions that can be reached (Kazdin, 2015, 2013, 2006).
Despite these difficulties, the job of evaluating therapies must be done, and clinical researchers have plowed ahead with it. Investigators have, in fact, conducted thousands of therapy outcome studies, studies that measure the effects of various treat- ments. The studies typically ask one of three questions: (1) Is therapy in general effective? (2) Are particular therapies generally effective? (3) Are particular therapies effective for particular problems?
Is Therapy Generally Effective? Studies suggest that therapy often is more helpful than no treatment or than placebos. A pioneering review examined 375 controlled studies, covering a total of almost 25,000 people seen in a wide assort- ment of therapies (Smith, Glass, & Miller, 1980; Smith & Glass, 1977). The review- ers combined the findings of these studies by using a special statistical technique called meta-analysis. According to this analysis, the average person who received treatment was better off than 75 percent of the untreated persons (see Figure 3-4). Other meta-analyses have found similar relationships between treatment and improvement (Sharf, 2015).
Some clinicians have concerned themselves with an important related question: Can therapy be harmful? A number of studies suggest that 5 to 10 percent of patients actually seem to get worse because of therapy (Lambert, 2010). Their symptoms may become more intense, or they may develop new ones, such as a sense of fail- ure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy (Lambert, 2010; Lambert et al., 1986).
Are Particular Therapies Generally Effective? The studies you have read about so far have lumped all therapies together to consider their general effec- tiveness. Many researchers, however, consider it wrong to treat all therapies alike. Some critics suggest that these studies are operating under a uniformity myth—a false belief that all therapies are equivalent despite differences in the therapists’ train- ing, experience, theoretical orientations, and personalities (Good & Brooks, 2005; Kiesler, 1995, 1966).
“Batman is getting more press than me.”
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figure 3-4 Does therapy help? Combining partici‑ pants and results from hundreds of studies, investigators have determined that the aver‑ age person who receives psychotherapy improves more than do 75 percent of all untreated people with similar problems. (Information from: Prochaska & Norcross, 2013; Lambert et al., 1993; Smith et al., 1980.)
: chapter 3100
Thus, an alternative approach examines the effectiveness of particular therapies. Most research of this kind shows each of the major forms of therapy to be superior to no treatment or to placebo treatment (Prochaska & Norcross, 2013). A number of other studies have compared particular therapies with one another and found that no one form of therapy generally stands out over all others (Luborsky et al., 2006, 2002, 1975).
If different kinds of therapy have similar successes, might they have something in common? People in the rapprochement movement have tried to identify a set of common factors, or common strategies, that may run through all effective therapies, regardless of the clinicians’ particular orientations (Sharf, 2015) (see InfoCentral on the next page). Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their clients are interacting, and try to promote self-mastery in their clients. In short, effective therapists of any type may practice more similarly than they preach.
Are Particular Therapies Effective for Particular Problems? People with different disorders may respond differently to the various forms of therapy (Norcross & Beutler, 2014; Beutler, 2011). In an oft-quoted statement, influential clinical theorist Gordon Paul said decades ago that the most appropriate question regarding the effectiveness of therapy may be “What specific treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (Paul, 1967, p. 111). Researchers have investigated how effec- tive particular therapies are at treating particular disorders, and they often have found sizable differences among the various therapies. Behavioral therapies, for example, appear to be the most effective of all in treating phobias (Antony, 2014), whereas drug therapy is the single most effective treatment for schizophrenia (Minzenberg et al., 2011).
As you read previously, studies also show that some clinical problems may respond better to combined approaches (Norcross & Beutler, 2014; Valencia et al., 2013). Drug therapy is sometimes combined with certain forms of psychotherapy, for example, to treat depression. In fact, it is now common for clients to be seen by two therapists—one of them a psychopharmacologist, a psychiatrist who pri- marily prescribes medications, and the other a psychologist, social worker, or other therapist who conducts psychotherapy.
Obviously, knowledge of how particular therapies fare with particular disorders can help therapists and clients alike make better decisions about treatment (Holt et al., 2015; Beutler, 2011, 2002, 2000). We will keep returning to this issue as we examine the various disorders throughout the book.
➤ SUMMING UP TREATMENT The treatment decisions of therapists may be influenced by assess‑ ment information, the diagnosis, the clinician’s theoretical orientation and famil‑ iarity with research, and the state of knowledge in the field. Determining the effectiveness of treatment is difficult. Nevertheless, therapy outcome studies have led to three general conclusions: (1) people in therapy are usually better off than people with similar problems who receive no treatment; (2) the various therapies do not appear to differ dramatically in their general effectiveness; and (3) certain therapies or combinations of therapies do appear to be more effec‑ tive than others for certain disorders. Some therapists currently advocate empir‑ ically supported treatment—the active identification, promotion, and teaching of those interventions that have received clear research support.
▶▶ rapprochement movement A movement to identify a set of common factors, or common strategies, that run through all successful therapies.
▶▶ psychopharmacologist A psychia- trist who primarily prescribes medications.
B e t W e e n t h e L i n e s
Contradictory Trends • Since 1998, the number of patients
receiving psychotherapy alone has fallen by 34 percent. The number receiving medication alone has increased by 23 percent.
• However, today’s patients express a three times greater preference for psychotherapy over medications (Gaudiano, 2013).
InfoCentral
COMMON FACTORS IN THERAPY The evidence-based treatment approach identifies the “specific therapies and techniques” that are most helpful for a particular disorder. In contrast, the common factors treatment approach
contends that successful therapies share common components that greatly inf luence the outcome of therapy. Both likely contribute to the success of treatment (Hofman & Barlow, 2014; Weinberger, 2014; Laska et al., 2013).
Common Factors There are three kinds of common factors that help contribute to a positive treatment outcome: client factors, therapist factors, and client-therapist relationship.
Client Factors: Strongly related to positive outcome High motivation High involvement
Moderately related to positive outcome Positive attitude Accurate expectation of what therapy
will be like Comfortable in close relationships Good interpersonal skills Nonperfectionism Openness
Therapist Factors: Moderately related to positive outcome Sense of well-being Training and experience Supervision during treatment Confidence about course of therapy
Client-Therapist Relationship: Strongly related to positive outcome Agreement on goals Collaboration Therapist empathizes with client Therapist offers accurate interpretations
Moderately related to positive outcome Therapist is positive, warm, and accepting toward client Therapist listens to, guides, and advises client Therapist gives mostly positive feedback to client Therapist manages own feelings toward client
Modestly related to positive outcome Therapist is genuine Therapist discloses information about self Therapist interprets relationship (a little bit)
(Duncan et al., 2010; Bachelor, 1988)
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What kind of empathy do clients want from their therapist? What do clients say is most important when choosing a therapist?
Despite conventional wisdom, research does not indicate that the following factors affect the outcome of therapy: the client’s gender, age, sexual orien- tation, or income; and the therapist’s gender, age, specific personality traits, or personal background.
15% 15%
30% 10%
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What Factors Contribute to Therapy Outcomes?
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Evidence-Based Treatments: High Batting Averages According to numerous studies, just about all of today’s leading treat- ments are highly effective for at least one psychological disorder.
(Davidson & Chan, 2014; Norcross, 2011; Cooper, 2008)
101
: chapter 3102
PuTTING IT...together Assessment and Diagnosis at a Crossroads In Chapter 2 you read that today’s leading models of abnormal behavior often dif- fer widely in their assumptions, conclusions, and treatments. It should not surprise you, then, that clinicians also differ considerably in their approaches to assessment and diagnosis. Yet when all is said and done, no single assessment technique stands out as superior to the rest. Each of the hundreds of available tools has major limitations, and each produces at best an incomplete picture of how a person is functioning and why.
In short, the present state of assessment and diagnosis argues against relying exclusively on any one approach. That is why the majority of today’s clinicians use batteries of assessment tools in their work. Some of these batteries provide invaluable information and guidance, as in the assessment of Alzheimer’s disease and certain other disorders that are particularly difficult to diagnose, as you shall see later in the book.
Attitudes toward clinical assessment have shifted back and forth over the past several decades. Before the 1950s, assessment was a highly regarded part of clinical practice. As the number of clinical models grew during the 1960s and 1970s, how- ever, followers of each model favored certain tools over others, and the practice of assessment became fragmented. Meanwhile, research began to reveal that a number of tools were inaccurate or inconsistent. In this atmosphere, many clinicians lost confidence in and abandoned systematic assessment and diagnosis.
Today, however, respect for assessment and diagnosis is on the rise once again. One reason for this renewal of interest is the development of more precise diag- nostic criteria. Another is the drive by researchers for more rigorous tests to help them select appropriate participants for clinical studies. Still another factor is the awareness in the clinical field that certain disorders can be properly identified only after careful assessment procedures. A final factor is the growing confidence in the field that brain-scanning techniques may soon offer assessment information about a wide range of psychological disorders.
Along with heightened respect for assessment and diagnosis has come increased research. Indeed, today’s researchers are carefully examining every major kind of assessment tool—from projective tests to personality inventories to scanning
procedures. This work is helping many clinicians per- form their work with more accuracy and consistency— welcome news for people with psychological problems.
Ironically, just as today’s clinicians and researchers are rediscovering systematic assessment, rising costs and economic factors may be conspiring to discourage the use of assessment tools. As you read in Chapter 1, insur- ance parity and treatment coverage for people with psy- chological problems are expected to improve as a result of recent federal parity laws and the Affordable Care Act (see pages 17–18). However, many experts fear that clinical testing procedures will continue to receive only limited insurance support. Which forces will ultimately have a stronger influence on clinical assessment and diagnosis—promising research or economic pressure? Only time will tell.
Finally, the practice of assessment and diagnosis of psychological disorders is expected to be affected tre- mendously by the use of DSM-5. Will this new edition of the classification system prove to be an improvement
Raising public awareness Believing that more public awareness about psychological disorders will lead to better assessment and treatment, the Gadsden Museum of Art in Gadsden, Alabama, sponsored an exhibit called “Heads Up Alabama! Psychology Promotes Healthy Living.” Artists designed 20 heads, including these two, to bring attention to psy‑ chological issues faced by children and adults.
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B e t W e e n t h e L i n e s
Believe It or Not By a strange coincidence, Hermann Rorschach’s young schoolmates gave him the nickname Klex, a variant of the German Klecks, which means “inkblot” (Schwartz, 1993).
Clinical Assessment, Diagnosis, and Treatment : 103
over past systems? Will it be embraced by more clinicians? Will it unite or divide the clinical field? What impact will DSM-5 have on the use of assessment procedures? The answers to these important questions should emerge soon, as current studies reach fruition and lead to journal publications. Clearly, the practice of clinical assess- ment and diagnosis is currently at a crossroads.
KEY TERMS idiographic understanding, p. 77
assessment, p. 77
standardization, p. 78
reliability, p. 78
validity, p. 78
clinical interview, p. 79
mental status exam, p. 80
clinical test, p. 81
projective test, p. 81
Rorschach test, p. 82
Thematic Apperception Test (TAT), p. 82
personality inventory, p. 84
Minnesota Multiphasic Personality Inventory (MMPI), p. 84
response inventories, p. 86
psychophysiological test, p. 86
neurological test, p. 88
EEG, p. 88
neuroimaging techniques, p. 88
CAT scan, p. 88
PET scan, p. 88
MRI, p. 88
fMRI, p. 88
neuropsychological test, p. 88
battery, p. 89
intelligence test, p. 89
intelligence quotient (IQ), p. 89
naturalistic observation, p. 89
analog observation, p. 89
self-monitoring, p. 89
diagnosis, p. 92
syndrome, p. 92
classification system, p. 93
DSM-5, p. 93
categorical information, p. 93
dimensional information, p. 94
empirically supported treatment, p. 98
therapy outcome study, p. 99
rapprochement movement, p. 100
common factors, p. 100
psychopharmacologist, p. 100
QuickQuiz
1. What forms of reliability and validity should clinical assessment tools display? pp. 78–79
2. What are the strengths and weaknesses of structured and unstructured interviews? pp. 80–81
3. List and describe today’s leading projective tests. pp. 82–83
4. What are the key features of the MMPI? pp. 84–85
5. What are the strengths and weaknesses of projective tests (p. 84), personality inventories (pp. 85–86), and other kinds of clinical tests (pp. 86–89)?
6. How do clinicians determine whether psychological problems are linked to brain damage? pp. 88–89
7. Describe the ways in which clinicians may make observations of clients’ behaviors. pp. 89–91
8. What is the purpose of clinical diagnoses? p. 92
9. Describe DSM-5. What problems may accompany the use of classification systems and the process of clinical diagnosis? pp. 93–95, 96–97
10. According to therapy outcome studies, how effective is therapy? pp. 99–100
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
Ed F
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T omas, a 25-year-old Web designer, was afraid that he was “losing his mind.” He had always been a worrier. He worried about his health, his girlfriend, his work, his social life, his future, his finances, and so on. Would his best friend get angry at him? Was his girlfriend tiring of him? Was he investing his money wisely?
Were his clients pleased with his work? But, lately, those worries had increased to an unbearable level. He was becoming consumed with the notion that something terrible was about to happen to him. Within an hour’s time, he might have intense concerns about going broke, developing cancer, losing one of his parents, offend- ing his friends, and more. He was certain that disaster awaited him at every turn. No amount of reassurance, from himself or from others, brought relief for very long.
He started therapy with Dr. Adena Morven, a clinical psychologist. Dr. Morven im- mediately noticed how disturbed Tomas appeared. He looked tense and frightened and could not sit comfortably in his chair; he kept tapping his feet and jumped when he heard traffic noise from outside the office building. He kept sighing throughout the visit, fidgeting and shifting his position, and he appeared breathless while telling Dr. Morven about his difficulties.
Tomas described his frequent inability to concentrate to the therapist. When design- ing client Web sites, he would lose his train of thought. Less than 5 minutes into a project, he’d forget much of his overall strategy. During conversations, he would begin a sentence and then forget the point he was about to make. TV watching had become impossible. He found it almost impossible to concentrate on anything for more than 5 minutes; his mind kept drifting away from the task at hand.
To say the least, he was worried about all of this. “I’m worried about being so wor- ried,” he told Dr. Morven, almost laughing at his own remark. At this point, Tomas expected the worst whenever he began a conversation, task, plan, or outing. If an event or interaction did in fact start to go awry, he would find himself overwhelmed with uncomfortable feelings—his heart would beat faster, his breathing would in- crease, and he’d sweat profusely. On some occasions, he thought he was actually having a heart attack—at the ripe old age of 25.
Typically, such physical reactions lasted but a matter of seconds. However, those few seconds felt like an eternity to Tomas. He acknowledged coming back down to earth after those feelings subsided—but, for him, “back down to earth” meant back to worrying and then worrying some more.
Dr. Morven empathized with Tomas about how upsetting this all must be. She asked him why he had decided to come into therapy now—as opposed to last year, last month, or last week. Tomas was able to pinpoint several things. First, all the wor- rying and anxiety seemed to be on the increase. Second, he was finding it hard to sleep. His nights were filled by tossing and turning—and, of course, more worrying. Third, he suspected that all of his worrying, physical symptoms, and lack of sleep were bad for his health. Wouldn’t they eventually lead to a major medical problem of some kind? And finally, his constant anxiety had begun to interfere with his life. Although his girlfriend and other acquaintances did not seem to realize how much he was suffering, he was growing weary of covering it all up. He found himself turn- ing down social invitations and work opportunities more and more. He had even quit his once-beloved weekly poker game. Not that staying home helped in any real way. He wondered how much longer he could go on this way.
Anxiety, Obsessive- Compulsive, and Related Disorders
4
T o p i c o v e r v i e w
Generalized Anxiety Disorder The Sociocultural Perspective: Societal and Multicultural Factors The Psychodynamic Perspective The Humanistic Perspective The Cognitive Perspective The Biological Perspective
Phobias Specific Phobias Agoraphobia What Causes Phobias? How Are Phobias Treated?
Social Anxiety Disorder What Causes Social Anxiety Disorder? Treatments for Social Anxiety Disorder
Panic Disorder The Biological Perspective The Cognitive Perspective
Obsessive-Compulsive Disorder What Are the Features of Obsessions and Compulsions? The Psychodynamic Perspective The Behavioral Perspective The Cognitive Perspective The Biological Perspective Obsessive-Compulsive-Related Disorders
Putting It Together: Diathesis-Stress in Action
: chapter 4106
You don’t need to be as troubled as Tomas to experience fear and anxiety. Think about a time when your breathing quickened, your muscles tensed, and your heart pounded with a sudden sense of dread. Was it when your car almost skidded off the road in the rain? When your professor announced a pop quiz? What about when the person you were in love with went out with someone else or your boss suggested that your job performance ought to improve? Any time you face what seems to be a serious threat to your well-being, you may react with the state of immediate alarm known as fear. Sometimes you cannot pinpoint a specific cause for your alarm, but still you feel tense and edgy, as if you expect something unpleasant to happen. The vague sense of being in danger is usually called anxiety, and it has the same features—the same increases in breathing, muscular tension, perspiration, and so forth—as fear.
Although everyday experiences of fear and anxiety are not pleasant, they often are use- ful. They prepare us for action—for “fight or flight”—when danger threatens. They may lead us to drive more cautiously in a storm, keep up with our reading assignments, treat our friends more sensitively, and work harder at our jobs. Unfortunately, some people suffer such dis- abling fear and anxiety that they cannot lead normal lives. Their discomfort is too severe or too frequent, lasts too long, or is triggered too easily. These people are said to have an anxiety disorder or a related kind of disorder.
Anxiety disorders are the most common mental disorders in the United States. In any given year around 18 percent of the adult population suffer from one or another of the anxiety disorders identified by DSM-5, while close to 29 percent of all people develop one of the disorders at some point in their lives (Kessler et al., 2012, 2010, 2009; Daitch, 2011). Only around one-fifth of these individuals seek treatment (Wang et al., 2005).
People with generalized anxiety disorder experience general and persistent feelings of worry and anxiety. People with specific phobias have a persistent and irrational fear of a particular object, activity, or situation. People with agoraphobia fear traveling to public places such as stores or movie theaters. Those with social anxiety disorder are intensely afraid of social or performance situations in which they may become embarrassed. And people with panic disorder have recurrent attacks of terror. Most individuals with one anxiety disorder suffer from a second one as well (Leyfer et al., 2013; Merikangas & Swanson, 2010) (see Figure 4-1). Tomas, for example, has the excessive worry found in generalized anxiety disorder and the repeated attacks of terror that mark panic disorder. In addition, many of those with an anxiety disorder also experience depression (Starr et al., 2014).
Anxiety also plays a major role in a different group of problems, called obsessive- compulsive and related disorders. People with these disorders feel overrun by recurrent thoughts that cause anxiety or by the need to perform certain repetitive actions to reduce anxiety. Because anxiety is so prominent in these disorders, they will be examined in this chapter along with the anxiety disorders.
Generalized Anxiety Disorder People with generalized anxiety disorder experience excessive anxiety under most circumstances and worry about practically anything. In fact, their problem is sometimes described as free-floating anxiety. Like the young Web designer Tomas, they typically feel restless, keyed up, or on edge; tire easily; have difficulty concentrating; suffer from muscle tension; and have sleep problems (see Table 4-1). The symptoms last at least 6 months (APA, 2013). Nevertheless, most people with the disorder are able, although with some difficulty, to carry on social relationships and job activities.
Two or more anxiety disorders, one caused by the other (55%)
Two or more independent anxiety disorders (26%)
One anxiety disorder only (19%)
figure 4-1 Does anxiety beget anxiety? People with one anxiety disorder usually experience another as well, either simultaneously or at another point in their lives. (Information from: Merikangas & Swanson, 2010; Ruscio et al., 2007; Rodriguez et al., 2004; Hunt & Andrews, 1995.)
If fear is so unpleasant, why
do many people seek out
the feelings of fear brought
about by amusement park
rides, scary movies, bungee
jumping, and the like?
▶▶ fear The central nervous system’s physiological and emotional response to a serious threat to one’s well-being.
▶▶ anxiety The central nervous system’s physiological and emotional response to a vague sense of threat or danger.
▶▶ generalized anxiety disorder A disorder marked by persistent and exces- sive feelings of anxiety and worry about numerous events and activities.
Anxiety, Obsessive-Compulsive, and Related Disorders : 107
Generalized anxiety disorder is common in Western society. Surveys suggest that as much as 4 percent of the U.S. population has the symptoms of this disorder in any given year, a rate that holds across Canada, Britain, and other Western countries (Kessler et al., 2012, 2010; Ritter et al., 2010). Altogether, more than 6 percent of all people develop generalized anxiety disorder sometime during their lives. It may emerge at any age, but usually it first appears in childhood or adolescence. Women diagnosed with the disorder outnumber men 2 to 1. Around one-quarter of the people who have generalized anxiety disorder are currently in treatment (NIMH, 2011; Wang et al., 2005).
A variety of factors have been cited to explain the development of this disorder. Here you will read about the views and treatments offered by the sociocultural, psychodynamic, humanistic, cognitive, and biological models. We will examine the behavioral perspective when we turn to phobias later in the chapter because that model approaches generalized anxiety disorder and phobias in basically the same way.
The Sociocultural Perspective: Societal and Multicultural Factors According to sociocultural theorists, generalized anxiety disorder is most likely to develop in people who are faced with ongoing societal conditions that are danger- ous. Studies have found that people in highly threatening environments are indeed more likely to develop the general feelings of tension, anxiety, and fatigue and the sleep disturbances found in this disorder (Slopen et al., 2012).
Take, for example, a classic study that was done on the psychological impact of living near the Three Mile Island nuclear power plant after the nuclear reactor accident of March 1979 (Baum et al., 2004; Wroble & Baum, 2002). In the months following the accident, local mothers of preschool children were found to display five times as many anxiety or depression disorders as mothers living elsewhere. Although the number of disorders decreased during the next year, the Three Mile Island mothers still displayed high levels of anxiety or depression a year later. Simi- larly, studies conducted more recently have found that in the months and years fol- lowing Hurricane Katrina in 2005 and the Haitian earthquake in 2010, the rate of generalized and other anxiety disorders was twice as high among area residents who lived through the disasters as among unaffected persons living elsewhere (Cénat & Derivois, 2015; Shultz et al., 2012; Galea et al., 2007).
One of the most powerful forms of societal stress is poverty. People without finan- cial means are likely to live in rundown communities with high crime rates, have fewer educational and job opportunities, and run a greater risk for health problems (Moore, Radcliffe, & Liu, 2014). As sociocultural theorists would predict, such people also have a higher rate of generalized anxiety disorder (McLaughlin et al., 2012). In the United States, the rate is almost twice as high among people with low incomes as among those with higher incomes (Sareen et al., 2011). As wages decrease, the rate of generalized anxiety disorder steadily increases (see Table 4-2 on the next page).
Since race is closely tied to stress in the United States (related to discrimination, low income, and reduced job opportunities), it is not surprising that it too is sometimes tied to the prevalence of generalized anxiety disorder (Sibrava et al., 2013; Soto et al., 2011). In any given year, African Americans are 30 percent more likely than white Americans to suffer from this disorder. Moreover, although researchers have not consistently found a heightened rate of generalized anxiety disorder among Hispanic Americans, they have noted
table: 4-1
Dx Checklist Generalized Anxiety Disorder 1. For six months or more, person
experiences disproportionate, uncontrollable, and ongoing anxiety and worry about multiple matters.
2. The symptoms include at least three of the following: edginess, fatigue, poor concentration, irritability, muscle tension, sleep problems.
3. Significant distress or impairment.
Information from: APA, 2013.
The role of society Bishop Richard Garcia hugs the father of a 6-year-old child who was killed by a stray bullet fired by gang members outside his house. People who live in danger- ous environments experience greater anxiety and have a higher rate of generalized anxiety disorder than those who live in other settings.
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that many Hispanics in both the United States and Latin America suffer from nervios (“nerves”), a pattern that bears great similarity to generalized anxiety disorder (López & Guarnaccia, 2005, 2000). People with nervios experience enormous emotional distress, somatic symptoms such as headaches and stomachaches, so-called brain aches marked by poor concentration and nervousness, and symptoms of irritability, tearfulness, and trembling.
Although poverty and various societal and cultural pressures may help create a climate in which generalized anxiety disorder is more likely to develop, socio- cultural variables are not the only factors at work. After all, most people in poor or dangerous environments do not develop this disorder. Even if sociocultural factors play a broad role, theorists still must explain why some people develop the disorder and others do not. The psychodynamic, humanistic-existential, cognitive, and biological schools of thought have all tried to explain why and have offered corresponding treatments.
The Psychodynamic Perspective Sigmund Freud (1933, 1917) believed that all children experience some degree of anxiety as part of growing up and that all use ego defense mechanisms to help control such anxiety (see pages 45–47). Children feel realistic anxiety when they face actual danger; neurotic anxiety when they are repeatedly prevented, by parents or by circumstances, from expressing their id impulses; and moral anxiety when they are punished or threatened for expressing their id impulses. According to Freud, some children have particularly high levels of such anxiety, or their defense mechanisms are particularly inadequate, and these individuals may develop generalized anxiety disorder.
Psychodynamic Explanations: When Childhood Anxiety Goes Unresolved According to Freud, when a child is overrun by neurotic or moral anxiety, the stage is set for generalized anxiety disorder. Early developmental experi- ences may produce an unusually high level of anxiety in such a child. Say that a boy is spanked every time he cries for milk as an infant, messes his pants as a 2-year- old, and explores his genitals as a toddler. He may eventually come to believe that
Eye on Culture:
Prevalence of Anxiety Disorders and Obsessive-Compulsive Disorder (Compared to Rate in Total Population)
Female Low Income
African American
Hispanic American Elderly
Generalized anxiety disorder Higher Higher Higher Same Higher
Specific phobias Higher Higher Higher Higher Lower
Agoraphobia Higher Higher Same Same Higher
Social anxiety disorder Higher Higher Higher Lower Lower
Panic disorder Higher Higher Same Same Lower
Obsessive-compulsive disorder Same Higher Same Same Lower
Information from: Polo et al., 2011; Sareen et al., 2011; Bharani & Lantz, 2008; Hopko et al., 2008; Nazarian & Craske, 2008; Schultz et al., 2008.
table: 4-2
B e t w e e n t h e L I n e s
Google’s Most Searched Symptoms 1. Pregnancy symptoms
2. Influenza symptoms
3. Diabetes symptoms
4. Anxiety symptoms
5. Thyroid symptoms
(Sifferlin, 2013)
Anxiety, Obsessive-Compulsive, and Related Disorders : 109
his various id impulses are very dangerous, and he may feel overwhelming anxiety whenever he has such impulses.
Alternatively, a child’s ego defense mechanisms may be too weak to cope with even normal levels of anxiety. Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms. When they face the pressures of adult life, their defense mechanisms may be too weak to cope with the resulting anxieties.
Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation for generalized anxiety disorder. Most continue to believe, however, that the disorder can be traced to inadequacies in the early relationships between children and their parents (Sharf, 2015). Researchers have tested the psychodynamic explanations in various ways. In one strategy, they have tried to show that people with generalized anxiety disorder are particularly likely to use defense mechanisms. For example, one team of investigators examined the early therapy transcripts of patients with this diagnosis and found that the patients often reacted defensively. When asked by therapists to discuss upsetting experiences, they would quickly forget (repress) what they had just been talking about, change the direction of the discussion, or deny having negative feelings (Luborsky, 1973).
In another line of research, investigators have studied people who as children suffered extreme punishment for id impulses. As psychodynamic theorists would predict, these people have higher levels of anxiety later in life (Busch et al., 2010; Chiu, 1971). In addition, several studies have supported the psychodynamic position that extreme protectiveness by parents may often lead to high levels of anxiety in their children (Manfredi et al., 2011; Hudson & Rapee, 2004).
Although these studies are consistent with psychodynamic explanations, some scientists question whether they show what they claim to show. When people have difficulty talking about upsetting events early in therapy, for example, they are not necessarily repressing those events. They may be focusing purposely on the positive aspects of their lives, or they may be too embarrassed to share personal negative events until they develop trust in the therapist.
Psychodynamic Therapies Psychodynamic therapists use the same general techniques to treat all psychological problems: free association and the therapist’s interpretations of transference, resistance, and dreams. Freudian psychodynamic therapists
“Since my mother was rarely home, I guess I blame my nanny.”
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Insecurity, Adult Style Children may cling to blankets or cud- dly toys to feel more secure. Adults, too, may hug a beloved object in order to relax: 1 in 5 women and 1 in 20 men admit to sleeping with a stuffed animal on a regular basis (Kanner, 1995).
B e t w e e n t h e L I n e s
Young Dreams Studies indicate that infants who are generally anxious or “difficult” are more likely than other infants to later experi- ence nightmares throughout their child- hood (Simard et al., 2008).
: chapter 4110
use these methods to help clients with generalized anxiety disorder become less afraid of their id impulses and more successful in controlling them. Other psycho- dynamic therapists, particularly object relations therapists, use them to help anxious patients identify and settle the childhood relationship problems that continue to produce anxiety in adulthood (Blass, 2014; Lucas, 2006).
Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with generalized anxiety disorder (Craske, 2010). An excep- tion to this trend is short-term psychodynamic therapy (see Chapter 2), which has in some cases significantly reduced the levels of anxiety, worry, and social difficulty of patients with this disorder (Bressi et al., 2014; Salzer et al., 2011).
The Humanistic Perspective Humanistic theorists propose that generalized anxiety disorder, like other psycholog- ical disorders, arises when people stop looking at themselves honestly and acceptingly. Repeated denials of their true thoughts, emotions, and behavior make these people extremely anxious and unable to fulfill their potential as human beings.
The humanistic view of why people develop this disorder is best illustrated by Carl Rogers’ explanation. As you saw in Chapter 2, Rogers believed that children who fail to receive unconditional positive regard from others may become overly criti- cal of themselves and develop harsh self-standards, what Rogers called conditions of worth. They try to meet these standards by repeatedly distorting and denying their true thoughts and experiences. Despite such efforts, however, threatening self- judgments keep breaking through and causing them intense anxiety. This onslaught of anxiety sets the stage for generalized anxiety disorder or some other form of psychological dysfunctioning.
Practitioners of Rogers’ treatment approach, client-centered therapy (also called person-centered therapy), try to show unconditional positive regard for their clients and to empathize with them. The therapists hope that an atmosphere of genuine acceptance and caring will help clients feel secure enough to recognize their true needs, thoughts, and emotions. When clients eventually are honest and comfortable with themselves, their anxiety or other symptoms will subside. In the following excerpt, Rogers describes the progress made by a client with anxiety and related symptoms:
Therapy was an experiencing of her self, in all its aspects, in a safe relationship . . . the experiencing of self as having a capacity for wholeness . . . a self that cared about others. This last followed . . . the realization that the therapist cared, that it really mattered to him how therapy turned out for her, that he really valued her. . . . She gradually became aware of the fact that . . . there was nothing fundamentally bad, but rather, at heart she was positive and sound.
(Rogers, 1954, pp. 261–264)
Despite such optimistic case reports, controlled studies have failed to offer strong support for this approach. Although research does suggest that client-centered therapy is usually more helpful to anxious clients than no treatment, the approach is only sometimes superior to placebo therapy (Prochaska & Norcross, 2013, 2006, 2003). In addition, researchers have found, at best, only limited support for Rogers’ explanation of generalized anxiety disorder and other forms of abnor- mal behavior. Nor have other humanistic theories and treatment received much research support.
▶▶ client-centered therapy The humanistic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately, and conveying genuineness. Also known as person-centered therapy.
▶▶ basic irrational assumptions The inaccurate and inappropriate beliefs held by people with various psychological problems, according to Albert Ellis.
B e t w e e n t h e L I n e s
Needless Worries 60 Percentage of things people
worry about that will never occur
30 Percentage of past, unchangeable events that people worry about
88 Percentage of health-related things people worry about that will not occur
90 Percentage of things people worry about that are objectively considered insignificant
(NIMh, 2012)
Anxiety, Obsessive-Compulsive, and Related Disorders : 111
The Cognitive Perspective Followers of the cognitive model suggest that psychological problems are often caused by dysfunctional ways of thinking (see PsychWatch on page 113). Given that excessive worry—a cognitive symptom—is a key characteristic of generalized anxi- ety disorder (see Figure 4-2), it is not surprising that cognitive theorists have had much to say about the causes of and treatments for this particular disorder.
Maladaptive Assumptions Initially, cognitive theorists suggested that gen- eralized anxiety disorder is primarily caused by maladaptive assumptions, a notion that continues to be influential. Albert Ellis, for example, proposed that many people are guided by irrational beliefs that lead them to act and react in inappropriate ways (Ellis, 2014, 2002, 1962). Ellis called these basic irrational assumptions, and he claimed that people with generalized anxiety disorder often hold the following ones:
“It is a dire necessity for an adult human being to be loved or approved of by virtually every significant other person in his community.”
“It is awful and catastrophic when things are not the way one would very much like them to be.”
“If something is or may be dangerous or fearsome, one should be terribly con- cerned about it and should keep dwelling on the possibility of its occurring.”
“One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile.”
(Ellis, 1962)
When people who make these assumptions are faced with a stressful event, such as an exam or a first date, they are likely to interpret it as dangerous, to overreact, and to feel fear. As they apply the assumptions to more and more events, they may begin to develop generalized anxiety disorder.
Similarly, cognitive theorist Aaron Beck argued that people with generalized anxiety disorder constantly hold silent assumptions (for example, “A situation or a person is unsafe until proven to be safe” or “It is always best to assume the worst”) that imply they are in imminent danger (Clark & Beck, 2012, 2010; Beck & Emery, 1985). Since the time of Ellis’ and Beck’s initial proposals, researchers have repeat- edly found that people with generalized anxiety disorder do indeed hold maladap- tive assumptions, particularly about dangerousness (Clark & Beck, 2012, 2010).
New-Wave Cognitive Explanations In recent years, several new expla- nations for generalized anxiety disorder, sometimes called the new-wave cognitive explanations, have emerged. Each of them builds on the work of Ellis and Beck and
their emphasis on danger. The metacognitive theory, developed by researcher
Adrian Wells (2014, 2011, 2005), suggests that peo- ple with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying. On the positive side, they believe that worrying is a useful way of appraising and coping with threats in life. And so they look for and examine all possible
signs of danger—that is, they worry constantly. At the same time, Wells argues, people with generalized anxiety disorder also
hold negative beliefs about worrying, and these negative attitudes are the ones that open the door to the disorder. Because society teaches them that worrying is a bad thing, they come to believe that their repeated worrying is in fact harmful (men- tally and physically) and uncontrollable. Now they further worry about the fact that they always seem to be worrying (so-called meta-worries). Their meta-worries may
9% worry 2 hours or more
11% worry 1–2 hours
38% worry 1–10 minutes
24% worry less than 1 minute
18% worry 10–60 minutes
figure 4-2 How long do your worries last? In one survey, 62 percent of college students said they spend less than 10 minutes at a time worrying about something. In contrast, 20 percent worry for more than an hour. (Information from: Tallis et al., 1994.)
why might many people
believe, at least implicitly,
that worrying is useful—
even necessary—for
problems to work out?
: chapter 4112
include concerns that they are going crazy with worry, making themselves ill with worry, and losing out in life because of worrying. The net effect of all this worrying: generalized anxiety disorder.
This explanation has received considerable research support. Studies indicate, for example, that people who generally hold both positive and negative beliefs about worrying are particularly prone to developing generalized anxiety disorder and that repeated meta-worrying is a powerful predictor of developing the disorder (Wells, 2014, 2011, 2005).
According to another new explanation for generalized anxiety disorder, the intolerance of uncertainty theory, certain individuals cannot tolerate the knowledge that negative events may occur, even if the possibility of occurrence is very small. Inasmuch as life is filled with uncertain events, these individuals worry constantly that such events are about to occur. Such intolerance and worrying leave them highly vulnerable to the development of generalized anxiety disorder (Dugas et al., 2012, 2010, 2004; Fisher & Wells, 2011). Think of when you meet someone you’re attracted to and how you then feel prior to texting or calling call him or her for the first time—or how you feel while you’re waiting for that person to contact you for the first time. The worry that you experience in such instances—the sense of sometimes unbearable uncertainty over the possibility of an unacceptable negative outcome—is, according to this theory, how people with generalized anxiety disor- der feel all the time.
Proponents of this theory believe people with generalized anxiety disorder keep worrying and worrying in their efforts to find “correct” solutions for various situa- tions in their lives and to restore certainty to the situations. However, because they can never really be sure that a given solution is a correct one, they are always left to grapple with intolerable levels of uncertainty, triggering new rounds of worrying and new efforts to find correct solutions. Like the metacognitive theory of worry, con- siderable research supports this theory. Studies have found, for example, that people with generalized anxiety disorder display higher levels of intolerance of uncertainty than people with normal degrees of anxiety (Dugas et al., 2012, 2004).
Finally, a third new explanation for generalized anxiety disorder, the avoidance theory, developed by researcher Thomas Borkovec, suggests that people with this disorder have greater bodily arousal (higher heart rate, perspiration, respiration) than other people and that worrying actually serves to reduce this arousal, perhaps by distracting the individuals from their unpleasant physical feelings (Liera & Newman, 2014; Borkovec et al., 2004). In short, the avoidance theory holds that people with generalized anxiety disorder worry repeatedly in order to reduce or avoid uncomfort- able states of bodily arousal. When, for example, they find themselves in an uncomfortable job situation or social relationship, they implicitly choose to intellectualize (that is, worry about) losing their job or losing their friend rather than having to stew in a state of intense negative arousal. The wor- rying serves as a quick, though ultimately maladaptive, way of coping with unpleasant bodily states.
Borkovec’s explanation has also been supported by numerous studies. Research reveals that people with generalized anxiety disorder experience particularly fast and intense bodily reactions, find such reactions over- whelming and unpleasant, worry more than other people upon becoming aroused, and successfully reduce their arousal whenever they worry (Liera & Newman, 2014; Hirsch et al., 2012).
Cognitive Therapies Two kinds of cognitive approaches are used in cases of generalized anxiety disorder. In one, based on the pioneering work of Ellis and Beck, therapists help clients change the maladaptive assumptions that characterize their disorder. In the other, new-wave cognitive therapists
Worry-free workers This famous Bill Jones motivational poster, displayed in workplaces throughout the United States in the 1920s, reflects the view of today’s new-wave cognitive theorists—that worrying is a dysfunctional pro- cess that can be brought under control.
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▶▶ rational-emotive therapy A cogni- tive therapy developed by Albert Ellis that helps clients identify and change the irrational assumptions and thinking that help cause their psychological disorder.
Anxiety, Obsessive-Compulsive, and Related Disorders : 113
help clients to understand the special role that worrying may play in their disorder and to change their views about and reactions to worrying.
Changing Maladaptive assuMptions In Ellis’ technique of rational-emotive therapy, therapists point out the irrational assumptions held by clients, suggest more appropriate assumptions, and assign homework that gives the clients practice at chal- lenging old assumptions and applying new ones (Ellis, 2014, 2008, 2005). Studies suggest that this approach and similar cognitive approaches bring at least modest relief to those suffering from generalized anxiety (Clark & Beck, 2012, 2010). Ellis’ approach is illustrated in the following discussion between him and an anxious client who fears failure and disapproval at work, especially over a testing procedure that she has developed for her company:
PsychWatch
P eople with anxiety disorders have many unreasonable fears, but mil-lions of other people, too, worry about disaster every day. Most of the catastrophes they fear are not probable. Perhaps the ability to live by laws of prob- ability rather than possibility is what sepa- rates the fearless from the fearful. What are the odds, then, that commonly feared events will happen? The range of prob- ability is wide, but the odds are usually heavily in our favor.
A city resident will be a victim of a violent crime: 1 in 237
A suburbanite will be a victim of a violent crime: 1 in 408
A child will suffer a high-chair injury this year: 1 in 6,000
The IRS will audit you this year: 1 in 100
You will be murdered this year: 1 in 20,000
You will be a victim of burglary this year: 1 in 35
You will be a victim of robbery this year: 1 in 885
You will be killed on your next bus ride: 1 in 500 million
You will be hit by a baseball at a major- league game: 1 in 42,000
You will drown in the tub this year: 1 in 685,000
Your house will have a fire this year: 1 in 200
Your carton will contain a broken egg: 1 in 10
You will develop a tooth cavity: 1 in 6
You will contract AIDS from a blood trans- fusion: 1 in 286,000
You will die in a tsunami: 1 in 500,000
You will be attacked by a shark: 1 in 4 million
You will receive a diagnosis of cancer this year: 1 in 8,000
A woman will develop breast cancer dur- ing her lifetime: 1 in 8
A piano player will eventually develop lower back pain: 1 in 3
You will be killed on your next automobile outing: 1 in 4 million
Condom use will eventually fail to prevent pregnancy: 1 in 8
An IUD will eventually fail to prevent pregnancy: 1 in 167
Coitus interruptus will eventually fail to prevent pregnancy: 1 in 5
You will die as a result of a lightning strike: 1 in 10 million
(Information from: FBI, 2014; Glovin, 2014; CDC, 2013; Quillian & Pager, 2012; Britt, 2005)
Fears, Shmears: The odds Are Usually on our Side
Watch out! The statistical chance of being hit by a foul ball at a major league baseball game is 1 in 42,000. But try telling that to these fans.
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Client: I’m so distraught these days that I can hardly concentrate on anything for more than a minute or two at a time. My mind just keeps wandering to that damn testing procedure I devised, and that they’ve put so much money into; and whether it’s going to work well or be just a waste of all that time and money. . . .
Ellis: Point one is that you must admit that you are telling yourself something to start your worrying going, and you must begin to look, and I mean really look, for the specific nonsense with which you keep reindoctrinating your- self. . . . The false statement is: “If, because my testing procedure doesn’t work and I am functioning inefficiently on my job, my co-workers do not want me or approve of me, then I shall be a worthless person.” . . .
Client: But if I want to do what my firm also wants me to do, and I am useless to them, aren’t I also useless to me?
Ellis: No—not unless you think you are. You are frustrated, of course, if you want to set up a good testing procedure and you can’t. But need you be des- perately unhappy because you are frustrated? And need you deem yourself completely unworthwhile because you can’t do one of the main things you want to do in life?
(Ellis, 1962, pp. 160–165)
Breaking down worrying Alternatively, some of today’s new-wave cognitive therapists specifically guide clients with generalized anxiety disorder to recognize and change their dysfunctional use of worrying (Wells, 2014, 2010; Newman et al., 2011). They begin by educating the clients about the role of worrying in their disorder and have them observe their bodily arousal and cognitive responses across various life situations. In turn, the clients come to appreciate the triggers of their worrying, their misconceptions about worrying, and their misguided efforts to control their lives by worrying. As their insights grow, clients are expected to see
the world as less threatening (and so less arousing), try out more constructive ways of dealing with arousal, and worry less about the fact that they worry so much. Research has begun to indicate that a concentrated focus on worrying is indeed a helpful addition to the traditional cognitive treatment for generalized anxiety disorder (Wells, 2014, 2011, 2010).
Treating individuals with generalized anxiety dis- order by helping them to recognize their inclination to worry is similar to another cognitive approach that has gained popularity in recent years. The approach, mindfulness-based cognitive therapy, was developed by psy- chologist Steven Hayes and his colleagues as part of their broader treatment approach called acceptance and commitment therapy (Hayes et al., 2013). Here therapists
help clients to become aware of their streams of thoughts, including their wor- ries, as they are occurring and to accept such thoughts as mere events of the mind. By accepting their thoughts rather than trying to eliminate them, the clients are expected to be less upset and affected by them.
Mindfulness-based cognitive therapy has also been applied to a range of other psychological problems, such as depression, posttraumatic stress disorder, personal- ity disorders, and substance use disorders, often with promising results (Roemer & Orsillo, 2014). This cognitive approach borrows heavily from a form of meditation called mindfulness meditation, which teaches people to pay attention to the thoughts and feelings that flow through their mind during meditation and to accept such thoughts in a nonjudgmental way (see InfoCentral on the next page).
Fearful delights Many people enjoy the feeling of fear as long as it occurs under controlled circumstances, as when they are safely watching the tension grow in the hugely popular series of movies Paranormal Activity 1, 2, 3, and 4 (plus the Latino-oriented spinoff Paranormal Activity: The Marked Ones), among the most profitable films ever made. In this shot from a scene in the first film, the lead character Katie tries to escape a supernatural presence in her house.
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MINDFULNESS Over the past decade, mindfulness has become one of the most common terms in psychology. Mindfulness involves being in the present moment, intentionally and nonjudgmentally. Mindfulness
training programs use mindfulness meditation techniques to help treat people suffering from pain, anxiety disorders, and depres- sive disorders, as well as a variety of other psychological disorders.
Why Do People Seek Out Mindfulness? “Cell phones, texting, social networking, emailing, etc., easily distract me from what I’m doing.”
RESEARCH- SUPPORTED EFFECTS OF MINDFULNESS Mindfulness appears to
• improve control over anxiety and related emotions (amygdala)
• promote more peaceful sleep
• improve functioning of the autonomic nervous system
• produce alpha rhythm brain waves tied to an alert, but non- anxious, mental state
• improve functioning of the thalamus, which heightens sensory signaling and consciousness
Millennials Gen Xers Boomers
Total Adults
61% 46%
32%
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MINDFULNESS TRAINING PROGRAMS -non ,lanoitnetni fo etats a gniveihca fo laog eht evaH •
judgmental attention on the present.
attention to body sensations
attention to breathing sensations
attention to wandering and busy thoughts
simple yoga
homework assignments (practice and journal keeping)
(Noonan, 2014; Russell, 2014; Chan, 2013; Kerr et al., 2013; Plaza et al., 2013)
• Help reduce the anxiety found in . . .
generalized anxiety disorder social anxiety disorder
panic disorder test anxiety
illness anxiety depressive disorder with anxious distress
(Kraemer et al., 2014; Hoge et al., 2013; Kerr et al., 2013; Khoury et al., 2013; Carlson, 2012; Cunha & Paiva, 2012)
• Help treat other disorders, including:
pain conditions PTSD and other stress disorders
depressive disorders obsessive-compulsive disorder
substance use disorders borderline personality disorder
(Kerr et al., 2013; King et al., 2013; Hanstede et al., 2008)
• lower stress
• improve decision- making under stress ( frontal cortex)
• heighten attention (basal ganglia)
• improve working memory and verbal
reasoning ( frontal cortex and hippocampus)
• improve functioning of the immune system
• increase enjoyment and cisum fo ecneirepxe
• decrease feelings of loneliness among elderly people
Amount that U.S. adults spend on mind-
fulness programs each year $8 billion
Number of certi�ed
instructors around the world in
desa b-ssenlufdnim stress reduction
1,000
8 weeks of instruction
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MINDFUL LIFE STRATEGIES
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Percentage of the U.S. popula- tion that practice
mindfulness medita- tion techniques
10% Number
of medical schools in North
America that teach mindfulness
>100 Number
of scienti�c papers and books on
mindfulness 9,300
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: chapter 4116
The Biological Perspective Biological theorists believe that generalized anxiety disorder is caused chiefly by biological factors. For years this claim was supported primarily by family pedi- gree studies, in which researchers determine how many and which relatives of a person with a disorder have the same disorder. If biological tendencies toward gen- eralized anxiety disorder are inherited, people who are biologically related should have similar probabilities of developing this disorder. Studies have in fact found that biological relatives of persons with generalized anxiety disorder are more likely than nonrelatives to have the disorder also (Schienle et al., 2011). Approximately 15 percent of the relatives of people with the disorder display it themselves—a much higher prevalence rate than that found in the general population. And the closer the relative (an identical twin, for example), the greater the likelihood that he or she will also have the disorder.
Biological Explanations: GABA Inactivity In recent decades, impor- tant discoveries by brain researchers have offered clearer evidence that generalized anxiety disorder is related to biological factors (Bergado-Acosta et al., 2014; Craig & Chamberlain, 2010). One of the first such discoveries was made in the 1950s, when researchers determined that benzodiazepines, the family of drugs that includes alprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium), provide relief from anxiety. At first, no one understood why benzodiazepines reduce anxiety. Eventually, however, the development of radioactive techniques enabled researchers to pinpoint the exact sites in the brain that are affected by benzodiazepines (Mohler & Okada, 1977). Apparently certain neurons have receptors that receive the benzodiazepines, just as a lock receives a key.
Investigators soon discovered that these benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA), a common neurotransmitter in the brain. As you read in Chapter 2, neurotransmitters are chemicals that carry mes- sages from one neuron to another. GABA carries inhibitory messages: when GABA is received at a receptor, it causes the neuron to stop firing.
On the basis of such findings, biological researchers eventually pieced together several scenarios of how fear reactions may occur. A leading one began with the notion that in normal fear reactions, key neurons throughout the brain fire more rapidly, triggering the firing of still more neurons and creating a general state of excitability throughout the brain and body. Perspiration, breathing, and muscle tension increase. This state is experienced as fear or anxiety. Continuous firing of neurons eventually triggers a feedback system—that is, brain and body activities that reduce the level of excitability. Some neurons throughout the brain release the neurotransmitter GABA, which then binds to GABA receptors on certain neurons and instructs those neurons to stop firing. The state of excitability ceases, and the experience of fear or anxiety subsides (Atack, 2010; Costa, 1985, 1983).
Some researchers have concluded that a malfunction in this feedback system can cause fear or anxiety to go unchecked (Salari et al., 2015; Bremner & Charney, 2010). In fact, when investigators reduced GABA’s ability to bind to GABA recep- tors, they found that animal subjects reacted with a rise in anxiety (Costa, 1985; Mohler et al., 1981). This finding suggested that people with generalized anxiety disorder might have ongoing problems in their anxiety feedback system. Perhaps they have too few GABA receptors, or perhaps their GABA receptors do not readily capture the neurotransmitter.
This explanation continues to have many supporters, but it is also problematic. First, according to recent biological discoveries, other neurotransmitters may also play important roles in anxiety and generalized anxiety disorder, either acting alone or in conjunction with GABA (Mandrioli & Mercolini, 2015; Baldwin et al., 2013). Second, biological theorists are faced with the problem of establishing a causal
▶▶ family pedigree study A research design in which investigators determine how many and which relatives of a person with a disorder have the same disorder.
▶▶ benzodiazepines The most com- mon group of antianxiety drugs, which includes Valium and Xanax.
▶▶ gamma-aminobutyric acid (GABA) A neurotransmitter whose low activity has been linked to generalized anxiety disorder.
▶▶ sedative-hypnotic drugs Drugs that calm people at lower doses and help them to fall asleep at higher doses.
B e t w e e n t h e L I n e s
Top-Grossing Fear Movie Franchises Jurassic Park/World series
Twilight series
Paranormal Activity series
Scream series
Alien series
Saw series
Final Destination series
The Exorcist series
Jaws series
The Mummy series
Friday the 13th series
Anxiety, Obsessive-Compulsive, and Related Disorders : 117
relationship. The abnormal GABA responses of anxious persons may be the result, rather than the cause, of their anxiety disorders. Perhaps long-term anxiety eventually leads to poorer GABA reception, for example.
In fact, research conducted in recent years indicates that the root of generalized anxiety disorder is prob- ably more complicated than the activity of a single neu- rotransmitter or group of neurotransmitters. Researchers have determined, for example, that emotional reactions of various kinds are tied to brain circuits—networks of brain structures that work together, triggering each other into action with the help of neurotransmitters and producing a particular kind of emotional reaction. It turns out that the circuit that produces anxiety reactions includes the pre- frontal cortex; the anterior cingulate cortex; and the amygdala, a small almond-shaped brain structure that usually starts the emotional ball rolling. Recent studies suggest that this circuit often functions improperly in people with general- ized anxiety disorder (Lang, McTeague, & Bradley, 2014; Schienle et al., 2011) (see Figure 4-3).
Biological Treatments The leading biological treatment for generalized anxiety disorder is drug therapy (see Table 4-3). Other biological interventions are relaxation training and biofeedback.
antianxiety drug therapy In the late 1950s, benzodiazepines were originally marketed as sedative-hypnotic drugs—drugs that calm people in low doses and help them fall asleep in higher doses. These new antianxiety drugs seemed less addictive than previous sedative-hypnotic medications, such as barbiturates, and they appeared to produce less tiredness. Thus, they were quickly embraced by both doc- tors and patients.
Only years later did investigators come to understand the reasons for the effec- tiveness of benzodiazepines. As you have read, researchers eventually learned that there are specific neuron sites in the brain that receive benzodiazepines and that these same receptor sites ordinarily receive the neurotransmitter GABA. Apparently,
Amygdala
Anterior cingulate cortex
Prefrontal cortex
figure 4-3 The biology of anxiety The circuit in the brain that helps produce anxiety reactions includes areas such as the amygdala, the prefrontal cortex, and the anterior cingulate cortex.
table: 4-3
Some Benzodiazepine Drugs
Generic Name Trade Name(s) Generic Name Trade Name(s) Alprazolam Xanax, Xanax XR Halazepam Paxipam
Bromazepam Lectopam, Lexotan, Bromaze Lorazepam Ativan
Chlordiazepoxide Librium Midazolam Versed
Clonazepam Klonopin Nitrazepam Mogadon, Alodorm, Pacisyn, Dumolid
Clorazepate Tranxene Oxazepam Serax
Diazepam Valium Prazepam Lysanxia, Centrax
Estazolam ProSom Quazepam Doral
Flunitrazepam Rohypnol Temazepam Restoril
Flurazepam Dalmadorm, Dalmane Triazolam Halcion
: chapter 4118
when benzodiazepines bind to these neuron receptor sites, particularly those recep- tors known as GABA-A receptors, they increase the ability of GABA to bind to them as well, and so improve GABA’s abil- ity to stop neuron firing and reduce anxiety (Griebel & Holmes, 2013).
Studies indicate that benzodiazepines often provide relief for people with gener- alized anxiety disorder (Islam et al., 2014). However, clinicians have come to realize the potential dangers of these drugs. First, for many people, when the medications are stopped, anxiety returns as strong as ever. Second, we now know that people who take benzodiazepines in large doses for an extended time can become physi- cally dependent on them. Third, the drugs can produce undesirable effects such as drowsiness, lack of coordination, memory loss, depression, and aggressive behavior. Finally, the drugs mix badly with certain other drugs or substances. If, for example, people on benzodiazepines drink even small amounts of alcohol, their breathing can slow down dangerously (Chollet et al., 2013).
In recent decades, still other kinds of drugs have become available for people with generalized anxiety disorder. In particular, it has been discovered that a num- ber of antidepressant medications, drugs that are usually used to lift the moods of depressed persons, and antipsychotic medications, drugs commonly given to people who lose touch with reality, are also helpful to many people with generalized anxi- ety disorder (Chollet et al., 2013; Comer et al., 2011).
relaxation training A nonchemical biological technique commonly used to treat generalized anxiety disorder is relaxation training. The notion behind this approach is that physical relaxation will lead to a state of psychological relaxation. In one version, therapists teach clients to identify individual muscle groups, tense them, release the tension, and ultimately relax the whole body. With continued practice, they can bring on a state of deep muscle relaxation at will, reducing their state of anxiety.
Research indicates that relaxation training is more effective than no treatment or placebo treatment in cases of generalized anxiety disorder (Hayes-Skelton et al., 2013). The improvement it produces, however, tends to be modest (Leahy, 2004), and other techniques that are known to relax people, such as basic meditation, often seem to be equally effective (Bourne et al., 2004). Relaxation training is of greatest help to people with generalized anxiety disorder when it is combined with cogni- tive therapy or with biofeedback (Cuijpers et al., 2014).
BiofeedBaCk In biofeedback, therapists use electrical signals from the body to train people to control physiological processes such as heart rate or muscle tension. Clients are connected to a monitor that gives them continuous information about
their bodily activities. By attending to the signals from the monitor, they may gradually learn to control even seem- ingly involuntary physiological processes.
The most widely applied method of biofeedback for the treatment of anxiety uses a device called an elec- tromyograph (EMG), which provides feedback about the level of muscular tension in the body. Electrodes are attached to the client’s muscles—usually the forehead muscles—where they detect the minute electrical activity that accompanies muscle tension (see Figure 4-4). The device then converts the electric energy, or potentials, coming from the muscles into an image, such as lines on a screen, or into a tone whose pitch changes along
why are antianxiety drugs so
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figure 4-4 Biofeedback at work This biofeedback system records tension in the forehead muscles of an anxious person. The system receives, amplifies, converts, and displays information about the tension, allowing the client to “observe” it and to try to reduce his tension responses.
▶▶ relaxation training A treatment pro- cedure that teaches clients to relax at will so they can calm themselves in stressful situations.
▶▶ biofeedback A technique in which a client is given information about physio- logical reactions as they occur and learns to control the reactions voluntarily.
▶▶ electromyograph (EMG) A device that provides feedback about the level of muscular tension in the body.
▶▶ phobia A persistent and unreasonable fear of a particular object, activity, or situation.
Anxiety, Obsessive-Compulsive, and Related Disorders : 119
with changes in muscle tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. Through repeated trial and error, the individuals become skilled at voluntarily reducing muscle tension and, theoretically, at reducing tension and anxiety in everyday stressful situations.
Research finds that, in most cases, EMG biofeedback, like relaxation training, has only a modest effect on a person’s anxiety level (Brambrink, 2004). As you will see in Chapter 8, biofeedback has had its greatest impact when it plays an adjunct role in the treatment of certain medical problems, including headaches and back pain (Flor, 2014; Young & Kemper, 2013).
➤ Summing Up GENERALIZED ANXIETY DISORDER People with generalized anxiety disorder experience excessive anxiety and worry about a wide range of events and activi- ties. Various explanations and treatments for this anxiety disorder have been offered.
According to the sociocultural view, societal dangers, economic stress, or related racial and cultural pressures may create a climate in which cases of gen- eralized anxiety disorder are more likely to develop.
In the original psychodynamic explanation, Freud said that generalized anxi- ety disorder may develop when anxiety is excessive and defense mechanisms break down and function poorly. Psychodynamic therapists use free association, interpretation, and related psychodynamic techniques to help people over- come this problem.
Carl Rogers, the leading humanistic theorist, believed that people with generalized anxiety disorder fail to receive unconditional positive regard from significant others during their childhood and so become overly critical of them- selves. He treated such individuals with client-centered therapy.
Cognitive theorists believe that generalized anxiety disorder is caused by maladaptive assumptions and beliefs. Many cognitive theorists further believe that implicit beliefs about the power and value of worrying are particularly important in the development and maintenance of this disorder. Cognitive therapists help their clients to change such thinking and to find more effective ways of coping during stressful situations.
Biological theorists hold that generalized anxiety disorder results from low activity of the neurotransmitter GABA. A common biological treatment is anti- anxiety drugs. Certain antidepressant drugs and antipsychotic drugs may also be of help. Relaxation training and biofeedback are also applied in many cases.
Phobias A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear of a particular object, activity, or situation. People with a phobia become fearful if they even think about the object or situation they dread, but they usually remain comfortable as long as they avoid it or thoughts about it.
We all have our areas of special fear, and it is normal for some things to upset us more than other things (see MediaSpeak on page 121). How do such common fears differ from phobias? DSM-5 indicates that a phobia is more intense and persistent and the desire to avoid the object or situation is stronger (APA, 2013). People with phobias often feel so much distress that their fears may interfere dramatically with their lives.
B e t w e e n t h e L I n e s
Famous People, Famous Fears Adele Seagulls
Rihanna Fish
Justin Bieber Elevators, enclosed places
Aretha Franklin Air travel
Kristen Stewart Public speaking
Johnny Depp Clowns, spiders, ghosts
Jennifer Aniston Air travel
Justin Timberlake Snakes
Keanu Reeves Darkness
Scarlett Johansson Cockroaches
Miley Cyrus Spiders
Nicole Kidman Butterflies
Madonna Thunder
: chapter 4120
Most phobias technically fall under the category of specific phobias, DSM-5’s label for an intense and persistent fear of a specific object or situation. In addition, there is a broader kind of phobia called agoraphobia, a fear of venturing into public places or situations where escape might be difficult if one were to become panicky or incapacitated.
Specific Phobias A specific phobia is a persistent fear of a specific object or situation (see Table 4-4). When sufferers are exposed to the object or situation, they typically experience immediate fear. Common specific phobias are intense fears of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood. Here Andrew talks about his phobic fear of flying:
We got on board, and then there was the take-off. There it was again, that horrible feeling as we gathered speed. It was creeping over me again, that old feeling of panic. I kept seeing everyone as puppets, all strapped to their seats with no control over their destinies, me included. Every time the plane did a variation of speed or route, my heart would leap and I would hurriedly ask what was happening. When the plane started to lose height, I was terrified that we were about to crash.
(Melville, 1978, p. 59)
Each year around 12 percent of all people in the United States have the symp- toms of a specific phobia (Kessler et al., 2012). Almost 14 percent of individuals develop such phobias at some point during their lives, and many people have more than one at a time. Women with the disorder outnumber men by at least 2 to 1. For reasons that are not clear, the prevalence of specific phobias also differs among racial and ethnic minority groups. In some studies, African Americans and Hispanic Americans report having at least 50 percent more specific phobias than do white Americans, even when economic factors, education, and age are held steady across the groups (Stein & Williams, 2010; Breslau et al., 2006). It is worth noting, however, that these heightened rates are at work only among African and Hispanic Americans who were born in the United States, not those who emigrated to the United States at some point during their lives (Hopko et al., 2008).
The impact of a specific phobia on a person’s life depends on what arouses the fear (Costa et al., 2014). People whose phobias center on dogs, insects, or water will keep encountering the objects they dread. Their efforts to avoid them must be elabo- rate and may greatly restrict their activities. Urban residents with snake phobias have a much easier time. The vast majority of people with a specific phobia do not seek treatment (NIMH, 2011). They try instead to avoid the objects they fear.
Agoraphobia People with agoraphobia are afraid of being in public places or situations where escape might be difficult or help unavailable, should they experience panic or become incapacitated (APA, 2013) (see Table 4-5 on page 122). This is a pervasive and complex phobia, which usually begins in one’s twenties or thirties. In any given year, 1.7 percent of the population experience agoraphobia, women twice as fre- quently as men (Kessler et al., 2012). The disorder also is twice as common among poor people as wealthy people (Sareen et al., 2011). At least one-fifth of those with agoraphobia are currently in treatment (NIMH, 2011).
table: 4-4
Dx Checklist
Specific Phobia 1. Marked, persistent, and dispro-
portionate fear of a particular object or situation, usually lasting at least six months.
2. Immediate fear is produced by exposure to the object.
3. Avoidance of the feared situation.
4. Significant distress or impairment.
Information from: APA, 2013.
▶▶ specific phobia A severe and persis- tent fear of a specific object or situation.
▶▶ agoraphobia An anxiety disorder in which a person is afraid to be in public situations from which escape might be difficult or help unavailable if paniclike or embarrassing symptoms were to occur.
Anxiety, Obsessive-Compulsive, and Related Disorders : 121
It is typical of people with agoraphobia to avoid entering crowded streets or stores, driving in parking lots or on bridges, and traveling on public transporta- tion or in airplanes. If they venture out of the house at all, it is usually only in the company of close relatives or friends. Some insist that family members or friends stay with them at home, but even at home and in the company of others they may continue to feel anxious.
In many cases the intensity of the agoraphobia fluctuates. In severe cases, people become virtual prisoners in their own homes. Their social life dwindles and they
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every job requires a special skill set.In this business, screaming is one of those skills. Also, being certified on a chainsaw.
“We’re always looking for folks who have a passion for wielding a chainsaw while wearing makeup and costume and just scaring the heck out of people,” says Jennifer Struever.
Streuver is the event manager for Scream Zone at the Del Mar Fairgrounds in San Diego County, Calif. Haunted houses are part of the multibillion-dollar busi- ness of Halloween—and they need employees.
Streuver is conducting interviews inside the Scream Zone’s tented maze, in a room that could be Leather- face’s kitchen. It has a slab of meat hanging from the ceiling and impressive cutlery on the wall.
“We do ask people if they have any problem with chainsaw fumes, moving floors, strobe lights, loud noises,” Streuver says. “We need to know if they’re allergic to stage blood or latex, because they will be experiencing that in their costumes and makeup.”
Over at the haunted castle end of the Scream Zone tent, a huge green demon salivates over potential victims—ahem, applicants—as they wait to be called for their interview. It’s so hot that the multiple fans do little to help, and the heat feels like it could melt the flesh off the living dead.
Geraldo Figueroa could get into that. “I’d like to be a zombie,” he says. “It seems like it’d be really fun, especially with the new attraction”—zombie paintball safari. . . .
. . . Lung power [is important]—as Samantha Topacio demonstrates. “I mean, I haven’t screamed in awhile because no one really recreationally screams just for fun,” she says. Topacio performed better at her audition. “I did one that was a victim-type thing,” she says, “and then the other one was more like a creepy
MediaSpeak The Fear Business
By Beth Accomando, NPR, October 6, 2013
antagonist-type character.” The screams landed her the job and got her a high-five from Ashley Amaral, who’s been working at the Scream Zone for years. The petite, perky blond takes wicked delight in her job.
“It is so awesome to see big burly men crumble to the ground,” she says. “You think they’re so tough. They come in like, ‘Oh, you’re just a girl, please.’ And they just crumble. They will run out of this and say, ‘Oh, blank, no, I’m out of here.’”
Each time someone flees for an emergency exit, it’s a bloody feather in her co-workers’ cap. There’s a scoreboard where they keep a tally of victims who don’t make it through the House of Horror. Last year it was 523. It gives a whole new meaning to customer satisfaction.
“The Fear Business.” Source: “In This Business, Scaredy Cats Need Not Apply,” by Beth Accomando, NPR, October 6, 2013 (from KPBS).
Yikes! Phobophobia, a Halloween show at the London Bridge Experience in London, brings the worst and most typical phobic objects to patrons and has them handle the creatures. Here, a patron confronts a clown, a big spider, and a snake simultaneously.
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cannot hold a job. People with agoraphobia may also become depressed, sometimes as a result of the severe limitations that their disorder places on their lives.
Many people with agoraphobia do, in fact, have extreme and sudden explosions of fear, called panic attacks, when they enter public places, a problem that may have first set the stage for their development of agoraphobia. Such individuals may receive two diagnoses—agoraphobia and panic disorder, an anxiety disorder that you will read about later in this chapter—because their difficulties extend considerably beyond an excessive fear of venturing away from home into public places (APA, 2013).
What Causes Phobias? Each of the models offers explanations for phobias. Evidence tends to support the behavioral explanations. Behaviorists believe that people with phobias first learn to fear certain objects, situations, or events through conditioning (Cherry, 2014; Field & Purkis, 2012). Once the fears are acquired, the individuals avoid the dreaded object or situation, permitting the fears to become all the more entrenched.
Behavioral Explanations: How Are Fears Learned? Behaviorists propose classical conditioning as a common way of acquiring phobic reactions. Here, two events that occur close together in time become strongly associated in a person’s mind, and, as you saw in Chapter 2, the person then reacts similarly to both of them. If one event triggers a fear response, the other may also.
In the 1920s, a clinician described the case of a young woman who apparently acquired a specific phobia of running water through classical conditioning (Bagby, 1922). When she was 7 years old she went on a picnic with her mother and aunt and ran off by herself into the woods after lunch. While she was climbing over some large rocks, her feet were caught between two of them. The harder she tried to free herself, the more trapped she became. No one heard her screams, and she grew more and more terrified. In the language of behaviorists, the entrapment was eliciting a fear response.
Entrapment → Fear response
As she struggled to free her feet, the girl heard a waterfall nearby. The sound of the running water became linked in her mind to her terrifying battle with the rocks, and she developed a fear of running water as well.
Running water → Fear response
Eventually the aunt found the screaming child, freed her from the rocks, and comforted her, but the psychological damage had been done. From that day forward, the girl was terrified of running water. For years family members had to hold her down to bathe her. When she traveled on a train, friends had to cover the windows so that she would not have to look at any streams. The young woman had appar- ently acquired a specific phobia through classical conditioning.
In conditioning terms, the entrapment was an unconditioned stimulus (US) that understandably elicited an unconditioned response (UR) of fear. The running water represented a conditioned stimulus (CS), a formerly neutral stimulus that became asso- ciated with entrapment in the child’s mind and came also to elicit a fear reaction. The newly acquired fear was a conditioned response (CR).
US: Entrapment → UR: Fear
CS: Running water → CR: Fear
Another way of acquiring a fear reaction is through modeling, that is, through observation and imitation (Bandura & Rosenthal, 1966). A person may observe that others are afraid of certain objects or events and develop fears of the same things.
table: 4-5
Dx Checklist
Agoraphobia 1. Pronounced, disproportionate,
and repeated fear about being in at least two of the following situations: Public transportation (e.g., auto or plane travel) • Parking lots, bridges, or other open spaces • Shops, theaters, or other confined places • Lines or crowds • Away from home unaccompanied.
2. Fear of such agoraphobic situa- tions derives from a concern that it would be hard to escape or get help if panic, embarrassment, or disabling symptoms were to occur.
3. Avoidance of the agoraphobic situations.
4. Symptoms usually continue for at least six months.
5. Significant distress or impairment.
Information from: APA, 2013.
Anxiety, Obsessive-Compulsive, and Related Disorders : 123
Consider a young boy whose mother is afraid of illnesses, doctors, and hospitals. If she frequently expresses those fears, before long the boy himself may fear illnesses, doctors, and hospitals.
Why should one or a few upsetting experiences or observations develop into a long-term phobia? Shouldn’t the trapped girl see later that running water will bring her no harm? Shouldn’t the boy see later that illnesses are temporary and doctors and hospitals helpful? Behaviorists believe that after acquiring a fear response, people try to avoid what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.
Behaviorists also propose that learned fears of this kind will blossom into a gen- eralized anxiety disorder if a person acquires a large number of them. This develop- ment is presumed to come about through stimulus generalization: responses to one stimulus are also elicited by similar stimuli. The fear of running water acquired by the girl in the rocks could have generalized to such similar stimuli as milk being poured into a glass or even the sound of bubbly music. Perhaps a person experiences a series of upsetting events, each event produces one or more feared stimuli, and the person’s reactions to each of these stimuli generalize to yet other stimuli. That person may then build up a large number of fears and eventually develop general- ized anxiety disorder.
How Have Behavioral Explanations Fared in Research? Some laboratory studies have found that animals and humans can indeed be taught to fear objects through classical conditioning (Miller, 1948; Mowrer, 1947, 1939). In one
famous report, psychologists John B. Watson and Rosalie Rayner (1920) described how they taught a baby boy called Little Albert to fear white rats. For weeks Albert was allowed to play with a white rat and appeared to enjoy doing so. One time when Albert reached for the rat, however, the experimenter struck a
steel bar with a hammer, making a very loud noise that frightened Albert. The next several times that Albert reached for the rat, the experimenter again made the loud noise. Albert acquired a fear and avoidance response to the rat.
Research has also supported the behavioral position that fears can be acquired through modeling. Psychologists Albert Bandura and Theodore Rosenthal (1966), for example, had human research participants observe a person apparently being shocked by electricity whenever a buzzer sounded. The victim was actually the experimenter’s accomplice—in research terminology, a confederate—who pretended to feel pain by twitching and yelling whenever the buzzer went on. After the unsuspecting participants had observed several such episodes, they themselves had a fear reaction whenever they heard the buzzer.
Although these studies support behaviorists’ explanations of phobias, other research has called those explanations into question (Gamble et al., 2010). Several laboratory studies with children and adults have failed to con- dition fear reactions. In addition, although most case studies trace phobias to incidents of classical conditioning or modeling, quite a few fail to do so. So, although it appears that a phobia can be acquired by classical conditioning or modeling, researchers have not established that the disorder is ordinarily acquired in this way.
A Behavioral-Evolutionary Explanation Some phobias are much more common than others. Phobic reactions to animals, heights, and darkness are more common than phobic reactions to meat, grass, and houses. Theorists often account for these differences by proposing that human beings, as a species, have a predisposition to develop certain fears (Cherry,
New best friends? Is a mouse’s fear of cats a conditioned reaction or genetically hardwired? Scientists at Tokyo University used genetic engineering to switch off this rodent’s instinct to cower at the smell or presence of cats. But mouse beware! The cat has not been genetically engineered correspondingly.
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▶▶ classical conditioning A process of learning in which two events that repeat- edly occur close together in time become tied together in a person’s mind and so produce the same response.
▶▶ modeling A process of learning in which a person observes and then imi- tates others. Also, a therapy approach based on the same principle.
▶▶ stimulus generalization A phenom- enon in which responses to one stimulus are also produced by similar stimuli.
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2014; Lundqvist & Ohman, 2005). This idea is referred to as preparedness because human beings, theoretically, are “prepared” to acquire some phobias and not others. The following case makes the point:
A four-year-old girl was playing in the park. Thinking that she saw a snake, she ran to her parents’ car and jumped inside, slamming the door behind her. Unfortunately, the girl’s hand was caught by the closing car door, the results of which were se- vere pain and several visits to the doctor. Before this, she may have been afraid of snakes, but not phobic. After this experience, a phobia developed, not of cars or car doors, but of snakes. The snake phobia persisted into adulthood, at which time she sought treatment from me.
(Marks, 1977, p. 192)
Where might such predispositions to fear come from? According to some theorists, the predispositions have been transmitted genetically through an evolutionary process. Among our ancestors, the ones who more readily acquired fears of animals, darkness, heights, and the like were more likely to survive long enough to reproduce and to pass on their fear inclinations to their offspring (Cherry, 2014; Ohman & Mineka, 2003).
How Are Phobias Treated? Every theoretical model has its own approach to treating phobias, but behavioral techniques are more widely used than the rest, particularly for specific phobias. In addition, research has shown such techniques to fare better than other approaches in most head-to-head comparisons. Thus we shall focus here primarily on the behavioral interventions.
Treatments for Specific Phobias Specific phobias were among the first anxiety disorders to be treated successfully. The major behavioral approaches to treating them are systematic desensitization, flooding, and modeling. Together, these approaches are called exposure treatments because in all of them people are exposed to the objects or situations they dread (Gordon et al., 2013; Abramowitz et al., 2011).
People treated by systematic desensitization, a technique developed by Joseph Wolpe (1987, 1969), learn to relax while gradually facing the objects or situ-
ations they fear. Since relaxation and fear are incompatible, the new relaxation response is thought to substitute for the fear response. Desensitization therapists first offer relaxation training to clients, teaching them how to bring on a state of deep muscle relaxation at will. In addition, the therapists help clients create a fear hierarchy, a list of feared objects or situations, ordered from mildly to extremely upsetting.
Then clients learn how to pair relaxation with the objects or situations they fear. While the client is in a state of relaxation, the therapist has the client face the event at the bottom of his or her hierarchy. This may be an actual confrontation, a process called in vivo desensitization. A per- son who fears heights, for example, may stand on a chair or climb a stepladder. Or the confrontation may be imagined, a process called covert desensitization. In this case, the person imagines the frightening event while the therapist describes it. The client moves through the entire list, pairing his or
Recovering lost revenues These riders scream out as they experience a sudden steep drop from the top of an amusement park ride. Several parks offer behavioral programs to help prospective customers overcome their fears of roller coasters and other horror rides. After “treatment,” some clients are able to ride the rails with the best of them. For others, it’s back to the relative calm of the Ferris wheel.
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▶▶ preparedness A predisposition to develop certain fears.
▶▶ exposure treatments Behavioral treatments in which persons are exposed to the objects or situations they dread.
▶▶ systematic desensitization A behavioral treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.
▶▶ flooding A treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.
Anxiety, Obsessive-Compulsive, and Related Disorders : 125
her relaxation responses with each feared item. Because the first item is only mildly frightening, it is usually only a short while before the person is able to relax totally in its presence. Over the course of several sessions, clients move up the ladder of their fears until they reach and overcome the one that frightens them most of all.
Another behavioral treatment for specific phobias is flooding. Therapists who use flooding believe that people will stop fearing things when they are exposed to them repeatedly and made to see that they are actually quite harmless. Clients are forced to face their feared objects or situations without relaxation training and without a gradual buildup. The flooding procedure, like desensitization, can be either in vivo or covert.
When flooding therapists guide clients in imagining feared objects or situations, they often exaggerate the description so that the clients experience intense emo- tional arousal. In the case of a woman with a snake phobia, the therapist had her imagine the following scene, among others:
Close your eyes again. Picture the snake out in front of you, now make yourself pick it up. Reach down, pick it up, put it in your lap, feel it wiggling around in your lap, leave your hand on it, put your hand out and feel it wiggling around. Kind of explore its body with your fingers and hand. You don’t like to do it, make yourself do it. Make yourself do it. Really grab onto the snake. Squeeze it a little bit, feel it. Feel it kind of start to wind around your hand. Let it. Leave your hand there, feel it touching your hand and winding around it, curling around your wrist.
(Hogan, 1968, p. 423)
In modeling it is the therapist who confronts the feared object or situation while the fearful person observes (Bandura, 2011, 1977, 1971; Bandura et al., 1977). The behavioral therapist acts as a model to demonstrate that the person’s fear is ground- less. After several sessions many clients are able to approach the objects or situations calmly. In one version of modeling, participant modeling, the client is actively encour- aged to join in with the therapist.
Clinical researchers have repeatedly found that each of the exposure treatments helps people with specific phobias (Tellez et al., 2015; Antony & Roemer, 2011). The key to greater success in all of these therapies appears to be actual contact with
Flight without fear No, these people are not sleeping, or worse. They are going through relaxation and meditation exercises prior to going on an airplane flight from Kansas City to Denver. They are students in an eight- week course called “Flight Without Fear” that applies the principles of behavioral desensitiza- tion to help people overcome their phobic fear of flying.RE
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B e t w e e n t h e L I n e s
Famous Movie Phobias Number 23 (The Number 23)
Enclosed spaces (The Da Vinci Code)
Bats (Batman Begins)
Spiders (Harry Potter movies)
Snakes (Raiders of the Lost Ark)
Illness (Hannah and Her Sisters)
The outside world (Copycat)
Social situations (Annie Hall)
Social situations (The 40-Year-Old Virgin)
Social situations (Coyote Ugly)
Air travel (Rain Man)
Air travel (Red Eye)
Heights (Vertigo)
The color red (Marnie)
Enclosed spaces (Body Double)
Spiders (Arachnophobia)
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the feared object or situation. In vivo desensitization is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling. In addition, a growing number of therapists are using virtual reality—3D computer graphics that simulate real-world objects and situations—as a useful exposure tool (Dunsmoor et al., 2014).
Treatments for Agoraphobia For years clinicians made little impact on agoraphobia, the fear of leaving one’s home and entering public places. However, approaches have now been developed that enable many people with agoraphobia to venture out with less anxiety. These new approaches do not always bring as much relief to sufferers as the highly successful treatments for specific phobias, but they do offer considerable relief to many people.
Behaviorists have again led the way, this time by developing a variety of exposure approaches for agoraphobia (Gloster et al., 2014, 2011). Therapists typically help clients to venture farther and farther from their homes and to gradually enter out- side places, one step at a time. Sometimes the therapists use support, reasoning, and coaxing to get clients to confront the outside world. They also use more systematic exposure methods, such as those described in the following case study:
[Lenita] was a young woman who, shortly after she married, found herself unable to leave home. Even walking a few yards from her front door terrified her. . . .
It is not surprising . . . that this young woman found herself unable to function independently after leaving home to marry. Her inability to leave her new home was reinforced by an increasing dependence on her husband and by the solicitous overconcern of her mother, who was more and more frequently called in to stay with her. . . . Since she was cut off from her friends and from so much enjoyment in the outside world, depression added to her misery. . . .
[After several years of worsening symptoms, Lenita was admitted to our psychiat- ric hospital.] To measure [her] improvement, we laid out a mile-long course from the hospital to downtown, marked at about 25-yard intervals. Before beginning [treat- ment], we asked the patient to walk as far as she could along the course. Each time she balked at the front door of the hospital. Then the first phase of [treatment] began: we held two sessions each day in which the patient was praised for staying out of the hospital for a longer and longer time. The reinforcement schedule was simple. If the patient stayed outside for 20 seconds on one trial and then on the next attempt stayed out for 30 seconds, she was praised enthusiastically. Now, however, the crite- rion for praise was raised—without the patient’s knowledge—to 25 seconds. If she met the criterion she was again praised, and the time was increased again. If she did not stay out long enough, the therapist simply ignored her performance. To gain the therapist’s attention, which she valued, she had to stay out longer each time.
This she did, until she was able to stay out for almost half an hour. But was she walking farther each time? Not at all. She was simply circling around in the front drive of the hospital, keeping the “safe place” in sight at all times. We therefore changed the reinforcement to reflect the distance walked. Now she began to walk farther and farther each time. Supported by this simple therapeutic procedure, the patient was progressively able to increase her self-confidence. . . .
Praise was then thinned out, but slowly, and the patient was encouraged to walk anywhere she pleased. Five years later, she [is] still perfectly well. We might assume that the benefits of being more independent maintained the gains and compen- sated for the loss of praise from the therapist.
(Agras, 1985, pp. 77–80)
Exposure therapy for people with agoraphobia often includes additional features— particularly the use of support groups and home-based self-help programs—to
B e t w e e n t h e L I n e s
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Anxiety, Obsessive-Compulsive, and Related Disorders : 127
motivate clients to work hard at their treatment. In the support group approach, a small number of people with agoraphobia go out together for exposure sessions that last for several hours. The group members support and encourage one another and eventually coax one another to move away from the safety of the group and perform exposure tasks on their own. In the home-based self-help programs, clinicians give clients and their families detailed instructions for carrying out exposure treat- ments themselves.
Between 60 and 80 percent of agoraphobic clients who receive exposure treat- ment find it easier to enter public places, and the improvement persists for years after the beginning of treatment (Craske & Barlow, 2014; Gloster et al., 2014, 2011). Unfortunately, these improvements are often partial rather than complete, and as many as half of successfully treated clients have relapses, although these people read- ily recapture previous gains if they are treated again. Those whose agoraphobia is accompanied by a panic disorder seem to benefit less than others from exposure therapy alone. We shall take a closer look at this group when we investigate treat- ments for panic disorder.
➤ Summing Up PHOBIAS A phobia is a severe, persistent, and unreasonable fear of a particular object, activity, or situation. There are two main categories of phobias: specific phobias and agoraphobia. Behaviorists believe that phobias are often learned from the environment through classical conditioning or through modeling, and then are maintained by avoidance behaviors.
Specific phobias have been treated most successfully with behavioral expo- sure techniques by which people are led to confront the objects they fear. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling). Agoraphobia is also treated effectively by exposure ther- apy. However, for people with both agoraphobia and panic disorder, exposure therapy alone is not as effective.
Social Anxiety Disorder Many people are uncomfortable when interacting with others or talking or per- forming in front of others. A number of entertainers and sports figures, from singer Barbra Streisand to baseball pitcher Zack Greinke, have described episodes of sig- nificant anxiety before performing. Social fears of this kind certainly are unpleasant, but usually the people who have them manage to function adequately.
People with social anxiety disorder, by contrast, have severe, persistent, and irrational anxiety about social or performance situations in which they may face scrutiny by others and possibly feel embarrassment (APA, 2013) (see Table 4-6). The social anxiety may be narrow, such as a fear of talking in public or eating in front of others, or it may be broad, such as a general fear of functioning poorly in front
of others. In both forms, people repeatedly judge themselves as performing less compe- tently than they actually do (see MindTech on page 129). It is because of its wide-ranging scope that this disorder is now called social anxiety disorder rather than social phobia, the
label it had in past editions of the DSM (Heimberg et al., 2014). Social anxiety disorder can interfere greatly with one’s life (Cooper, Hildebrandt,
& Gerlach, 2014). A person who cannot interact with others or speak in public may fail to carry out important responsibilities. One who cannot eat in public may reject
table: 4-6
Dx Checklist
Social Anxiety Disorder 1. Pronounced, disproportionate,
and repeated anxiety about social situation(s) in which individual could be exposed to possible scrutiny by others, typically lasting six months or more.
2. Fear of being negatively evaluated by or offensive to others.
3. Anxiety is almost always produced by exposure to the social situation.
4. Avoidance of feared situations.
5. Significant distress or impairment.
Information from: APA, 2013.
why do so many professional
performers seem prone to
performance anxiety?
▶▶ social anxiety disorder A severe and persistent fear of social or perfor- mance situations in which embarrassment may occur.
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meal invitations and other social offerings. Since many people with this disorder keep their fears secret, their social reluctance is often misinterpreted as snobbery, lack of interest, or hostility.
Surveys reveal that 7.4 percent of people in the United States and other Western countries (around 60 percent of them female) experience social anxiety disorder in any given year (see Table 4-7). Around 13 percent develop this disorder at some point in their lives (Kessler et al., 2012; Alfano & Beidel, 2011). It tends to begin in late childhood or adolescence and may continue into adulthood. At least one-quarter of individuals with social anxiety disorder are currently in treatment (NIMH, 2011).
Research finds that poor people are 50 percent more likely than wealthier peo- ple to have social anxiety disorder (Sareen et al., 2011). Moreover, in several studies, African Americans and Asian Americans, but not Hispanic Americans, have scored higher than white Americans on surveys of social anxiety (Polo et al., 2011; Stein & Williams, 2010). In addition, a culture-bound disorder called taijin kyofusho seems to be particularly common in Asian countries such as Japan and Korea. Although this disorder is traditionally defined as a fear of making other people feel uncomfortable, a number of clinicians now suspect that its sufferers primarily fear being evaluated negatively by other people, a key feature of social anxiety disorder.
What Causes Social Anxiety Disorder? The leading explanation for social anxiety disorder has been proposed by cognitive theorists and researchers (Iza et al., 2014; Heimberg et al., 2010). They contend that people with this disorder hold a group of social beliefs and expectations that consistently work against them. These include:
➤ They hold unrealistically high social standards and so believe that they must perform perfectly in social situations.
➤ They view themselves as unattractive social beings. ➤ They view themselves as socially unskilled and inadequate. ➤ They believe they are always in danger of behaving incompetently in social situations.
➤ They believe that inept behaviors in social situations will inevitably lead to terrible consequences.
➤ They believe that they have no control over feelings of anxiety that emerge in social situations.
table: 4-7
Profile of Anxiety Disorders and Obsessive-Compulsive Disorder
One-Year Prevalence
Female- to-Male Ratio
Typical Age at Onset
Prevalence Among Close Relatives
Percentage Currently Receiving Clinical Treatment
Generalized anxiety disorder 4.0% 2:1 0–20 years Elevated 25.5%
Specific phobia 12.0% 2:1 Variable Elevated 19.0%
Agoraphobia 1.7% 2:1 15–35 years Elevated 20.9%
Social anxiety disorder 7.4% 3:2 10–20 years Elevated 24.7%
Panic disorder 2.4% 5:2 15–35 years Elevated 34.7%
Obsessive-compulsive disorder 1.0–2.0% 1:1 4–25 years Elevated 41.3%
Information from: NIMH, 2011; Kessler et al., 2010, 2005, 1999, 1994; Ritter et al., 2010; Ruscio et al., 2007; Wang et al., 2005; Regier et al., 1993.
Anxiety, Obsessive-Compulsive, and Related Disorders : 129
Cognitive theorists hold that, because of these beliefs, people with social anxi- ety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters (Moscovitch et al., 2013). Avoidance behaviors include, for example, talking only to people they already know well at gatherings or parties. Safety behaviors include wearing makeup to cover up blushing.
MindTech
Social Media Jitters In recent years, researchers have learned that computer and mobile device use can unintentionally produce various forms of anxiety, including social and generalized anxiety (Lepp et al., 2014; Smith, 2014; Krasnova et al., 2013).
The biggest culprit here seems to be spending too much time on social networks such as Facebook. Although frequenting social network sites helps many people feel supported and included, for others, the visits seem to produce significant insecurities and fears. Surveys suggest, for example, that more than one-third of Facebook users develop a fear that others will post or use information or photos of them without their permis- sion (Smith, 2014; Szalavitz, 2013). In addition, a fourth of all users feel a constant pressure to disclose too much personal information on their social networks, and a number feel intense pressure to post material that will be popular and get numerous comments and “likes.” More than a few users also worry that they will discover posts about social activities from which they were excluded.
One study found that a third of users feel distinctly worse after visiting Facebook— more anxious, more envious, and more dissatisfied with their lives (Krasnova et al., 2013). These feelings are particularly triggered when users observe vacation photos of other users, read birthday greet- ings received by other users, and see how many “likes” or comments others receive for their postings or photos. Such experiences seem to lead some users to worry that they are less desirable, less interesting, or less capable than most other social media users.
Of course, many of today’s users do feel more positive about their social network visits. But even these people may have some social network–induced anxiety and tension. Around two-thirds, for example, are truly afraid that they will miss something if they don’t check their social networks constantly—a phenomenon known as FOMO (“fear of miss- ing out”) (Cool Infographics, 2013; Szalavitz, 2013).
Social networking is not the only digital source of anxiety. Recent studies show that excessive cell phone use often results in high levels of anxiety and tension (Lepp et al., 2014). Why? Some theorists speculate that frequent phone users feel obligated to stay in touch with friends, another version of FOMO. Others believe that the rise in anxiety among heavy cell phone users is really the result of other cell phone effects, such as poorer performance in school or a reduction in positive time spent alone and self-reflecting (Archer, 2013). Whatever the explanation, two-thirds of cell phone users report feeling “panicked” when they misplace or lose their phones, even for a few minutes. Many experience “nomophobia” (no-mobile-phone-phobia), a pop term for the rush of fear that people have when they realize that they are disconnected from the world, friends, and family (Archer, 2013).
can you think of other
negative feelings that
might be triggered by
social networking?
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Beset by such beliefs and expectations, people with social anxiety disorder find that their anxiety levels increase as soon as they enter into a social situation. Moreover, because they are convinced that their social flaws are the cause of the anxiety, certain that they do not have the social skills to deal with the situation, and concerned that they cannot contain their negative arousal, they become filled with anxiety.
Later, after the social event has taken place, the indi- viduals repeatedly review the details of the event. They overestimate how poorly things went and what negative results may take place. These persistent thoughts actually keep the event alive and further increase the individuals’ fears about future social situations.
Researchers have indeed found that people with social anxiety disorder manifest the beliefs, expectations, inter- pretations, and feelings listed here (Moscovitch et al., 2013;
Rosenberg et al., 2010). At the same time, cognitive theorists often differ on why some individuals have such cognitions and others do not. Various factors have been uncovered by researchers, including genetic predispositions, trait tendencies, biologi- cal abnormalities, traumatic childhood experiences, and overprotective parent–child interactions during childhood (Heimberg & Magee, 2014; Rapee, 2014).
Treatments for Social Anxiety Disorder Only in the past 15 years have clinicians been able to treat social anxiety disorder successfully. Their newfound success is due in part to the growing recognition that the disorder has two distinct features that may feed upon each other: (1) sufferers have overwhelming social fears, and (2) they often lack skill at starting conversa- tions, communicating their needs, or meeting the needs of others. Armed with this insight, clinicians now treat social anxiety disorder by trying to reduce social fears, by providing training in social skills, or both.
How Can Social Fears Be Reduced? Social fears are often reduced through medication (Pelissolo & Moukheiber, 2013). Somewhat surprisingly, it is antidepressant medications that seem to be the drugs of most help for this disorder, often more helpful than benzodiazepines or other kinds of antianxiety medications. At the same time, several types of psychotherapy have proved to be at least as effec- tive as medication at reducing social fears, and people helped by such psychological treatments appear less likely to relapse than those treated with medications alone (Abramowitz et al., 2011). This finding suggests to some clinicians that the psycho- logical approaches should always be included in the treatment of social fears.
One psychological approach is exposure therapy, the behavioral intervention so effective with phobias (Heimberg & Magee, 2014; Anderson et al., 2013). Exposure therapists encourage clients with social fears to expose themselves to the dreaded social situations and to remain until their fears subside. Usually the exposure is gradual, and it often includes homework assignments that are carried out in the social situations. In addition, group therapy offers an ideal setting for exposure treat- ments by allowing people to face social situations in an atmosphere of support and caring (McEvoy, 2007). In one group, for example, a man who was afraid that his hands would tremble in the presence of other people had to write on a blackboard in front of the group and serve tea to the other members (Emmelkamp, 1982).
Cognitive therapies have also been widely used to treat social fears, often in combination with behavioral techniques (Heimberg & Magee, 2014; Goldin et al., 2013, 2012). In the following discussion, cognitive therapist Albert Ellis uses
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Man’s best therapist? Dan McManus and his service dog Shadow hang glide together outside Salt Lake City, Utah, in 2013. McManus experiences anxiety, and Shadow’s presence and companionship help him to confront feared objects and situations. The two have been flying together for about nine years with a specially made harness for Shadow.
B e t w e e n t h e L I n e s
In Their Words
“When all by myself, I can think of all kinds of clever remarks, quick come- backs to what no one said, and flashes of witty sociability with nobody. But all of this vanishes when I face someone in the flesh. . . .”
Fernando pessoa
Anxiety, Obsessive-Compulsive, and Related Disorders : 131
rational-emotive therapy to help a man who fears he will be rejected if he speaks up at gatherings. The discussion took place after the man had done a homework assignment in which he was asked to identify his negative social expectations and force himself to say anything he had on his mind in social situations, no matter how stupid it might seem to him:
After two weeks of this assignment, the patient came into his next session of ther- apy and reported: “I did what you told me to do. . . . [Every] time, just as you said, I found myself retreating from people, I said to myself: ‘Now, even though you can’t see it, there must be some sentences. What are they?’ And I finally found them. And there were many of them! And they all seemed to say the same thing.”
“What thing?” “That I, uh, was going to be rejected. . . . [If] I related to them I was going to be
rejected. And wouldn’t that be perfectly awful if I was to be rejected. And there was no reason for me, uh, to take that, uh, sort of thing, and be rejected in that awful manner.” . . .
“And did you do the second part of the homework assignment?” “The forcing myself to speak up and express myself ?” “Yes, that part.” “That was worse. That was really hard. Much harder than I thought it would be.
But I did it.” “And?” “Oh, not bad at all. I spoke up several times; more than I’ve ever done before.
Some people were very surprised. Phyllis was very surprised, too. But I spoke up.” . . . “And how did you feel after expressing yourself like that?” “Remarkable! I don’t remember when I last felt this way. I felt, uh, just remark-
able—good, that is. It was really something to feel! But it was so hard. I almost didn’t make it. And a couple of other times during the week I had to force myself again. But I did. And I was glad!”
(Ellis, 1962, pp. 202–203)
Studies show that rational-emotive therapy and other cognitive approaches do indeed help reduce social fears (Heimberg & Magee, 2014; Ollendick, 2014). And these reductions typically persist for years. On the other hand, research also suggests that while cognitive therapy often reduces social fears, it does not consistently help people perform effectively in social settings. This is where social skills training has come to the forefront.
How Can Social Skills Be Improved? In social skills training, thera- pists combine several behavioral techniques in order to help people improve their social skills. They usually model appropriate social behaviors for clients and encour- age the individuals to try them out. The clients then role-play with the therapists, rehearsing their new behaviors until they become more effective. Throughout the process, therapists provide frank feedback and reinforce (praise) the clients for effective performances.
Reinforcement from other people with similar social difficulties is often more powerful than reinforcement from a therapist alone. In social skills training groups and assertiveness training groups, members try out and rehearse new social behav- iors with other group members. The group can also provide guidance on what is socially appropriate. According to research, social skills training, both individual and group formats, has helped many people perform better in social situations (Sarver, Beidel, & Spitalnick, 2014).
▶▶ social skills training A therapy approach that helps people learn or improve social skills and assertiveness through role playing and rehearsing of desirable behaviors.
B e t w e e n t h e L I n e s
Young Dr. Ellis Early in his career, in order to combat his own social anxiety (as well as test his theories), Albert Ellis sat on a park bench in Manhattan’s Central Park day after day for a year, asking out every woman who passed by.
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➤ Summing Up SOCIAL ANXIETY DISORDER People with social anxiety disorder experience severe and persistent anxiety about social or performance situations in which they may be scrutinized by others or be embarrassed. Cognitive theorists believe that the disorder is particularly likely to develop among people who hold and act on certain dysfunctional social beliefs and expectations.
Therapists who treat social anxiety disorder typically distinguish two compo- nents of this disorder: social fears and poor social skills. They try to reduce social fears by drug therapy, exposure techniques, group therapy, various cognitive approaches, or a combination of these interventions. They may try to improve social skills by social skills training.
Panic Disorder Sometimes an anxiety reaction takes the form of a smothering, nightmarish panic in which people lose control of their behavior and, in fact, are practically unaware of what they are doing. Anyone can react with panic when a real threat looms up suddenly. Some people, however, experience panic attacks—periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass (APA, 2013).
The attacks feature at least four of the following symptoms of panic: palpitations of the heart, tingling in the hands or feet, shortness of breath, sweating, hot and cold flashes, trembling, chest pains, choking sensations, faintness, dizziness, and a feeling of unreality (APA, 2013). Small wonder that during a panic attack many people fear they will die, go crazy, or lose control.
My first panic attack happened when I was traveling for spring break with my mom. . . . [W]hile I was driving . . . , a random thought entered my head, . . . and BOOM—it was like my body . . . had been waiting for an invitation and jumped me right in to a full-blown panic attack. I felt huge waves of warm adrenaline surg- ing across my chest and back, my hands were shaking, and I felt scared that I was losing control—whatever that meant. “I’ve got to pull over,” I said. . . . Catching my breath, a part of me knew I had experienced a panic attack, but was still utterly bewildered at why it happened and how quickly it came on, taking over body and mind. . . . If you’ve never had a panic attack before, it feels as scary as if someone jumped out from a dark alley and put a gun to your head, leaving you pleading for your life. You would do whatever it took to get away and fast. . . . It’s so intense that in the height of panic, the survival instinct kicks in and it seems like a toss-up whether you’ll make it out alive or with your mental faculties in place. . . .
(LeCroy & Holschuh, 2012)
More than one-quarter of all people have one or more panic attacks at some point in their lives (Kessler et al., 2010, 2006). Some people, however, have panic attacks repeatedly and unexpectedly and without apparent reason. They may be suffering from panic disorder. In addition to the panic attacks, people who are diagnosed with panic disorder experience dysfunctional changes in their thinking or behavior as a result of the attacks (see Table 4-8). They may, for example, worry persistently about having additional attacks, have concerns about what such attacks mean (“Am I losing my mind?”), or plan their lives around the possibility of future attacks (APA, 2013).
table: 4-8
Dx Checklist
Panic Disorder 1. Unforeseen panic attacks occur
repeatedly.
2. One or more of the attacks precedes either of the following symptoms:
(a) At least a month of continual concern about having additional attacks.
(b) At least a month of dysfunctional behavior changes associated with the attacks (for example, avoiding new experiences).
Information from: APA, 2013.
B e t w e e n t h e L I n e s
In Their Words “There are two types of speakers. Those who get nervous and those who are liars.”
Mark twain
Anxiety, Obsessive-Compulsive, and Related Disorders : 133
Around 2.4 percent of all people in the United States suffer from panic disorder in a given year; more than 5 percent develop it at some point in their lives (Kessler et al., 2012). The disorder tends to develop in late adolescence or early adulthood and is at least twice as common among women as among men. Poor people are 50 percent more likely than wealthier people to experience panic disorder (Sareen et al., 2011).
For reasons that are not understood, the prevalence of this disorder is somewhat higher among white Americans than among minority groups in the United States (Levine et al., 2013). In addi- tion, the features of panic attacks seem to differ somewhat from group to group (Barrera et al., 2010). For example, Asian Americans appear more likely than white Americans to experience dizziness, unsteadiness, and choking, while African Americans seem less likely than white Americans to have those particular symptoms. Surveys indicate that at least one-third of those with panic disorder in the United States are currently in treatment (NIMH, 2011; Wang et al., 2005).
As you read earlier, panic disorder is often accompanied by agoraphobia, the broad phobia in which people are afraid to travel to public places where escape might be difficult should they have panic symptoms or become incapacitated. In such cases, the panic disorder typically sets the stage for the development of ago- raphobia. That is, after experiencing multiple unpredictable panic attacks, a person becomes increasingly fearful of having new attacks in public places.
The Biological Perspective In the 1960s, clinicians made the surprising discovery that panic disorder was helped more by certain antidepressant drugs, drugs that are usually used to reduce the symp- toms of depression, than by most of the benzodiazepine drugs, the drugs useful in treating generalized anxiety disorder (Klein, 1964; Klein & Fink, 1962). This observa- tion led to the first biological explanations and treatments for panic disorder.
What Biological Factors Contribute to Panic Disorder? To understand the biology of panic disorder, researchers worked backward from their understanding of the antidepressant drugs that seemed to control it. They knew that these particular antidepressant drugs operate in the brain primarily by changing the activity of norepinephrine, yet another one of the neurotransmitters that carries messages between neurons. Given that the drugs were so helpful in eliminating panic attacks, researchers began to suspect that panic disorder might be caused in the first place by abnormal norepinephrine activity.
Several studies produced evidence that norepinephrine activity is indeed irregu- lar in people who suffer from panic attacks. For example, the locus coeruleus is a brain area rich in neurons that use norepinephrine, and it serves as a kind of “on–off ” switch for most norepinephrine-using neurons throughout the brain (Hedaya, 2011). When this area is electrically stimulated in monkeys, the monkeys have a paniclike reaction, suggesting that panic reactions may be related to increases in norepinephrine activity in the locus coeruleus (Redmond, 1981, 1979, 1977). Similarly, in another line of research, scientists were able to produce panic attacks in human beings by injecting them with chemicals known to increase the activity of norepinephrine (Bourin et al., 1995; Charney et al., 1990, 1987).
These findings strongly tied norepinephrine and the locus coeruleus to panic attacks. However, research conducted in recent years suggests that the root of panic attacks is probably more complicated than a single neurotransmitter or a single brain area. It turns out that panic reactions are produced in part by a brain circuit consisting of areas such as the amygdala, hippocampus, ventromedial nucleus of the
At any time The golfing world was shocked when professional golfer Charlie Beljan— usually a cool customer during competitions—had to sit down and wait for a panic attack to pass on the 18th fairway during a tournament in Lake Buena Vista, Florida, in 2012. Beljan success- fully completed the competition, and has since received enormous praise for his comfortable and public candor about his problem.
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▶▶ panic attacks Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.
▶▶ panic disorder An anxiety disorder marked by recurrent and unpredictable panic attacks.
▶▶ norepinephrine A neurotransmitter whose abnormal activity is linked to panic disorder and depression.
▶▶ locus coeruleus A small area of the brain that seems to be active in the regu- lation of emotions. Many of its neurons use norepinephrine.
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hypothalamus, central gray matter, and locus coeruleus (Henn, 2013; Etkin, 2010) (see Figure 4-5). When a person confronts a frightening object or situation, the amygdala is stimulated. In turn, the amygdala stimulates the other brain areas in the circuit, temporarily setting into motion an “alarm and escape” response (increased heart rate, res- piration, blood pressure, and the like) that is very similar to a panic reaction (Gray & McNaughton, 1996). Most of today’s researchers believe that this brain circuit— including the neurotransmitters at work throughout the circuit—probably functions improperly in people who experience panic disorder (Henn, 2013; Bremner & Charney, 2010).
Note that the brain circuit responsible for panic reac- tions appears to be different from the one responsible for broad and worry-dominated anxiety reactions—the circuit that was discussed on page 117. Although some of the brain areas and neurotransmitters in the two circuits obviously overlap—particularly the amygdala, which seems to be at the center of each circuit—the finding that the panic brain circuit and the anxiety brain
circuit are different has further convinced many researchers that panic disorder is biologically different from generalized anxiety disorder and, for that matter, from other kinds of anxiety disorders.
Why might some people have abnormalities in norepinephrine activity, locus coeruleus functioning, and other parts of the panic brain circuit? One possibility is that a predisposition to develop such abnormalities is inherited (Gloster et al., 2015; Torgersen, 1990, 1983). Once again, if a genetic factor is at work, close rela- tives should have higher rates of panic disorder than more distant relatives. Studies do find that among identical twins (twins who share all of their genes), if one twin has panic disorder, the other twin has the same disorder in as many as 31 percent of cases (Tsuang et al., 2004). Among fraternal twins (who share only some of their genes), if one twin has panic disorder, the other twin has the same disorder in only 11 percent of cases (Kendler et al., 1995, 1993).
Ventromedial nucleus of the hypothalamus
Locus coeruleus
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Central gray matter
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figure 4-5 The biology of panic The circuit in the brain that produces panic reactions includes areas such as the amygdala, hippocampus, ventromedial nucleus of the hypothalamus, central gray matter, and locus coeruleus. This circuit appears to be different from the one limited to anxiety reactions, although the panic and anxiety circuits do share the amygdala.
Panic’s aftermath Flowers and photos are placed in front of the Kiss nightclub in Santa Maria, Brazil, on January 29, 2013, to pay trib- ute to the victims of a horrific fire at the club a few days earlier. A total of 242 clubbers were killed and 112 injured in the fire, many as a result of crowd panic, stampeding, and crush- ing. Catastrophes such as this remind us that people with panic disorder are not the only ones to experience panic. ©
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Drug Therapies As you have just read, researchers discovered in 1962 that certain antidepressant drugs could prevent panic attacks or reduce their frequency. Since the time of this surprising finding, studies across the world have repeatedly confirmed the initial observation (Cuijpers et al., 2014; Stein et al., 2010).
It appears that all antidepressant drugs that restore proper activity of norepi- nephrine in the locus coeruleus and other parts of the panic brain circuit are able to help prevent or reduce panic symptoms (Pollack, 2005; Redmond, 1985). Such drugs bring at least some improvement to 80 percent of patients who have panic disorder, and the improvement can last indefinitely, as long as the drugs are contin- ued. In addition, alprazolam (Xanax) and other powerful benzodiazepine drugs have also proved effective in the treatment of panic disorder (NIMH, 2013; Bandelow & Baldwin, 2010). Apparently, the benzodiazepines help individuals with this disorder by indirectly affecting the activity of norepinephrine throughout the brain. Clinicians also have found the same antidepressant drugs and powerful benzodiazepines to be helpful in cases of panic disorder accompanied by agoraphobia.
The Cognitive Perspective Cognitive theorists have come to recognize that biological factors are only part of the cause of panic attacks. In their view, full panic reactions are experienced only by people who further misinterpret the physiological events that are taking place within their bodies. Cognitive treatments are aimed at correcting such misinterpretations.
The Cognitive Explanation: Misinterpreting Bodily Sensations Cognitive theorists believe that panic-prone people may be very sensitive to certain bodily sensations; when they unexpectedly experience such sensations, they misin- terpret them as signs of a medical catastrophe (Gloster et al., 2014; Clark & Beck, 2012, 2010). Rather than understanding the probable cause of their sensations as “something I ate” or “a fight with the boss,” those prone to panic grow increasingly upset about losing control, fear the worst, lose all perspective, and rapidly plunge into panic. For example, many people with panic disorder seem to “overbreathe,” or hyperventilate, in stressful situations. The abnormal breathing makes them think that they are in danger of suffocation, so they panic. They further develop the belief that these and other “dangerous” sensations may return at any time and so set themselves up for future panic attacks.
In biological challenge tests, researchers produce hyperventilation or other biological sensations by administering drugs or by instructing clinical research par- ticipants to breathe, exercise, or simply think in certain ways. As you might expect, participants with panic disorder experience greater upset during these tests than participants without the disorder, particularly when they believe that their bodily sensations are dangerous or out of control (Bunaciu et al., 2012).
Why might some people be prone to such misinterpretations? One possibil- ity is that panic-prone individuals generally experience, through no fault of their own, more frequent or more intense bodily sensations than other people do (Nillni et al., 2012; Nardi et al., 2001). In fact, the kinds of sensations that are most often misinterpreted in panic disorders seem to be carbon dioxide increases in the blood, shifts in blood pressure, and rises in heart rate—bodily events that are controlled in part by the locus coeruleus and other regions of the panic brain circuit. Another possibility, supported by some research, is that people prone to bodily misinterpreta- tions have had more trauma-filled events over the course of their lives than other persons (Hawks et al., 2011).
Whatever the precise causes of such misinterpretations may be, research suggests that panic-prone individuals generally have a high degree of what is called anxiety sensitivity; that is, they focus on their bodily sensations much of the time, are unable to assess them logically, and interpret them as potentially harmful. Studies
▶▶ biological challenge test A proce- dure used to produce panic in partici- pants or clients by having them exercise vigorously or perform some other poten- tially panic-inducing task in the presence of a researcher or therapist.
▶▶ anxiety sensitivity A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful.
B e t w e e n t h e L I n e s
In Their Words “Neither a man nor a crowd nor a na- tion can be trusted to act humanely or to think sanely under the influence of a great fear.”
Bertrand russell
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have found that people who scored high on anxiety-sensitivity surveys are up to five times more likely than other people to develop panic disorder (Hawks et al., 2011; Maller & Reiss, 1992). Other studies have found that individuals with panic disorder typically earn higher anxiety-sensitivity scores than other persons do (Allan et al., 2014; Reinecke et al., 2011).
Cognitive Therapy Cognitive therapists try to correct people’s misinterpreta- tions of their bodily sensations (Craske & Barlow, 2014; Clark & Beck, 2012, 2010). The first step is to educate clients about the general nature of panic attacks, the actual causes of bodily sensations, and the tendency of clients to misinterpret their sensations. The next step is to teach clients to apply more accurate interpretations during stressful situations, thus short-circuiting the panic sequence at an early point.
Therapists may also teach clients to cope better with anxiety— for example, by using relaxation and breathing techniques—and to distract themselves from their sensations, perhaps by striking up a conversation with someone.
In addition, cognitive therapists may use biological challenge procedures to induce panic sensations, so that clients can apply their new skills under watchful supervision (Gloster et al., 2014). Individuals whose attacks typically are triggered by a rapid heart rate, for example, may be told to jump up and down for several minutes or to run up a flight of stairs. They can then prac- tice interpreting the resulting sensations appropriately, without dwelling on them.
According to research, cognitive treatments often help people with panic disorder (Wesner et al., 2015; Craske & Barlow, 2014). In studies across the world, around 80 percent of participants given these treatments have become free of panic, compared with only 13 percent of control participants. Cognitive therapy has proved to be at least as helpful as antidepressant drugs or alpra-
zolam in the treatment of panic disorder, sometimes even more so (Bandelow et al., 2015; Baker, 2011). In view of the effectiveness of both cognitive and drug treat- ments, many clinicians have tried, with some success, to combine them (Cuijpers et al., 2014). For individuals who display both panic disorder and agoraphobia, research suggests that it is most helpful to combine behavioral exposure techniques with cognitive treatments and/or drug therapy (Gloster et al., 2014, 2011).
➤ Summing Up PANIC DISORDER Panic attacks are periodic, discrete bouts of panic that occur suddenly. Sufferers of panic disorder experience panic attacks repeatedly and unexpectedly and without apparent reason. Panic disorder may be accompa- nied by agoraphobia in some cases, leading to two diagnoses.
Some biological theorists believe that abnormal norepinephrine activity in the brain’s locus coeruleus may be central to panic disorder. Others believe that related neurotransmitters or a panic brain circuit may also play key roles. Bio- logical therapists use certain antidepressant drugs or powerful benzodiazepines to treat people with this disorder.
Cognitive theorists suggest that panic-prone people become preoccupied with some of their bodily sensations and misinterpret them as signs of medi- cal catastrophe. In turn, they panic and in some cases develop panic disorder. Cognitive therapists teach patients to interpret their physical sensations more accurately and to cope better with anxiety.
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“Weekends I like to be able to panic without having all the distractions.”
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Obsessive-Compulsive Disorder Obsessions are persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness. Compulsions are repetitive and rigid behaviors or mental acts that people feel they must perform in order to prevent or reduce anxiety. As Figure 4-6 indicates, minor obsessions and compulsions are familiar to almost everyone. You may find yourself filled with thoughts about an upcoming performance or exam or keep wondering whether you forgot to turn off the stove or lock the door. You may feel better when you avoid stepping on cracks, turn away from black cats, or arrange your closet in a particular manner. Repetitive thoughts or behaviors of this kind, however, are hardly a reflection of abnormality.
According to DSM-5, a diagnosis of obsessive- compulsive disorder is called for when obsessions or compulsions feel excessive or unreasonable, cause great distress, take up much time, and interfere with daily functions (see Table 4-9 on the next page). Although obsessive-compulsive disorder is not clas- sified as an anxiety disorder in DSM-5, anxiety does play a major role in this pattern. The obsessions cause intense anxiety, while the compulsions are aimed at preventing or reducing anxiety. In addition, anxiety rises if a person tries to resist his or her obses- sions or compulsions.
An individual with this disorder observed: “I can’t get to sleep unless I am sure everything in the house is in its proper place so that when I get up in the morning, the house is organized. I work like mad to set everything straight before I go to bed, but, when I get up in the morn- ing, I can think of a thousand things that I ought to do. . . . I can’t stand to know something needs doing and I haven’t done it” (McNeil, 1967, pp. 26–28). Research indicates that several additional disorders are closely related to obsessive-compulsive disorder in their features, causes, and treatment responsiveness, and so, as you will soon see, DSM-5 has grouped them together with obsessive-compulsive disorder.
Between 1 and 2 percent of the people in the United States and other countries throughout the world suffer from obsessive-compulsive disorder in any given year (Kessler et al., 2012; Björgvinsson & Hart, 2008). As many as 3 percent develop the disorder at some point during their lives. It is equally common in men and women and among people of different races and ethnic groups (Matsunaga & Seedat, 2011). The disorder usually begins by young adulthood and typically persists for many years, although its symptoms and their severity may fluctuate over time. It is estimated that more than 40 percent of people with obsessive-compulsive disorder may seek treat- ment, many for an extended period (Patel et al., 2014; Kessler et al., 1999, 1994).
What Are the Features of Obsessions and Compulsions? Obsessive thoughts feel both intrusive and foreign to the people who experience them. Attempts to ignore or resist these thoughts may arouse even more anxiety, and before long they come back more strongly than ever. People with obsessions typically are quite aware that their thoughts are excessive.
Certain basic themes run through the thoughts of most people troubled by obsessive thinking (Bokor & Anderson, 2014). The most common theme appears to be dirt or contamination (Torres et al., 2013). Other common ones are violence and aggression, orderliness, religion, and sexuality.
Compulsions are similar to obsessions in many ways. For example, although compulsive behaviors are technically under voluntary control, the people who feel
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figure 4-6 Normal routines Most people find it comforting to follow set routines when they carry out everyday activities, and, in fact, 40 percent become irritated if they must depart from their routines. (Information from: Kanner, 2005, 1998, 1995.)
▶▶ obsession A persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.
▶▶ compulsion A repetitive and rigid behavior or mental act that a person feels driven to perform in order to prevent or reduce anxiety.
▶▶ obsessive-compulsive disorder A disorder in which a person has recurrent and unwanted thoughts, a need to per- form repetitive and rigid actions, or both.
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they must do them have little sense of choice in the matter. Most of these individuals recognize that their behavior is unreasonable, but they believe at the same time something terrible will hap- pen if they don’t perform the compulsions. After performing a compulsive act, they usually feel less anxious for a short while. For some people the compulsive acts develop into detailed rituals. They must go through the ritual in exactly the same way every time, according to certain rules.
Like obsessions, compulsions take various forms. Cleaning com- pulsions are very common. People with these compulsions feel compelled to keep cleaning themselves, their clothing, or their homes. The cleaning may follow ritualistic rules and be repeated dozens or hundreds of times a day. People with checking compul- sions check the same items over and over—door locks, gas taps, important papers—to make sure that all is as it should be. Another common compulsion is the constant effort to seek order or balance. People with this compulsion keep placing certain items (cloth- ing, books, foods) in perfect order in accordance with strict rules. Touching, verbal, and counting compulsions are also common.
Although some people with obsessive-compulsive disorder experience obsessions only or compulsions only, most experience both. In fact, compulsive acts are often a response to obsessive thoughts. One study found that in most cases, compulsions seemed to represent a yielding to obsessive doubts, ideas, or urges (Akhtar et al., 1975). A woman who keeps doubting that her house is secure may yield to that obsessive doubt by repeatedly checking locks and gas jets, or a man who obsessively fears contamination may yield to that fear by performing cleaning rituals. The study also found that compulsions sometimes serve to help control obsessions. A teenager describes how she tried to control her obsessive fears of contamination by performing counting and verbal rituals:
Patient: If I heard the word, like, something that had to do with germs or dis- ease, it would be considered something bad, and so I had things that would go through my mind that were sort of like “cross that out and it’ll make it okay” to hear that word.
Interviewer: What sort of things? Patient: Like numbers or words that seemed to be sort of like a protector. Interviewer: What numbers and what words were they? Patient: It started out to be the number 3 and multiples of 3 and then words
like “soap and water,” something like that; and then the multiples of 3 got really high, and they’d end up to be 124 or something like that. It got real bad then.
(Spitzer et al., 1981, p. 137)
Obsessive-compulsive disorder was once among the least understood of the psychological disorders. In recent decades, however, researchers have begun to learn more about it. The most influential explanations and treatments come from the psychodynamic, behavioral, cognitive, and biological models.
The Psychodynamic Perspective As you have seen, psychodynamic theorists believe that an anxiety disorder develops when children come to fear their own id impulses and use ego defense mechanisms to lessen the resulting anxiety. What distinguishes obsessive-compulsive disorder
Cultural rituals Rituals do not necessarily reflect compulsions. Indeed, cultural and reli- gious rituals often give meaning and comfort to their practitioners. Here Buddhist monks splash water over themselves during their annual win- ter prayers at a temple in Tokyo. This cleansing ritual is performed to pray for good luck.
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Dx Checklist Obsessive-Compulsive Disorder 1. Occurrence of repeated
obsessions, compulsions, or both.
2. The obsessions or compulsions take up considerable time.
3. Significant distress or impairment.
Information from: APA, 2013.
Anxiety, Obsessive-Compulsive, and Related Disorders : 139
from other anxiety disorders, in their view, is that here the battle between anxiety- provoking id impulses and anxiety-reducing defense mechanisms is not buried in the unconscious but is played out in overt thoughts and actions. The id impulses usually take the form of obsessive thoughts, and the ego defenses appear as counter- thoughts or compulsive actions. A woman who keeps imagining her mother lying broken and bleeding, for example, may counter those thoughts with repeated safety checks throughout the house.
Sigmund Freud traced obsessive-compulsive disorder to the anal stage of devel- opment (occurring at about 2 years of age). He proposed that during this stage some children experience intense rage and shame as a result of negative toilet- training experiences. Other psychodynamic theorists have argued instead that such early rage reactions are rooted in feelings of insecurity (Erikson, 1963; Sullivan, 1953; Horney, 1937). Either way, these children repeatedly feel the need to express their strong aggressive id impulses while at the same time knowing they should try to restrain and control the impulses. If this conflict between the id and ego continues, it may eventually blossom into obsessive-compulsive disorder. Overall, research has not clearly supported the psychodynamic explanation (Busch et al., 2010; Fitz, 1990).
When treating patients with obsessive-compulsive disorder, psychodynamic therapists try to help the individuals uncover and overcome their underlying con- flicts and defenses, using the customary techniques of free association and therapist interpretation. Research has offered little evidence, however, that a traditional psy- chodynamic approach is of much help (Ponniah, Magiati, & Hollon, 2013). Thus some psychodynamic therapists now prefer to treat these patients with short-term psychodynamic therapies, which, as you saw in Chapter 2, are more direct and action-oriented than the classical techniques.
The Behavioral Perspective Behaviorists have concentrated on explaining and treating compulsions rather than obsessions. They propose that people happen upon their compulsions quite ran- domly. In a fearful situation, they happen just coincidentally to wash their hands, say, or dress a certain way. When the threat lifts, they link the improvement to that particular action. After repeated accidental associations, they believe that the action is bringing them good luck or actually changing the situation, and so they perform the same actions again and again in similar situations. The act becomes
a key method of avoiding or reduc- ing anxiety (Grayson, 2014; Frost & Steketee, 2001).
Famous clinical scientist Stanley Rachman and his associates have shown that compulsions do appear to be rewarded by a reduction in anxi- ety. In one of their experiments, for
example, 12 research participants with compulsive hand-washing rituals were placed in contact with objects that they considered contaminated (Hodgson & Rachman, 1972). As behaviorists would predict, the hand- washing rituals of these participants seemed to lower their anxiety.
If people keep performing compulsive behaviors in order to prevent bad outcomes and ensure positive outcomes, can’t they be taught that such behaviors are not really serving this purpose? In a behavioral treat- ment called exposure and response prevention (or exposure and ritual prevention), first developed by psychiatrist Victor Meyer (1966), clients are repeatedly exposed to objects or situations that produce anxi- ety, obsessive fears, and compulsive behaviors, but they are told to resist
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Getting down and dirty In one exposure and response prevention assignment, clients with cleaning compulsions might be instructed to do heavy-duty gardening and then resist washing their hands or taking a shower. They may never go so far as to participate in and enjoy mud wrestling, like these delightfully filthy individuals at the annual Mud Day event in Westland, Michigan, but you get the point.
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▶▶ exposure and response prevention A behavioral treatment for obsessive- compulsive disorder that exposes a client to anxiety-arousing thoughts or situations and then prevents the client from perform- ing his or her compulsive acts. Also called exposure and ritual prevention.
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performing the behaviors they feel so bound to perform. Because people find it very difficult to resist such behaviors, therapists may set an example first.
Many behavioral therapists now use exposure and response prevention in both individual and group therapy formats. Some of them also have people carry out self-help procedures at home (Franklin & Foa, 2014). That is, they assign homework in exposure and response prevention, such as these assignments given to a woman with a cleaning compulsion:
➤ Do not mop the floor of your bathroom for a week. After this, clean it within three minutes, using an ordinary mop. Use this mop for other chores as well without cleaning it.
➤ Buy a fluffy mohair sweater and wear it for a week. When taking it off at night do not remove the bits of fluff. Do not clean your house for a week.
➤ You, your husband, and children all have to keep shoes on. Do not clean the house for a week.
➤ Drop a cookie on the contaminated floor, pick the cookie up and eat it. ➤ Leave the sheets and blankets on the floor and then put them on the beds. Do not change these for a week.
(Emmelkamp, 1982, pp. 299–300)
Eventually this woman was able to set up a reasonable routine for cleaning herself and her home.
Between 55 and 85 percent of clients with obsessive-compulsive disorder have been found to improve considerably with exposure and response prevention, improvements that often continue indefinitely (Abramowitz et al., 2011, 2008; McKay, Taylor, & Abramowitz, 2010). The effectiveness of this approach suggests that people with this disorder are like the superstitious man in the old joke who keeps snapping his fingers to keep elephants away. When someone points out, “But there aren’t any elephants around here,” the man replies, “See? It works!” One review concludes, “With hindsight, it is possible to see that the [obsessive- compulsive] individual has been snapping his fingers, and unless he stops (response prevention) and takes a look around at the same time (exposure), he isn’t going to learn much of value about elephants” (Berk & Efran, 1983, p. 546).
The Cognitive Perspective Cognitive theorists begin their explanation of obsessive-compulsive disorder by pointing out that everyone has repetitive, unwanted, and intrusive thoughts. Any- one might have thoughts of harming others or being contaminated by germs, for example, but most people dismiss or ignore them with ease. Those who develop this disorder, however, typically blame themselves for such thoughts and expect that somehow terrible things will happen (Grayson, 2014; Salkovskis, 1999, 1985). To avoid such negative outcomes, they try to neutralize the thoughts—thinking or behaving in ways meant to put matters right or to make amends ( Jacob et al., 2014; Salkovskis et al., 2003).
Neutralizing acts might include requesting special reassurance from others, deliberately thinking “good” thoughts, washing one’s hands, or checking for possible sources of danger. When a neutralizing effort brings about a temporary reduction in discomfort, it is reinforced and will likely be repeated. Eventually the neutral- izing thought or act is used so often that it becomes, by definition, an obsession or compulsion. At the same time, the individual becomes more and more convinced that his or her unpleasant intrusive thoughts are dangerous. As the person’s fear of such thoughts increases, the thoughts begin to occur more frequently and they, too, become obsessions.
Personal knowledge The HBO hit series Girls follows the struggles of Hannah Horvath and her friends as they navigate their 20s, “one mistake at a time.” The show’s creator and star, Lena Dunham, says that Hannah’s difficulties often are inspired by her own real-life experi- ences, including her childhood battle with OCD and anxiety.
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Repetitious Behaviors According to surveys, almost half of adults double back after leaving home to make sure they have turned off an appliance.
More than half of all people who use an alarm clock check it repeatedly to be sure they’ve set it.
(Kanner, 1995)
Anxiety, Obsessive-Compulsive, and Related Disorders : 141
In support of this explanation, studies have found that peo- ple with obsessive-compulsive disorder have intrusive thoughts more often than other people, resort to more elaborate neu- tralizing strategies, and experience reductions in anxiety after using neutralizing techniques ( Jacob et al., 2014; Salkovskis et al., 2003).
Although everyone sometimes has undesired thoughts, only some people develop obsessive-compulsive disorder. Why do these individuals find such normal thoughts so disturbing to begin with? Researchers have found that this population tends (1) to have exceptionally high standards of conduct and morality (Whitton, Henry, & Grisham, 2014; Rachman, 1993), (2) to believe intrusive negative thoughts are equivalent to actions and capable of causing harm (Lawrence & Williams, 2011), and (3) to believe that they should have perfect control over all of their thoughts and behaviors in life (Gelfand & Radomsky, 2013).
Cognitive therapists help clients focus on the cognitive processes involved in their obsessive-compulsive disorder. Initially, they educate the clients, pointing out how misinterpretations of unwanted thoughts, an excessive sense of responsibility, and neutralizing acts help produce and maintain their symptoms. The therapists then guide the clients to identify, challenge, and change their distorted cognitions. It appears that cognitive techniques of this kind often help reduce the number and impact of obsessions and compulsions (Franklin & Foa, 2014). While the behavioral approach (exposure and response prevention) and the cognitive approach have each been of help to clients with obsessive-compulsive disorder, some research suggests that a combination of the two approaches is often more effective than either inter- vention alone (Grayson, 2014; McKay et al., 2010).
The Biological Perspective In recent years, two lines of research have uncovered more direct evidence that biological factors play a key role in obsessive-compulsive disorder, and promising biological treatments for the disorder have been developed as well. This research points to (1) abnormally low activity of the neurotransmitter serotonin and (2) abnor- mal functioning in key regions of the brain.
Serotonin, like GABA and norepinephrine, is a brain chemical that carries messages from neuron to neuron. The first clue to its role in obsessive-compulsive disorder was, once again, a surprising finding by clinical researchers—this time that two antidepressant drugs, clomipramine and fluoxetine (Anafranil and Prozac), reduce obsessive and compulsive symptoms (Bokor & Anderson, 2014). Since these particu- lar drugs increase serotonin activity, some researchers concluded that the disorder might be caused by low serotonin activity. In fact, only those antidepressant drugs that increase serotonin activity help in cases of obsessive-compulsive disorder; anti- depressants that mainly affect other neurotransmitters typically have little or no effect on it ( Jenike, 1992). Although serotonin is the neurotransmitter most often cited in explanations of obsessive-compulsive disorder, recent studies have suggested that other neurotransmitters, particularly glutamate, GABA, and dopamine, may also play important roles in the development of the disorder (Bokor & Anderson, 2014).
Another line of research has linked obsessive-compulsive disorder to the abnor- mal functioning of specific regions of the brain, particularly the orbitofrontal cortex ( just above each eye) and the caudate nuclei (structures located within the brain region known as the basal ganglia). These regions are part of a brain circuit that usually converts sensory information into thoughts and actions. The
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▶▶ neutralizing A person’s attempt to eliminate unwanted thoughts by thinking or behaving in ways that put matters right internally, making up for the unaccept- able thoughts.
▶▶ serotonin A neurotransmitter whose abnormal activity is linked to depression, obsessive-compulsive disorder, and eat- ing disorders.
▶▶ orbitofrontal cortex A region of the brain in which impulses involving excre- tion, sexuality, violence, and other primi- tive activities normally arise.
▶▶ caudate nuclei Structures in the brain, within the region known as the basal ganglia, that help convert sensory information into thoughts and actions.
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circuit begins in the orbitofrontal cortex, where sexual, violent, and other primitive impulses normally arise. These impulses next move on to the caudate nuclei, which act as filters that send only the most powerful impulses on to the thalamus, the next stop on the circuit (see Figure 4-7). If impulses reach the thalamus, the person is driven to think further about them and perhaps to act. Many theorists now believe that either the orbitofrontal cortex or the caudate nuclei of some people are too active, lead- ing to a constant eruption of troublesome thoughts and actions (Endrass et al., 2011). Additional parts of this brain circuit have also been identified in recent years, including the cingulate cortex and, yet again, the amygdala (Via et al., 2014; Stein & Fineberg, 2007).
In support of this brain circuit explanation, medical sci- entists have observed for years that obsessive- compulsive symptoms do sometimes arise or subside after the orbi- tofrontal cortex, caudate nuclei, or other regions in the circuit are damaged by accident or illness (Hofer et al., 2013). Similarly, brain scan studies have shown that the caudate nuclei and the orbitofrontal cortex of research participants with obsessive-compulsive disorder are more active than those of control participants (Marsh et al.,
2014; Baxter et al., 2001, 1990). The serotonin and brain circuit explanations may themselves be linked. It
turns out that serotonin—along with the neurotransmitters glutamate, GABA, and dopamine—plays a key role in the operation of the orbitofrontal cortex, caudate nuclei, and other parts of the brain circuit; certainly abnormal activity by one or more of these neurotransmitters could be contributing to the improper functioning of the circuit.
Ever since researchers first discovered that particular antidepressant drugs help to reduce obsessions and compulsions, these drugs have been used to treat obsessive- compulsive disorder (Bokor & Anderson, 2014). We now know that the drugs not only increase brain serotonin activity but also help produce more normal activity in the orbitofrontal cortex and caudate nuclei (McCabe & Mishor, 2011). Studies have found that these antidepressant drugs bring improvement to between 50 and 80 percent of those with obsessive-compulsive disorder (Bareggi et al., 2004). The obsessions and compulsions do not usually disappear totally, but on average they are cut almost in half within 8 weeks of treatment (DeVeaugh-Geiss et al., 1992).
People who are treated with such drugs alone, however, tend to relapse if their medication is stopped. Thus, more and more individuals with obsessive-compulsive disorder are now being treated by a combination of behavioral, cognitive, and drug therapies. According to research, such combinations often yield higher levels of symptom reduction and bring relief to more clients than do each of the approaches alone—improvements that may continue for years (Romanelli et al., 2014; Simpson et al., 2013).
Obviously, the treatment picture for obsessive-compulsive disorder has improved greatly over the past 15 years, and indeed, this disorder is now helped by several forms of treatment, often used in combination. In fact, some studies suggest that the behavioral, cognitive, and biological approaches may ultimately have the same effect on the brain. In these investigations, both participants who responded to cognitive-behavioral treatments and those who responded to antidepressant drugs showed marked reductions in activity in the caudate nuclei and other parts of the obsessive-compulsive brain circuit ( Jabr, 2013; Baxter et al., 2000, 1992).
Orbital frontal cortex
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Cingulate cortex
figure 4-7 The biology of obsessive-compulsive disorder Brain structures that have been linked to obsessive-compulsive disorder include the orbitofrontal cortex, caudate nucleus, thalamus, amygdala, and cingulate cortex. The structures may be too active in people with the disorder.
B e t w e e n t h e L I n e s
An Obsession That Changed the World The experiments that led Louis Pasteur to the pasteurization process may have been driven in part by his obsession with contamination and infection. Ap- parently he would not shake hands and regularly wiped his glass and plate be- fore dining (Asimov, 1997).
Anxiety, Obsessive-Compulsive, and Related Disorders : 143
Obsessive-Compulsive-Related Disorders Some people perform particular patterns of repetitive and excessive behavior that greatly disrupt their lives. Among the most common such patterns are excessive appearance-checking, hoarding, hair-pulling, and skin-picking. DSM-5 has created the group name obsessive-compulsive-related disorders and assigned four of these pat- terns to that group: hoarding disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and body dysmorphic disorder. Collectively, these four disorders are displayed by at least 5 percent of all people (Frost et al., 2012; Keuthen et al., 2012, 2010; Wolrich, 2011).
People who display hoarding disorder feel that they must save items, and they become very distressed if they try to discard them (APA, 2013). These feelings make it difficult for them to part with possessions, resulting in an extraordinary accumulation of items that clutters their lives and living areas. This pattern causes the individuals significant distress and may greatly impair their personal, social, or occupational functioning (Ong et al., 2015; Frost et al., 2012). It is common for them to wind up with numerous useless and valueless items, from junk mail to bro- ken objects to unused clothes. Parts of their homes may become inaccessible because of the clutter. For example, sofas, kitchen appliances, or beds may be unusable. In addition, the pattern often results in fire hazards, unhealthful sanitation conditions, or other dangers.
People with trichotillomania, also known as hair-pulling disorder, repeat- edly pull out hair from their scalp, eyebrows, eyelashes, or other parts of the body (APA, 2013). The disorder usually centers on just one or two of these body sites, most often the scalp. Typically, those with the disorder pull one hair at a time. It is common for anxiety or stress to trigger or accompany the hair-pulling behavior. Some sufferers follow specific rituals as they pull their hair, including pulling until the hair feels “just right” and selecting certain types of hairs for pulling (Starcevic, 2015; Keuthen et al., 2012). Because of the distress, impairment, or embarrassment caused by this behavior, the individuals often try to reduce or stop the hair-pulling. The term “trichotillomania” is derived from the Greek for “frenzied hair-pulling.”
People with excoriation (skin-picking) disorder keep picking at their skin, resulting in significant sores or wounds (APA, 2013). Like those with hair-pulling
A messy aftermath This man prepares to clean out his mother’s home after her death. This is not an easy task—emotionally or physically—under the best of circumstances, but it is particularly difficult in this instance: his mother had suffered from hoarding disorder.©
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▶▶ hoarding disorder A disorder in which individuals feel compelled to save items and become very distressed if they try to discard them, resulting in an exces- sive accumulation of items.
▶▶ trichotillomania A disorder in which people repeatedly pull out hair from their scalp, eyebrows, eyelashes, or other parts of the body. Also called hair-pulling disorder.
▶▶ excoriation disorder A disorder in which people repeatedly pick at their skin, resulting in significant sores or wounds. Also called skin-picking disorder.
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disorder, they often try to reduce or stop the behavior. Most sufferers pick with their fingers and center their picking on one area, most often the face (Grant et al., 2015, 2012; Odlaug & Grant, 2012). Other common areas of focus include the arms, legs, lips, scalp, chest, and extremities such as fingernails and cuticles. The behavior is typically triggered or accompanied by anxiety or stress.
People with body dysmorphic disorder become preoccupied with the belief that they have a particular defect or flaw in their physical appearance. Actually, the perceived defect or flaw is imagined or greatly exaggerated in the person’s mind (APA, 2013). Such beliefs drive the individuals to repeatedly check themselves in the mirror, groom themselves, pick at the perceived flaw, compare themselves with others, seek reassurance, or perform other, similar behaviors. Here, too, those with the problem experience significant distress or impairment.
Body dysmorphic disorder is the obsessive-compulsive-related disorder that has received the most study to date. Researchers have found that, most often, individu- als with this problem focus on wrinkles; spots on the skin; excessive facial hair; swelling of the face; or a misshapen nose, mouth, jaw, or eyebrow (Fang & Wilhelm, 2015; Veale & Bewley, 2015). Some worry about the appearance of their feet, hands, breasts, penis, or other body parts. Still others, like the woman described here, are concerned about bad odors coming from sweat, breath, genitals, or the rectum.
A woman of 35 had for 16 years been worried that her sweat smelled terrible. . . . For fear that she smelled, for 5 years she had not gone out anywhere except when accompanied by her husband or mother. She had not spoken to her neighbors for 3 years. . . . She avoided cinemas, dances, shops, cafes, and private homes. . . . Her husband was not allowed to invite any friends home; she constantly sought re- assurance from him about her smell. . . . Her husband bought all her new clothes as she was afraid to try on clothes in front of shop assistants. She used vast quantities of deodorant and always bathed and changed her clothes before going out, up to 4 times daily.
(Marks, 1987, p. 371)
Of course, it is common in our society to worry about appearance (see Figure 4-8). Many teenagers and young adults worry about acne, for instance. The con- cerns of people with body dysmorphic disorder, however, are extreme. Sufferers may
severely limit contact with other people, be unable to look others in the eye, or go to great lengths to conceal their “defects”—say, always wearing sunglasses to cover their supposedly misshapen eyes. As many as half of people with the disorder seek plastic surgery or dermatology treatment, and often they feel worse rather than better afterward (Dey et al., 2015; McKay et al., 2008). A large number are housebound, and more than 10 percent may attempt suicide (Buhlmann et al., 2010; Phillips et al., 1993).
As with the other obsessive-compulsive-related dis- orders, theorists typically account for body dysmorphic disorder by using the same kinds of explanations, both psychological and biological, that have been applied to obsessive-compulsive disorder (Hartmann et al., 2015; Witthöft & Hiller, 2010). Similarly, clinicians typically treat clients with this disorder by applying the kinds of treat- ment used with obsessive-compulsive disorder, particularly
Worldwide influence A lingerie ad in a subway station in Shanghai, China, displays a woman in a push-up bra. As West meets East, Asian women have been bombarded by ads encouraging them to make Western-like changes to their various body parts. Perhaps not so coincidentally, cases of body dysmorphic disorder among Asians are becoming more and more similar to those among Westerners.
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▶▶ body dysmorphic disorder A disor- der in which individuals become preoccu- pied with the belief that they have certain defects or flaws in their physical appear- ance. Such defects or flaws are imagined or greatly exaggerated.
Anxiety, Obsessive-Compulsive, and Related Disorders : 145
antidepressant drugs, exposure and response prevention, and cognitive therapy (Fang & Wilhelm, 2015; Krebs et al., 2012).
In one study, for example, 17 clients with this disorder were treated with expo- sure and response prevention. Over the course of 4 weeks, the clients were repeat- edly reminded of their perceived physical defects and, at the same time, prevented from doing anything to help reduce their discomfort (such as checking their appear- ance) (Neziroglu et al., 2004, 1996). By the end of treatment, these individuals were less concerned with their “defects” and spent less time checking their body parts and avoiding social interactions.
➤ Summing Up OBSESSIVE-COMPULSIVE DISORDER People with obsessive-compulsive dis- order are beset by obsessions, perform compulsions, or both. Compulsions are often a response to a person’s obsessive thoughts.
According to the psychodynamic view, obsessive-compulsive disorder arises out of a battle between id impulses and ego defense mechanisms. Behaviorists believe that compulsive behaviors develop through chance associations. The leading behavioral treatment combines prolonged exposure with response pre- vention. Cognitive theorists believe that obsessive- compulsive disorder grows from a normal human tendency to have unwanted and unpleasant thoughts. The efforts of some people to understand, eliminate, or avoid such thoughts actually lead to obsessions and compulsions. Cognitive therapists educate cli- ents and help them correct their misinterpretations of the unwanted thoughts. Research suggests that a combined cognitive-behavioral approach may be more effective than either therapy alone.
Biological researchers have tied obsessive-compulsive disorder to low sero- tonin activity and abnormal functioning in the orbitofrontal cortex and caudate nuclei. Antidepressant drugs that raise serotonin activity are a useful form of treatment.
99%People who would change something about their appearance
if they could
People who daydream about being beautiful or handsome
People who wear uncomfortable shoes because they look good
People who have stuffed their bras (women) or shorts (men)
93%
16%
6%
People who undergo surgical or nonsurgical cosmetic
procedures each year
10%
1%
8%
4%
45%
20%
Women
Men
People who are dissatisfied with general appearance of their teeth
35%
41%
figure 4-8 “Mirror, mirror, on the wall . . .” People with body dysmorphic disorder are not the only ones who have concerns about their appearance. Surveys find that in our appearance- conscious society, large percent- ages of people regularly think about and try to change the way they look. (Information from: ASAPS, 2015; Samorodnitzky-Naveh et al., 2007; Noonan, 2003; Kimball, 1993; Poretz & Sinrod, 1991; Weiss, 1991; Simmon, 1990.)
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B e t w e e n t h e L I n e s
Losing Battle People who try to avoid all contamina- tion and rid themselves and their world of all germs are fighting a losing battle. While talking, the average person sprays 300 microscopic saliva droplets per minute, or 2.5 per word.
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In addition to obsessive-compulsive disorder, DSM-5 lists a group of obsessive- compulsive-related disorders, disorders in which obsessive-like con- cerns drive individuals to repeatedly and excessively perform specific patterns of behavior that greatly disrupt their lives. This group consists of hoarding disor- der, trichotillomania, excoriation (skin-picking) disorder, and body dysmorphic disorder.
PUTTING IT...together Diathesis-Stress in Action Clinicians and researchers have developed many ideas about generalized anxiety dis- order, phobias, panic disorder, and obsessive-compulsive disorder. At times, however, the sheer quantity of concepts and findings makes it difficult to grasp what is really known about the disorders.
Overall, it is fair to say that clinicians currently know more about the causes of phobias, panic disorder, and obsessive-compulsive disorder than about generalized anxiety disorder and social anxiety disorder. It is worth noting that the insights about panic disorder and obsessive-compulsive disorder—once among the field’s most puzzling patterns—did not emerge until clinical theorists took a look at the disorders from more than one perspective and integrated those views. Today’s cog- nitive explanation of panic disorder, for example, builds squarely on the biological theorists’ idea that the disorder begins with abnormal brain activity and unusual
physical sensations. Similarly, the cognitive explanation of obsessive- compulsive disorder takes its lead from the biological position that some people are predisposed to having more unwanted and intrusive thoughts than others do.
It may be that a fuller understanding of generalized anxiety disorder and social anxiety disorder awaits a similar integration of the various models. In fact, such integrations have already begun. Recall, for exam- ple, that one of the new-wave cognitive explanations for generalized anxiety disorder links the cognitive process of worrying to heightened bodily arousal in people with the disorder.
Similarly, a growing number of theorists are adopting a diathesis-stress view of generalized anxiety disorder. They believe that certain individu-
als have a biological vulnerability toward developing the disorder—a vulnerability that is eventually brought to the surface by psychological and sociocultural factors. Indeed, genetic investigators have discovered that certain genes may determine whether a person reacts to life’s stressors calmly or in a tense manner, and develop- mental researchers have found that even during the earliest stages of life some infants become particularly aroused when stimulated (Burijon, 2007; Kalin, 1993). Perhaps these easily aroused infants have inherited defects in GABA functioning or other biological limitations that predispose them to generalized anxiety disorder. If, over the course of their lives, they also face intense societal pressures, learn to interpret the world as a dangerous place, or come to regard worrying as a useful tool, they may be candidates for developing generalized anxiety disorder.
In the treatment realm, integration of the models is already on display for each of the anxiety disorders and for obsessive-compulsive disorder. Therapists have discovered, for example, that treatment is at least sometimes more effective when medications are combined with cognitive techniques to treat panic disorder and when medications are combined with cognitive-behavioral techniques to treat obsessive-compulsive disorder. Similarly, cognitive techniques are often combined
C li n i C al C h o i C e s Now that you’ve read about anxiety, obsessive- compulsive and related disorders, try the interactive case study for this chapter. See if you are able to identify Priya’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Priya? Go to LaunchPad to access Clinical Choices.
▶▶ stress-management program An approach to treating generalized and other anxiety disorders that teaches cli- ents techniques for reducing and control- ling stress.
Anxiety, Obsessive-Compulsive, and Related Disorders : 147
with relaxation training or biofeedback in the treatment of generalized anxiety disorder—a treatment package known as a stress-management program. For the millions of people who suffer from these various anxiety disorders, such treatment combinations are a welcome development.
KEY TERMS fear, p. 106
anxiety, p. 106
generalized anxiety disorder, p. 106
unconditional positive regard, p. 110
client-centered therapy, p. 110
basic irrational assumptions, p. 111
metacognitive theory, p. 111
rational-emotive therapy, p. 113
mindfulness-based cognitive therapy, p. 114
family pedigree studies, p. 116
benzodiazepines, p. 116
gamma-aminobutyric acid (GABA), p. 116
sedative-hypnotic drugs, p. 117
relaxation training, p. 118
biofeedback, p. 118
electromyograph (EMG), p. 118
phobia, p. 119
specific phobia, p. 120
agoraphobia, p. 120
classical conditioning, p. 122
modeling, p. 122
stimulus generalization, p. 123
preparedness, p. 124
exposure treatments, p. 124
systematic desensitization, p. 124
flooding, p. 125
social anxiety disorder, p. 127
social skills training, p. 131
panic attacks, p. 132
panic disorder, p. 132
norepinephrine, p. 133
locus coeruleus, p. 133
biological challenge test, p. 135
anxiety sensitivity, p. 135
obsession, p. 137
compulsion, p. 137
obsessive-compulsive disorder, p. 137
exposure and response prevention, p. 139
neutralizing, p. 140
serotonin, p. 141
orbitofrontal cortex, p. 141
caudate nuclei, p. 141
hoarding disorder, p. 143
trichotillomania, p. 143
excoriation disorder, p. 143
body dysmorphic disorder, p. 144
stress management program, p. 147
QuickQuiz
1. What are the key principles in the socio- cultural, psychodynamic, humanistic, cognitive, and biological explanations of generalized anxiety disorder? pp. 107–117
2. How effective have treatments been for generalized anxiety disorder? pp. 109–119
3. Define and compare specific phobias and agoraphobia. pp. 120–122
4. How do behaviorists explain phobias? What evidence exists for these explanations? pp. 122–124
5. Describe the three behavioral exposure techniques used to treat specific phobias. pp. 124–126
6. What are the various components of social anxiety disorder, and how is this disorder treated? pp. 127–131
7. How do biological and cognitive clinicians explain and treat panic disorder? pp. 133–136
8. Which factors do psychodynamic, behavioral, cognitive, and biological theorists believe are at work in
obsessive-compulsive disorder? pp. 138–142
9. Describe and compare the effectiveness of exposure and response prevention and antidepressant medications as treatments for obsessive-compulsive disorder. pp. 139–140, 142
10. Describe the four obsessive- compulsive-related disorders. pp. 143–145
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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S pecialist Latrell Robinson, a 25-year-old single African American man, was an activated National Guardsman [serving in the Iraq war]. He [had been] a full-time college student and competitive athlete raised by a single mother in public housing. . . . Initially trained in transportation, he was called to active duty
and retrained as a military policeman to serve with his unit in Baghdad. He described enjoying the high intensity of his deployment and [became] recognized by others as an informal leader because of his aggressiveness and self-confidence. He [had] numerous [combat] exposures while performing convoy escort and security details [and he came] under small arms fire on several occasions, witnessing dead and in- jured civilians and Iraqi soldiers and on occasion feeling powerless when forced to detour or take evasive action. He began to develop increasing mistrust of the [Iraq] environment as the situation “on the street” seemed to deteriorate. He often felt that he and his fellow soldiers were placed in harm’s way needlessly.
On a routine convoy mission [in 2003], serving as driver for the lead HUMVEE, his vehicle was struck by an Improvised Explosive Device showering him with shrapnel in his neck, arm, and leg. Another member of his vehicle was even more seriously injured. . . . He was evacuated to the Combat Support Hospital (CSH) where he was treated and returned to duty . . . after several days despite requiring crutches and suffering chronic pain from retained shrapnel in his neck. He began to become angry at his command and doctors for keeping him in [Iraq] while he was unable to perform his duties effectively. He began to develop insomnia, hypervigilance, and a startle response. His initial dreams of the event became more intense and frequent and he suffered intrusive thoughts and flashbacks of the attack. He began to withdraw from his friends and suffered anhedonia, feeling detached from others, and he feared his future would be cut short. He was referred to a psychiatrist at the CSH. . . .
After two months of unsuccessful rehabilitation for his battle injuries and worsening depressive and anxiety symptoms, he was evacuated to a . . . military medical center [in the United States]. . . . He was screened for psychiatric symptoms and was referred for outpatient evaluation and management. He met . . . criteria for acute PTSD and was offered medication management, supportive therapy, and group therapy. . . . He was ambivalent about taking passes or convalescent leave to his home because of fears of being “different, irritated, or aggressive” around his family or girlfriend. After three months at the military service center, he was [deactivated from service and] referred to his local VA Hospital to receive follow-up care.
(National Center for PTSD, 2008)
During the horror of combat, soldiers often become highly anxious and depressed, confused and disoriented, even physically ill. Moreover, for many, like Latrell, these and related reactions to extraordinary stress or trauma con- tinue well beyond the combat experience itself.
Of course, it is not just combat soldiers who are affected by stress. Nor does stress have to rise to the level of combat trauma to have a profound effect on psychological and physical functioning. Stress comes in all sizes and shapes, and we are all greatly affected by it.
We feel some degree of stress whenever we are faced with demands or opportunities that require us to change in some manner. The state of stress has two components: a stressor, the event that creates the demands, and a stress response, the person’s reactions to the demands. The stressors of life may include annoying everyday hassles, such as rush-hour traffic; turning-point
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Stress and Arousal: The Fight-or-Flight Response
Acute and Posttraumatic Stress Disorders What Triggers Acute and Posttraumatic Stress Disorders? Why Do People Develop Acute and Posttraumatic Stress Disorders? How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?
Dissociative Disorders Dissociative Amnesia Dissociative Identity Disorder How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? How Are Dissociative Amnesia and Dissociative Identity Disorder Treated? Depersonalization-Derealization Disorder
Putting It Together: Getting a Handle on Trauma and Stress
Disorders of Trauma and Stress
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events, such as college graduation or marriage; long-term problems, such as poverty or poor health; or traumatic events, such as major accidents, assaults, tornadoes, or military combat. Our response to such stressors is influenced by the way we judge both the events and our capacity to react to them in an effective way (Biron & Link, 2014; Lazarus & Folkman, 1984). People who sense that they have the ability and the resources to cope are more likely to take stressors in stride and to respond well.
When we view a stressor as threatening, a natural reaction is arousal and a sense of fear—a response frequently discussed in Chapter 4. As you saw in that chapter, fear is actually a package of responses that are physical, emotional, and cognitive. Physi- cally, we perspire, our breathing quickens, our muscles tense, and our heart beats faster. Turning pale, developing goose bumps, and feeling nauseated are other physi- cal reactions. Emotional responses to extreme threats include horror, dread, and even panic, while in the cognitive realm fear can disturb our ability to concentrate and remember and may distort our view of the world. We may, for example, remember things incorrectly or exaggerate the harm that actually threatens us.
Stress reactions, and the sense of fear they produce, are often at play in psy- chological disorders. People who experience a large number of stressful events are particularly vulnerable to the onset of the anxiety disorders that you read about in Chapter 4. Similarly, increases in stress have been linked to the onset of depression, schizophrenia, sexual dysfunctioning, and other psychological problems.
Extraordinary stress and trauma play an even more central role in certain psy- chological disorders. In these disorders, the reactions to stress become severe and debilitating, linger for a long period of time, and may make it impossible for the individual to live a normal life. Under the heading “Trauma- and Stressor-Related Disorders,” DSM-5 lists several disorders in which trauma and extraordinary stress trigger a wide range of stress symptoms, including heightened arousal, anxiety and mood problems, memory and orientation difficulties, and behavioral disturbances. Two of these disorders, acute stress disorder and posttraumatic stress disorder, are discussed in this chapter. In addition, DSM-5 lists the “dissociative disorders,” a group of dis- orders also triggered by traumatic events, in which the primary symptoms are severe memory and orientation problems. These disorders—dissociative amnesia, dissocia- tive identity disorder (multiple personality disorder), and depersonalization-derealization disorder—are also examined in this chapter.
To fully understand these various stress-related disorders, it is important to appreciate the precise nature of stress and how the brain and body typically react to stress. Thus let’s first discuss stress and arousal, then move on to discussions of acute and posttraumatic stress disorders and the dissociative disorders.
Different strokes for different folks Some people are exhilarated by the oppor- tunity to chase bulls through the streets of Pamplona, Spain, during the annual “running of the bulls” (left). Others are terrified by such a prospect and prefer instead to engage tamer animals, such as ostriches, during the “running of the ostriches” fiesta in Irurzun, Spain (right).
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In Their Words “Reality is the leading cause of stress among those in touch with it.”
Lily tomlin
Disorders of Trauma and Stress : 151
Stress and Arousal: The Fight-or-Flight Response The features of arousal and fear are set in motion by the brain area called the hypo- thalamus. When our brain interprets a situation as dangerous, neurotransmitters in the hypothalamus are released, triggering the firing of neurons throughout the brain and the release of chemicals throughout the body. Actually, the hypothalamus acti- vates two important systems—the autonomic nervous system and the endocrine system (Biran et al., 2015). The autonomic nervous system (ANS) is the extensive net- work of nerve fibers that connect the central nervous system (the brain and spinal cord) to all the other organs of the body. These fibers help control the involuntary activities of the organs—breathing, heartbeat, blood pressure, perspiration, and the like (see Figure 5-1). The endocrine system is the network of glands located throughout the body. (As you read in Chapter 2, glands release hormones into the bloodstream and on to the various body organs.) The ANS and the endocrine system often overlap in their responsibilities. There are two pathways, or routes, by which these systems produce arousal and fear reactions—the sympathetic nervous system pathway and the hypothalamic-pituitary-adrenal pathway.
When we face a dangerous situation, the hypothalamus first excites the sym- pathetic nervous system, a group of ANS fibers that work to quicken our heartbeat and produce the other changes that we experience as fear or anxiety. These nerves may stimulate the organs of the body directly—for example, they may
Allows blood flow to sex organs
Contracts bladder
Stimulates gallbladder
Stimulates ejaculation in male
Relaxes bladder
Stimulates secretion of epinephrine and norepinephrine
Stimulates release of glucose
Adrenal gland
Kidney
Parasympathetic nervous system
Sympathetic nervous system
Relaxes bronchi
Dilates pupil
Inhibits salivation
Stimulates digestive activity
Slows heartbeat
Constricts bronchi
Stimulates salivation
Contracts pupil
Inhibits digestive activity
Accelerates heartbeat
figure 5-1 The autonomic nervous system (ANS) When the sympathetic division of the ANS is activated, it stimulates some organs and inhibits others. The result is a state of general arousal. In contrast, activation of the parasym- pathetic division leads to an overall calming effect.
▶▶ autonomic nervous system (ANS) The network of nerve fibers that con- nect the central nervous system to all the other organs of the body.
▶▶ endocrine system The system of glands located throughout the body that help control important activities such as growth and sexual activity.
▶▶ sympathetic nervous system The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal and fear.
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directly stimulate the heart and increase heart rate. The nerves may also influence the organs indirectly, by stimulating the adrenal glands (glands located on top of the kidneys), particularly an area of these glands called the adrenal medulla. When the adrenal medulla is stimulated, the chemi- cals epinephrine (adrenaline) and norepinephrine (noradrenaline) are released. You have already seen that these chemicals are important neurotrans- mitters when they operate in the brain (see pages 133–134). When released from the adrenal medulla, however, they act as hormones and travel through the bloodstream to various organs and muscles, further producing arousal and fear.
When the perceived danger passes, a second group of autonomic nervous system fibers, called the parasympathetic nervous system, helps return our heartbeat and other body processes to normal. Together the sympathetic and parasympathetic nervous systems help control our arousal and fear reactions.
The second pathway by which arousal and fear reactions are produced is the hypothalamic-pituitary-adrenal (HPA) pathway (see Figure 5-2). When we are faced by stressors, the hypothalamus also signals the pituitary gland, which lies nearby, to secrete the adrenocorticotropic hormone (ACTH ), sometimes called the body’s “major stress hormone.” ACTH, in turn, stimulates the outer layer of the adrenal glands, an area called the
adrenal cortex, triggering the release of a group of stress hormones called corticoste- roids, including the hormone cortisol. These corticosteroids travel to various body organs, where they further produce arousal and fear reactions (Seaward, 2013).
The reactions on display in these two pathways are collectively referred to as the fight-or-flight response, precisely because they arouse our body and prepare us for a response to danger. Each person has a particular pattern of autonomic and endo- crine functioning and so a particular way of experiencing arousal and fear. Some people are almost always relaxed, while others typically feel tension, even when no threat is apparent. A person’s general level of arousal and anxiety is sometimes called trait anxiety because it seems to be a general trait that each of us brings to the events in our lives (Tolmunen et al., 2014; Spielberger, 1985, 1972, 1966). Psychologists have found that differences in trait anxiety appear soon after birth (Schwartz et al., 2015; Kagan, 2003).
People also differ in their sense of which situations are threatening (Moore et al., 2014). Walking through a forest may be fearsome for one person but relaxing for another. Flying in an airplane may arouse terror in some people and boredom in others. Such variations are called differences in situation, or state, anxiety.
Acute and Posttraumatic Stress Disorders Of course when we actually confront stressful situations, we do not think to ourselves, “Oh, there goes my autonomic nervous system” or “My fight-or-flight response seems to be kicking in.” We just feel aroused psychologically and physi- cally and experience a growing sense of fear. If the stressful situation is perceived as extraordinary and/or unusually dangerous, we may temporarily experience levels of arousal, anxiety, and depression that are beyond anything we have ever known.
For most people, such reactions subside soon after the danger passes. For oth- ers, however, the symptoms of anxiety and depression, as well as other kinds of symptoms, persist well after the upsetting situation is over. These people may be suffering from acute stress disorder or posttraumatic stress disorder, patterns that arise in reaction to a psychologically traumatic event. A traumatic event is one in which a person is exposed to actual or threatened death, serious injury, or sexual violation (APA, 2013). Unlike the anxiety disorders that you read about in Chapter 4, which typically are triggered by situations that most people would not find threatening,
Hypothalmus
Pituitary gland
Adrenal cortex
Secretion of ACTH
Corticosteroids
figure 5-2 The endocrine system: The HPA path- way When a person perceives a stressor, the hypothalamus activates the pituitary gland to secrete the adrenocorticotropic hormone, or ACTH, which stimulates the adrenal cortex. The adrenal cortex releases stress hormones called corticosteroids that act on other body organs to trigger arousal and fear reactions.
▶▶ parasympathetic nervous system The nerve fibers of the autonomic ner- vous system that help return bodily processes to normal.
▶▶ hypothalamic-pituitary-adrenal (HPA) pathway One route by which the brain and body produce arousal and fear.
▶▶ corticosteroids A group of hormones, including cortisol, released by the adrenal glands at times of stress.
▶▶ acute stress disorder A disorder in which a person experiences fear and related symptoms soon after a traumatic event but for less than a month.
▶▶ posttraumatic stress disorder (PTSD) A disorder in which a person continues to experience fear and related symptoms long after a traumatic event.
Disorders of Trauma and Stress : 153
the situations that cause acute stress disorder or posttraumatic stress disorder—combat, rape, an earthquake, an airplane crash—would be traumatic for anyone.
If the symptoms begin within four weeks of the traumatic event and last for less than a month, DSM-5 assigns a diagnosis of acute stress disorder (APA, 2013). If the symptoms continue longer than a month, a diagnosis of posttraumatic stress disorder (PTSD) is given. The symptoms of PTSD may begin either shortly after the trau- matic event or months or years afterward (see Table 5-1).
Studies indicate that at least half of all cases of acute stress disorder develop into posttraumatic stress disorder (Bryant et al., 2015, 2005). Think back to Latrell, the soldier in Iraq whose case opened this chapter. As you’ll recall, Latrell became overrun by anxiety, insomnia, worry, anger, depression, irritability, intrusive thoughts, flashback mem- ories, and social detachment within days of the attack on his convoy mission—thus qualifying him for a diagnosis of acute stress disorder. As his symptoms worsened and continued beyond one month—even long after his return to the United States—this diagnosis became PTSD. Aside from the differences in onset and duration, the symptoms of acute stress disorder and PTSD are almost identical:
ReexpeRiencing the tRaumatic event People may be battered by recurring thoughts, memories, dreams, or nightmares connected to the event (APA, 2013). A few relive the event so vividly in their minds (flashbacks) that they think it is actually happening again.
avoidance People usually avoid activities that remind them of the traumatic event and try to avoid related thoughts, feelings, or con- versations (APA, 2013).
Reduced Responsiveness People feel detached from other people or lose inter- est in activities that once brought enjoyment. Some experience symptoms of dis- sociation, or psychological separation: they feel dazed, have trouble remembering things, or have a sense of derealization (feeling that the environment is unreal or strange) (APA, 2013).
incReased aRousal, negative emotions, and guilt People with these dis- orders may feel overly alert (hyperalertness), be easily startled, have trouble con- centrating, and develop sleep problems (APA, 2013). They may display anxiety, anger, or depression and feel extreme guilt because they survived the traumatic event while others did not (Worthen et al., 2014). Some also feel guilty about what they may have had to do to survive.
You can see these symptoms in the recollections of a Vietnam combat veteran years after he returned home:
I can’t get the memories out of my mind! The images come flooding back in vivid detail, triggered by the most inconsequential things, like a door slamming or the smell of stir-fried pork. Last night I went to bed, was having a good sleep for a change. Then in the early morning a storm-front passed through and there was a bolt of crackling thunder. I awoke instantly, frozen in fear. I am right back in Vietnam, in the middle of the monsoon season at my guard post. I am sure I’ll get hit in the next volley and convinced I will die. My hands are freezing, yet sweat pours from my entire body. I feel each hair on the back of my neck standing on end. I can’t catch my breath and my heart is pounding. I smell a damp sulfur smell.
(Davis, 1992)
table: 5-1
Dx Checklist
Posttraumatic Stress Disorder 1. Person is exposed to a traumatic event—death or
threatened death, severe injury, or sexual violation.
2. Person experiences at least one of the following intrusive symptoms: • Repeated, uncontrolled, and distressing memories • Repeated and upsetting trauma-linked dreams • Dissociative experiences such as flashbacks • Significant upset when exposed to trauma-linked cues • Pronounced physical reactions when reminded of the event(s).
3. Person continually avoids trauma-linked stimuli.
4. Person experiences negative changes in trauma- linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions.
5. Person displays conspicuous changes in arousal and reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.
6. Person experiences significant distress or impair- ment, with symptoms lasting more than a month.
Information from: APA, 2013.
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What Triggers Acute and Posttraumatic Stress Disorders? An acute or posttraumatic stress disorder can occur at any age, even in childhood, and can affect one’s personal, family, social, or occupational life (Alisic et al., 2014; Monson et al., 2014). People with these stress disor- ders may also experience depression, another anxi- ety disorder, or substance abuse or become suicidal. Surveys indicate that at least 3.5 percent of people in the United States have one of the stress disorders in any given year; 7 to 9 percent suffer from one of them during their lifetimes (Kessler et al., 2012; Peterlin et al., 2011). Around two-thirds of these individuals seek treatment at some point in their lives, but relatively few do so when they first develop the disorder (Hoge et al., 2014; Wang et al., 2005).
Women are at least twice as likely as men to develop stress disorders: around 20 percent of women who are exposed to a serious trauma may develop one, compared with 8 percent of men (Perrin et al., 2014; Russo & Tartaro, 2008). Moreover, people with low incomes are twice as likely as people with higher incomes to experience one of the stress disorders (Sareen et al., 2011).
Any traumatic event can trigger a stress disorder; however, some are par- ticularly likely to do so. Among the most common are combat, disasters, and abuse and victimization.
Combat For years clinicians have recognized that many soldiers develop symptoms of severe anxiety and depression during combat. It was called “shell shock” during World War I and “combat fatigue” during World War II and the Korean War (Figley, 1978). Not until after the Vietnam War, however, did clinicians learn that a great many soldiers also experience serious psychologi- cal symptoms after combat (Ruzek et al., 2011).
By the late 1970s, it became apparent that many Vietnam combat veter- ans were still experiencing war-related psychological difficulties (Roy-Byrne et al., 2004). We now know that as many as 29 percent of all Vietnam veter- ans, male and female, suffered an acute or posttraumatic stress disorder, while another 22 percent have had at least some stress symptoms (Hermes et al., 2014; Krippner & Paulson, 2006). In fact, 10 percent of the veterans of that war still deal with posttraumatic stress symptoms, including flashbacks, night terrors, nightmares, and persistent images and thoughts.
A similar pattern unfolded among the nearly 2 million veterans of the wars in Afghanistan and Iraq (Ruzek et al., 2011). For example, a few years ago, the RAND Corporation, a nonprofit research organization, conducted a large-scale study of military service members who served in those wars (Zoroya, 2013; RAND Corporation, 2010, 2008). It found that around
20 percent of the Americans deployed to the wars had so far reported symptoms of posttraumatic stress disorder. Given that not all of those studied were in fact exposed to prolonged periods of combat-related stress, this is indeed a very large percent- age. Half of the veterans interviewed in this study described traumas in which they had seen friends seriously wounded or killed, 45 percent reported seeing dead or gravely wounded civilians, and 10 percent said they themselves had been injured and hospitalized.
It is also worth noting that the wars in Afghanistan and Iraq involved repeated deployments of many of the combat veterans and that the soldiers who served such multiple deployments were 50 percent more likely than those with one tour of service to have experienced severe combat stress, significantly raising their risk of developing posttraumatic stress disorder (Tyson, 2006).
“Marlboro Man” One of the most famous photos to emerge from the war in Iraq was that of a U.S. Marine, dubbed “the Marlboro Man” by the news media, taken during the battle for Fallujah in 2004. In the photo—praised by the president, military commanders, and national media, among millions of others—the soldier’s face was smeared with dirt and blood, and a cigarette dangled from his lips. Two years after the photo was taken, 21-year-old James Blake Miller was sitting outside his home in Kentucky, holding the famous picture of him- self and revealing that he had since received a diagnosis of posttraumatic stress disorder.
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▶▶ rape Forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse between an adult and an underage person.
Disorders of Trauma and Stress : 155
Disasters Acute and posttraumatic stress disorders may also follow natural and accidental disasters such as earth- quakes, floods, tornadoes, fires, airplane crashes, and serious car accidents (see Table 5-2). Researchers have found, for example, unusually high rates of posttraumatic stress disorder among the survivors of 2005’s Hurricane Katrina, 2010’s BP Gulf Coast oil spill, and the devastating tornado that struck Moore, Oklahoma, in 2013 (Cherry et al., 2015; Pearson, 2013; Voelker, 2010). In fact, because they occur more often, civilian traumas have been the trigger of stress disorders at least 10 times as often as combat traumas (Bremner, 2002). Studies have even found that between 15 and 40 percent of people involved in traffic accidents—adult or child—may develop PTSD within a year of the accident (Noll-Hussong et al., 2013; Hickling & Blanchard, 2007).
Victimization People who have been abused or victim- ized often have stress symptoms that linger. Research suggests that more than one-third of all victims of physical or sexual assault develop posttraumatic stress disorder (Walsh et al., 2014; Koss et al., 2011) and that as many as half of all people who are directly exposed to terrorism or torture may develop the disorder (Basoglu et al., 2001).
sexual assault A common form of victimization in our society today is sexual assault (see InfoCentral on the next page). Rape is forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse between an adult and an underage person. In the United States, approximately 100,000 cases of rape or attempted rape are reported to the police each year (Berzofsky et al., 2013; Koss et al., 2011). Most experts believe that these are but a fraction of the actual number of rapes and rape attempts, given the reluctance of many victims to report their sexual assaults. Most rapists are men and most victims are women. Around one in six women is raped at some time during her life. Approximately 73 percent of the victims are raped by acquaintances, intimates, or relatives (BJS, 2013).
The rates of rape differ from race to race. Around 27 percent of American Indian women and 22 percent of African American women have been raped at some point in their lives, compared with 19 percent of white American women, 15 percent of
Hispanic American women, and 12 percent of Asian American women (Black et al., 2011).
The psychological impact of rape on a victim is immediate and may last a long time (Koss et al., 2011, 2008; Koss, 2005, 1993). Rape vic-
tims typically experience enormous distress during the week after the assault. Stress continues to rise for the next three weeks, maintains a peak level for another month or so, and then starts to improve. In one study, 94 percent of rape victims fully qualified for a clinical diagnosis of acute stress disorder when they were observed around 12 days after the assault (Rothbaum et al., 1992). Although some rape victims improve psychologically within three or four months, for many others, the profound effects of their assault persist for up to 18 months or longer. Victims typically continue to have higher-than-average levels of
Raising awareness and sensitivity This woman joins a rally in front of Ireland’s national parliament to protest “jokes” made by three policemen about raping women they had recently arrested. A recording of the police conversation was leaked to the public in 2011, causing a public uproar.
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table: 5-2
Worst Natural Disasters of the Past 100 Years
Disaster Year Location Number
Killed Flood 1931 Huang He River, China 3,700,000
Tsunami 2004 South Asia 280,000
Earthquake 1976 Tangshan, China 255,000
Heat wave 2003 Europe 35,000
Volcano 1985 Nevado del Ruiz, Colombia 23,000
Hurricane 1998 (Mitch) Central America 18,277
Landslide 1970 Yungay, Peru 17,500
Avalanche 1916 Italian Alps 10,000
Blizzard 1972 Iran 4,000
Tornado 1989 Shaturia, Bangladesh 1,300
Information from: USGS, 2011; CBC, 2008; Ash, 2001.
how might physicians, police,
and the courts better meet
the psychological needs of
rape victims?
InfoCentral
(Adams, 2013; RAINN, 2009)
suffer from depression 3 X
contemplate suicide 4 X
suffer from PTSD 6 X
SEXUAL ASSAULT People who are sexually assaulted have been forced to engage in a sexual act against their will. According to most definitions, people who are raped have been forced into sexual intercourse or other forms of sexual penetration. Rape victims often experience
rape trauma syndrome (RTS), a pattern of problematic physical and psychological symptoms. RTS is actually a form of PTSD. Ap- proximately one-third of rape victims develop PTSD.
suicidal thoughts attempted suicide
vulnerability to develop psychological disorders
feelings of self-blame and betrayal flashbacks
panic attacks sleep problems
memory problems
THE PSYCHOLOGICAL EFFECTS OF RAPE
men
women 18%
3%
Gender
WHO ARE THE VICTIMS? Age
15%
29%
36%
20%
under 12 years old
12-18 years old
19-30 years old
over 30 years old
Adams, 2013
Crisis on College Campuses
(CFJ, 2012; Black et al., 2011; Adams, 2013; BJS, 2013; NRC, 2014; NISVS, 2010)
26%
7%
38%
28%
a friend or an acquaintance
an intimate partner or spouse
a stranger
a relative
Who commits rape?
89,000 rapes are re- ported to police per year, but the number of rapes per year is estimated to
be at least 225,000
(CFJ, 2012; Black et al., 2011; Adams, 2013; BJS, 2013; NRC, 2014; NISVS, 2010)
(RAINN, 2009; NCVS, 2013)
Factors Delaying Recovery
Prior victimization Chronic life stressors Lack of social support Low self-esteem Degree of violence during attack
(NCVS, 2014)
women sexually assaulted in college
20%
college rapes estimated to be unreported
95%
college rape victims who sustain bodily injuries
47% (Anderson, 2014; CRCC, 2014; Weiner, 2014; Adams, 2013; BJS, 2013;
Statistic Brain, 2013; CDC, 2012: RAINN, 2009)
Factors Aiding Recovery
Positive self-esteem Social support Previous success in coping with stress Economic security Accurate information about rape and rape trauma syndrome Constructive decision-making
(NCVS, 2014)
Rape victims are more likely to:
SEXUAL ASSAULT ON COLLEGE CAMPUSES
The White House has criticized the poor job that colleges are doing preventing sexual assault on campus, punishing perpetrators, and providing proper support for victims. It has pushed colleges to de- velop guidelines to help prevent sexual assaults (Anderson, 2014). Among other measures, the White House initiative encourages all students and university staff to sign the “It’s On Us” pledge, which makes everyone on campus responsible for preventing and interven- ing in sexual assaults. (White House Task Force, 2014; RAINN, 2009)
I pledge:
To RECOGNIZE that nonconsensual sex is sexual assault. To IDENTIFY situations in which sexual assault may occur. To INTERVENE in situations where consent has not or cannot be
given.
To CREATE an environment in which sexual assault is unacceptable and survivors are supported.
abuse alcohol 12 X
abuse drugs 26 X
Disorders of Trauma and Stress : 157
anxiety, suspiciousness, depression, self-esteem problems, self-blame, flashbacks, sleep problems, and sexual dysfunction (Pietrzak et al., 2014; Street et al., 2011).
Female victims of rape and other crimes also are much more likely than other women to suffer serious long-term health problems (Morgan et al., 2015; Koss & Heslet, 1992). Interviews with 390 women revealed that such victims had poorer physical well-being for at least five years after the crime and made twice as many visits to physicians.
Ongoing victimization and abuse in the family—specifically child and spouse abuse—may also lead to psychological stress disorders. Because these forms of abuse may occur over the long term and violate family trust, many victims develop other symptoms and disorders as well (Koss et al., 2011).
teRRoRism People who are victims of terrorism or who live under the threat of ter- rorism often experience posttraumatic stress symptoms (Stene et al., 2015). Unfor- tunately, this source of traumatic stress is on the rise in our society. Few will ever forget the events of September 11, 2001, when hijacked airplanes crashed into and brought down the World Trade Center in New York City and partially destroyed the Pentagon in Washington, DC, killing thousands of victims and rescue workers and forcing thousands more to desperately run, crawl, and even dig their way to safety. A number of studies have indicated that in the aftermath of that fateful day, many individuals developed immediate and long-term psychological effects, ranging from brief stress reactions, such as shock, fear, and anger, to enduring psychological disorders, such as posttraumatic stress disorder (Ruggero et al., 2013; Mitka, 2011; Galea et al., 2007).
Follow-up studies suggest that many of these individuals continue to struggle with terrorism-related stress reactions (Cone et al., 2015; Adams & Boscarino, 2005). Indeed, even years after the attacks, 42 percent of all adults in the United States and 70 percent of all New York adults report high terrorism fears; 23 percent of all adults in the United States report feeling less safe in their homes; 15 percent of all U.S. adults report drinking more alcohol than they did prior to the attacks; and 9 percent of New York adults display PTSD, compared with the national annual prevalence of 3.5 percent. Studies of subsequent acts of terrorism, such as the 2004 commuter train bombings in Madrid, the 2005 London subway and bus bombings, and the 2013 Boston Marathon bombing, tell a similar story (Comer et al., 2014; Chacón & Vecina, 2007).
The horror of terrorism Fearful shoppers at the Westgate shopping center in Kenya scramble for safety as armed police hunt the terrorist gunmen who went on a 4-day shoot- ing spree in 2013, leaving 67 people dead and 175 wounded. ©G
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Gender and Posttraumatic Stress Disorder Many researchers believe that women’s higher rates of posttraumatic stress disorder are tied to the types of violent traumas they experience—namely, interpersonal assaults such as rape or sexual abuse (Street et al., 2011; Russo & Tartaro, 2008).
: chapter 5158
toRtuRe Torture refers to the use of “brutal, degrading, and disorienting strate- gies in order to reduce victims to a state of utter helplessness” (Okawa & Hauss, 2007). Often, it is done on the orders of a government or another authority to force persons to yield information or make a confession (Gerrity et al., 2001). As you will see in Chapter 16, the question of the morality of torturing prisoners who are considered suspects in the “war on terror” has been the subject of much discussion over the past several years.
It is hard to know how many people are in fact tortured around the world because such numbers are typically hidden by governments (Basoglu et al., 2001). It has been estimated, however, that between 5 and 35 percent of the world’s 15 million refugees have suffered at least one episode of torture and that more than 400,000 torture survivors from around the world now live in the United States (ORR, 2011, 2006; AI, 2000; Baker, 1992). Of course, these numbers do not take into account the many thousands of victims who have remained in their countries even after being tortured.
People from all walks of life are subjected to torture worldwide—from suspected terrorists to student activists and members of religious, ethnic, and cultural minor- ity groups. The techniques used on them may include physical torture (beatings, waterboarding, electrocution), psychological torture (threats of death, mock execu- tions, verbal abuse, degradation), sexual torture (rape, violence to the genitals, sexual humiliation), or torture through deprivation (sleep, sensory, social, nutritional, medical, or hygiene deprivation).
Torture victims often experience physical ailments as a result of their ordeal, from scarring and fractures to neurological problems and chronic pain. But many theorists believe that the lingering psychological effects of torture are even more problematic (Gjini et al., 2013; Punamäki et al., 2010). It appears that between 30 and 50 percent of torture victims develop posttraumatic stress disorder. Even for those who do not develop a full-blown disorder, symptoms such as nightmares, flashbacks, repressed memories, depersonalization, poor concentration, anger out- bursts, sadness, and suicidal thoughts are common (Taylor et al., 2013).
Why Do People Develop Acute and Posttraumatic Stress Disorders? Clearly, extraordinary trauma can cause a stress disorder. The stressful event alone, however, may not be the entire explanation. Certainly, anyone who experiences an
unusual trauma will be affected by it, but only some people develop a stress disorder (see PsychWatch on the next page). To understand the develop- ment of these disorders more fully, researchers have looked to the survivors’ biological processes, personalities, childhood experiences, social support systems, and cultural backgrounds and to the severity of the traumas.
Biological and Genetic Factors Investigators have learned that traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions and, in some cases, to stress disorders (Yehuda et al., 2015; Pace & Heim, 2011). They have, for example, found abnormal activity of the hormone cortisol and the neurotransmitter/hormone nor- epinephrine in the urine, blood, and saliva of combat soldiers, rape victims, concentration camp survivors, and survivors of other severe stresses (Groer et al., 2015; Gola et al., 2012).
Evidence from brain studies also shows that once a stress disorder sets in, it may lead to further biochemical arousal, and this continuing arousal may eventually damage key brain areas (Lee et al., 2014; Pace & Heim, 2011). As we have seen in earlier chapters, researchers have determined that emotional reactions of various kinds are tied to brain circuits—networks
Children, too A 10-year-old boy sits in a devastated area of Japan after the 2011 earthquake and tsunami. Children also may develop posttraumatic stress disorder after natural disasters, leading clinicians to worry about the mental health of the many Japanese children who experienced the magnitude 9.0 earthquake.
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▶▶ torture The use of brutal, degrading, and disorienting strategies to reduce vic- tims to a state of utter helplessness.
Disorders of Trauma and Stress : 159
of brain structures that, with the help of neurotransmitters, trigger each other into action to produce various emotions. It appears that abnormal activity in one such circuit may contribute to posttraumatic stress reactions. This circuit includes the hippocampus and amygdala, which send and receive messages to and from each other (Li et al., 2014; Bremner & Charney, 2010).
Normally, the hippocampus plays a major role both in memory and in the regulation of the body’s stress hormones. Clearly, a dysfunctional hippocampus may help produce the intrusive memories and constant arousal found in post- traumatic stress disorder (Bremner et al., 2004). Similarly, as you read in Chapter 4, the amygdala helps control anxiety and many other emotional responses. It also works with the hippocampus to produce the emotional components of memory. Thus, a dysfunctional amygdala may help produce the repeated emotional symp- toms and strong emotional memories common to people with posttraumatic stress disorder (Protopopescu et al., 2005). In short, the arousal produced by extraordi- narily traumatic events may lead to stress disorders in some people, and the stress disorders may produce yet further brain abnormalities, locking in the disorders all the more firmly.
PsychWatch
Some people react to a major stressor in their lives with extended and ex-cessive feelings of anxiety, depressed mood, or antisocial behaviors. The symp- toms do not quite add up to acute stress disorder or posttraumatic stress disorder, nor do they reflect an anxiety or mood
disorder, but they do cause considerable distress or interfere with the person’s job, schoolwork, or social life. Should we consider such reactions normal? No, says DSM-5. Somewhere between effective coping strategies and stress disorders lie the adjustment disorders, patterns that
are included in DSM-5’s group of trauma- and stressor-related disorders (APA, 2013).
DSM-5 lists several types of adjustment disorders, including adjustment disorder with anxiety and adjustment disorder with depressed mood. People receive such diagnoses if they develop their symptoms within three months of the onset of a stressor. If the stressor is long-term, such as a medical condition, the adjustment disorder may last indefinitely.
Almost any kind of stressor may trigger an adjustment disorder. Common ones are the breakup of a relationship, marital prob- lems, business difficulties, and living in a crime-ridden neighborhood. The disorder may also be triggered by developmental events such as going away to school, get- ting married, or retiring from a job.
Up to 30 percent of all people in out- patient therapy receive this diagnosis; it accounts for far more treatment claims submitted to insurance companies than any other. However, some experts doubt that adjustment disorders are as com- mon as this figure suggests. Rather, the diagnosis seems to be a favorite among clinicians—it can easily be applied to a range of problems yet is less stigmatizing than many other categories.
Adjustment Disorders: A category of compromise?
Candidates for dysfunction? A stock trader reacts with exhaustion, worry, and disbelief at the stock exchange in Chicago after a particularly bad—stock-plummeting— day in 2011. Business difficulties are among the most common stressors known to trigger adjustment disorders.
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The Smell of Stress? Stress is odorless. The bacteria that feed off of our sweat are what give our bodies odor during very stressful events.
: chapter 5160
It may also be that posttraumatic stress disorder leads to the transmission of bio- chemical abnormalities to the children of people with the disorder (Yehuda et al., 2015). One team of researchers examined the cortisol levels of women who had been pregnant during the September 11, 2001, terrorist attacks and had developed PTSD (Yehuda & Bierer, 2007). Not only did these women have higher-than- average cortisol levels, but the babies to whom they gave birth after the attacks also displayed higher cortisol levels, suggesting that the babies inherited a predisposition to develop the same disorder.
Many theorists believe that people whose biochemical reactions to stress are unusually strong are more likely than others to develop acute and posttraumatic stress disorders. But why would certain people be prone to such strong biological
reactions? One possibility is that the propensity is inherited (Clark et al., 2013). Clearly, this is suggested by the mother– offspring studies just discussed. Similarly, studies conducted on thousands of pairs of twins who have served in the military find that if one twin develops stress symptoms after combat, an identical twin is more likely than a fraternal twin to develop the same problem (Koenen et al., 2003; True & Lyons, 1999).
Personality Some studies suggest that people with cer- tain personalities, attitudes, and coping styles are particularly likely to develop acute and posttraumatic stress disorders (DiGangi et al., 2013). In the aftermath of Hurricane Hugo in 1989, for example, children who had been highly anxious before the storm were more likely than other children to develop severe stress reactions (Hardin et al., 2002). Research has also found that people who generally view life’s nega-
tive events as beyond their control tend to develop more severe stress symptoms after sexual or other kinds of traumatic events than people who feel that they have more control over their lives (Catanesi et al., 2013; Bremner, 2002). Similarly, people who generally find it difficult to derive any- thing positive from unpleasant situations adjust more poorly after traumatic events than people who are generally resilient and who typically find value in negative events (Kunst, 2011).
Childhood Experiences Researchers have found that certain childhood experiences seem to leave some people at risk for later acute and posttraumatic stress disorders (Pervanidou & Chrousos, 2014). People whose childhoods have been marked by poverty appear more likely to develop these disorders in the face of later trauma. So do people who went through an assault, abuse, or a catastrophe at an early age; who were younger than 10 when their parents separated or divorced; or whose family members suffered from psychological disorders (Ogle et al., 2014; Yehuda et al., 2010).
Social Support People whose social and family support systems are weak are also more likely to develop acute or posttraumatic stress disorder after a traumatic event (DiGangi et al., 2013). Rape victims who feel loved, cared for, valued, and accepted by their friends and relatives recover more successfully (Street et al., 2011). So do those treated with dignity and respect by the criminal justice system (Patterson, 2011). In contrast, clinical reports have suggested that poor social support
Do the vivid images seen
daily on the web, on tV,
and in video games make
people more vulnerable to
developing psychological
stress disorders or less
vulnerable?
Building resiliency Noting that a resilient, or “hardy,” personality style may help protect people from developing stress disorders, many programs now claim to build resiliency. Here young South Korean schoolchildren fall on a mud flat at a five-day winter military camp designed to strengthen them mentally and physically.
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Disorders of Trauma and Stress : 161
contributes to the development of posttraumatic stress disorder in some combat veterans (Schumm et al., 2014).
Multicultural Factors There is a growing suspicion among clinical researchers that the rates of posttraumatic stress disorder may differ among ethnic groups in the United States. In particular, Hispanic Americans may be more vulnerable to the disorder than other cultural groups (Hinton & Lewis-Fernandez, 2011; Koch & Haring, 2008). Some cases in point: (1) Studies of combat veterans from the wars in Afghanistan, Iraq, and Vietnam have found higher rates of posttraumatic stress disorder among Hispanic American veterans than among white American and African American veterans (RAND Corporation, 2010, 2008; Kulka et al., 1990). (2) In surveys of police officers, Hispanic American officers typically report more severe duty-related stress symptoms than their non-Hispanic coun- terparts (Pole et al., 2001). (3) Data on hurricane victims reveal that after some hurricanes Hispanic American victims have had a significantly higher rate of PTSD than victims from other ethnic groups (Perilla et al., 2002). (4) Surveys of New York City residents conducted in the months follow- ing the terrorist attacks of September 11, 2001, revealed that 14 percent of Hispanic American residents developed PTSD, compared with 9 percent of African American residents and 7 percent of white American residents (Hinton & Lewis-Fernandez, 2011; Galea et al., 2002).
Why might Hispanic Americans be more vulnerable to posttraumatic stress disorder than other racial or ethnic groups? Several explanations have been suggested. One holds that as part of their cultural belief system, many Hispanic Americans tend to view traumatic events as inevitable and unalterable, a coping response that may heighten their risk for posttraumatic stress disorder (Perilla et al., 2002). Another explanation suggests that their culture’s emphasis on social rela- tionships and social support may place Hispanic American victims at special risk when traumatic events deprive them—temporarily or permanently—of important relationships and support systems. Indeed, a study conducted almost three decades ago found that among Hispanic American Vietnam combat veterans with stress disorders, those with poor family and social relationships suffered the most severe symptoms (Escobar et al., 1983).
Severity of Trauma As you might expect, the severity and nature of the trau- matic event that a person goes through help determine whether the person will develop a stress disorder. Some events can override even a nurturing childhood, positive attitudes, and social support (Ogle, Rubin, & Siegler, 2014). One study examined 253 Vietnam War prisoners five years after their release. Some 23 percent qualified for a clinical diagnosis of posttraumatic stress disorder, though all had been evaluated as well adjusted before their imprisonment (Ursano et al., 1981).
Generally, the more severe the trauma and the more direct one’s exposure to it, the higher the likelihood of developing a stress disorder (Ogle et al., 2014). Mutila- tion, severe physical injury, or sexual abuse in particular seem to increase the risk of stress reactions, as does witnessing the injury or death of other people (Perrin et al., 2014; Ursano et al., 2003).
How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? Treatment can be very important for people who have been overwhelmed by trau- matic events (Church, 2014). Overall, about half of all cases of posttraumatic stress disorder improve within six months (Asnis et al., 2004). The remainder of cases may
Cultural disparity The horror of witnessing the World Trade Center’s twin towers burn and collapse on September 11, 2001, was shared by millions of onlookers that fateful day. How- ever, for reasons not fully understood, Hispanic Americans developed more cases of PTSD in the aftermath of this event than did other cultural groups — a difference also on display after other mass traumas (Hinton & Lewis- Fernandez, 2011).
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Stress and Coping: Eye on Culture 57 percent of American Indians and African Americans feel stressed by fi- nances, compared with 47 percent of the entire American population.
41 percent of Hispanic Americans feel stressed by employment issues, com- pared with 32 percent of the entire American population.
(Mha, 2010, 2008)
: chapter 5162
persist for years, and, indeed, more than one-third of people with PTSD do not respond to treatment even after many years (Byers et al., 2014).
Today’s treatment procedures for troubled survivors typically vary from trauma to trauma. Was it combat, an act of terrorism, sexual molestation, or a major acci- dent? Yet all the programs share basic goals: they try to help survivors put an end to their stress reactions, gain perspective on their painful experiences, and return to constructive living (Taylor, 2010). Programs for combat veterans who suffer from PTSD illustrate how these issues may be addressed.
Treatment for Combat Veterans Therapists have used a variety of tech- niques to reduce veterans’ posttraumatic symptoms. Among the most common are drug therapy, behavioral exposure techniques, insight therapy, family therapy, and group ther- apy. Typically the approaches are combined, as no one of them successfully reduces all the symptoms (Mott et al., 2014; Rothbaum et al., 2014).
Antianxiety drugs help control the tension that many veterans experience (Writer et al., 2014). In addition, antidepressant medications may reduce the occur- rence of nightmares, panic attacks, flashbacks, and feelings of depression (Morgan et al., 2012).
Behavioral exposure techniques, too, have helped reduce specific symptoms, and they have often led to improvements in overall adjustment (Steenkamp et al., 2015). In fact, some studies indicate that exposure treatment is the single most helpful intervention for people with posttraumatic stress disorder (Haagen et al., 2015). This finding suggests to many clinical theorists that exposure of one kind or another should always be part of the treatment picture (see MindTech on the next page). In a classic case, the exposure technique of flooding, along with relaxation training, helped rid a 31-year-old veteran of frightening flashbacks and nightmares (Fairbank & Keane, 1982). The therapist and the veteran first singled out combat scenes that the man had been reexperiencing frequently. The therapist then helped the veteran to imagine one of these scenes in great detail and urged him to hold on to the image until his anxiety stopped. After each of these flooding exercises, the therapist had the veteran switch to a positive image and led him through relaxation exercises.
A widely applied form of exposure therapy is eye movement desensitiza- tion and reprocessing (EMDR), in which clients move their eyes in a rhythmic
Standing down To help prevent, reduce, or treat combat-related PTSD, the U.S. military and other organizations now offer stress- and trauma-release exercises for soldiers and ex- soldiers to perform. Here relaxation training and yoga are taught to veterans during the 2013 Veteran Stand Down hosted by Goodwill Southern California. Br
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Top Stressors in the United States 1. Job pressure
2. Money
3. Health
4. Relationships
5. Poor nutrition
6. Media overload
7. Sleep deprivation
(apa, 2013)
Disorders of Trauma and Stress : 163
manner from side to side while flooding their minds with images of the objects and situations they ordinarily try to avoid. Case studies and controlled studies suggest that this treatment can often be helpful to people with posttraumatic stress disorder (Chen et al., 2015; Rothbaum et al., 2011). Many theorists argue that it is the expo- sure feature of EMDR, rather than the eye movement, that accounts for its success as a treatment for PTSD (Lamprecht et al., 2004).
Although drug therapy and exposure techniques bring some relief, most clini- cians believe that veterans with posttraumatic stress disorder cannot fully recover with these approaches alone: they must also come to grips in some way with their
MindTech
Virtual Reality Therapy: Better Than the Real Thing? As you have read, exposure-based treatment may be the single most helpful intervention for people with PTSD (Le et al., 2014). However, in vivo (actual) exposure to upsetting stimuli is more effective in treating PTSD
than covert (imaginary) exposure. For years, this meant that treatment for PTSD for combat veterans was less than optimal. Unable to revisit real-life battle settings, veterans had to imagine rifle fire, bomb explosions, dead bodies, and/or other traumatic stimuli for their treatment.
All that changed a decade ago, when “virtual” exposure to combat conditions became available for veterans with PTSD. The Office of Naval Research funded the develop- ment of “Virtual Iraq,” a war simulation treatment game (McIlvaine, 2011). This game was able to produce sights and sounds that seemed every bit as real and produced as much—or more—alarm as real battle conditions. The use of virtual reality as an exposure technique has since become a standard in PTSD treatment.
In virtual reality therapy, PTSD clients use wraparound goggles and joysticks to navigate their way through a computer-generated military convoy, battle, or bomb attack in a landscape that looks like Iraq or Afghanistan.
The therapist controls the intensity of the hor- rifying sights, terrifying sounds, and awful smells of combat, triggering very real feelings of fear or panic in the client. Exposure therapy pro- ceeds with the therapist applying the exposures to these stimuli in either gradual steps or a flooding approach (see pages 124–126).
Study after study has suggested that virtual reality therapy is extremely help- ful for combat veterans with PTSD, much more so than covert exposure therapy (Nauert, 2014; McLay, 2013; Rauch, Eftekhari, & Ruzek, 2012). In addition, the improvements produced by this intervention appear to last for extended periods, perhaps indefinitely. Small wonder that virtual reality therapy is now also becom- ing common in the treatment of other anxiety disorders and phobias, including social anxiety disorder and fears of heights, flying, and closed spaces (Anderson et al., 2013).
can you design a virtual
reality exposure treatment
program for people with
social anxiety disorder?
“Virtual” exposure An ex-soldier’s headset and video game–type controller take him back to a battle scene in Iraq.
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▶▶ eye movement desensitization and reprocessing (EMDR) An expo- sure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid.
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combat experiences and the impact those experiences continue to have. Thus clini- cians often try to help veterans bring out deep-seated feelings, accept what they have done and experienced, become less judgmental of themselves, and learn to trust other people once again (Rothbaum et al., 2011; Turner et al., 2005). In a similar vein, cognitive therapists typically guide such veterans to examine and change the dysfunctional attitudes and styles of interpretation that they have developed as a result of their traumatic experiences (Spence et al., 2014).
Veterans who have posttraumatic stress disorder may be further helped in a couple, family, or group therapy format (Shnaider et al., 2014; Vogt et al., 2011). The symptoms of PTSD are particularly apparent to family members, who may be directly affected by the client’s anxieties, depressed mood, or angry outbursts (Owens et al., 2014). With the help and support of their family members, they may come to examine their impact on others, learn to communicate better, and improve their problem-solving skills.
In group therapy sessions, called rap groups when initiated during the 1980s, the veterans meet with others like themselves to share experiences and feelings (particularly guilt and rage), develop insights, and give mutual support (Ellis et al., 2014). Today hundreds of small Veterans Outreach Centers across the country, as well as treatment programs in Veterans Administration hospitals and mental health clin- ics, provide group treatment (Schumm et al., 2015; Ruzek & Batten, 2011). These agencies also offer individual therapy, counseling for spouses and children, family therapy, and aid in seeking jobs, education, and benefits (Mott et al., 2014). Clinical reports suggest that these programs offer a necessary, sometimes life-saving, treat- ment opportunity.
Psychological Debriefing People who are traumatized by disasters, vic- timization, or accidents profit from many of the same treatments that are used to help survivors of combat (Monson et al., 2014). In addition, because their traumas occur in their own community, where mental health resources are close at hand, they may, according to many clinicians, further benefit from immediate community interventions.
One of the leading such approaches is called psychological debriefing, or critical incident stress debriefing, an intervention applied widely over the past 30 years. The use of this intervention has, however, come under careful scrutiny in recent years, reminding the clinical field of the ongoing need for systematic research into its assumptions and applications.
Psychological debriefing is a form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident (Tuckey & Scott, 2014; Mitchell, 2003, 1983). Based on the assumption that such sessions prevent or reduce stress reactions, they are often provided to trauma victims who have not yet displayed any symptoms at all, as well as to those who have. During the sessions, often conducted in a group format, counselors guide the individuals to describe the details of the recent trauma, to vent and relive the emotions provoked at the time of the event, and to express their current feelings. The clinicians then clarify to the victims that their reactions are perfectly normal responses to a terrible event, offer stress management tips, and, in some cases, refer the victims to professionals for long-term counseling.
Many thousands of counselors, both professionals and nonprofessionals, have been trained in psychological debriefing since its beginnings in the early 1980s, and the intense approach has been applied in the aftermath of countless traumatic events (Pfefferbaum, Newman, & Nelson, 2014; Wei et al., 2010). Indeed, when a traumatic incident affects numerous individuals, debriefing-trained counselors may come from far and wide to conduct debriefing sessions with the victims. Large mobilizations of this kind have offered free emergency mental health services at disaster sites such
▶▶ psychological debriefing A form of crisis intervention in which victims are helped to talk about their feelings and reactions to traumatic incidents. Also called critical incident stress debriefing.
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Personal Impact of Stress 33 Percentage of people who feel
they are living with extreme stress
48 Percentage of people who lie awake at night due to stress
48 Percentage of people who say stress negatively affects their personal and professional lives
54 Percentage of people who say stress has caused them to fight with close friends or relatives
(apa, 2013)
Disorders of Trauma and Stress : 165
as the 1999 shooting of 23 people at Columbine High School in Colorado, the 2001 World Trade Center attack, the 2004 tsunami in South Asia, the floods caused by Hurricane Katrina in 2005, and the Haitian and Japanese earthquakes in 2010 and 2011.
In such community-wide mobilizations, the counselors may knock on doors or approach victims at shelters. Although victims from all socioeconomic groups may be engaged, those who live in poverty have been viewed traditionally as most in need and so have been targeted for psychological debriefing most often.
Does Psychological Debriefing Work? Over the years, personal tes- timonials for rapid mobilization programs have often been favorable (Watson & Shalev, 2005; Mitchell, 2003). However, as you read earlier, a growing number of studies conducted in the twenty-first century have called into question the effec- tiveness of this kind of intervention (Tuckey & Scott, 2014; Gist & Devilly, 2010).
Actually, an investigation conducted in the early 1990s was the first to raise con- cerns about disaster debriefing programs (Bisson & Deahl, 1994). Crisis counselors offered immediate debriefing sessions to 62 British soldiers whose job during the Gulf War was to handle and identify the bodies of people who had been killed. Despite such sessions, half of the soldiers displayed posttraumatic stress symptoms when interviewed nine months later.
In a properly controlled study conducted a few years later on hospitalized burn victims, researchers sepa- rated the victims into two groups (Bisson et al., 1997). One group received a single one-on-one debriefing session within days of their burn accidents, while the other (control) group of burn victims received no such intervention. Three months later, it was found that the debriefed and the control patients had similar rates of posttraumatic stress disorder. Moreover, researchers found that 13 months later, the rate of posttraumatic stress disorder was actually higher among the debriefed burn victims (26 percent) than among the control victims (9 percent).
More recent studies, focusing on yet other kinds of disasters, have yielded similar patterns of findings, raising important questions about the effectiveness of psychological debriefing (Tuckey & Scott, 2014; Szumilas et al., 2010). Some clinicians have come to believe that the early intervention programs may encourage victims to dwell too long on the traumatic events that they have experienced. And a number worry that early disaster counseling may unintentionally “suggest” problems to certain victims, thus helping to produce stress disorders (McNally, 2004; McClelland, 1998).
Many mental health professionals continue to believe in psychological debrief- ing programs. However, given the unsupportive and even contradictory research findings of recent years, the current clinical climate is moving away from outright acceptance. A number of clinical theorists now believe that certain high-risk indi- viduals may profit from debriefing programs, and that those people should receive debriefing techniques immediately after a traumatic event, but that other trauma victims should not receive such interventions (Delahanty, 2011). Of course, a key to this notion is the ability to effectively identify the risk factors that predict PTSD and the personality factors that predict responsiveness to psychological debrief- ing. Research into these issues is now under way (North & Pfefferbaum, 2013; Delahanty, 2011).
A change of direction A Chilean miner is helped by rescue workers after being pulled out of the gold and copper mine in which he and 32 other miners had been trapped for more than two months in 2010. On the advice of international psychologists, Chilean officials decided to make counseling available, but not required, for the rescued miners. This advice was a departure from the widely used proce- dure of psychological debriefing, which has failed to receive consistent research support in recent years.
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➤ Summing Up ACUTE AND POSTTRAUMATIC STRESS DISORDERS When we view a stressor as threatening, we often experience a stress response consisting of arousal and a sense of fear. The features of arousal and fear are set in motion by the hypothalamus, a brain area that activates the autonomic nervous system and the endocrine system. There are two pathways by which these systems produce arousal and fear—the sympathetic nervous system pathway and the hypothalamic-pituitary-adrenal pathway.
People with acute stress disorder or posttraumatic stress disorder react with arousal, anxiety, and other stress symptoms after a traumatic event, including reexperiencing the traumatic event, avoiding related events, being markedly less responsive than normal, and feeling guilt. The symptoms of acute stress disorder begin soon after the trauma and last less than a month. Those of post- traumatic stress disorder may begin at any time (even years) after the trauma and may last for months or years.
In attempting to explain why some people develop a psychological stress disorder and others do not, researchers have focused on biological factors, personality, childhood experiences, social support, multicultural factors, and the severity of the traumatic event. Techniques used to treat the stress disorders include drug therapy, behavioral exposure, cognitive and other insight thera- pies, family therapy, and group therapy. Rapidly mobilized community inter- ventions often follow the principles of critical incident stress debriefing. Such approaches initially appeared helpful after large-scale disasters; however, some recent studies have raised questions about their usefulness.
Dissociative Disorders As you have just read, people with acute and posttraumatic stress disorders may have symptoms of dissociation along with their other symptoms. They may, for example, feel dazed, have trouble remembering things, or have a sense of derealization. Symp- toms of this kind are also on display in dissociative disorders, another group of disorders triggered by traumatic events (Armour et al., 2014). In fact, the memory
difficulties and other dissociative symptoms found in these disor- ders are particularly intense, extensive, and disruptive. Moreover, in such disorders, dissociative reactions are the main or only symptoms. People with dissociative disorders do not typically have the significant arousal, negative emotions, sleep difficulties, and other problems that characterize acute and posttraumatic stress disorders. Nor are there clear physical factors at work in dissociative disorders.
Most of us experience a sense of wholeness and continuity as we interact with the world. We perceive ourselves as being more than a collection of isolated sensory experiences, feelings, and behaviors. In other words, we have an identity, a sense of who we are and where we fit in our environment. Memory is a key to this sense of identity, the link between our past, present, and future. Without a memory, we would always be starting over; with it, our life and our identity move forward. In dissociative disorders, one part of a person’s memory or identity becomes dissociated, or separated, from other parts of his or her memory or identity.
There are several kinds of dissociative disorders. People with dis- sociative amnesia are unable to recall important personal events and information. People with dissociative identity disorder, once known as multiple personality disorder, have two or more separate identities that
At risk A U.S. Marine takes a short break before going on patrol in southern Afghani- stan in 2011. Combat soldiers are particularly vulnerable to amnesia and other dissociative reactions. They may forget specific horrors, personal information, or even their identities.
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▶▶ dissociative disorders Disorders marked by major changes in memory that do not have clear physical causes.
▶▶ memory The faculty for recalling past events and past learning.
▶▶ dissociative amnesia A disorder marked by an inability to recall important personal events and information.
Disorders of Trauma and Stress : 167
may not always be aware of each other’s memories, thoughts, feelings, and behav- ior. And people with depersonalization-derealization disorder feel as though they have become detached from their own mental processes or bodies or are observing themselves from the outside.
Several famous books and movies have portrayed dissociative disorders. Two classics are The Three Faces of Eve and Sybil, each about a woman who developed multiple personalities after having been subject to traumatic events in childhood. The topic is so fascinating that most television drama series seem to include at least one case of dissociation every season, creating the impression that the disorders are very common. Many clinicians, however, believe that they are rare.
Dissociative Amnesia People with dissociative amnesia are unable to recall important information, usu- ally of a stressful nature, about their lives (APA, 2013). The loss of memory is much more extensive than normal forgetting and is not caused by physical factors such as a blow to the head (see Table 5-3). Typically, an episode of amnesia is directly trig- gered by a traumatic or upsetting event (Kikuchi et al., 2010).
Dissociative amnesia may be localized, selective, generalized, or continuous. In localized amnesia, the most common type of dissociative amnesia, a person loses all memory of events that took place within a limited period of time, almost always beginning with some very disturbing occurrence. A soldier, for example, may awaken a week after a horrific combat battle and be unable to recall the battle or any of the events surrounding it. She may remember everything that happened up to the battle and may recall everything that has occurred over the past several days, but the events in between remain a total blank. The forgotten period is called the amnestic episode. During an amnestic episode, people may appear confused; in some cases they wander about aimlessly. They are already experiencing memory difficul- ties but seem unaware of them.
People with selective amnesia, the second most common form of dissociative amnesia, remember some, but not all, events that took place during a period of time. If the combat soldier mentioned in the previous paragraph had selective amnesia, she might remember certain interactions or conversations that occurred during the battle, but not more disturbing events such as the death of a friend or the screams of enemy soldiers.
In some cases the loss of memory extends back to times long before the upset- ting period. In addition to forgetting battle-linked events, the soldier may not remember events that occurred earlier in her life. In this case, she would have what is called generalized amnesia. In extreme cases, she might not even recognize relatives and friends.
In the forms of dissociative amnesia just discussed, the period affected by the amnesia has an end. In continuous amnesia, however, forgetting continues into the present. The soldier might forget new and ongoing experiences as well as what happened before and during the battle.
These various forms of dissociative amnesia are similar in that the amnesia inter- feres mostly with a person’s memory of personal material. Memory for abstract or encyclopedic information usually remains. People with dissociative amnesia are as likely as anyone else to know the name of the president of the United States and how to read or drive a car.
Clinicians do not know how common dissociative amnesia is (Pope et al., 2007), but they do know that many cases seem to begin during serious threats to health and safety, as in wartime and natural disasters. Like the soldier in the earlier examples, combat veterans often report memory gaps of hours or days, and some forget per- sonal information, such as their name and address (Bremner, 2002).
table: 5-3
Dx Checklist
Dissociative Amnesia
1. Person cannot recall important life-related information, typically traumatic or stressful information. The memory problem is more than simple forgetting.
2. Significant distress or impairment.
3. The symptoms are not caused by a substance or medical condition.
Dissociative Identity Disorder
1. Person experiences a disruption to his or her identity, as reflected by at least two separate personality states or experiences of possession.
2. Person repeatedly experiences memory gaps regarding daily events, key personal information, or traumatic events, beyond ordinary forgetting.
3. Significant distress or impairment.
4. The symptoms are not caused by a substance or medical condition.
Information from: APA, 2013.
why do many people question
the authenticity of individuals
who seem to lose their memories
at times of severe stress?
: chapter 5168
Childhood abuse, particularly child sexual abuse, can also trigger dissociative amnesia; indeed, in the 1990s there were many reports in which adults claimed to recall long-forgotten experiences of child- hood abuse (Wolf & Nochajski, 2013) (see PsychWatch on the next page). In addition, dissociative amnesia may occur under more ordi- nary circumstances, such as the sudden loss of a loved one through rejection or death or extreme guilt over certain actions (for example, an extramarital affair) (Koh et al., 2000).
The personal impact of dissociative amnesia depends on how much is forgotten. Obviously, an amnestic episode of two years is more of a problem than one of two hours. Similarly, an amnestic epi- sode during which a person’s life changes in major ways causes more difficulties than one that is quiet.
An extreme version of dissociative amnesia is called dissociative fugue. Here persons not only forget their personal identities and details of their past lives but also flee to an entirely different location. Some people travel a short distance and make few social contacts
in the new setting (APA, 2013). Their fugue may be brief—a matter of hours or days—and end suddenly. In other cases, however, the person may travel far from home, take a new name, and establish a new identity, new relationships, and even a new line of work. Such people may also display new personality characteristics; often they are more outgoing. This pattern is seen in the century-old case of the Reverend Ansel Bourne, whose last name was the inspiration for Jason Bourne, the memory-deprived secret agent in the modern-day Bourne books and movies.
On January 17, 1887, [the Reverend Ansel Bourne, of Greene, R.I.] drew 551 dol- lars from a bank in Providence with which to pay for a certain lot of land in Greene, paid certain bills, and got into a Pawtucket horsecar. This is the last incident which he remembers. He did not return home that day, and nothing was heard of him for two months. He was published in the papers as missing, and foul play being sus- pected, the police sought in vain his whereabouts. On the morning of March 14th, however, at Norristown, Pennsylvania, a man calling himself A. I. Brown who had rented a small shop six weeks previously, stocked it with stationery, confectionery, fruit and small articles, and carried on his quiet trade without seeming to any one unnatural or eccentric, woke up in a fright and called in the people of the house to tell him where he was. He said that his name was Ansel Bourne, that he was entirely ignorant of Norristown, that he knew nothing of shop keeping, and that the last thing he remembered—it seemed only yesterday—was drawing the money from the bank, etc. in Providence. . . . He was very weak, having lost apparently over twenty pounds of flesh during his escapade, and had such a horror of the idea of the candy-store that he refused to set foot in it again.
( James, 1890, pp. 391–393)
Fugues tend to end abruptly. In some cases, as with Reverend Bourne, the person “awakens” in a strange place, surrounded by unfamiliar faces, and wonders how he or she got there. In other cases, the lack of personal history may arouse suspicion. Perhaps a traffic accident or legal problem leads police to discover the false identity; at other times friends search for and find the missing person. When people are found before their state of fugue has ended, therapists may find it necessary to ask them many questions about the details of their lives, repeatedly remind them who they are, and even begin psychotherapy before they recover their memories (Igwe, 2013; Mamarde et al., 2013). As these people recover their past, some forget the events of the fugue period.
Lost and found Cheryl Ann Barnes is helped off a plane by her grandmother and stepmother upon arrival in Florida in 1996. The 17-year-old high school honor student had disappeared from her Florida home and was found one month later in a New York City hospital listed as Jane Doe, apparently suffer- ing from a dissociative fugue.
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In Their Words “There are lots of people who mistake their imagination for their memory.”
Josh Billings
Disorders of Trauma and Stress : 169
The majority of people who go through a dissociative fugue regain most or all of their memories and never have a recurrence. Since fugues are usually brief and totally reversible, those who have experienced them tend to have few aftereffects. People who have been away for months or years, however, often do have trouble adjusting to the changes that took place during their flight. In addition, some people commit illegal or violent acts in their fugue state and later must face the consequences.
PsychWatch
Throughout the 1990s, re-ports of repressed childhood memory of abuse attracted much public attention. Adults with this type of dissociative amnesia seemed to recover buried memo- ries of sexual and physical abuse from their childhood. A woman might claim, for example, that her father had sexually molested her repeatedly between the ages of 5 and 7. Or a young man might remember that a family friend had made sexual advances on several occasions when he was very young. Often the repressed memories surfaced during therapy for another problem.
Although the number of such claims has declined in recent years, experts remain split on this issue (Wolf & Nochajski, 2013; Birrell, 2011). Some believe that recovered memories are just what they appear to be—horrible memories of abuse that have been buried for years in the person’s mind. Other experts believe that the memories are actually illusions— false images created by a mind that is confused. Opponents of the repressed memory concept hold that the details of childhood sexual abuse are often remem- bered all too well, not completely wiped from memory (Loftus & Cahill, 2007). They also point out that memory in general is often flawed (Haaken & Reavey, 2010; Lindsay et al., 2004). Moreover, false memories of various kinds can be created in the laboratory by tapping into research participants’ imaginations (Weinstein & Shanks, 2010; Brainerd et al., 2008).
If the alleged recovery of childhood memories is not what it appears to be, what is it? According to opponents of the concept, it may be a powerful case of suggestibility (Loftus & Cahill, 2007; Loftus, 2003, 2001). These theorists hold that the attention paid to the phenom- enon by both clinicians and the public has led some therapists to make the diagnosis without sufficient evidence (Haaken & Reavey, 2010). The therapists may actively search for signs of early abuse in clients and even encourage clients to produce repressed memories (McNally & Garaerts, 2009). Certain therapists in fact use spe- cial memory recovery techniques, includ- ing hypnosis, regression therapy, journal writing, dream interpretation, and inter-
pretation of bodily symptoms. Perhaps some clients respond to the techniques by unknowingly forming false memories of abuse. The apparent memories may then become increasingly familiar to them as a result of repeated ther- apy discussions of the alleged incidents.
Of course, repressed memo- ries of childhood sexual abuse do not emerge only in clinical settings. Many individuals come forward on their own. Opponents of the repressed memory concept explain these cases by pointing to various books, articles, Web sites, and television shows that seem to validate repressed mem- ories of childhood abuse (Haaken & Reavey, 2010; Loftus, 1993). Still other opponents of the re- pressed memory concept believe
that, for biological or other reasons, some individuals are more prone than others to experience false memories—either of childhood abuse or of other kinds of events (McNally et al., 2005).
It is important to recognize that the experts who question the recovery of repressed childhood memories do not in any way deny the problem of child sexual abuse. In fact, proponents and opponents alike are greatly concerned that the public may take this debate to mean that clini- cians have doubts about the scope of the problem of child sexual abuse. Whatever may be the final outcome of the re- pressed memory debate, the problem of childhood sexual abuse is all too real and all too common.
repressed childhood Memories or False Memory Syndrome?
Early recall These three siblings, all born on the same day in different years, have very different reactions to their cakes at a 1958 birthday party. But how do they each remember that party today? Research suggests that our memories of early childhood may be influenced by the reminiscences of family members, our dreams, television and movie plots, and our present self-image.
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Dissociative Identity Disorder Dissociative identity disorder is both dramatic and disabling, as we see in the case of Luisa:
Luisa was first brought in for treatment after she was found walking in circles by the side of the road in a suburban neighborhood near Denver. Agitated, malnourished, and dirty, this 30-year-old woman told police that her name was Franny and that she was a 15-year-old who was running away from her home in Telluride. At first, the police officers suspected she was giving a false identity to avoid prosecution for prostitution or drug possession, but there really was no evidence for either crime when she was found.
Once it became apparent that she fully believed what she was saying, the woman, who carried no identification of any kind, was transferred to a psychiatric hospital for observation. By the time she met with a therapist, she was no longer a young child speaking rapidly about a terrible family situation. She was now calling herself Luisa, and she spoke in slow, measured, and sad tones—eloquent but often confused.
Luisa described how she had been sexually abused for years by her stepfather, starting when she was six. She said she had run away from home at the age of 15 and had not spoken since to either her mother or stepfather. She claimed that, al- though she had spent considerable time living on the streets over the years, she was currently living with her boyfriend, Tim, in a small apartment. However, when pressed, she was unable to say what Tim did for a living, nor could she provide his address or last name. Thus she remained in treatment.
Over the course of treatment, as her therapist continued to probe for details of her unhappy childhood and sexual abuse, Luisa became more and more agitated, until finally, she actually transformed back into 15-year-old Franny during one ses- sion. Her therapist wrote in his notes, “Her entire physical presence transformed itself suddenly and almost violently. Her face, previously relaxed and even flat, be- came tense and scrunched up, and her entire body hunched over. She moved her chair back almost two feet and repeatedly flinched from me if I even gestured in her direction. Her voice became high-pitched, clipped, and fast, spitting out words, and her vocabulary became limited, to that which a child would display. She seemed to be a different person in every way possible.”
Over the following several sessions, Luisa’s therapist wound up meeting still other personalities. One was Miss Johnson, a strict school principal who claimed to have taught Luisa when she was younger. Another was Roger—homeless, tough, and threatening—who made it clear that he was in charge of Luisa and the other person- alities. In addition there was Sarah, aged 55 and divorced, and Lilly, aged 24, a math genius and accountant who seemed to appear whenever Luisa needed to deal with money or complex mathematical issues.
A person with dissociative identity disorder, known in the past as multiple personality disorder, develops two or more distinct personalities, often called sub- personalities, or alternate personalities, each with a unique set of memories, behaviors, thoughts, and emotions (see again Table 5-3). At any given time, one of the subpersonalities takes center stage and dominates the person’s functioning. Usu- ally one subpersonality, called the primary, or host, personality, appears more often than the others.
The transition from one subpersonality to another, called switching, is usually sudden and may be dramatic (Barlow & Chu, 2014). Luisa, for example, twisted her face and hunched her shoulders and body forward violently. Switching is usually triggered by a stressful event, although clinicians can also bring about the change with hypnotic suggestion.
▶▶ dissociative identity disorder A dissociative disorder in which a person develops two or more distinct personali- ties. Also known as multiple personality disorder.
▶▶ subpersonalities The two or more distinct personalities found in individuals suffering with dissociative identity disor- der. Also known as alternate personalities.
B e t w e e n t h e L i n e s
Cultural Ties Some clinical theorists argue that dissociative identity disorder is culture- bound (tied to one’s culture) (Boysen & VanBergen, 2013). While the prevalence of this disorder may be substantial in North America, it is rare or nonexistent in Great Britain, Sweden, Russia, India, and Southeast Asia. Moreover, within the United States the prevalence is particularly low among Hispanic Americans and Asian Americans.
Disorders of Trauma and Stress : 171
Cases of dissociative identity disorder were first reported almost three centuries ago (Rieber, 2006, 2002). Many clinicians consider the disorder to be rare, but some reports suggest that it may be more com- mon than was once thought (Dorahy et al., 2014). Most cases are first diagnosed in late adolescence or early adulthood, but more often than not, the symptoms actually began in early childhood after episodes of trauma or abuse (often sexual abuse) (Sar et al., 2014; Steele, 2011; Ross & Ness, 2010). Women receive this diagnosis at least three times as often as men.
How Do Subpersonalities Interact? How subpersonalities relate to or recall one another varies from case to case (Barlow & Chu, 2014). Generally, however, there are three kinds of relationships. In mutually amnesic relationships, the subpersonalities have no awareness of one another (Ellenberger, 1970). Conversely, in mutually cognizant patterns, each subpersonality is well aware of the rest. They may hear one another’s voices and even talk among themselves. Some are on good terms, while others do not get along at all.
In one-way amnesic relationships, the most common relationship pattern, some subpersonalities are aware of others, but the awareness is not mutual. Those who are aware, called coconscious subpersonalities, are “quiet observers” who watch the actions and thoughts of the other subpersonalities but do not interact with them. Sometimes while another subpersonality is present, the coconscious personality makes itself known through indirect means, such as auditory hallucinations (perhaps a voice giving commands) or “automatic writing” (the current personality may find itself writing down words over which it has no control).
Investigators used to believe that most cases of dissociative identity disorder involved two or three subpersonalities. Studies now suggest, however, that the average number of subpersonalities per patient is much higher—15 for women and 8 for men (APA, 2000). In fact, there have been cases in which 100 or more subpersonalities were observed. Often the subpersonalities emerge in groups of two or three at a time.
In the case of “Eve White,” made famous in the book and movie The Three Faces of Eve, a woman had three subpersonalities—Eve White, Eve Black, and Jane (Thigpen & Cleckley, 1957). Eve White, the primary personality, was quiet and serious; Eve Black was carefree and mischievous; and Jane was mature and intelligent. Accord- ing to the book, these three subpersonalities eventually merged into Evelyn, a stable personality who was really an integration of the other three.
The book was mistaken, however; this was not to be the end of Eve’s dissocia- tion. In an autobiography 20 years later, she revealed that altogether 22 subpersonali- ties had come forth during her life, including 9 subpersonalities after Evelyn. Usually they appeared in groups of three, and so the authors of The Three Faces of Eve appar- ently never knew about her previous or subsequent subpersonalities. She has now overcome her disorder, achieving a single, stable identity, and has been known as Chris Sizemore for more than 35 years (Ramsland & Kuter, 2011; Sizemore, 1991).
How Do Subpersonalities Differ? As in Chris Sizemore’s case, subper- sonalities often exhibit dramatically different characteristics. They may also have their own names and different identifying features, abilities and preferences, and even physiological responses.
identifying featuRes The subpersonalities may differ in features as basic as age, gender, race, and family history, as in the case of Sybil Dorsett, whose disorder is described in the famous novel Sybil (Schreiber, 1973). According to the novel, Sybil displayed 17 subpersonalities, all with different identifying features. They included adults, a teenager, and even a baby. One subpersonality, Vicky, saw herself as attrac- tive and blonde, while another, Peggy Lou, believed herself to be “a pixie with a pug nose.” Yet another, Mary, was plump with dark hair, and Vanessa was a tall, thin
why might women be much
more likely than men to receive
a diagnosis of dissociative
identity disorder?
The real Sybil Clinical historians have iden- tified painter Shirley A. Mason (shown here) as the real-life person on whom the famous work of fiction Sybil was based.
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redhead. (It is worth noting that the accuracy of the real-life case on which this novel was based has been challenged in recent years.)
abilities and pRefeRences Although memories of abstract or encyclopedic infor- mation are not usually affected in dissociative amnesia, they are often disturbed in dissociative identity disorder. It is not uncommon for the different subpersonalities to have different abilities: one may be able to drive, speak a foreign language, or play a musical instrument, while the others cannot (Coons & Bowman, 2001). Their handwriting can also differ. In addition, the subpersonalities usually have different tastes in food, friends, music, and literature. Chris Sizemore (“Eve”) later pointed out, “If I had learned to sew as one personality and then tried to sew as another, I couldn’t do it. Driving a car was the same. Some of my personalities couldn’t drive” (Sizemore & Pitillo, 1977, p. 4).
physiological Responses Researchers have discovered that subpersonalities may have physiological differences, such as differences in blood pressure levels and aller- gies (Spiegel, 2009; Putnam et al., 1990). A pioneering study looked at the brain activities of different subpersonalities by measuring their evoked potentials—that is, brain-response patterns recorded on an electroencephalograph (Putnam, 1984). The brain pattern a person produces in response to a specific stimulus (such as a flashing light) is usually unique and consistent. However, when an evoked potential test was administered to four subpersonalities of each of 10 people with dissociative identity disorder, the results were dramatic. The brain-activity pattern of each subpersonality was unique, showing the kinds of variations usually found in totally different people. A number of other studies conducted over the past two decades have yielded similar findings (Boysen & VanBergen, 2014).
How Common Is Dissociative Identity Disorder? As you have seen, dissociative identity disorder has traditionally been thought of as rare. Some researchers even argue that many or all cases are iatrogenic—that is, unintentionally produced by practitioners (Lynn & Deming, 2010; Piper & Merskey, 2005, 2004). They believe that therapists create this disorder by subtly suggesting the existence of other personalities during therapy or by explicitly asking a patient to produce different personalities while under hypnosis. In addition, they believe, a therapist who is looking for multiple personalities may reinforce these patterns by displaying greater interest when a patient displays symptoms of dissociation.
These arguments seem to be supported by the fact that many cases of dissociative identity disorder first come to attention while the person is already in treatment for a less serious problem. But such is not true of all cases; many people seek treatment because they have noticed time lapses throughout their lives or because relatives and friends have observed their subpersonalities (Putnam, 2006, 2000).
The number of people diagnosed with dissociative identity disorder increased dramatically in the 1980s and 1990s, only to decrease again over
the past 15 years (Paris, 2012). Not withstanding this decline, thousands of cases have now been diagnosed in the United States and Canada alone, and some clinical theo- rists estimate that as much as 1 percent of the population in the United States and other Western countries displays the disorder (Dorahy et al., 2014). On the other side of the coin, many clinicians continue to question the legitimacy of this category.
How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? A variety of theories have been proposed to explain dissociative amnesia and disso- ciative identity disorder. Older explanations, such as those offered by psychodynamic and behavioral theorists, have not received much investigation (Merenda, 2008).
what verdict is appropriate for
accused criminals with disso
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crimes are committed by one
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B e t w e e n t h e L i n e s
More to the Story? Recent reports, including claims by several colleagues who worked closely with the author of Sybil and with Sybil’s real-life therapist, suggest that Shirley Mason (the person on whom Sybil was based) was highly hypnotizable, extremely suggestible, and anxious to please her therapist, and that her disor- der was in fact induced largely by hyp- nosis, sodium pentothal, and therapist suggestion (Nathan, 2011; Rieber, 2002, 1999; Miller & Kantrowitz, 1999).
Disorders of Trauma and Stress : 173
However, newer viewpoints, which combine cognitive-behavioral and biological principles and highlight such factors as state-dependent learning and self-hypnosis, have captured the interest of clinical scientists.
The Psychodynamic View Psychodynamic theorists believe that these dis- sociative disorders are caused by repression, the most basic ego defense mechanism: people fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness. Everyone uses repression to a degree, but people with dissociative amnesia and dissociative identity disorder are thought to repress their memories excessively (Henderson, 2010).
In the psychodynamic view, dissociative amnesia is a single episode of massive repression. A person unconsciously blocks the memory of an extremely upsetting event to avoid the pain of facing it (Kikuchi et al., 2010). Repressing may be his or her only protection from overwhelming anxiety.
In contrast, dissociative identity disorder is thought to result from a lifetime of excessive repression (Howell, 2011; Wang & Jiang, 2007). Psychodynamic theorists believe that this continuous use of repression is motivated by traumatic childhood events, particularly abusive parenting (Baker, 2010; Ross & Ness, 2010). Children who experience such traumas may come to fear the dangerous world they live in and take flight from it by pretending to be another person who is looking on safely from afar. Abused children may also come to fear the impulses that they believe are the reasons for their excessive punishments. Whenever they experience “bad” thoughts or impulses, they unconsciously try to disown and deny them by assigning them to other personalities.
Most of the support for the psychodynamic explanation of dissociative identity disorder is drawn from case histories, which report such brutal childhood experi- ences as beatings, cuttings, burnings with cigarettes, imprisonment in closets, rape, and extensive verbal abuse (Ross & Ness, 2010). Yet some individuals with this disorder do not seem to have experiences of abuse in their background (Ross & Ness, 2010; Bliss, 1980). For example, Chris Sizemore, the subject of The Three Faces of Eve, has reported that her disorder first emerged during her preschool years after she witnessed two deaths and a horrifying accident within a three-month period.
The Behavioral View Behaviorists believe that dissociation grows from nor- mal memory processes such as drifting of the mind or forgetting (see PsychWatch on page 175). Specifically, they hold that dissociation is a response learned through operant conditioning (Casey, 2001). People who experience a horrifying event may later find temporary relief when their mind drifts to other subjects. For some, this momentary forgetting, leading to a drop in anxiety, increases the likelihood of future forgetting. In short, they are reinforced for the act of forgetting and learn—without being aware that they are learning—that such acts help them escape anxiety. Thus,
“I think I accidentally repressed my good memories.”
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At the Movies: Recent Films about Memory Disturbances Finding Dori (2016)
Before I Go to Sleep (2014)
Trance (2013)
Total Recall (2012, 1990)
The Vow (2012)
The Bourne series (2002–2012)
Black Swan (2010)
Shutter Island (2010)
The Hangover (2009)
The Number 23 (2007)
Spider-Man 3 (2007)
Eternal Sunshine of the Spotless Mind (2004)
The Manchurian Candidate (2004, 1962)
Finding Nemo (2003)
Mulholland Drive (2001)
Memento (2000)
: chapter 5174
like psychodynamic theorists, behaviorists see dissociation as escape behavior. But behaviorists believe that a reinforcement process rather than a hardworking uncon- scious is keeping the individuals unaware that they are using dissociation as a means of escape. Like psychodynamic theorists, behaviorists have relied largely on case histories to support their view. Moreover, the behavioral explanation fails to explain precisely how temporary and normal escapes from painful memories grow into a complex disorder or why more people do not develop dissociative disorders.
State-Dependent Learning If people learn something when they are in a particular situation or state of mind, they are likely to remember it best when they are again in that same condition. If they are given a learning task while under the influence of alcohol, for example, their later recall of the information may be strongest under the influence of alcohol. Similarly, if they smoke cigarettes while learning, they may later have better recall when they are again smoking.
This link between state and recall is called state-dependent learning. It was initially observed in animals who learned things dur- ing experiments while under the influence of certain drugs (Ardjmand et al., 2011; Overton, 1966, 1964). Research with human participants later showed that state-dependent learning can
be associated with mood states as well: material learned during a happy mood is recalled best when the participant is again happy, and sad-state learning is recalled best during sad states (de l’Etoile, 2002; Bower, 1981) (see Figure 5-3).
What causes state-dependent learning? One possibility is that arousal levels are an important part of learning and memory. That is, a particular level of arousal will have a set of remembered events, thoughts, and skills attached to it. When a situation produces that particular level of arousal, the person is more likely to recall the memories linked to it.
Although people may remember certain events better in some arousal states than in others, most can recall events under a variety of states. However, perhaps people who are prone to develop dis- sociative disorders have state-to-memory links that are unusually rigid and narrow (Barlow, 2011). Maybe each of their thoughts, memories, and skills is tied exclusively to a particular state of arousal, so that they recall a given event only when they experi-
ence an arousal state almost identical to the state in which the memory was first acquired. When such people are calm, for example, they may forget what happened during stressful times, thus laying the groundwork for dissociative amnesia. Similarly, in dissociative identity disorder, different arousal levels may produce entirely differ- ent groups of memories, thoughts, and abilities—that is, different subpersonalities (Dorahy & Huntjens, 2007). This could explain why personality transitions in dis- sociative identity disorder tend to be sudden and stress-related.
Self-Hypnosis As you first saw in Chapter 1, people who are hypnotized enter a sleeplike state in which they become very suggestible. While in this state, they can behave, perceive, and think in ways that would ordinarily seem impossible. They may, for example, become temporarily blind, deaf, or insensitive to pain. Hypnosis can also help people remember events that occurred and were forgotten years ago, a capability used by many psychotherapists. Conversely, it can make people forget facts, events, and even their personal identities—an effect called hypnotic amnesia.
The parallels between hypnotic amnesia and the dissociative disorders we have been examining are striking (van der Kruijs et al., 2014). Both are conditions in which people forget certain material for a period of time yet later remember it. And
figure 5-3 State-dependent learning In one study, participants who learned a list of words while in a hypnotically induced happy state remembered the words better if they were in a happy mood when tested later than if they were in a sad mood. Conversely, participants who learned the words when in a sad mood recalled them better if they were sad during testing than if they were happy. (Information from: Bower, 1981.)
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Might it be possible to use the
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results in school or at work?
▶▶ state-dependent learning Learning that becomes associated with the condi- tions under which it occurred, so that it is best remembered under the same conditions.
▶▶ self-hypnosis The process of hypno- tizing oneself, sometimes for the purpose of forgetting unpleasant events.
Disorders of Trauma and Stress : 175
in both, the people forget without any insight into why they are forgetting or any awareness that something is being forgotten. These parallels have led some theorists to conclude that dissociative disorders may be a form of self-hypnosis in which people hypnotize themselves to forget unpleasant events (Dell, 2010). Dissociative amnesia may develop, for example, in people who, consciously or unconsciously, hypnotize themselves into forgetting horrifying experiences that have recently taken place in their lives. If the self-induced amnesia covers all memories of a per- son’s past and identity, that person may undergo a dissociative fugue.
The self-hypnosis theory might also be used to explain dissociative identity dis- order. On the basis of several investigations, some theorists believe that this disorder often begins between the ages of 4 and 6, a time when children are generally very suggestible and excellent hypnotic subjects (Kohen & Olness, 2011; Kluft, 2001, 1987). These theorists argue that some children who experience abuse or other horrifying events manage to escape their threatening world by self-hypnosis, men- tally separating themselves from their bodies and fulfilling their wish to become some other person or persons (Giesbrecht & Merckelbach, 2009). One patient with multiple personalities observed, “I was in a trance often [during my childhood]. There was a little place where I could sit, close my eyes and imagine, until I felt very relaxed just like hypnosis” (Bliss, 1980, p. 1392).
PsychWatch
Usually memory problems must inter-fere greatly with a person’s function-ing before they are considered a sign of a disorder. Peculiarities of memory, on the other hand, fill our daily lives. Memory investigators have identified a number of these peculiarities—some familiar, some useful, some problematic, but none abnormal.
➤ Absentmindedness Often we fail to register information because our thoughts are focusing on other things. If we haven’t absorbed the information in the first place, it is no surprise that later we can’t recall it.
➤ Déjà vu Almost all of us have at some time had the strange sensation of rec- ognizing a scene that we happen upon for the first time. We feel sure we have been there before.
➤ Jamais vu Sometimes we have the op- posite experience: a situation or scene that is part of our daily life seems sud- denly unfamiliar. “I knew it was my car, but I felt as if I’d never seen it before.”
➤ The tip-of-the-tongue phenomenon To have something on the tip of the tongue is an acute “feeling of knowing”: we are unable to recall some
piece of information, but we know that we know it.
➤ Eidetic images Some people have such vivid visual afterimages that they can describe a picture in detail after look- ing at it just once. The images may be
memories of pictures, events, fantasies, or dreams.
➤ Memory while under anesthesia As many as 2 of every 1,000 anesthetized patients process enough of what is said in their presence during surgery to af- fect their recovery. In many such cases, the ability to understand language has continued under anesthesia, even though the patient cannot explicitly recall it.
➤ Memory for music Even as a small child, Mozart could memorize and reproduce a piece of music after hav- ing heard it only once. While no one yet has matched the genius of Mozart, many musicians can mentally hear whole pieces of music and can rehearse anywhere, far from their instruments.
➤ Visual memory Most people recall vi- sual information better than other kinds of information: they easily can bring to their mind the appearance of places, objects, faces, or the pages of a book. They almost never forget a face, yet they may well forget the name attached to it. Other people have stronger verbal memories: they remember sounds or words particularly well, and the memo- ries that come to their minds are often puns or rhymes.
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B e t w e e n t h e L i n e s
In Their Words “Be yourself; everyone else is already taken.”
Oscar Wilde
: chapter 5176
How Are Dissociative Amnesia and Dissociative Identity Disorder Treated? As you have seen, people with dissociative amnesia often recover on their own. Only sometimes do their memory problems linger and require treatment. In contrast, people with dissociative identity disorder usually require treatment to regain their lost memories and develop an integrated personality. Treatments for dissociative amnesia tend to be more successful than those for dissociative identity disorder, probably because the former pattern is less complex.
How Do Therapists Help People with Dissociative Amnesia? The leading treatments for dissociative amnesia are psychodynamic therapy, hypnotic therapy, and drug therapy, although support for these interventions comes largely from
case studies rather than controlled investigations (Gentile et al., 2014, 2013). Psychodynamic therapists guide patients to search their uncon- scious in the hope of bringing forgotten expe- riences back to consciousness (Howell, 2011). The focus of psychodynamic therapy seems particularly well suited to the needs of peo- ple with dissociative amnesia. After all, the patients need to recover lost memories, and the general approach of psychodynamic thera- pists is to try to uncover memories—as well as other psychological processes—that have been repressed. Thus many theorists, including some who do not ordinarily favor psychodynamic approaches, believe that psychodynamic ther- apy may be the most appropriate treatment for dissociative amnesia.
Another common treatment for dissociative amnesia is hypnotic therapy, or hypnotherapy. Therapists hypnotize patients and then guide them to recall their forgotten events (Rathbone et al., 2014). Given the possibility that dissocia- tive amnesia may be a form of self-hypnosis, hypnotherapy may be a particularly useful intervention. It has been applied both alone and in combination with other approaches (Colletti et al., 2010).
Sometimes injections of barbiturates such as sodium amobarbital (Amytal) or sodium pentobarbital (Pentothal) have been used to help patients with dissociative amnesia regain their lost memories. These drugs are often called “truth serums,” but actually their effect is to calm people and free their inhibitions, thus helping them to recall anxiety-producing events (Ahern et al., 2000). These drugs do not always work, however, and if used at all, they are likely to be combined with other treatment approaches.
How Do Therapists Help People with Dissociative Identity Disorder? Unlike victims of dissociative amnesia, people with dissociative iden- tity disorder do not typically recover without treatment. Treatment for this pattern is complex and difficult, much like the disorder itself. Therapists usually try to help the clients (1) recognize fully the nature of their disorder, (2) recover the gaps in their memory, and (3) integrate their subpersonalities into one functional personal- ity (Gentile et al., 2014, 2013; Howell, 2011).
Recognizing the disoRdeR Once a diagnosis of dissociative identity disorder is made, therapists typically try to bond with the primary personality and with each of the subpersonalities (Howell, 2011). As bonds are formed, therapists try to educate patients and help them to recognize fully the nature of their disorder.
Hypnotic recall Northwood University students react while under hypnosis to the suggestion of being on a beach in Hawaii and needing suntan lotion. Many clinicians use hypnotic procedures to help clients recall past events, but research reveals that such proce- dures often create false memories.
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▶▶ hypnotic therapy A treatment in which the patient undergoes hypnosis and is then guided to recall forgotten events or perform other therapeutic activities. Also known as hypnotherapy.
▶▶ fusion The final merging of two or more subpersonalities in dissociative identity disorder.
▶▶ depersonalization-derealization disorder A dissociative disorder marked by the presence of persistent and recur- rent episodes of depersonalization, derealization, or both.
Disorders of Trauma and Stress : 177
Some therapists actually introduce the subpersonalities to one another, by hypnosis, for example, or by having patients look at videos of their other personalities (Howell, 2011; Ross & Gahan, 1988). A number of therapists have also found that group therapy helps to educate patients (Fine & Madden, 2000). In addition, family therapy may be used to help edu- cate spouses and children about the disorder and to gather helpful information about the patient (Kluft, 2001, 2000).
RecoveRing memoRies To help patients recover the miss- ing pieces of their past, therapists typically use the same approaches applied in dissociative amnesia, including psycho- dynamic therapy, hypnotherapy, and drug treatment (Brand et al., 2014; Kluft, 2001, 1991). These techniques work slowly for patients with dissociative identity disorder, however, as some subpersonalities may keep denying experiences that the others recall. One of the subpersonalities may even assume a “protector” role to prevent the primary personality from suf- fering the pain of recollecting traumatic experiences.
integRating the subpeRsonalities The final goal of therapy is to merge the dif- ferent subpersonalities into a single, integrated identity. Integration is a continuous process that occurs throughout treatment until patients “own” all of their behaviors, emotions, sensations, and knowledge. Fusion is the final merging of two or more subpersonalities. Many patients distrust this final treatment goal, and their subper- sonalities may see integration as a form of death (Howell, 2011; Kluft, 2001, 1991). Therapists have used a range of approaches to help merge subpersonalities, includ- ing psychodynamic, supportive, cognitive, and drug therapies (Cronin et al., 2014; Baker, 2010).
Once the subpersonalities are integrated, further therapy is typically needed to maintain the complete personality and to teach social and coping skills that may help prevent later dissociations. In case reports, some therapists note high success rates (Brand et al., 2014; Dorahy et al., 2014), but others find that patients continue to resist full integration. A few therapists have in fact questioned the need for full integration.
Depersonalization-Derealization Disorder As you read earlier, DSM-5 categorizes depersonalization-derealization disor- der as a dissociative disorder, even though it is not characterized by the memory difficulties found in the other dissociative disorders. Its central symptoms are per- sistent and recurrent episodes of depersonalization (the sense that one’s own mental functioning or body is unreal or detached) and/or derealization (the sense that one’s surroundings are unreal or detached).
A 24-year-old graduate student . . . had begun to doubt his own reality. He felt he was living in a dream in which he saw himself from without, and did not feel con- nected to his body or his thoughts. When he saw himself through his own eyes, he perceived his body parts as distorted—his hands and feet seemed quite large. As he walked across campus, he often felt the people he saw might be robots. . . .
[By] his second session, he . . . had begun to perceive [his girlfriend] in a distorted manner. He . . . hesitated before returning, because he wondered whether his thera- pist was really alive.
(Kluft, 1988, p. 580)
Sensory memories Sensory stimuli often trigger important memories. Thus some clini- cians practice olfactotherapy, a method that uses the smells and vibrations of essential oils to help elicit memories from clients.
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Like this graduate student, people experiencing depersonalization feel as though they have become separated from their body and are observing themselves from outside. Occasionally their mind seems to be floating a few feet above them—a sensation known as doubling. Their body parts feel foreign to them, their hands and feet smaller or bigger than usual. Many sufferers describe their emotional state as “mechanical,” “dreamlike,” or “dizzy.” Throughout the whole experience, however, they are aware that their perceptions are distorted, and in that sense they remain in contact with reality. In some cases this sense of unreality also extends to other sensory experiences and behavior. People may, for example, have distortions in their sense of touch or smell or their judgments of time or space, or they may feel that they have lost control over their speech or actions.
In contrast to depersonalization, derealization is characterized by feeling that the external world is unreal and strange. Objects may seem to change shape or size; other people may seem removed, mechanical, or even dead. The graduate student, for example, saw other people as robots, perceived his girlfriend in a distorted man- ner, and hesitated to return for a second session of therapy because he wondered whether his therapist was really alive.
Depersonalization and derealization experiences by themselves do not indicate a depersonalization-derealization disorder. Transient depersonalization or derealiza-
tion reactions are fairly common (Michal, 2011). One-third of all people say that on occasion they have felt as though they were watching themselves in a movie. Similarly, one-third of individu- als who confront a life-threatening danger experience feelings of depersonalization or derealization (van Duijl et al., 2010). People sometimes have feelings of depersonalization after practicing meditation or after traveling to new places. Young children may
also experience depersonalization from time to time as they are developing their capacity for self-awareness. In most such cases, the affected people are able to com- pensate for the distortion and continue to function with reasonable effectiveness until the temporary episode eventually ends.
The symptoms of depersonalization-derealization disorder, in contrast, are per- sistent or recurrent, cause considerable distress, and may impair social relationships
Religious dissociations As part of reli- gious or cultural practices, many people voluntarily enter into trances that are similar to the symptoms found in dissociative identity disorder and depersonalization-derealization disorder. Here, voodoo followers sing and flail about in trances inside a sacred pool at a temple in Souvenance, Haiti. Da
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Disorders of Trauma and Stress : 179
and job performance (Gentile et al., 2014; Michal, 2011). The disorder occurs most frequently in adolescents and young adults, hardly ever in people over 40 (Moyano, 2010). It usually comes on suddenly and may be triggered by extreme fatigue, physical pain, intense stress, or recovery from substance abuse. Survivors of trau- matic experiences or people caught in life-threatening situations, such as hostages or kidnap victims, seem to be particularly vulnerable to this disorder. The disorder tends to be long-lasting; the symptoms may improve and even disappear for a time, only to return or intensify during times of severe stress. Like the graduate student in our case discussion, many sufferers fear that they are losing their minds and become preoccupied with worry about their symptoms. Few theories have been offered to explain this disorder.
➤ Summing Up DISSOCIATIVE DISORDERS People with dissociative disorders experience major changes in memory and identity that are not caused by clear physical factors—changes that often emerge after a traumatic event. Typically, one part of the memory or identity is dissociated, or separated, from the other parts. People with dissociative amnesia are unable to recall important personal infor- mation or past events in their lives. Those with dissociative fugue, an extreme form of dissociative amnesia, not only fail to remember personal information but also flee to a different location and may establish a new identity. In another dissociative disorder, dissociative identity disorder (previously called multiple personality disorder), a person develops two or more distinct subpersonalities.
Dissociative amnesia and dissociative identity disorder are not well under- stood. Among the processes that have been cited to explain them are extreme repression, operant conditioning, state-dependent learning, and self-hypnosis.
Dissociative amnesia may end on its own or may require treatment. Disso- ciative identity disorder typically requires treatment. Approaches commonly used to help people with dissociative amnesia recover their lost memories are psychodynamic therapy, hypnotic therapy, and sodium amobarbital or sodium pentobarbital. Therapists who treat people with dissociative identity disorder use the same approaches and also try to help the clients recognize the nature and scope of their disorder, recover the gaps in their memory, and integrate their subpersonalities into one functional personality.
People with yet another kind of dissociative disorder, depersonalization- derealization disorder, feel as though they are detached from their own mental processes or body and are observing themselves from the outside or feel as though the people or objects around them are unreal or detached. Transient depersonalization and derealization experiences seem to be relatively common, while depersonalization-derealization disorder is not.
PUTTING IT...together Getting a Handle on Trauma and Stress The concepts of trauma and stress have been prominent in the field of abnormal psychology since its earliest days. Dating back to Sigmund Freud, for example, psychodynamic theorists have proposed that most forms of psychopathology— from depression to schizophrenia—begin with traumatic losses or events. Even theorists from the other clinical models agree that people under stress are par- ticularly vulnerable to psychological disorders of various kinds, including anxiety
B e t w e e n t h e L i n e s
In Their Words “I was trying to daydream, but my mind kept wandering.”
Steven Wright, comedian
B e t w e e n t h e L i n e s
Most Commonly Forgotten Matters Online passwords
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Where remote control was left
Phone numbers
Names
Dream content
Birthdays/anniversaries
: chapter 5180
disorders, depressive disorders, eating disorders, substance use disorders, and sexual dysfunctions.
But why and how do trauma and stress translate into psychopathology? That question has, in fact, eluded clinical theorists and researchers—until recent times. In part because of the identification and study of acute and posttraumatic stress disorders, researchers now better understand the relationship between trauma, stress,
and psychological dysfunction—viewing it as a complex interaction of many variables, including biological and genetic factors, personality traits, childhood experiences, social support, multicultural factors, and environmental events. Similarly, clinicians are now developing more effective treatment programs for people with acute and posttraumatic stress disorders—programs that combine biological, behavioral, cognitive, family, and social interventions.
Insights and treatments for the dissociative disorders, the other group of trauma-triggered disorders discussed in this chapter, have not moved as quickly. Although these disorders were among the field’s earliest iden- tified problems, the clinical field stopped paying much attention to them during the latter part of the twentieth century, with some clinicians even
questioning the legitimacy of the diagnoses. However, the field’s focus on dissocia- tive disorders has surged during the past two decades—partly because of intense clinical interest in stress reactions and partly because of the growing effort to under- stand physically rooted memory disorders such as Alzheimer’s disease. Researchers have begun to appreciate that dissociative disorders may be more common than clinical theorists had previously recognized. In fact, there is growing evidence that the disorders may be rooted in processes that are already well known from other areas of study, such as state-dependent learning and self-hypnosis.
Amidst the rapid developments in the realms of trauma and stress lies a cau- tionary tale. When problems are studied heavily, it is common for the public, as well as some researchers and clinicians, to draw conclusions that may be too bold. For example, many people—perhaps too many—are now receiving diagnoses of posttraumatic stress disorder, partly because the symptoms of PTSD are many and because PTSD has received so much attention (Holowka et al., 2014; Wakefield & Horwitz, 2010). Similarly, some of today’s clinicians worry that the resurging interest in dissociative disorders may be creating a false impression of their prevalence. We shall see such potential problems again when we look at other forms of pathology that are currently receiving great focus, such as bipolar disorder among children and attention deficit/hyperactivity disorder. The line between enlightenment and overenthusiasm is often thin.
C li n i C al C h o i C e s Now that you’ve read about disorders of trauma and stress, try the interactive case study for this chapter. See if you are able to identify Michelle’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Michelle? Go to LaunchPad to access Clinical Choices.
“I’m more interested in hearing about the eggs you’re hiding from yourself.”
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Disorders of Trauma and Stress : 181
KEY TERMS stressor, p. 149
hypothalamus, p. 151
autonomic nervous system (ANS), p. 151
endocrine system, p. 151
sympathetic nervous system, p. 151
epinephrine, p. 152
norepinephrine, p. 152
parasympathetic nervous system, p. 152
hypothalamic-pituitary-adrenal (HPA) pathway, p. 152
corticosteroids, p. 152
acute stress disorder, p. 153
posttraumatic stress disorder (PTSD), p. 153
rape, p. 155
torture, p. 158
eye movement desensitization and reprocessing (EMDR), p. 162
rap groups, p. 164
psychological debriefing, p. 164
dissociative disorders, p. 166
memory, p. 166
dissociative amnesia, p. 167
amnestic episode, p. 167
dissociative fugue, p. 168
dissociative identity disorder, p. 170
subpersonalities, p. 170
iatrogenic disorder, p. 172
state-dependent learning, p. 173
self-hypnosis, p. 173
repression, p. 173
hypnotic therapy, p. 176
fusion, p. 177
depersonalization-derealization disorder, p. 177
QuickQuiz
1. What factors determine how people react to stressors in life? pp. 149–152
2. What factors seem to help influence whether persons will develop acute and posttraumatic stress disorders after experiencing a traumatic event? pp. 158–161
3. What treatment approaches have been used with people suffering from acute or posttraumatic stress disorder? pp. 161–165
4. List and describe the different disso- ciative disorders. What is dissociative fugue? pp. 166–179
5. What are the various patterns of disso- ciative amnesia? pp. 167–169
6. What are the different kinds of relation- ships that the subpersonalities may have in dissociative identity disorder? p. 171
7. Describe the psychodynamic, behav- ioral, state-dependent learning, and self-hypnosis explanations of dissocia-
tive amnesia and dissociative identity disorder. How well is each explanation supported by research? pp. 172–175
8. What approaches have been used to treat dissociative amnesia? p. 176
9. What are the key features of treatment for dissociative identity disorder? Is treatment successful? pp. 176–177
10. Define and describe depersonalization- derealization disorder. How well is this problem understood? pp. 177–179
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T he first conscious thought that all was not well with me came . . . when I was twenty-two. I had been living in Los Angeles for two years, working various temp jobs while trying to establish myself as a writer and performance artist. Out of nowhere and for no apparent reason—or so it seemed—I started feeling
strong sensations of grief. I don’t remember the step-by-step progression of the ill- ness. What I can recall is that my life disintegrated; first, into a strange and terrifying space of sadness and then, into a cobweb of fatigue. I gradually lost my ability to function. It would take me hours to get up out of bed, get bathed, put clothes on. By the time I was fully dressed, it was well into the afternoon. . . .
After a while I stopped showing up at my temp job, stopped going out altogether, and locked myself in my home. It was over three weeks before I felt well enough to leave. During that time, I cut myself off from everything and everyone. Days would go by before I bathed. I did not have enough energy to clean up myself or my home. There was a trail of undergarments and other articles of clothing that ran from the living room to the bedroom to the bathroom of my tiny apartment. Dishes with de- caying food covered every counter and tabletop in the place. Even watching TV or talking on the phone required too much concentration. . . . All I could do was. . . wait for whatever I was going through to pass. And it did. Slowly. . . .
. . . Deep down, I knew that something had gone wrong with me, in me. But what could I do? Stunned and defenseless, the only thing I felt I could do was move on. I assured myself that my mind and the behaviors it provoked were well within my control. In the future I would just have to be extremely aware. I would make sure that what happened did not happen again. But it did. Again and again, no matter how aware, responsible, or in control I tried to be. . . .
Each wave of the depression cost me something dear. I lost my job because the temp agencies where I was registered could no longer tolerate my lengthy ab- sences. Unable to pay rent, I lost my apartment and ended up having to rent a small room in a boarding house. I lost my friends. Most of them found it too troublesome to deal with my sudden moodiness and passivity so they stopped calling and com- ing around.
(Danquah, 1998)
Most people’s moods come and go. Their feelings of elation or sadness are understandable reactions to daily events and do not affect their lives greatly. However, the moods of certain people last a long time. As in the case of Meri Nana-Ama Danquah, a performance artist and poet who described her disor- der in the opening of this chapter, their moods color all of their interactions with the world and even interfere with normal functioning. Such people struggle in particular with depression, mania, or both. Depression is a low, sad state in which life seems dark and its challenges overwhelming. Mania, the opposite of depression, is a state of breathless euphoria, or at least frenzied energy, in which people may have an exaggerated belief that the world is theirs for the taking.
Mood problems of these kinds are at the center of two groups of disorders— depressive disorders and bipolar disorders (APA, 2013). These groups are examined in this chapter. People with depressive disorders suffer only from depression, a pattern called unipolar depression. They have no history of mania and return to a normal or nearly normal mood when their depression
6
T o p i c o v e r v i e w
Unipolar Depression: The Depressive Disorders How Common Is Unipolar Depression? What Are the Symptoms of Depression? Diagnosing Unipolar Depression Stress and Unipolar Depression The Biological Model of Unipolar Depression Psychological Models of Unipolar Depression The Sociocultural Model of Unipolar Depression
Bipolar Disorders What Are the Symptoms of Mania? Diagnosing Bipolar Disorders What Causes Bipolar Disorders? What Are the Treatments for Bipolar Disorders?
Putting It Together: Making Sense of All That Is Known
Depressive and Bipolar Disorders
: chapter 6184
lifts. In contrast, those with bipolar disorders have periods of mania that alternate with periods of depression.
Mood problems have always captured people’s interest, in part because so many famous people have suffered from them. The Bible speaks of the severe depressions of Nebuchadnezzar, Saul, and Moses. Queen Victoria of England and Abraham Lincoln seem to have experienced recurring depressions. Mood difficulties also have plagued writers Ernest Hemingway and Sylvia Plath, comedian Jim Carrey, and musical performers Eminem and Beyoncé. Their problems have been shared by millions (NAMI, 2014).
Unipolar Depression: The Depressive Disorders Whenever we feel particularly unhappy, we are likely to describe ourselves as “depressed.” In all likelihood, we are merely responding to sad events, fatigue, or unhappy thoughts. This loose use of the term confuses a perfectly normal mood swing with a clinical syndrome (see InfoCentral ). All of us experience dejection from time to time, but only some experience a depressive disorder. Such disorders bring severe and long-lasting psychological pain that may intensify as time goes by. Those who suffer from them may lose their will to carry out the simplest of life’s activities; some even lose their will to live.
How Common Is Unipolar Depression? Around 9 percent of adults in the United States suffer from a severe unipolar pat- tern of depression in any given year, while as many as 5 percent suffer from mild forms (Kessler et al., 2012, 2010). Around 18 percent of all adults experience an episode of severe unipolar depression at some point in their lives. These prevalence rates are similar in Canada, England, and many other countries. Moreover, the rate of depression—mild or severe—is higher among poor people than wealthier people (Sareen et al., 2011).
Women are at least twice as likely as men to have episodes of severe unipolar depression (WHO, 2014; Astbury, 2010). As many as 26 percent of women have an episode at some time in their lives, compared with 12 percent of men. As you will see in Chapter 14, among children the prevalence of unipolar depression is similar for girls and boys.
Approximately 85 percent of people with unipolar depression recover, some without treatment. At least 40 percent of them have at least one other episode of depression later in their lives (Halverson et al., 2015; Monroe, 2010).
What Are the Symptoms of Depression? The picture of depression may vary from person to person. Earlier you saw how Meri’s profound sadness, fatigue, and cognitive deterioration brought her job and social life to a standstill. Some depressed people have symptoms that are less severe. They manage to function, although their depression typically robs them of much effectiveness or pleasure.
As the case of Meri indicates, depression has many symptoms other than sadness. The symptoms, which often exacerbate one another, span five areas of functioning: emotional, motivational, behavioral, cognitive, and physical.
Emotional Symptoms Most people who are depressed feel sad and dejected. They describe themselves as feeling “miserable,” “empty,” and “humiliated.” They tend to lose their sense of humor, report getting little pleasure from anything, and in
almost every day we have ups
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▶▶ depression A low, sad state marked by significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms.
▶▶ mania A state or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the world is theirs for the taking.
▶▶ depressive disorders The group of disorders marked by unipolar depression.
▶▶ unipolar depression Depression without a history of mania.
▶▶ bipolar disorder A disorder marked by alternating or intermixed periods of mania and depression.
Taking a bite out of depression To raise public awareness about depression, a charity cake shop in London sells cakes and cookies with decorations that reflect the symptoms of depressive disorders. Some of the decora- tions are even unfinished in order to echo how depression decreases the ability to pursue or complete work tasks and other activities.
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185InfoCentral
SADNESS Depression, a clinical disorder that causes considerable distress and impairment, features a range of symptoms, including emo- tional, motivational, behavioral, cognitive, and physical symp-
toms. Sadness is often one of the symptoms found in depression, but most often it is a perfectly normal negative emotion triggered by a loss or other painful circumstance.
(Horwitz & Wakefield, 2012, 2007)
As a negative emotion, sadness often has negative effects.
Decreases creativity and original thinking
Decreases ability to multitask
Decreases ability to delay gratification
Decreases patience
Decreases awareness of the “big picture”
Decreases playfulness
Increases preference for smaller immediate financial rewards over deferred larger rewards
Increases poor financial decisions (Forgas, 2014, 2013; Lerner et al., 2013; Bower, 2013; Schwartz, 2011).
.
Studies have found that temporary states of sadness can have numerous benefits.
Improves attention to details
Improves accuracy of memory
Improves ability to detect deception
Increases perseverance
Promotes generosity
Improves social judgments
Increases altruism
Improves interpersonal strategies
(Forgas, 2014, 2013; Lerner et al., 2013; Bower, 2013).
SADNESS DIFFERS FROM CLINICAL DEPRESSION
THE HOLIDAY BLUES Many people become especially happy as holidays approach and during the holidays themselves. Others, however, become sad and anxious at holiday time—a reaction called “the holiday blues.”
What causes the holiday blues?
Stress and fatigue
Unrealistic expectations
Excessive responsibility
Overcommercialization
Overactivity and/or overspending
Being without family and friends
Reminders of sorrowful events
Benefi ts of sadnessDisadvantages of sadness
Lifestyle Factors • Physical exercise
• Active involvement
• Spending time in natural light
• Getting organized
• Spending time with a pet
• Getting enough sleep
• Eating healthfully
Social Factors • Social support
• Professional support
Cognitive Factors • Positive thinking
• Creativity
• Accepting sadness with an understanding it may take a while to get over
• Challenging negative thoughts
• Scheduling positive events
Sadness is context-specific.
The intensity of sadness is proportionate to the triggering loss.
Sadness ends when the loss situation ends.
(Horwitz & Wakefield, 2012, 2007)
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THE COLOR OF SADNESS When people are sad, they often see the world as dreary. Perception researchers have found that sad people actually prefer dreary and dark colors, particularly gray. Which colors are sad people drawn to?
SADNESS BUSTERS
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(Ekman,1971)
: chapter 6186
some cases display anhedonia, an inability to experience any pleasure at all. A number also experience anxiety, anger, or agitation. Terrie Williams, author of Black Pain, a book about depression in African Americans, describes the agony she went through each morning as her depression was unfolding:
My mornings were unmanageable. To wake up each morning was to remember once again that the world by which I defined myself was no more. Soon after open- ing my eyes, the crying bouts would start and I’d sit alone for hours, weeping and mourning my losses.
(Williams, 2008, p. 9)
Motivational Symptoms Depressed people typically lose the desire to pur- sue their usual activities. Almost all report a lack of drive, initiative, and spontaneity. They may have to force themselves to go to work, talk with friends, eat meals, or have sex. Terrie describes her social withdrawal during a depressive episode:
I woke up one morning with a knot of fear in my stomach so crippling that I couldn’t face light, much less day, and so intense that I stayed in bed for three days with the shades drawn and the lights out.
Three days. Three days not answering the phone. Three days not checking my e-mail. I was disconnected completely from the outside world, and I didn’t care.
(Williams, 2008, p. xxiv)
Suicide represents the ultimate escape from life’s challenges. As you will see in Chapter 7, many depressed people become uninterested in life or wish to die; oth- ers wish they could kill themselves, and some actually do. It has been estimated that between 6 and 15 percent of people who suffer from severe depression commit suicide (MHF, 2014; Alridge, 2012).
Behavioral Symptoms Depressed people are usually less active and less pro- ductive. They spend more time alone and may stay in bed for long periods. One man recalls, “I’d awaken early, but I’d just lie there—what was the use of getting
up to a miserable day?” (Kraines & Thetford, 1972, p. 21). Depressed people may also move and even speak more slowly (Behrman, 2014).
Cognitive Symptoms Depressed people hold extremely nega- tive views of themselves. They consider themselves inadequate, unde- sirable, inferior, perhaps evil (Lopez Molina et al., 2014). They also blame themselves for nearly every unfortunate event, even things that have nothing to do with them, and they rarely credit themselves for positive achievements.
Another cognitive symptom of depression is pessimism. Sufferers are usually convinced that nothing will ever improve, and they feel helpless to change any aspect of their lives. Because they expect the worst, they are likely to procrastinate. Their sense of hopelessness and helplessness makes them especially vulnerable to suicidal thinking (Shiratori et al., 2014).
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▶▶ major depressive disorder A severe pattern of depression that is dis- abling and is not caused by such factors as drugs or a general medical condition.
▶▶ persistent depressive disorder A chronic form of unipolar depression marked by ongoing and repeated symp- toms of either major or mild depression.
▶▶ premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation.
Depressive and Bipolar Disorders : 187
distracted, and unable to solve even the smallest problems. In laboratory studies, depressed people do perform more poorly than nondepressed people on some tasks of memory, attention, and reasoning (Chen et al., 2013). It may be, however, that these difficulties sometimes reflect motivational problems rather than cogni- tive ones.
Physical Symptoms People who are depressed frequently have such physical ailments as headaches, indigestion, constipation, dizzy spells, and general pain (Bai et al., 2014; Goldstein et al., 2011). In fact, many depressions are misdiagnosed as medical problems at first (Parker & Hyett, 2010). Disturbances in appetite and sleep are particularly common ( Jackson et al., 2014). Most depressed people eat less, sleep less, and feel more fatigued than they did prior to the disorder. Some, however, eat and sleep excessively.
Diagnosing Unipolar Depression According to DSM-5, a major depressive episode is a period of two or more weeks marked by at least five symptoms of depression, including sad mood and/or loss of pleasure (see Table 6-1 on the next page). In extreme cases, the episode may include psychotic symptoms, ones marked by a loss of contact with reality, such as delusions—bizarre ideas without foundation—or hallucinations—perceptions of things that are not actually present. A depressed man with psychotic symptoms may imagine that he cannot eat “because my intestines are deteriorating and will soon stop working,” or he may believe that he sees his dead wife.
DSM-5 lists several types of depressive disorders. People who go through a major depressive episode without having any history of mania receive a diagnosis of major depressive disorder (APA, 2013) (see Table 6-1 again). The disorder may be further described as seasonal if it changes with the seasons (for example, if the depression recurs each winter), catatonic if it is marked by either immobility or exces- sive activity, peripartum if it occurs during pregnancy or within four weeks of giving birth, or melancholic if the person is almost totally unaffected by pleasurable events.
People whose unipolar depression is particularly long-lasting receive a diagnosis of persistent depressive disorder (APA, 2013) (see Table 6-1 again). Some people with this chronic disorder have repeated major depres- sive episodes, a pattern technically called persistent depressive disorder with major depressive episodes. Others have less severe and less disabling symptoms, a pat- tern called persistent depressive disorder with dysthymic syndrome.
A third type of depressive disorder is premenstrual dysphoric disorder, a diagnosis given to certain women who repeatedly have clinically significant depressive and related symptoms during the week before menstruation. The inclusion of this pattern in DSM-5 is controversial, as you will see later (see page 209).
Yet another kind of depressive disorder, disruptive mood dysregulation disorder, is characterized by a combination of persistent depressive symptoms and recur- rent outbursts of severe temper. This disorder emerges during mid- childhood or adolescence and so is discussed in Chapter 14, “Disorders Common Among Children and Adolescents.”
Stress and Unipolar Depression Episodes of unipolar depression often seem to be triggered by stressful events (Fried et al., 2015). In fact, researchers have found that depressed people have a larger number of stressful life events during the month just before the onset of their disorder than do other people during the same period of time. Of course, stressful life events also precede other psychological disorders, but depressed people often report more such events than anybody else.
Lincoln’s private war In 1841 Abraham Lincoln wrote to a friend, “I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would be not one cheerful face on earth.”
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In Their Words
“Given the choice between the expe- rience of pain and nothing, I would choose pain.”
William Faulkner
: chapter 6188
Some clinicians consider it important to distinguish a reactive (exogenous) depression, which follows clear-cut stressful events, from an endogenous depression, which seems to be a response to internal factors. But can one ever know for certain whether a depres- sion is reactive or not? Even if stressful events occurred before the onset of depression, that depression may not be reactive. The events could actually be a coincidence. Thus, today’s clinicians usually concentrate on recognizing both the situational and the internal aspects of any given case of unipolar depression.
The Biological Model of Unipolar Depression Medical researchers have been aware for years that certain diseases and drugs pro- duce mood changes. Could unipolar depression itself have biological causes? Evi- dence from genetic, biochemical, anatomical, and immune system studies suggests that often it does.
Genetic Factors Four kinds of research—family pedigree, twin, adoption, and molecular biology gene studies—suggest that some people inherit a predisposition to unipolar depression (McGuffin, 2014). Family pedigree studies select people with unipolar depression, examine their relatives, and see whether depression also afflicts other members of the family. If a predisposition to unipolar depression is inher- ited, the relatives should have a higher rate of depression than the population at
table: 6-1
Dx Checklist
Major Depressive Episode
1. For a 2-week period, person displays an increase in depressed mood for the majority of each day and/or a decrease in enjoyment or interest across most activities for the majority of each day.
2. For the same 2 weeks, person also experiences at least 3 or 4 of the following symptoms: • Considerable weight change or appetite change • Daily insomnia or hypersomnia • Daily agitation or decrease in motor activity • Daily fatigue or lethargy • Daily feelings of worthlessness or excessive guilt • Daily reduction in concentration or decisiveness • Repeated focus on death or suicide, a suicide plan, or a suicide attempt.
3. Significant distress or impairment.
Major Depressive Disorder
1. Presence of a major depressive episode
2. No pattern of mania or hypomania.
Persistent Depressive Disorder
1. Person experiences the symptoms of Major Depressive Disorder or Dysthymic Disorder for at least 2 years.
2. During the two-year period, symptoms not absent for more than two months at a time.
3. No history of mania or hypomania.
4. Significant distress or impairment.
Information from: APA, 2013.
why do you think stressful
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and other negative emotions?
B e t w e e n t h e L i n e s
Medical Problems and Depression 50% Stroke victims who experience
clinical depression
30% Cancer patients who experience depression
20% Heart attack victims who become depressed
18% People with diabetes who are depressed
(Udesky, 2014; Jiang et al., 2011; Kerber et al., 2011; NIMh, 2004)
Depressive and Bipolar Disorders : 189
large. Researchers have in fact found that as many as 30 percent of those relatives are depressed (see Table 6-2), compared with fewer than 10 percent of the general population (Levinson & Nichols, 2014; Berrettini, 2006).
If a predisposition to unipolar depression is inherited, you might also expect to find a particularly large number of cases among the close relatives of a proband. Twin studies have supported this expectation (Levinson & Nichols, 2014). One study looked at nearly 200 pairs of twins. When an identical twin had unipolar depression, there was a 46 percent chance that the other twin would have the same disorder. In contrast, when a fraternal twin had unipolar depression, the other twin had only a 20 percent chance of developing the disorder (McGuffin et al., 1996).
Finally, today’s scientists have at their disposal techniques from the field of molec- ular biology to help them directly identify genes and determine whether certain gene abnormalities are related to depression. Using such techniques, researchers have found evidence that unipolar depression may be tied to genes on chromosomes 1, 4, 9, 10, 11, 12, 13, 14, 17, 18, 20, 21, 22, and X ( Jansen et al., 2015; Preuss et al., 2013). For example, a number of researchers have found that people who are depressed often have an abnormality of their 5-HTT gene, a gene located on chromosome 17 that is responsible for the activity of the neurotransmitter serotonin. As you will read in the next section, low activity of serotonin is closely tied to depression.
Biochemical Factors Low activity of two neurotransmitter chemicals, nor- epinephrine and serotonin, has been strongly linked to unipolar depression. In the 1950s, several pieces of evidence began to point to this relationship. First, medical researchers discovered that certain medications for high blood pressure often caused depression (Ayd, 1956). As it turned out, some of these medications lowered nor- epinephrine activity and others lowered serotonin. A second piece of evidence was the discovery of the first truly effective antidepressant drugs. Although these drugs were discovered by accident, researchers soon learned that they relieve depression by increasing either norepinephrine or serotonin activity.
For years it was thought that low activity of either norepinephrine or serotonin was capable of producing depression, but investigators now believe that their relation to depression is more complicated (Ding et al., 2014; Goldstein et al., 2011). Research suggests that interactions between serotonin and norepinephrine activity, or between these and other kinds of neurotransmitters in the brain, rather than the operation of any one neurotransmitter alone, may account for unipolar depression.
table: 6-2
Comparing Depressive and Bipolar Disorders
One-Year Prevalence (Percent)
Female- to-Male Ratio
Typical Age at Onset (Years)
Prevalence among First-Degree Relatives
Percentage Currently Receiving Treatment
Major depressive disorder
8.0% 2:1 24–29 Elevated 50.0%
Persistent depressive disorder (with dysthymic syndrome)
1.5–5.0% Between 3:2 and 2:1
10–25 Elevated 36.8%
Bipolar I disorder 1.6% 1:1 15–44 Elevated 33.8%
Bipolar II disorder 1.0% 1:1 15–44 Elevated 33.8%
Cyclothymic disorder 0.4% 1:1 15–25 Elevated Unknown
Information from: APA, 2013, 2000; Kessler et al., 2012, 2010, 2005; Gonzalez et al., 2010; Taube-Schiff & Lau, 2008; Regier et al., 1993; Weissman et al., 1991.
▶▶ norepinephrine A neurotransmit- ter whose abnormal activity is linked to depression and panic disorder.
▶▶ serotonin A neurotransmitter whose abnormal activity is linked to depression, obsessive-compulsive disorder, and eat- ing disorders.
: chapter 6190
Biological researchers have also learned that the body’s endocrine system may play a role in unipolar depression (see PsychWatch). As you have seen, endocrine glands throughout the body release hormones, chemicals that in turn spur body organs into action (see Chapter 5). People with unipolar depression have been found to have abnormally high levels of cortisol, one of the hormones released by the adrenal glands during times of stress (Owens et al., 2014; Treadway & Pizzagalli, 2014). This relationship is not all that surprising, given that stressful events often seem to trigger depression. Another hormone that has been tied to depression is melatonin,
PsychWatch
Women usually expect the birth of a child to be a happy experi-ence. But for 10 to 30 percent of new mothers, the weeks and months after childbirth bring clinical depression (Guintivano et al., 2014). Peripartum de- pression, popularly called postpartum depression, typically begins within four weeks after the birth of a child; many cases actually begin during pregnancy (APA, 2013). This disorder is far more severe than simple “baby blues.” It is also different from other postpartum syn- dromes such as postpartum psychosis, a problem that is examined in Chapter 12.
The “baby blues” are so common—as many as 80 percent of women experience them—that most researchers consider them normal. As new mothers try to cope with the wakeful nights and other stresses that accompany the arrival of a new baby, they may have crying spells, fatigue, anxiety, insomnia, and sadness (Enatescu et al., 2014). These symptoms usually disappear within days or weeks (Kendall- Tackett, 2010).
In postpartum depression, however, depressive symptoms continue and may last up to a year or more. The symptoms include extreme sadness, despair, tearful- ness, insomnia, anxiety, intrusive thoughts, compulsions, panic attacks, feelings of inability to cope, and suicidal thoughts. Women who have an episode of postpar- tum depression have a 25 to 50 percent chance of developing it again with a sub- sequent birth (Stevens et al., 2002).
Many clinicians believe that the hor- monal changes accompanying child- birth trigger postpartum depression. All women go through a kind of hormone “withdrawal” after delivery, as estrogen and progesterone levels, which rise as
much as 50 times above normal during pregnancy, now drop sharply to levels far below normal (Horowitz et al., 2005, 1995). Perhaps some women are particu- larly influenced by these dramatic hor- mone changes (Mehta et al., 2014). Other theorists suggest that some women may have a genetic predisposition to postpar- tum depression (Guintivano et al., 2014).
At the same time, psychological and sociocultural factors may play important roles in the disorder (Mauthner, 2010). The birth of a baby brings enormous changes for women—changes in her mar- ital relationship, daily routines, and social roles. Sleep and relaxation are likely to decrease, and financial pressures may increase. Perhaps she feels the added stress of giving up a career—or of trying to maintain one. This pileup of stress may heighten the risk of depression (Phillips, 2011; Kendall-Tackett, 2010). Mothers whose infants are sick or temperamentally “difficult” may be under yet additional pressure.
Fortunately, treatment can make a big difference for most women with postpar- tum depression. Self-help support groups have proved extremely helpful for many women who have or who are at risk for postpartum depression (Dennis, 2014; Evans et al., 2012). In addition, many re- spond well to the same approaches that are applied to other forms of depression— antidepressant medications, cognitive therapy, interpersonal psychotherapy, or a combination of these approaches (Hou et al., 2014; Kim et al., 2014).
However, many women who would benefit from treatment do not seek help because they feel ashamed about being sad at a time that is supposed to be joyous and are concerned about being
judged harshly (Bina, 2014; Mauthner, 2010). For them, a large dose of educa- tion is in order. Even positive events, such as the birth of a child, can be stressful if they also bring major change to one’s life. Recognizing and addressing such feelings are in everyone’s best interest.
Sadness at the Happiest of Times
“I felt like a failure.” Accomplished actress and musician Gwyneth Paltrow, seen here per- forming at the Annual Country Music Awards in Nashville, Tennessee, recently revealed that she suffered from postpartum depression for a number of months after giving birth to her second child in 2006. Said Paltrow, “I felt like a zombie. . . . I couldn’t connect. . . . I thought it meant I was a terrible mother and person. . . . I felt like a failure.”
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sometimes called the “Dracula hormone” because it is released only in the dark. People who experience a recurrence of depression each winter (a pattern called seasonal affective disorder) may secrete more melatonin during the winter’s long nights than other individuals do.
Still other biological researchers are starting to believe that unipolar depression is tied more closely to what happens within neurons than to the chemicals that carry messages between neurons. They believe that activity by key neurotransmitters or hormones ultimately leads to deficiencies of certain proteins and other chemicals within neurons—deficiencies that may impair the health of the neurons and lead in turn to depression (Duman, 2014).
The biochemical explanations of unipolar depression have produced much enthusiasm, but research in this area has certain limitations. Some of it has relied on analogue studies, which create depression-like symptoms in laboratory animals. Researchers cannot be certain that these symptoms do in fact reflect the human disorder. Similarly, until recent years, technology was limited, and studies of human depression had to measure brain biochemical activity indirectly. As a result, investigators could never be certain of the biochemical events that were taking place in the brain. Current studies using newer technology, such as PET and MRI scans, are helping to eliminate such uncertainties about such brain activity.
Brain Anatomy and Brain Circuits In earlier chapters, you read that many biological researchers now believe that emotional reactions of various kinds are tied to brain circuits—networks of brain structures that work together, triggering each other into action and producing a particular kind of emotional reaction. Although research is far from complete, a brain circuit responsible for unipolar depres- sion has begun to emerge (Treadway & Pizzagalli, 2014; Brockmann et al., 2011). An array of brain-imaging studies point to several brain areas that are likely members of this circuit, including the prefrontal cortex, the hippocampus, the amygdala, and Brodmann Area 25, an area located just under the brain part called the cingulate cortex (see Figure 6-1). Research suggests that, among depressed people, activity and blood flow are low in certain parts of the prefrontal cortex (Vialou et al., 2014), yet high in other parts (Lemogne et al., 2010); the hip- pocampus is undersized and its production of new neurons is low
Amygdala
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figure 6-1 The biology of depression Researchers believe that the brain circuit involved in unipolar depression includes the prefrontal cortex, the hippocampus, the amygdala, and Brodmann Area 25.
Lighting up depression In London’s Trafalgar Square, people sit and stand around an art installation called the Trafalgar Sun dur- ing the gloomy days of January, basking in the rays of the artificial sun. Winter depression has been linked to a decrease in the amount of light people are exposed to at that time of the year and to an accompanying shift in secretions of the hormone melatonin.©
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(Kubera et al., 2011; Campbell et al., 2004); activity and blood flow are elevated in the amygdala (Treadway & Pizzagalli, 2014; Goldstein et al., 2011); and Brodmann Area 25 is relatively small and overactive (Eggers, 2014; Mayberg et al., 2005).
The Immune System As you will see in Chapter 8, the immune system is the body’s network of activities and body cells that fight off bacteria, viruses, and other foreign invaders. When people are under intense stress for a while, their immune systems may become dysregulated, leading to lower functioning of important white blood cells called lymphocytes and to increased production of C-reactive protein (CRP ), a protein that spreads throughout the body and causes inflammation and various illnesses. There is a growing belief among some researchers that immune system dysregulation of this kind helps produce depression (Anderson et al., 2014; Yoon et al., 2012).
What Are the Biological Treatments for Unipolar Depression? Usually biological treatment means antidepressant drugs or popular herbal supple- ments, but for severely depressed people who do not respond to other forms of treatment, it sometimes means electroconvulsive therapy, or a relatively new group of approaches called brain stimulation.
ElEctroconvulsivE thErapy One of the most controversial forms of treatment for depression is electroconvulsive therapy (ECT). In this procedure, two electrodes are attached to the patient’s head, and 65 to 140 volts of electricity are passed through the brain for half a second or less. This results in a brain seizure that lasts from 25 seconds to a few minutes. After 6 to 12 such treatments, spaced over two to four weeks, most patients feel less depressed (Fink, 2014, 2007).
The discovery that electric shock can be therapeutic was made by accident. In the 1930s, clinical researchers mistakenly came to believe that brain seizures, or the convulsions (severe body spasms) that accompany them, could cure schizophrenia and other psychotic disorders, and so they searched for ways to induce seizures as a treatment for patients with psychosis. One early technique was to give patients the drug metrazol. Another was to give them large doses of insulin (insulin coma therapy). These procedures produced the desired brain seizures, but each was quite dangerous and sometimes even caused death. Finally, an Italian psychiatrist named Ugo Cerletti
discovered that he could produce seizures more safely by applying electric currents to a patient’s head. ECT soon became popular and was tried out on a wide range of psychological problems, as new techniques so often are. Its effectiveness with severe depression in particular became apparent.
In the early years of ECT, broken bones and dislocations of the jaw or shoulders sometimes resulted from patients’ severe convul- sions. Today’s practitioners avoid these problems by giving patients strong muscle relaxants to minimize convulsions. They also use anesthetics to put patients to sleep during the procedure, reducing their terror.
Patients who receive ECT often have difficulty remember- ing certain events, most often events that took place immediately before and after their treatments (Martin et al., 2015; Merkl et al., 2011). In most cases, this memory loss clears up within a few
months, but some patients are left with gaps in more distant memory, and this form of amnesia can be permanent (Hanna et al., 2009; Wang, 2007).
ECT is clearly effective in treating unipolar depression, although it has been dif- ficult to determine why it works so well (Baldinger et al., 2014; Fink et al., 2014). The procedure seems to be particularly effective in cases of depression that include delusions (Rothschild, 2010).
ECT today The techniques for administer- ing ECT have changed significantly since the treatment’s early days. Today, patients are given drugs to help them sleep, muscle relax- ants to prevent severe jerks of the body and broken bones, and oxygen to guard against brain damage.
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▶▶ electroconvulsive therapy (ECT) A treatment for depression in which elec- trodes attached to a patient’s head send an electrical current through the brain, causing a convulsion.
▶▶ MAO inhibitor An antidepressant drug that prevents the action of the enzyme monoamine oxidase.
▶▶ tricyclic An antidepressant drug such as imipramine that has three rings in its molecular structure.
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antidEprEssant drugs Two kinds of drugs discovered in the 1950s reduce the symptoms of depression: monoamine oxidase (MAO) inhibitors and tricyclics. These drugs have now been joined by a third group, the so-called second-generation antide- pressants (see Table 6-3).
The effectiveness of MAO inhibitors as a treatment for unipolar depression was discovered accidentally. Physicians noted that iproniazid, a drug being tested on patients with tuberculosis, had an interesting effect: it seemed to make the patients happier (Sandler, 1990). It was found to have the same effect on depressed patients (Kline, 1958; Loomer et al., 1957). What this and several related drugs had in com- mon biochemically was that they slowed the body’s production of the enzyme monoamine oxidase (MAO). Thus they were called MAO inhibitors.
Normally, brain supplies of the enzyme MAO break down, or degrade, the neu- rotransmitter norepinephrine. MAO inhibitors block MAO from carrying out this activity and thereby stop the destruction of norepinephrine. The result is a rise in norepinephrine activity and, in turn, a reduction of depressive symptoms. Approxi- mately half of depressed patients who take MAO inhibitors are helped by them (Ciraulo et al., 2011; Thase et al., 1995). There is, however, a potential danger with regard to these drugs. When people who take MAO inhibitors eat foods contain- ing the chemical tyramine—including such common foods as cheeses, bananas, and certain wines—their blood pressure rises dangerously. Thus people on these drugs must stick to a rigid diet.
The discovery of tricyclics in the 1950s was also accidental. Researchers who were looking for a new drug to combat schizophrenia ran some tests on a drug called imipramine (Kuhn, 1958). They discovered that imipramine was of no help in cases of schizophrenia, but it did relieve unipolar depression in many people. The new drug (trade name Tofranil) and related ones became known as tricyclic antide- pressants because they all share a three-ring molecular structure.
In hundreds of studies, depressed patients taking tricyclics have improved much more than similar patients taking placebos, although the drugs must be taken for at least 10 days before such improvements take hold (Advokat et al., 2014). About 65 percent of patients who take tricyclics are helped by them (FDA, 2014). If the patients stop taking tricyclics immediately after obtaining relief, they run a high risk of relapsing within a year. If, however, they continue taking the drugs for five
table: 6-3
Drugs That Reduce Unipolar Depression
Generic Name Trade Name
Monoamine oxidase inhibitors
Isocarboxazid Marplan Phenelzine Nardil Tranylcypromine Parnate Selegiline Eldepryl
Tricyclics
Imipramine Tofranil Amitriptyline Elavil Doxepin Sinequan; Silenor Trimipramine Surmontil Desipramine Norpramin Nortriptyline Aventil; Pamelor Protriptyline Vivactil Clomipramine Anafranil Amoxapine Asendin Mirtazapine Remeron
Second-Generation Antidepressants
Maprotiline Ludiomil Trazodone Desyrel Fluoxetine Prozac Sertraline Zoloft Paroxetine Paxil Venlafaxine Effexor Fluvoxamine Luvox Bupropion Wellbutrin, Aplenzin Citalopram Celexa Escitalopram Lexapro Duloxetine Cymbalta Desvenlafaxine Pristiq Atomoxetine Strattera
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months or more after being free of depressive symptoms—“continuation therapy” or “maintenance therapy”—their chances of relapse decrease considerably (Borges et al., 2014; FDA, 2014).
Most researchers have concluded that tricyclics reduce depression by acting on neurotransmitter “reuptake” mechanisms (Ciraulo et al., 2011). Remember from Chapter 2 that messages are carried from the “sending” neuron across the synaptic space to a receiving neuron by a neurotransmitter, a chemical released from the axon ending of the sending neuron. However, there is a complication in this process. While the sending neuron releases the neurotransmitter, a pumplike mechanism in the neuron’s ending immediately starts to reabsorb it in a process called reuptake. The purpose of this reuptake process is to control how long the neurotrans- mitter remains in the synaptic space and to prevent it from overstimulating the receiving neuron. Unfortunately, the reuptake mechanism may be too successful in some people—cutting off norepinephrine or serotonin activity too soon, preventing messages from reaching the receiving neurons, and producing clinical depression. Tricyclics block this reuptake process, thus increasing their neurotransmitter activity (see Figure 6-2).
A third group of effective antidepressant drugs, structurally different from the MAO inhibitors and tricyclics, has been developed during the past few decades. Most of these second-generation antidepressants are called selective serotonin reuptake inhibitors (SSRIs) because they increase serotonin activity specifi- cally, without affecting norepinephrine or other neurotransmitters. The SSRIs include fluoxetine (trade name Prozac), sertraline (Zoloft), and escitalopram (Lexapro). More recently developed selective norepinephrine reuptake inhibitors, such as atomoxetine (Strattera), which increase norepinephrine activity only, and serotonin-norepinephrine reuptake inhibitors, such as venlafaxine (Effexor), which increase both serotonin and norepinephrine activity, are also now available (Advokat et al., 2014).
In effectiveness and speed of action, the second-generation antidepressant drugs are about on a par with the tricyclics, yet they are prescribed more often and their sales have skyrocketed. They do not pose the dietary problems of the MAO inhibi- tors or produce some of the unpleasant effects of the tricyclics, such as dry mouth and constipation. At the same time, the new antidepressants can produce undesirable
Receiving neuron Receiving neuron
Sending neuron
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Sending neuron
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Tricyclic or second- generation antidepressants block reuptake
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figure 6-2 Reuptake and antidepres- sants (Left) Soon after a neuron releases neurotransmit- ters such as norepinephrine or serotonin into its synaptic space, it activates a pumplike reuptake mechanism to reab- sorb excess neurotransmit- ters. In depression, however, this reuptake process is too active, removing too many neurotransmitters before they can bind to a receiving neuron. (Right) Tricyclic and most second-generation antidepres- sant drugs block the reuptake process, enabling norepineph- rine or serotonin to remain in the synapse longer and bind to the receiving neuron.
▶▶ selective serotonin reuptake inhibitors (SSRIs) A group of second- generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters.
▶▶ vagus nerve stimulation A treat- ment procedure for depression in which an implanted pulse generator sends regular electrical signals to a person’s vagus nerve; the nerve then stimulates the brain.
▶▶ transcranial magnetic stimula- tion (TMS) A treatment procedure for depression in which an electromag- netic coil, which is placed on or above a patient’s head, sends a current into the individual’s brain.
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side effects of their own. Some people gain weight or have a reduced sex drive, for example (Stahl, 2014).
As popular as the antidepressants are, it is important to recognize that they do not work for everyone. In fact, as you have read, even the most successful of them fails to help at least 35 percent of clients with depression. In fact, some recent reviews have raised the possibility that the failure rate is higher still (Hegerl et al., 2012; Isacsson & Alder, 2012). How are clients who do not respond to antidepressant drugs treated currently? Researchers have noted that, all too often, their psychiatrists or family physicians simply prescribe alternative antidepressants or antidepressant mixtures— one after another—without directing the clients to psychotherapy or counseling of some kind. Melissa, a depressed woman for whom psychotropic drug treatment has failed to work over many years, reflects on this issue:
[S]he spoke, in a wistful manner, of how she wished her treatment could have been different. “I do wonder what might have happened if [at age 16] I could have just talked to someone, and they could have helped me learn about what I could do on my own to be a healthy person. . . . Instead, it was you have this problem with your neurotransmitters, and so here, take this pill Zoloft, and when that didn’t work, it was take this pill Prozac, and when that didn’t work, it was take this pill Effexor, and then when I started having trouble sleeping, it was take this sleeping pill,” she says, her voice sounding more wistful than ever. “I am so tired of the pills.”
(Whitaker, 2010)
Brain stimulation In recent years, three additional biological approaches have been developed for the treatment of depressive disorders—vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation.
The vagus nerve, the longest nerve in the human body, runs from the brain stem through the neck down the chest and on to the abdomen. A number of years ago, a group of depression researchers surmised that they might be able to stimulate the brain by electrically stimulating the vagus nerve with ECT. Their efforts gave birth to a new treatment for depression—vagus nerve stimulation.
In this procedure, a surgeon implants a small device called a pulse generator under the skin of the chest. The surgeon then guides a wire, which extends from the pulse generator, up to the neck and attaches it to the vagus nerve (see Figure 6-3). Electrical signals travel from the pulse generator through the wire to the vagus nerve. The stimulated vagus nerve then delivers electrical signals to the brain. In 2005, the U.S. Food and Drug Administra- tion (FDA) approved this procedure.
Ever since vagus nerve stimulation was first tried on depressed human beings, research has found that it brings significant relief to many depressed people. In fact, in studies of severely depressed people who have not responded to any other form of treatment, as many as 40 percent improve significantly when treated with this procedure (Howland, 2014; Berry et al., 2013).
Transcranial magnetic stimulation (TMS) is another technique that is used to try to stimulate the brain without subjecting depressed patients to the undesired effects or trauma of ECT. In this procedure, the clinician places an electromagnetic coil on or above the patient’s head. The coil sends a current into the prefrontal cortex. As you’ll remember, some parts of the prefrontal cortex of depressed people
Pulse generator
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figure 6-3 Vagus nerve stimulation In the procedure called vagus nerve stimulation, an implanted pulse generator sends electrical signals to the vagus nerve, which then delivers electrical sig- nals to the brain. This stimulation of the brain helps reduce depression in many patients.
B e t w e e n t h e L i n e s
Publication Bias A review of 74 FDA-registered antide- pressant drug studies revealed a trou- bling pattern (Turner et al., 2008). Only 38 of the studies yielded positive find- ings (the drug was effective), and all but 1 of these studies were published. The other 36 studies yielded findings that were negative or questionable, and 22 of them were not published. This pub- lication bias may make the antidepres- sant drugs appear more effective than they actually are (Pigott et al., 2010).
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are underactive; TMS appears to increase neuron activity in those regions. A num- ber of studies have found that TMS reduces depression for many patients when it is administered daily for two to four weeks (Dunner et al., 2014; Fox et al., 2012).
As you read earlier, researchers have recently linked depression to high activity in Brodmann Area 25. This finding led neurologist Helen Mayberg and her colleagues (2005) to administer an experimental treatment called deep brain stimulation (DBS) to six severely depressed patients who had previously been unresponsive to all other forms of treatment. The Mayberg team drilled two tiny holes into the patient’s skull and implanted electrodes in Area 25. The electrodes were connected to a battery, or “pacemaker,” that was implanted in the patient’s chest (for men) or stom- ach (for women). The pacemaker powered the electrodes, sending a steady stream of low-voltage electricity to Area 25. Mayberg’s expectation was that this repeated stimulation would reduce Area 25 activity to a normal level and “recalibrate” and regulate the depression brain circuit.
In the initial study of DBS, four of the six severely depressed patients became almost depression-free within a matter of months (Mayberg et al., 2005). Subse- quent research with other severely depressed individuals has also yielded promising findings (Berlim et al., 2014; Taghva, Malone, & Rezai, 2013). Understandably, this work has produced considerable enthusiasm in the clinical field, but it is important to recognize that research on DBS is in its early stages.
Psychological Models of Unipolar Depression The psychological models that have been most widely applied to unipolar depres- sion are the psychodynamic, behavioral, and cognitive models. The psychodynamic model has not been strongly supported by research, and the behavioral model has received moderate support. In contrast, the cognitive model has received consider- able research support and gained a large following.
The Psychodynamic Model Sigmund Freud (1917) and his student Karl Abraham (1916, 1911) developed the first psychodynamic explanation and treat- ment for depression. Their emphasis on dependence and loss continues to influence today’s psychodynamic clinicians.
psychodynamic EXplanations Freud and Abraham began by noting the simi- larity between clinical depression and grief in people who lose loved ones: con- stant weeping, loss of appetite, difficulty sleeping, loss of pleasure in life, and social withdrawal. According to the theorists, a series of unconscious processes is set in motion when a loved one dies. Unable to accept the loss, mourn- ers at first regress to the oral stage of development, the period of total dependency when infants can- not distinguish themselves from their parents. By regressing to this stage, the mourners merge their own identity with that of the person they have lost, and so symbolically regain the lost person. They direct all their feelings for the loved one, including sadness and anger, toward themselves. For most mourners, this reaction is temporary. For some, however, grief worsens over time, and they, in fact, become depressed.
Of course, many people become depressed without losing a loved one. To explain why, Freud proposed the concept of symbolic, or imagined, loss, in which a person equates other kinds of events with the loss of a loved one. A college student may, for example, experience failure in a calculus course as the loss of her parents, believing that they love her only when she excels academically.
Although many psychodynamic theorists have parted company with Freud and Abraham’s theory of depression, it continues to influence current psychodynamic
Stimulating the brain In this version of transcranial magnetic stimulation, a woman sits under a helmet. The helmet contains an electromagnetic coil that sends currents into and stimulates her brain.
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DSM-5 Controversy: Does Bereavement Equal Depression? In past editions of the DSM, people who lose a loved one were excluded from receiving a diagnosis of major depressive disorder during the first 2 months of their bereavement. However, according to DSM-5, newly bereaved people can qualify for this diagnosis if their depressive symptoms are severe enough. Critics fear that many people undergoing a normal grief reaction may now receive an incorrect diagnosis of major depressive disorder.
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thinking (Desmet, 2013; Zuckerman, 2011). For example, object relations theorists (the psychodynamic theorists who emphasize relationships) propose that depres- sion results when people’s relationships leave them feeling unsafe and insecure (Schattner & Sharar, 2011; Blatt, 2004). People whose parents pushed them toward either excessive dependence or excessive self-reliance are more likely to become depressed when they later lose important relationships.
The following description by the therapist of a depressed middle-aged woman illustrates the psychodynamic concepts of dependence, loss of a loved one, and symbolic loss:
Marie Carls . . . had always felt very attached to her mother. . . . She always tried to placate her volcanic [emotions], to please her in every possible way. . . .
After marriage [to Julius], she continued her pattern of submission and compli- ance. Before her marriage she had difficulty in complying with a volcanic mother, and after her marriage she almost automatically assumed a submissive role. . . .
[W]hen she was thirty years old . . . [Marie] and her husband invited Ignatius, who was single, to come and live with them. Ignatius and [Marie] soon discovered that they had an attraction for each other. They both tried to fight that feeling; but when Julius had to go to another city for a few days, the so-called infatuation became much more than that. There were a few physical contacts. . . . There was an intense spiritual affinity. . . . A few months later everybody had to leave the city. . . . Noth- ing was done to maintain contact. Two years later . . . Marie heard that Ignatius had married. She felt terribly alone and despondent. . . .
Her suffering had become more acute as she [came to believe] that old age was approaching and she had lost all her chances. Ignatius remained as the memory of lost opportunities. . . . Her life of compliance and obedience had not permitted her to reach her goal. . . . When she became aware of these ideas, she felt even more depressed. . . . She felt that everything she had built in her life was false or based on a false premise.
(Arieti & Bemporad, 1978, pp. 275–284)
Studies have offered general support for the psychodynamic idea that major losses, especially ones suffered early in life, may set the stage for later depression (Gilman, 2013; Gutman & Nemeroff, 2011). When, for example, a depression scale was administered to 1,250 medical patients during visits to their family physicians, the patients whose fathers had died during their childhood scored higher on depression (Barnes & Prosen, 1985). At the same time, research does not indicate that loss is always at the core of depression. In fact, it is estimated that less than 10 percent of all people who have major losses in life actually become depressed (Bonanno, 2004; Paykel & Cooper, 1992). Moreover, research into the loss–depression link has yielded inconsistent findings. Though some studies find evidence of a relationship between childhood loss and later depression, others do not.
What arE thE psychodynamic trEatmEnts For unipolar dEprEs- sion? Believing that unipolar depression results from unconscious grief over real or imagined losses, compounded by excessive dependence on other people, psychodynamic therapists seek to help clients bring these underlying issues to consciousness and work through them. They encourage the depressed client to associate freely during therapy; sug- gest interpretations of the client’s associations, dreams, and displays of resistance and transference; and help the person review past events and
Early loss The young daughter of a police officer killed during the September 11, 2001, terrorist attacks stands onstage holding her father’s hand while the names of attack victims are read during ceremonies at Ground Zero marking the fifth anniversary of the event. Research has found that people who lose their parents as children have an increased likeli- hood of experiencing depression as adults.
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▶▶ deep brain stimulation (DBS) A treatment procedure for depression in which a pacemaker powers electrodes that have been implanted in Brodmann Area 25, thus stimulating that brain area.
▶▶ symbolic loss According to Freudian theory, the loss of a valued object (for example, a loss of employment) that is unconsciously interpreted as the loss of a loved one. Also called imagined loss.
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feelings (Busch et al., 2004). Free association, for example, helped one man recall the early experiences of loss that, according to his therapist, had set the stage for his depression:
Among his earliest memories, possibly the earliest of all, was the recollection of being wheeled in his baby cart under the elevated train structure and left there alone. Another memory that recurred vividly during the analysis was of an operation around the age of five. He was anesthetized and his mother left him with the doctor. He recalled how he had kicked and screamed, raging at her for leaving him.
(Lorand, 1968, pp. 325–326)
Despite successful case reports such as this, researchers have found that long- term psychodynamic therapy is only occasionally helpful in cases of unipolar depression (Prochaska & Norcross, 2013). Two features of the approach may help limit its effectiveness. First, depressed clients may be too passive and feel too weary to join fully into the subtle therapy discussions. And second, they may become discouraged and end treatment too early when this long-term approach is unable to provide the quick relief that they desperately seek. Short-term psychodynamic therapies have performed better than traditional, longer-term approaches (Midgley et al., 2013; Lemma et al., 2011).
The Behavioral Model Behaviorists believe that unipolar depression results from significant changes in the number of rewards and punishments people receive in their lives, and they treat depressed people by helping them build more desir- able patterns of reinforcement (Dygdon & Dienes, 2013). Clinical researcher Peter Lewinsohn was one of the first clinical theorists to develop a behavioral explanation (Lewinsohn et al., 1990, 1984).
thE BEhavioral EXplanation Lewinsohn suggested that the positive rewards in life dwindle for some people, leading them to perform fewer and fewer construc- tive behaviors. The rewards of campus life, for example, disappear when a young woman graduates from college and takes a job; and an aging baseball player loses the rewards of high salary and adulation when his skills deteriorate. Although many people manage to fill their lives with other forms of gratification, some become particularly disheartened. The positive features of their lives decrease even more, and the decline in rewards leads them to perform still fewer constructive behaviors. In this manner, they spiral toward depression.
In a number of studies, behaviorists have found that the number of rewards people receive in life is indeed related to the presence or absence of depression. Not only do depressed participants typically report fewer positive rewards than nonde- pressed participants, but when their rewards begin to increase, their mood improved as well (Bylsma et al., 2011; Lewinsohn et al., 1979). Similarly, other investigations have found a strong relationship between positive life events and feelings of life satisfaction and happiness (Carvalho & Hopko, 2011).
Lewinsohn and other behaviorists have further proposed that social rewards are particularly important in the downward spiral of depression (Martell et al., 2010). This claim has been supported by research showing that depressed persons receive fewer social rewards than nondepressed persons and that as their mood improves, their social rewards increase. Although depressed people are sometimes the victims of social circumstances (see MediaSpeak on the next page), it may also be that their dark mood and flat behaviors help produce a decline in social rewards (Constantino et al., 2012; Coyne, 2001).
Across the species Researcher Harry Harlow and his colleagues found that infant monkeys reacted with apparent despair to separation from their mothers. Even monkeys raised with surrogate mothers—wire cylinders wrapped with foam rubber and covered with terry cloth—formed an attachment to them and mourned their absence.
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Loss of Confidants Intimate social contact has been de- clining over the past 30 years. When research participants were asked in 1985 how many confidants they turned to for discussion of important matters, most answered 3. Today, the most com- mon response to the same question is 2 (Bryner, 2011; McPherson, Smith-Lovin, & Brashears, 2006).
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A Canadian woman was denied entry to the United States last month because she had been hospital- ized for depression in 2012. Ellen Richardson could not visit, she was told, unless she obtained “medical clear- ance” from one of three Toronto doctors approved by the Department of Homeland Security. Endorsement by her own psychiatrist, which she could presumably have obtained more efficiently, “would not suffice.” She had been en route to New York, where she had intended to board a cruise to the Caribbean. . . .
The border agent told her he was acting in ac- cordance with the United States Immigration and Nationality Act, Section 212, which allows patrols to block people from visiting the United States if they have a physical or mental disorder that threatens any- one’s “property, safety or welfare.” The [Toronto] Star reported that the agent produced a signed document stating that Ms. Richardson would need a medical eval- uation because of her “mental illness episode.” . . .
This is not the first time such measures have been reported. In 2011, Lois Kamenitz, a Canadian and a former teacher, was barred from entering the United States because she had once attempted suicide. [A police official] told the Star that he had heard of eight similar cases that year. After the in- cident, he wrote to me: “My sense is that there are a great many people being turned away. . . .”
People in treatment for mental illnesses do not have a higher rate of violence than people without mental illnesses. Furthermore, de- pression affects one in 10 American adults. . . . Pillorying depression is regressive, a swoop back into a period when any sign of mental illness was the basis for social exclu- sion. . . . [T]his border policy is not only unfair to visitors, but also constitutes an affront to the millions of Americans who are grappling with mental-health challenges.
Stigmatizing the condition is bad; stigmatizing the treatment is even worse. . . . Yet this incident will serve only to warn people against seeking treatment for
MediaSpeak immigration and Depression in the 21st century
By Andrew Solomon, New York Times, December 8, 2013
mental illness. . . . Ms. Richardson, who attempted suicide in 2001 and as a result is paraplegic, has asserted that she has had appropriate treat- ment, and that she now has a fulfilling, purposeful life. We should applaud people who get treatment and man- age to live deeply despite their chal- lenges [and] put to rest the idea that
people with mental health conditions who pose no danger are unwelcome in our country.
December 8, 2013, “Opinion: Shameful Profiling of the Mentally Ill” by Andrew Solomon. From the New York Times, 12/8/2013, © 2013 New York Times. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retrans- mission of this content without express written permission is prohibited.
“Give me your tired, your poor, your huddled masses . . .” An Italian immigrant and her family arrive at Ellis Island in New York City in 1905. Today’s U.S. immigration policies for persons with mental disorders are sometimes less generous than they were more than 100 years ago.
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What arE thE BEhavioral trEatmEnts For unipolar dEprEssion? Behavioral therapists use a variety of strategies to help increase the number of rewards experi- enced by their depressed clients (Dimidjian et al., 2014; Martell et al., 2010): (1) First the therapist selects activities that the client considers pleasurable, such as going shopping or taking photos, and encourages the person to set up a weekly schedule for engaging in them. Studies have shown that adding positive activities to a per- son’s life—sometimes called behavioral activation—can indeed lead to a better mood. (2) Second, while reintroducing pleasurable events into a client’s life, the therapist makes sure that the person’s various behaviors are reinforced correctly. Behavior- ists argue that when people become depressed, their negative behaviors—crying, ruminating, complaining, or self-criticism—keep others at a distance, reducing chances for rewarding interactions. To change this pattern, therapists guide clients to monitor their negative behaviors and to try new, more positive ones. In addition, the therapist may try to systematically ignore a client’s depressive behaviors while praising or otherwise rewarding constructive statements and behavior, such as going to work. (3) Finally, behavioral therapists may train clients in effective social skills. In group therapy programs, for example, members may work together to improve eye contact, facial expression, posture, and other behaviors that send social messages.
These behavioral techniques seem to be of only limited help when just one of them is applied. However, when two or more such techniques are combined, behavioral treatment does appear to reduce depressive symptoms, particularly if the depression is mild. It is worth noting that Lewinsohn himself has combined behav- ioral techniques with cognitive strategies in recent years in an approach similar to the cognitive-behavioral treatments discussed in the next section.
The Cognitive Model Cognitive theorists believe that people with unipolar depression persistently view events in negative ways and that such perceptions lead to their disorder. The two most influential cognitive explanations are the theory of learned helplessness and the theory of negative thinking.
lEarnEd hElplEssnEss Feelings of helplessness fill this account of a young wom- an’s depression:
Mary was 25 years old and had just begun her senior year in college. . . . Asked to recount how her life had been going recently, Mary began to weep. Sobbing, she said that for the last year or so she felt she was losing control of her life and that
When the applause stops According to behaviorists, the reduction in rewards brought about by retirement places high achievers at particular risk for depression. Former New York Giants running back Tiki Barber, seen here eluding a defender, recently described the severe depression he went through after he retired from pro football in 2006, lost his job as a TV network correspondent, and ended his marriage, in quick succession. “I remember there were days where I would literally . . . sit on the couch and do nothing for 10 hours. . . . I started to shrivel. . . . I didn’t have . . . that aura any more.”
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“Don’t cry because it’s over, smile be- cause it happened.”
Dr. Seuss
Depressive and Bipolar Disorders : 201
recent stresses (starting school again, friction with her boyfriend) had left her feel- ing worthless and frightened. Because of a gradual deterioration in her vision, she was now forced to wear glasses all day. “The glasses make me look terrible,” she said, and “I don’t look people in the eye much any more.” Also, to her dismay, Mary had gained 20 pounds in the past year. She viewed herself as overweight and unat- tractive. At times she was convinced that with enough money to buy contact lenses and enough time to exercise she could cast off her depression; at other times she believed nothing would help. . . . Mary saw her life deteriorating in other spheres, as well. She felt overwhelmed by schoolwork and, for the first time in her life, was on academic probation. . . . In addition to her dissatisfaction with her appearance and her fears about her academic future, Mary complained of a lack of friends. Her social network consisted solely of her boyfriend, with whom she was living. Although there were times she experienced this relationship as almost unbearably frustrating, she felt helpless to change it and was pessimistic about its permanence.
(Spitzer et al., 1983, pp. 122–123)
Mary feels that she is “losing control of her life.” According to psychologist Martin Seligman (1975), such feelings of helplessness are at the center of her depression. Since the mid-1960s Seligman has been developing the learned help- lessness theory of depression. It holds that people become depressed when they think (1) that they no longer have control over the reinforcements (the rewards and punishments) in their lives and (2) that they themselves are responsible for this helpless state.
Seligman’s theory first began to take shape when he was working with labora- tory dogs. In one procedure, he strapped dogs into an apparatus called a hammock, in which they received shocks periodically no matter what they did. The next day each dog was placed in a shuttle box, a box divided in half by a barrier over which the animal could jump to reach the other side (see Figure 6-4). Seligman applied shocks to the dogs in the box, expecting that they, like other dogs in this situation, would soon learn to escape by jumping over the barrier. However, most of these dogs failed to learn anything in the shuttle box. After a flurry of activ- ity, they simply “lay down and quietly whined” and accepted the shock.
Seligman decided that while receiving inescapable shocks in the hammock the day before, the dogs had learned that they had no control over unpleasant events (shocks) in their lives. That is, they had learned that they were helpless to do anything to change negative situations. Thus, when later they were placed in a new situation (the shuttle box) where they could in fact control their fate, they continued to believe that they were generally helpless. Seligman noted that the effects of learned helplessness greatly resemble the symptoms of human depres- sion, and he proposed that people in fact become depressed after devel- oping a general belief that they have no control over reinforcements in their lives.
In numerous human and animal studies, participants who undergo helplessness training have displayed reactions similar to depressive symp- toms (Dygdon & Dienes, 2013). When, for example, human participants are exposed to uncontrollable negative events, they later score higher than other individuals on a depressive mood survey (Miller & Seligman, 1975). Similarly, helplessness-trained animal subjects lose interest in sexual and social activities—a common symptom of human depression (Lindner, 1968).
The learned helplessness explanation of depression has been revised somewhat over the past several decades. According to a newer version of the theory, the attribution-helplessness theory, when people view events as beyond their control, they
figure 6-4 Jumping to safety Experimental animals learn to escape or avoid shocks that are administered on one side of a shuttle box by jumping to the other (safe) side.
▶▶ learned helplessness The percep- tion, based on past experiences, that one has no control over one’s reinforcements.
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ask themselves why this is so (Abramson et al., 2002, 1989, 1978). If they attribute their present lack of control to some internal cause that is both global and stable (“I am inadequate at everything and I always will be”), they may well feel helpless to prevent future negative outcomes and they may experience depression. If they make other kinds of attributions, they are unlikely to have this reaction.
Consider a college student whose girlfriend breaks up with him. If he attributes this loss of control to an internal cause that is both global and stable—“It’s my fault [internal], I ruin everything I touch [global], and I always will [stable]”—he then has reason to expect similar losses of control in the future and may generally experience a sense of helplessness. According to the learned helplessness view, he is a prime candidate for depression. If the student had instead attributed the breakup to causes that were more specific (“The way I’ve behaved the past couple of weeks blew this relationship”), unstable (“I don’t usually act like that”), or external (“She never did know what she wanted”), he might not expect to lose control again and would probably not experience helplessness and depression. Hundreds of studies have sup- ported the relationship between styles of attribution, helplessness, and depression (Rotenberg et al., 2012).
Some theorists have refined the helplessness model yet again in recent years. They suggest that attributions are likely to cause depression only when they further produce a sense of hopelessness in a person (Wain et al., 2011). By taking this factor into consideration, clinicians are often able to predict depression with still greater precision (Wang et al., 2013).
Although the learned helplessness theory of unipolar depression has been very influential, it too has imperfections. First, much of the learned helplessness research relies on animal subjects. It is impossible to know whether the animals’ symptoms do in fact reflect the clinical depression found in humans. Second, the attributional feature of the theory raises difficult questions. What about the dogs and rats who learn helplessness? Can animals make attributions, even implicitly?
nEgativE thinking Like Seligman, Aaron Beck believes that negative thinking lies at the heart of depression (Beck & Weishaar, 2014; Beck, 2002, 1991, 1967). According to Beck, maladaptive attitudes, a cognitive triad, errors in thinking, and automatic thoughts combine to produce the clinical syndrome.
Beck believes that some people develop maladaptive attitudes as children, such as “My general worth is tied to every task I perform” or “If I fail, others will feel
repelled by me.” The attitudes result from their early interactions and experiences (see Figure 6-5). Many failures are inevitable in a full, active life, so such attitudes are inaccurate and set the stage for all kinds of negative thoughts and reactions. Beck suggests that later in these people’s lives, upsetting situations may trigger an extended round of negative thinking. That thinking typically takes three forms, which he calls the cognitive triad: the individuals repeatedly interpret (1) their experiences,
(2) themselves, and (3) their futures in negative ways that lead them to feel depressed. The cognitive triad is at work in the thinking of this depressed person:
I can’t bear it. I can’t stand the humiliating fact that I’m the only woman in the world who can’t take care of her family, take her place as a real wife and mother, and be respected in her community. When I speak to my young son Billy, I know I can’t let him down, but I feel so ill-equipped to take care of him; that’s what frightens me. I don’t know what to do or where to turn; the whole thing is too overwhelming. . . . I must be a laughing stock. It’s more than I can do to go out and meet people and have the fact pointed up to me so clearly.
(Fieve, 1975)
One-third of people who felt
unhappy as children continue
to feel unhappy as adults.
why might this be so?
▶▶ cognitive triad The three forms of negative thinking that Aaron Beck theo- rizes lead people to feel depressed. The triad consists of a negative view of one’s experiences, oneself, and the future.
B e t w e e n t h e L i n e s
The Color of Depression In Western society, black is often the color of choice in describing depres- sion. British prime minister Winston Churchill called his recurrent episodes a “black dog always waiting to bare its teeth.” American novelist Ernest Hemingway referred to his bouts as “black-assed” days. And the Rolling Stones sing about depressive thinking: “I see a red door and I want to paint it black.”
Depressive and Bipolar Disorders : 203
According to Beck, depressed people also make errors in their thinking. In one common error of logic, they draw arbitrary inferences—negative conclusions based on little evidence. A man walking through the park, for example, passes a woman who is looking at nearby flowers and concludes, “She’s avoiding looking at me.” Similarly, depressed people often minimize the significance of positive experiences or magnify that of negative ones. A college student receives an A on a difficult English exam, for example, but concludes that the grade reflects the professor’s generosity rather than her own ability (minimization). Later in the week the same student must miss an English class and is convinced that she will be unable to keep up the rest of the semester (magnification).
Finally, depressed people have automatic thoughts, a steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and that their situ- ation is hopeless. Beck labels these thoughts “automatic” because they seem to just happen, as if by reflex. In the course of only a few hours, depressed people may be visited by hundreds of such thoughts: “I’m worthless. . . . I’ll never amount to anything . . . I let everyone down. . . . Everyone hates me. . . . My responsibilities are overwhelming. . . . I’ve failed as a parent. . . . I’m stupid. . . . Everything is dif- ficult for me. . . . Things will never change.”
Many studies have produced evidence in support of Beck’s explanation (Pössel & Black, 2014). Several of them confirm that depressed people hold maladaptive attitudes and that the more of these maladaptive attitudes they hold, the more depressed they tend to be (Thomas & Altareb, 2012). Still other research has found the cognitive triad at work in depressed people (Lai et al., 2014). And still other studies have supported Beck’s claims about errors in logic (Alcalar et al., 2012). In one study, female participants— some depressed, some not—were asked to read and interpret paragraphs about women in difficult situations. Depressed participants made more errors in logic (such as arbitrary inference) in their interpretations than nondepressed women did (Hammen & Krantz, 1976).
Finally, research has supported Beck’s claim that auto- matic thoughts are tied to depression (Alcalar et al., 2012).
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figure 6-5 How depressed parents and their children interact Depressed parents are less likely than nondepressed parents to play with, hug, read to, or sing to their young children each day or to employ the same routine each day. They are also more likely to get frustrated with their chil- dren on a daily basis. (Information from: Turney, 2011; Princeton Survey Research Associates, 1996.)
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In several classic studies, nondepressed participants who are tricked into reading negative automatic-thought-like statements about themselves become increasingly depressed (Bates et al., 1999; Strickland et al., 1975). In a related line of research, it has been found that people who generally make ruminative responses during their depressed moods—that is, repeatedly dwell mentally on their mood without acting to change it—feel dejection longer and are more likely to develop clinical depres- sion later in life than people who avoid such ruminations ( Johnson et al., 2014; Watkins & Nolen-Hoeksema, 2014).
What arE thE cognitivE trEatmEnts For unipolar dEprEssion? To help cli- ents overcome this negative thinking, Beck has developed a treatment approach that he calls cognitive therapy (Beck & Weishaar, 2014). However, as you will see, the approach also includes a number of behavioral techniques, particularly as therapists try to get clients moving again and encourage them to try out new behaviors. Thus, many theorists consider this approach a cognitive-behavioral therapy rather than the purely cognitive intervention implied by its name. The approach follows four phases and usually requires fewer than 20 sessions.
phasE 1: increasing activities and elevating mood Using behavioral techniques to set the stage for cognitive treatment, therapists first encourage clients to become more active and confident. Clients spend time during each session preparing a detailed schedule of hourly activities for the coming week. As they become more active from week to week, their mood is expected to improve. phasE 2: challenging automatic thoughts Once people are more active and feel- ing some emotional relief, cognitive therapists begin to educate them about their negative automatic thoughts. The individuals are instructed to recognize and record automatic thoughts as they occur and to bring their lists to each session. Therapist and client then test the reality behind the thoughts, often concluding that they are groundless. phasE 3: identifying negative thinking and biases As people begin to recognize the flaws in their automatic thoughts, cognitive therapists show them how illogi- cal thinking processes are contributing to these thoughts. The therapists also guide clients to recognize that almost all their interpretations of events have a negative bias and to change that style of interpretation. phasE 4: changing primary attitudes Therapists help clients change the maladap- tive attitudes that set the stage for their depression in the first place. As part of the process, therapists often encourage clients to test their attitudes, as in the following therapy discussion:
Therapist: On what do you base this belief that you can’t be happy without a man? Patient: I was really depressed for a year and a half when I didn’t have a man. Therapist: Is there another reason why you were depressed? Patient: As we discussed, I was looking at everything in a distorted way. But I still
don’t know if I could be happy if no one was interested in me. Therapist: I don’t know either. Is there a way we could find out? Patient: Well, as an experiment, I could not go out on dates for a while and see
how I feel. Therapist: I think that’s a good idea. Although it has its flaws, the experimental
method is still the best way currently available to discover the facts. You’re fortunate in being able to run this type of experiment. Now, for the first time in your adult life you aren’t attached to a man. If you find you can be happy without a man, this will greatly strengthen you and also make your future relationships all the better.
(Beck et al., 1979, pp. 253–254)
▶▶ cognitive therapy A therapy devel- oped by Aaron Beck that helps people identify and change the maladaptive assumptions and ways of thinking that help cause their psychological disorders.
Flower power Despite the effectiveness of antidepressant drugs and certain kinds of psy- chotherapy, many depressed people turn to herbal remedies such as Saint-John’s-wort, a low, wild-growing shrub. Studies indicate that this herb can be quite helpful in cases of mild or moderate depression.
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Depressive and Bipolar Disorders : 205
Over the past several decades, hundreds of studies have shown that Beck’s ther- apy and similar cognitive and cognitive-behavioral approaches help with unipolar depression. Depressed adults who receive these therapies improve much more than those who receive placebos or no treatment at all (Young et al., 2014; Hollon & Cuijpers, 2013). Around 50 to 60 percent show a near-total elimination of their symptoms.
It is worth noting that a growing number of today’s cognitive-behavioral therapists do not agree with Beck’s proposition that individuals must fully discard their negative cognitions in order to overcome depression. These therapists, the new-wave cognitive-behavioral therapists about whom you read in Chapters 2 and 4, including those who practice acceptance and commitment therapy (ACT ), guide depressed clients to recognize and accept their negative cognitions simply as streams of thinking that flow through their minds, rather than as valuable guides for behavior and decisions. As clients increasingly accept their negative thoughts for what they are, they can better work around the thoughts as they navigate their way through life (Levin et al., 2014; Hayes et al., 2006).
The Sociocultural Model of Unipolar Depression Sociocultural theorists propose that unipolar depression is strongly influenced by the social context that surrounds people. Their belief is supported by the finding, discussed earlier, that depression is often triggered by outside stressors. Once again, there are two kinds of sociocultural views—the family-social perspective and the multi- cultural perspective.
The Family-Social Perspective Earlier you read that some behaviorists believe that a decline in social rewards is particularly important in the development of depression. Although presented as part of their behavioral explanation, this view is consistent with the family-social perspective. Depression has been tied repeatedly to the unavailability of social support such as that found in a happy marriage (Ito
& Sagara, 2014). People who are separated or divorced display at least three times the depression rate of married or widowed people and double the rate of those who have never been married (Schultz, 2007; Weissman et al., 1991). In some cases, the spouse’s depression may contribute to marital discord, a separa-
tion, or divorce, but often the interpersonal conflicts and low social support found in troubled relationships seem to lead to depression (Najman et al., 2014).
Researchers have also found that people whose lives are isolated and without intimacy are particularly likely to become depressed at times of stress (Hölzel et al., 2011; Nezlek et al., 2000). Some highly publicized studies conducted in England several decades ago showed that women who had three or more young children, lacked a close confidante, and had no outside employment were more likely than other women to become depressed after going through stressful events (Brown, 2002; Brown & Harris, 1978). Studies have also found that depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendships.
Family-Social Treatments Therapists who use family and social approaches to treat depression help clients change how they deal with the close relationships in their lives. The most effective family-social approaches are interpersonal psycho- therapy and couple therapy.
why might problems in the
social arena—e.g., social loss,
social ties, and social rewards—
be tied to depression?
The “dogtor” will see you now A client talks through his problems and concerns to “Dogtor” Schnauzer at the first ever “Dogtor’s Surgery” program. According to research, many pet owners satisfy their basic need for social contact, and help thwart off depressed feelings, by talking to and confiding in their pets. Indeed, millions of pet owners say that they confide in their pets before their spouses, and one-quarter talk to their pets more than their spouses. The Dogtor’s Sur- gery program is designed to offer similar pet-related emotional benefits to people who are not pet owners.
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In Their Words “No one can make you feel inferior without your consent.”
eleanor roosevelt
: chapter 6206
intErpErsonal psychothErapy Developed by clinical researchers Gerald Klerman and Myrna Weissman, interpersonal psychotherapy (IPT) holds that various interpersonal situations may lead to depression and must be addressed. Particularly problematic are interpersonal loss, interpersonal role dispute, interpersonal role transition, and interpersonal deficits (Bleiberg & Markowitz, 2014; Verdeli, 2014). Over the course of around 16 sessions, IPT therapists address these areas.
First, depressed people may, as psychodynamic theorists suggest, be having a grief reaction over an important interpersonal loss, the loss of a loved one. In such cases, IPT therapists encourage clients to look closely at their relationship with the lost person and express any feelings of anger they may discover. Eventually clients develop new ways of remembering the lost person and also look for new relationships.
Second, depressed people may find themselves in the midst of an interpersonal role dispute. Role disputes occur when two people have different expectations of their relationship and of the role each should play. IPT therapists help clients examine what- ever role disputes they may be involved in and then develop ways of resolving them.
Depressed people may also be going through an interpersonal role transition, brought about by major life changes such as divorce or the birth of a child. They may feel overwhelmed by the role changes that accompany the life change. In such cases, IPT therapists help them develop the social supports and skills the new roles require.
Finally, some depressed people display interpersonal deficits, such as extreme shy- ness or social awkwardness, that prevent them from having intimate relationships (see MindTech on the next page). IPT therapists may help such clients identify their deficits and teach them social skills and assertiveness in order to improve their social effectiveness. In the following discussion, the therapist encourages a depressed man to recognize the effect his behavior has on others:
Role transition Major life changes such as marriage, the birth of a child, or divorce can create difficulties in role transition, one of the interpersonal problem areas addressed by IPT therapists in their work with depressed clients.
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▶▶ interpersonal psychotherapy (IPT) A treatment for unipolar depression that is based on the belief that clarifying and changing one’s interpersonal problems helps lead to recovery.
Client: (After a long pause with eyes downcast, a sad facial ex- pression, and slumped posture) People always make fun of me. I guess I’m just the type of guy who really was meant to be a loner, damn it. (Deep sigh)
Therapist: Could you do that again for me? Client: What? Therapist: The sigh, only a bit deeper. Client: Why? (Pause) Okay, but I don’t see what . . . okay. (Client
sighs again and smiles) Therapist: Well, that time you smiled, but mostly when you sigh
and look so sad I get the feeling that I better leave you alone in your misery, that I should walk on eggshells and not get too chummy or I might hurt you even more.
Client: (A bit of anger in his voice) Well, excuse me! I was only trying to tell you how I felt.
Therapist: I know you felt miserable, but I also got the message that you wanted to keep me at a distance, that I had no way to reach you.
Client: (Slowly) I feel like a loner, I feel that even you don’t care about me— making fun of me.
Therapist: I wonder if other folks need to pass this test, too? (Beier & Young, 1984, p. 270)
Studies suggest that IPT and related interpersonal treatments for depression have a success rate similar to that of cognitive and
Depressive and Bipolar Disorders : 207
cognitive-behavioral therapies (Bleiberg & Markowitz, 2014). That is, symptoms almost totally disappear in 50 to 60 percent of clients who receive treatment. Not surprisingly, IPT is considered especially useful for depressed people who are strug- gling with social conflicts or undergoing changes in their careers or social roles (Ravitz et al., 2013).
MindTech
Texting: A Relationship Buster? Texting has now become the leading way that most people communicate with others (Pew Research Center, 2015; Cocotas, 2013). The average 18- to 24-year-old sends and receives a total of 4,000 texts each month. Many
people text almost constantly throughout the day. In fact, surveys suggest that people often fail to fully attend to their current activities in order to juggle their text con-
versations. Some clinicians worry that excessive tex- ting may damage our relationships—relationships with the people we are texting and relationships with those we are ignoring while texting.
Based on her studies, MIT professor Sherry Turkle (2013, 2012) has concluded that communicating pri- marily via text does indeed affect relationships nega- tively. Many of her participants reported, “I’d rather
text than talk.” Turkle concludes from her research that people often use texting as a crutch to avoid direct communication and possible confrontations. Moreover, her participants said that texting saves valuable time over face-to-face conversations. However, concludes Turkle, “People who feel they are too busy to have conversations in person are not mak- ing the important emotional connections they other- wise would.”
In related work, researcher Karla Klein Murdock (2013) interviewed 83 college freshmen about their daily texting habits, along with their levels of social and personal stress, sleep patterns, and happiness. She found that hastily written texts (which is to say, most texts) often lend themselves to misunderstandings between senders and receivers— misunderstandings that can quickly spin out of control. Murdock also noted that many participants in her study felt the need to con- stantly keep up with ongoing text conversations, inter- rupting their in-person conversations—thus inviting damage to those relationships as well. Small wonder that the participants who averaged the most daily texts were more likely than other participants to report more stress, unhappiness, anxiety, and sleeping problems. Murdock believes that in many such cases, the negative effects of texting on the participants’ personal relationships are leading to broader feelings of stress and unhappiness.
None of this suggests that texting per se is a detriment to social or personal hap- piness. Rather, it seems to be the exclusive and excessive use of it that is the problem. It just may be that many important discussions are better served by in-person, or at least phone, conversations.
can you think of ways
in which texting might
sometimes be helpful
to relationships and
communications?
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couplE thErapy As you have read, depression can result from marital discord, and recovery from depression is often slower for people who do not receive support from their spouse (Park & Unützer, 2014). In fact, as many as half of all depressed clients may be in a dysfunctional relationship. Thus many cases of depression have been treated by couple therapy, the approach in which a therapist works with two people who share a long-term relationship (Cohen et al., 2014).
Therapists who offer integrative behavioral couples therapy teach specific commu- nication and problem-solving skills to couples and further guide them to be more accepting of each other (see Chapter 2). When a depressed person’s relationship is filled with conflict, couple treatments such as this may be as effective as individual cognitive therapy, interpersonal psychotherapy, or drug therapy in helping to reduce depression (Lebow et al., 2012, 2010).
The Multicultural Perspective Two issues have captured the interest of multicultural theorists: (1) links between gender and depression and (2) ties between cultural and ethnic background and depression.
gEndEr and dEprEssion As you have read, there is a strong link between gender and depression. Women in places as far apart as France, Sweden, Lebanon, New Zea- land, and the United States are at least twice as likely as men to receive a diagnosis of unipolar depression (Schuch et al., 2014). Why the huge difference between the sexes? A variety of theories have been offered.
The artifact theory holds that women and men are equally prone to depression but that clinicians often fail to detect depression in men (Emmons, 2010). Perhaps depressed women display more emotional symptoms, such as sadness and crying, which are easily diagnosed, while depressed men mask their depression behind traditionally “masculine” symptoms such as anger. Although a popular explanation, this view has failed to receive consistent research support. It turns out that women are actually no more willing or able than men to identify their depressive symptoms and to seek treatment (McSweeney, 2004; Nolen-Hoeksema, 1990).
The hormone explanation holds that hormone changes trigger depression in many women (Kurita et al., 2013). A woman’s biological life from her early teens to middle age is marked by frequent changes in hormone levels. Gender differences in rates of depression also span these same years. Research suggests, however, that hormone changes alone are not responsible for the high levels of depression in women (Whiffen & Demidenko, 2006). Important social and life events that occur at puberty, pregnancy, and menopause could likewise have an effect. Hormone explanations have also been criticized as sexist, since they imply that a woman’s normal biology is flawed (see PsychWatch on the next page).
The life stress theory suggests that women in our society are subject to more stress than men (Astbury, 2010). On average they face more poverty, more menial jobs, less adequate housing, and more discrimination than men—all factors that have been linked to depression. And in many homes, women bear a disproportionate share of responsibility for child care and housework.
The body dissatisfaction explanation states that females in Western society are taught, almost from birth, to seek a low body weight and slender body shape—goals that are unreasonable, unhealthy, and often unattainable. As you will observe in Chapter 9, the cultural standard for males is much more lenient. As girls approach adolescence, peer pressure may result in them becoming more and more dissatis- fied with their weight and body, increasing the likelihood of depression. Consistent with this theory, gender differences in depression do indeed first appear during adolescence (Naninck et al., 2011), and people with eating disorders often have high levels of depression (Calugi et al., 2014). However, it is not clear that eating and weight concerns actually cause depression; they may instead be the result of depression.
▶▶ couple therapy A therapy format in which the therapist works with two peo- ple who share a long-term relationship.
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Paternal Postpartum Depression Considerable research has already indicated that a mother’s postpartum depression can lead to disturbances in a child’s social, behavioral, and cognitive development. Research suggests that a father’s postpartum depression can have similar effects (Koh et al., 2014; Edoka et al., 2011).
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The lack-of-control theory draws on the learned helplessness research and proposes that women may be more prone to depression because they feel less control than men over their lives. It has been found that victimization of any kind, from burglary to rape, often produces a general sense of helplessness and increases the symptoms of depression. Women in our society are more likely than men to be victims, par- ticularly of sexual assault and child abuse (Astbury, 2010).
A final explanation for the gender differences found in depression is the rumina- tion theory. As you read earlier, rumination is the tendency to keep focusing on one’s feelings when depressed and to consider repeatedly the causes and consequences of that depression (“Why am I so down? . . . I won’t be able to finish my work if I keep going like this. . . .”). It turns out that women are more likely than men to rumi- nate when their mood darkens, perhaps making them more vulnerable to the onset of clinical depression ( Johnson & Whisman, 2013; Nolen-Hoeksema, 2002, 2000).
Each of these explanations for the gender difference in unipolar depression offers food for thought. Each has gathered just enough supporting evidence to make it interesting and just enough evidence to the contrary to raise questions about its usefulness. Thus, at present, the gender difference in depression remains one of the most talked-about but least understood phenomena in the clinical field.
cultural Background and dEprEssion Depression is a worldwide phenom- enon, and certain symptoms of this disorder seem to be constant across all countries. A landmark study of four countries—Canada, Switzerland, Iran, and Japan—found that the great majority of depressed people in these very different countries reported symptoms of sadness, joylessness, tension, lack of energy, loss of interest, loss of
PsychWatch
Back in the early 1990s, one of the biggest controversies in the devel-opment of DSM-IV centered on the category premenstrual dysphoric disorder (PMDD). The DSM-IV work group recom- mended that PMDD be formally listed as a new kind of depressive disorder. The category was to be applied when a woman was regularly impaired by at least 5 of 11 symptoms during the week before menstruation: depressed or hope- less feelings; tense or anxious feelings; marked mood changes; frequent irritabil- ity or anger and increased interpersonal conflicts; decreased interest in her usual activities; poor concentration; lack of energy; changes in appetite; insomnia or sleepiness; a sense of being overwhelmed or out of control; and physical symptoms such as swollen breasts, headaches, muscle pain, a “bloated” sensation, or weight gain.
This recommendation set off an uproar. Many clinicians (including some dissent-
ing members of the work group), several national organizations, interest groups, and the media warned that this diagnos- tic category would “pathologize” severe cases of premenstrual syndrome, or PMS, the premenstrual discomforts that are common and normal, and might cause women’s behavior in general to be at-
tributed largely to “raging hormones” (a stereotype that society was finally reject- ing). They argued that data were lacking to include the new category (Chase, 1993; DeAngelis, 1993).
The solution? A compromise. PMDD was not listed as a formal category in DSM-IV, but the pattern was listed in the DSM-IV appendix, with the suggestion that it be studied more thoroughly. Crit- ics hoped that PMDD would die a quiet death there. However, two decades later the category gained new life. When, in 2011, the DSM-5 task force published a list of changes being considered for the new edition of the DSM, premenstrual dysphoric disorder was included as one of the depressive disorders. The reaction? Another uproar among many clinicians and interest groups. This time, however, the proponents prevailed, citing several studies conducted over the past 20 years. PMDD is now an official category in DSM-5.
premenstrual Dysphoric Disorder: Déjà vu All over Again
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Parental Impact It has been estimated that 400,000 in- fants are born each year to depressed mothers (Murray & Nyp, 2011).
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ability to concentrate, ideas of insufficiency, and thoughts of suicide (Matsumoto & Juang, 2008). Beyond such core symptoms, however, research suggests that the precise picture of depression varies from country to country (Kok et al., 2012; Kleinman, 2004). Depressed people in non-Western countries—China and Nigeria, for example—are more likely to be troubled by physical symptoms such as fatigue, weakness, sleep disturbances, and weight loss. Depression in those countries is less often marked by cognitive symptoms such as self-blame, low self-esteem, and guilt.
Within the United States, researchers have found few differences in the symp- toms of depression among members of different ethnic or racial groups. Nor have they found significant differences in the overall rates of depression between such minority groups. On the other hand, recent research has revealed that there are often striking differences between ethnic/racial groups in the recurrence of depression. Hispanic Americans and African Americans are 50 percent more likely than white Americans to have recurrent episodes of depression (González et al., 2010). Why this difference? Around 54 percent of depressed white Americans receive treatment for their disorders (medication and/or psychotherapy), compared with 34 percent of depressed Hispanic Americans and 40 percent of depressed African Americans (González et al., 2010). It may be that minority groups in the United States are more vulnerable to repeated experiences of depression partly because many of their members have more limited treatment opportunities when they are depressed.
Research has also revealed that depression is distributed unevenly within some minority groups. This is not totally surprising, given that each minority group itself consists of people of varied backgrounds and cultural values. For example, depres- sion is more common among Hispanic and African Americans born in the United States than among Hispanic and African American immigrants (González et al., 2010; Miranda et al., 2005). Moreover, within the Hispanic American population, Puerto Ricans have a higher rate of depression than do Mexican Americans or Cuban Americans.
Multicultural Treatments In Chapter 2, you read that culture-sensitive therapies seek to address the unique issues faced by members of cultural minority groups (Comas-Díaz, 2014). For such approaches, therapists typically have special cultural training and a heightened awareness of their clients’ cultural values and the culture-related stressors, preju- dices, and stereotypes that their clients face. They make an effort to help clients develop a comfortable (for them) bicultural balance and to recognize the impact
of their own culture and the dominant culture on their views of themselves and on their behaviors (Prochaska & Norcross, 2013).
In the treatment of unipolar depression, culture- sensitive approaches increasingly are being combined with traditional forms of psychotherapy to help minor- ity clients overcome their disorders (Aguilera et al., 2010; Stacciarini et al., 2007). A number of today’s therapists, for example, offer cognitive-behavioral ther- apy for depressed minority clients while also focusing on the clients’ economic pressures, minority identity, and related cultural issues. A range of studies indicate that Hispanic American, African American, American Indian, and Asian American clients are more likely to overcome their depressive disorders when a culture- sensitive focus is added to the form of psychotherapy that they are otherwise receiving (Comas-Díaz, 2014).
Do you think culture-sensitive
therapies might be more useful
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than for other kinds?
Is laughter the best medicine? A man laughs during a 2013 session of laughter ther- apy in a public plaza in Caracas, Venezuela. He is one of many who attended this open session of laughter therapy, a relatively new group treatment being offered around the world, based on the belief that laughing at least 15 minutes each day drives away depression and other ills.
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World Count More than 350 million people suffer from depression worldwide (World Health Organization, 2012).
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➤ Summing Up UNIPOLAR DEPRESSION: THE DEPRESSIVE DISORDERS People with unipolar depression, the most common pattern of mood disorder, suffer from depres- sion only. The various disorders characterized by unipolar depression are called depressive disorders in DSM-5. The symptoms of depression span five areas of functioning: emotional, motivational, behavioral, cognitive, and physical. Women are at least twice as likely as men to experience severe unipolar depression.
According to the biological view, low activity of two neurotransmitters, nor- epinephrine and serotonin, helps cause depression. Hormonal factors may also be at work. So, too, may deficiencies of key proteins and other chemicals within certain neurons. Brain-imaging research has also tied depression to abnor- malities in a circuit of brain areas, including the prefrontal cortex, hippocampus, amygdala, and Brodmann Area 25. All such biological problems may be linked to genetic factors. Most biological treatments consist of antidepressant drugs, but electroconvulsive therapy is still used to treat some severe cases of depres- sion, and several brain stimulation techniques have been developed to treat depressed patients who are unresponsive to other forms of treatment.
According to the psychodynamic view, certain people who experience real or imagined losses may regress to an earlier stage of development, fuse with the person they have lost, and eventually become depressed. Psychodynamic ther- apists try to help persons with unipolar depression recognize and work through their losses and excessive dependence on others.
The behavioral view says that when people experience a large reduction in their positive rewards in life, they become more and more likely to become depressed. Behavioral therapists try to reintroduce clients to activities that they once found pleasurable, reward nondepressive behaviors, and teach effective social skills.
The leading cognitive views focus on learned helplessness and negative thinking. According to Seligman’s learned helplessness theory, people become depressed when they believe that they have lost control over the reinforce- ments in their lives and when they attribute this loss to causes that are internal, global, and stable. According to Beck’s theory of negative thinking, maladap- tive attitudes, the cognitive triad, errors in thinking, and automatic thoughts help produce unipolar depression. Cognitive therapists help depressed persons identify and change their dysfunctional cognitions, and cognitive-behavioral therapists try to reduce depression by combining cognitive and behavioral techniques.
Sociocultural theories propose that unipolar depression is influenced by social and cultural factors. Family-social theorists point out that a low level of social support is often linked to unipolar depression. Correspondingly, interper- sonal psychotherapy and couple therapy are often helpful in cases of depres- sion. Multicultural theories have noted that the character and prevalence of depression often vary by gender and sometimes by culture, an issue that culture-sensitive therapies for depression seek to address.
Bipolar Disorders People with a bipolar disorder experience both the lows of depression and the highs of mania. Many describe their life as an emotional roller coaster, as they shift back and forth between extreme moods. A number of sufferers eventually become sui- cidal. Their roller coaster ride also has a dramatic impact on relatives and friends (Barron et al., 2014).
Non-Western depression Depressed people in non-Western countries tend to have fewer cognitive symptoms, such as self-blame, and more physical symptoms, such as fatigue, weakness, and sleep disturbances.
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Clinical Oversight Around 70 percent of people with a bi- polar disorder are misdiagnosed at least once (Statistic Brain, 2012).
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What Are the Symptoms of Mania? Unlike people sunk in the gloom of depression, those in a state of mania typically experience dramatic and inappropriate rises in mood. The symptoms of mania span the same areas of functioning—emotional, motivational, behavioral, cognitive, and physical—as those of depression, but mania affects those areas in an opposite way.
A person in the throes of mania has powerful emotions in search of an outlet. The mood of euphoric joy and well-being is out of all proportion to the actual hap- penings in the person’s life. Not every person with mania is a picture of happiness, however. Some instead become very irritable and angry, especially when others get in the way of their exaggerated ambitions.
In the motivational realm, people with mania seem to want constant excitement, involvement, and companionship. They enthusiastically seek out new friends and old, new interests and old, and have little awareness that their social style is over- whelming, domineering, and excessive.
The behavior of people with mania is usually very active. They move quickly, as though there were not enough time to do everything they want to do. They may talk rapidly and loudly, their conversations filled with jokes and efforts to be clever or, conversely, with complaints and verbal outbursts. Flamboyance is not uncom- mon: dressing in flashy clothes, giving large sums of money to strangers, or even getting involved in dangerous activities.
In the cognitive realm, people with mania usually show poor judgment and planning, as if they feel too good or move too fast to consider possible pitfalls. Filled with optimism, they rarely listen when others try to slow them down. They may also hold an inflated opinion of themselves, and sometimes their self-esteem
approaches grandiosity. During severe episodes of mania, some have trouble remaining coherent or in touch with reality.
Finally, in the physical realm, people with mania feel remarkably energetic. They typically get little sleep yet feel and act wide awake (Armitage & Arnedt, 2011). Even if they miss a night or two of sleep, their energy level may remain high.
Diagnosing Bipolar Disorders People are considered to be in a full manic episode when for at least one week they display an abnormally high or irritable mood, increased activity or energy, and at least three other symptoms of mania (see Table 6-4). The episode may even include psychotic features such as delusions or hallucinations. When the symptoms of mania are less severe (causing little impairment), the person is said to be having a hypomanic episode (APA, 2013).
DSM-5 distinguishes two kinds of bipolar disorders—bipolar I and bipolar II. People with bipolar I disorder have full manic and major depressive episodes. Most of them experience an alternation of the episodes; for example, weeks of mania followed by a period of wellness, followed in turn by an episode of depression. Some, however, have mixed features, in which they display both manic and depressive symptoms within the same episode—for example, hav- ing racing thoughts amidst feelings of extreme sadness. In bipolar II disorder, hypomanic—that is, mildly manic—episodes alternate with major depressive episodes over the course of time. Some people with this pattern accomplish huge amounts of work during their mild manic periods (see PsychWatch on page 214).
Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder. If a person has four or more episodes within a one-year period, his or her disorder is considered
table: 6-4
Dx Checklist
Manic Episode 1. For one week or more, person displays a continually
abnormal, inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day.
2. Person also experiences at least three of the following symptoms: • grandiosity or overblown self-esteem • reduced sleep need • increased talkativeness, or drive to continue talking • rapidly shifting ideas or the sense that one’s thoughts are moving very fast • attention pulled in many directions • heightened activity or agitated movements • excessive pursuit of risky and potentially problematic activities.
3. Significant distress or impairment.
Bipolar I Disorder
1. Occurrence of a manic episode.
2. Hypomanic or major depressive episodes may precede or follow the manic episode.
Bipolar II Disorder
1. Presence or history of major depressive episode(s).
2. Presence or history of hypomanic episode(s).
3. No history of a manic episode.
Information from: APA, 2013.
▶▶ bipolar I disorder A type of bipolar disorder marked by full manic and major depressive episodes.
▶▶ bipolar II disorder A type of bipolar disorder marked by mildly manic (hypo- manic) episodes and major depressive episodes.
▶▶ cyclothymic disorder A disorder marked by numerous periods of hypo- manic symptoms and mild depressive symptoms.
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to be rapid cycling. A woman describes her rapid cycling in the following excerpt, taken from a journal article she wrote anonymously several years ago.
My mood may swing from one part of the day to another. I may wake up low at 10 am, but be high and excitable by 3 pm. I may not sleep for more than 2 hours one night, being full of creative energy, but by midday be so fatigued it is an effort to breathe.
If my elevated states last more than a few days, my spending can become uncontrollable. . . . I will sometimes drive faster than usual, need less sleep and can concentrate well, making quick and accurate decisions. At these times I can also be sociable, talkative and fun, focused at times, distracted at others. If this state of elevation continues I often find that feelings of violence and irritability towards those I love will start to creep in. . . .
My thoughts speed up. . . . I frequently want to be able to achieve several tasks at the same moment. . . . Physically my energy levels can seem limitless. The body moves smoothly, there is little or no fatigue. I can go mountain biking all day when I feel like this and if my mood stays elevated not a muscle is sore or stiff the next day. But it doesn’t last, my elevated phases are short. . . . [T]he shift into severe depres- sion or a mixed mood state occurs sometimes within minutes or hours, often within days and will last weeks often without a period of normality. . . .
Initially my thoughts become disjointed and start slithering all over the place. . . . I start to believe that others are commenting adversely on my appearance or behaviour. . . . My sleep will be poor and interrupted by bad dreams. . . . The world appears bleak. . . . I become repelled by the proximity of people. . . . I will be over- whelmed by the slightest tasks, even imagined tasks. . . . Physically there is immense fatigue: my muscles scream with pain. . . . . Food becomes totally uninteresting. . . .
I start to feel trapped, that the only escape is death. . . . I become passionate about one subject only at these times of deep and intense fear, despair and rage: suicide. . . . I have made close attempts on my life . . . over the last few years. . . .
Then inexplicably, my mood will shift again. The fatigue drops from my limbs like shedding a dead weight, my thinking returns to normal, the light takes on an intense clarity, flowers smell sweet and my mouth curves to smile at my children, my husband and I am laughing again. Sometimes it’s for only a day but I am myself again, the person that I was a frightening memory. I have survived another bout of this dreaded disorder. . . .
(Anonymous, 2006)
Surveys from around the world indicate that between 1 and 2.6 percent of all adults are suffering from a bipolar disorder at any given time (Kessler et al., 2012; Merikangas et al., 2011). As many as 4 percent experience one of the bipolar disor- ders at some time in their life. The bipolar disorders are equally common in women and men, but they are more common among people with low incomes than those with higher incomes (Sareen et al., 2011). Onset usually occurs between the ages of 15 and 44 years. In most untreated cases, the manic and depressive episodes eventu- ally subside, only to recur at a later time.
Some people have numerous periods of hypomanic symptoms and mild depres- sive symptoms, a pattern that is called cyclothymic disorder in DSM-5. The symptoms of this milder form of bipolar disorder continue for two or more years, interrupted occasionally by normal moods that may last for only days or weeks. This disorder, like bipolar I and bipolar II disorders, usually begins in adolescence or early adulthood and is equally common among women and men. At least 0.4 percent of the population develops cyclothymic disorder. In some cases, the milder symptoms eventually blossom into a bipolar I or II disorder (Zeschel et al., 2015; Goto et al., 2011).
Going public In June 2010, an exuberant Catherine Zeta-Jones received a Tony Award for her performance in the Broadway musical A Little Night Music. Less than a year later, she announced that she was receiving treatment for bipolar disorder, a public acknowledgment that received enormous praise from mental health advocacy groups. Entering a treatment program after the extended stress of helping her husband Michael Douglas battle apparent throat cancer, Jones said there was no need to suffer in silence and she hoped the pub- licity surrounding her treatment would help others.
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What Causes Bipolar Disorders? Throughout the first half of the twentieth century, the search for the causes of bipolar disorders made little progress. More recently, biological research has pro- duced some promising clues. The biological insights have come from research into neurotransmitter activity, ion activity, brain structure, and genetic factors.
Neurotransmitters Could overactivity of norepinephrine be related to mania? This was the expectation of clinicians back in the 1960s after investigators first found a relationship between low norepinephrine activity and unipolar depression. Indeed, some research did find the norepinephrine activity of people with mania to be higher than that of control participants (Post et al., 1980, 1978; Schildkraut, 1965).
Because serotonin activity often parallels norepinephrine activity in unipolar depression, theorists at first expected that mania would also be related to high sero- tonin activity, but no such relationship has been found. Instead, research suggests
PsychWatch
The ancient Greeks believed that various forms of “divine madness” inspired creative acts, from poetry to performance (Ludwig, 1995). Even today many people expect “creative geniuses” to be psychologically disturbed. A popular image of the artist includes a glass of liquor, a cigarette, and a tormented expression. Classic examples include writer William Faulkner, who suffered from alcohol- ism and received electroconvulsive therapy for depression; poet Sylvia Plath, who was depressed for most of her life and eventually commit- ted suicide at age 31; and dancer Vaslav Nijinsky, who suffered from schizophrenia and spent many years in institutions. In fact, a number of studies indicate that artists and writ- ers are somewhat more likely than others to suffer from certain mental disorders, particularly bipolar dis- orders (Kyaga et al., 2013, 2011; Galvez et al., 2011; Sample, 2005).
Why might creative people be prone to such psychological disorders? Some may be predisposed to such disorders long before they begin their artistic ca- reers (Simonton, 2010; Ludwig, 1995). In- deed, creative people often have a family history of psychological problems (Kyaga et al., 2013, 2011). A number also have experienced intense psychological trauma
during childhood. English writer Virginia Woolf, for example, endured sexual abuse as a child.
A second explanation for the link be- tween creativity and psychological disor- ders is that the creative professions offer a welcome climate for those with psy- chological disturbances. In the worlds of poetry, painting, and acting, for example, emotional expression, unusual thinking,
and/or personal turmoil are valued as sources of inspiration and suc- cess (Galvez et al., 2011; Sample, 2005).
Much remains to be learned about the relationship between emotional turmoil and creativity, but work in this area has already clarified two important points. First, psychological disturbance is hardly a requirement for creativ- ity. Most “creative geniuses” are, in fact, psychologically stable and happy throughout their entire lives (Kaufman, 2013). Second, mild psy- chological disturbances relate to creative achievement much more strongly than severe disturbances do (Galvez et al., 2011). For exam- ple, nineteenth-century composer Robert Schumann produced 27 works during one hypomanic year but next to nothing during years when he was severely depressed and suicidal (Jamison, 1995).
Some artists worry that their creativ- ity would disappear if their psychological suffering were to stop. In fact, however, research suggests that successful treat- ment for severe psychological disorders more often than not improves the creative process (Jamison, 1995; Ludwig, 1995). Romantic notions aside, severe mental dysfunctioning has little redeeming value, in the arts or anywhere else.
Abnormality and creativity: A Delicate Balance
The price of creativity? Like many other writers and artists, J. K. Rowling has had periods of depression and even suicidal feelings at certain times in her life. Here, the Harry Potter author looks at the laptop of a child while launching her new Web project, Pottermore, at a London museum in 2011.
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that mania, like depression, may be linked to low serotonin activity (Hsu et al., 2014; Nugent et al., 2013). Perhaps low activity of sero- tonin opens the door to a mood disorder and permits the activity of norepinephrine (or perhaps other neurotransmitters) to define the particular form the disorder will take. That is, low serotonin activity accompanied by low norepinephrine activity may lead to depres- sion; low serotonin activity accompanied by high norepinephrine activity may lead to mania.
Ion Activity While neurotransmitters play a significant role in the communication between neurons, electrically charged ions seem to play a critical role in relaying messages within a neuron. When a neuron receives an incoming message, its sodium ions (Na+) and potassium ions (K+) flow back and forth between the outside and inside of the neuron’s membrane, producing a wave of electrical activity that travels down the length of the neuron (the axon) and results in its “firing.”
If messages are to travel effectively down the axon, the ions must be able to move easily between the outside and the inside of the neural membrane. Some studies suggest that, among bipolar individuals, irregularities in the transport of these ions may cause neurons to fire too easily (resulting in mania) or to stubbornly resist firing (resulting in depression) (Manji & Zarate, 2011; Li & El-Mallakh, 2004).
Brain Structure Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorders (Eker et al., 2014; Chen et al., 2011; Savitz & Drevets, 2011). For example, the basal ganglia and cerebellum of these people tend to be smaller than those of other people, and their dorsal raphe nucleus, striatum, amygdala, hippocampus, and prefrontal cortex each have structural abnormalities. It is not clear what role such structural abnormalities play in bipolar disorders.
Genetic Factors Many theorists believe that people inherit a biological pre- disposition to develop bipolar disorders (Wiste et al., 2014; Gershon & Nurnberger, 1995). Family pedigree studies support this idea. Identical twins of those with a bipolar disorder have a 40 percent likelihood of developing the same disorder, and fraternal twins, siblings, and other close relatives of such persons have a 5 to 10 per- cent likelihood, compared with the 1 to 2.6 percent prevalence rate in the general population.
Researchers have also used techniques from molecular biology to more directly examine possible genetic factors. These various undertakings have linked bipolar disorders to genes on chromosomes 1, 4, 6, 10, 11, 12, 13, 15, 18, 20, 21, and 22 (Sinkus et al., 2015; Green et al., 2013; Bigdeli et al., 2013). Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders.
What Are the Treatments for Bipolar Disorders? Until the latter part of the twentieth century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster. Psychotherapists reported almost no success, and antidepressant drugs were of limited help. In fact, the drugs sometimes triggered a manic episode (Courtet et al., 2011; Post, 2011, 2005).
Lithium and Other Mood Stabilizers This gloomy picture changed dramatically in 1970 when the FDA approved the use of lithium, a silvery-white element found in various simple mineral salts throughout the natural world, as a treat- ment for bipolar disorders. Additional mood stabilizing, or antibipolar, drugs
War of a different kind While starring as Princess Leia, the invincible heroine in the Star Wars movies from 1977 to 1983, actress Carrie Fisher was diagnosed with bipolar disorder. The disorder is now under control with the help of medication, and Fisher says, “I don’t want peace [in my life], I just don’t want war” (Epstein, 2001, p. 36).
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▶▶ lithium A metallic element that occurs in nature as a mineral salt and is an effec- tive treatment for bipolar disorders.
▶▶ mood stabilizing drugs Psychotro- pic drugs that help stabilize the moods of people suffering from bipolar disorder. Also known as antibipolar drugs.
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have since been developed, including the antiseizure drugs carbamazepine (Tegretol) and valproate (Depoakote), and several of them are now used as widely as lithium, either because they produce fewer undesired effects or because they are even more effective than lithium.
Nevertheless, it was lithium that first brought hope to those suffering from bipo- lar disorders. In her widely read memoir, An Unquiet Mind, psychiatric researcher Kay Redfield Jamison describes how lithium, combined with psychotherapy, enabled her to overcome her bipolar disorder:
I took [lithium] faithfully and found that life was a much stabler and more predictable place than I had ever reckoned. My moods were still intense and my temperament rather quick to the boil, but I could make plans with far more certainty and the peri- ods of absolute blackness were fewer and less extreme. . . .
At this point in my existence, I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. [At the same time], ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. . . . No pill can help me deal with the problem of not wanting to take pills; likewise, no amount of psychotherapy alone can prevent my manias and depressions. I need both. . . .
( Jamison, 1995)
All manner of research has attested to the effectiveness of lithium and other mood stabilizers in treating manic episodes (Galling et al., 2015; Geddes & Miklowitz, 2013). More than 60 percent of patients with mania improve on these medications. In addition, most such patients have fewer new episodes as long as they continue taking the medications (Malhi et al., 2013). One study found that the risk of relapse is 28 times higher if patients stop taking a mood stabilizer (Suppes et al., 1991). Thus, today’s clinicians usually continue patients on some level of a mood stabilizing drug even after their manic episodes subside (Gao et al., 2010).
Powerful plot device In Homeland, one of television’s most popular series, actress Claire Danes plays Carrie Mathison, a CIA operative who is obsessed with Marine-turned-terrorist Nicholas Brody (played by actor Damian Lewis). One of the show’s key features is Mathison’s bipolar disorder, which both heightens and hinders her effectiveness in the pursuit of terrorists. Te
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▶▶ second messengers Chemical changes within a neuron just after the neuron receives a neurotransmitter mes- sage and just before it responds.
Depressive and Bipolar Disorders : 217
In the limited body of research that has been done on this subject, the mood stabilizers also seem to help those with bipolar disorder overcome their depressive episodes, though to a lesser degree than they help with their manic episodes (Malhi et al., 2013; Post, 2011). Given the drugs’ less powerful impact on depressive episodes, many clinicians use a combination of mood stabiliz- ers and antidepressant drugs to treat bipolar depression (Nivoli et al., 2011).
Researchers do not fully understand how mood sta- bilizing drugs operate (Malhi et al., 2013; Aiken, 2010). They suspect that the drugs change synaptic activity in neurons, but in a way different from that of antidepres- sant drugs. The firing of a neuron actually consists of several phases that ensue at lightning speed. When the neurotransmitter binds to a receptor on the receiving neuron, a series of changes occur within the receiving neuron to set the stage for firing. The substances in the neuron that carry out those changes are often called second messengers because they relay the original message from the receptor site to the firing mechanism of the neuron. (The neurotransmitter itself is considered the first messenger.) Whereas antidepressant drugs affect a neuron’s initial reception of neurotransmitters, mood stabilizers appear to affect a neuron’s second messengers.
In a similar vein, it has been found that lithium and other mood stabilizing drugs also increase the production of neuroprotective proteins—key proteins within certain neurons whose job is to prevent cell death. The drugs may increase the health and functioning of those cells and thus reduce bipolar symptoms (Malhi et al., 2013; Gray et al., 2003).
Adjunctive Psychotherapy As Jamison stated in her memoir, psychotherapy alone is rarely helpful for persons with bipolar disorders. At the same time, clinicians have learned that mood stabilizing drugs alone are not always sufficient either. Thirty percent or more of patients with these disorders may not respond to lithium or a related drug, may not receive the proper dose, or may relapse while taking it. In addition, a number of patients stop taking mood stabilizers on their own (Advokat et al., 2014).
In view of these problems, many clinicians now use individual, group, or family therapy as an adjunct to mood stabilizing drugs (Reinares et al., 2014; Geddes & Miklowitz, 2013). Most often, therapists use these formats to emphasize the impor- tance of continuing to take medications; to improve social skills and relationships that may be affected by bipolar episodes; to educate patients and families about bipolar disorders; to help patients solve the family, school, and occupational prob- lems caused by their disorder; and to help prevent patients from attempting suicide (Hollon & Ponniah, 2010). Few controlled studies have tested the effectiveness of such adjunctive therapy, but those that have been done, along with numerous clini- cal reports, suggest that it helps reduce hospitalization, improves social functioning, and increases patients’ ability to obtain and hold a job (Culver & Pratchett, 2010).
➤ Summing Up BIPOLAR DISORDERS In bipolar disorders, episodes of mania alternate or intermix with episodes of depression. These disorders are much less common than unipolar depression. They may take the form of bipolar I, bipolar II, or cyclothymic disorder.
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B e t w e e n t h e L i n e s
Frenzied Masterpiece George Frideric Handel wrote his Messiah in less than a month during a manic episode (Roesch, 1991).
: chapter 6218
Mania may be related to high norepinephrine activity along with a low level of serotonin activity. Some researchers have also linked bipolar disorders to improper transport of ions back and forth between the outside and the inside of a neuron’s membrane, others have focused on deficiencies of key proteins and other chemicals within certain neurons, and still others have uncovered abnor- malities in key brain structures. Genetic studies suggest that people may inherit a predisposition to these biological abnormalities.
Lithium and other mood stabilizing drugs have proved to be very effective in reducing and preventing the manic and the depressive episodes of bipolar disorders. These drugs may reduce bipolar symptoms by affecting the activity of second messengers or key proteins or other chemicals within certain neurons throughout the brain. Patients tend to fare better when mood stabilizing and/or other psychotropic drugs are combined with adjunctive psychotherapy.
PUTTING IT...together Making Sense of All That Is Known During the past 40 years, researchers and clinicians have made tremendous gains in the understanding and treatment of depressive and bipolar disorders. These are now
among the most treatable of all psychological disorders. The choice of treatment for bipolar disorders is narrow and simple: drug therapy, ideally accompanied by psychotherapy, is the single most successful approach. The picture for unipolar depression is more varied and complex, al- though no less promising. Cognitive, cognitive-behavioral, interpersonal, and antidepressant drug therapy are all helpful in cases of any severity; couple therapy is helpful in select cases; pure behavioral therapy helps in mild to moderate cases; and ECT is useful and effective in severe cases.
Several factors have been tied closely to unipolar depression, includ- ing biological abnormalities, a reduction in positive reinforcements, negative ways of thinking, a perception of helplessness, and life stress and
other sociocultural influences. Precisely how all of these factors relate to unipolar depression, however, is unclear. Several relationships are possible:
1. One of the factors may be the key cause of unipolar depression. 2. Different factors may be capable of initiating unipolar depression in different
people. Some people may, for example, begin with low serotonin activity, which predisposes them to react helplessly in stressful situations, interpret events negatively, and enjoy fewer pleasures in life. Others may first suffer a severe loss, which triggers helplessness reactions, low serotonin activity, and reductions in positive rewards.
3. An interaction between two or more specific factors may be necessary to produce unipolar depression. Perhaps people will become depressed only if they have low levels of serotonin activity, feel helpless, and repeatedly blame themselves for negative events.
4. The various factors may play different roles in unipolar depression. Some may cause the disorder, some may result from it, and some may keep it going.
As with unipolar depression, clinicians and researchers have learned much about bipolar disorders during the past 40 years. But bipolar disorders appear to be best explained by a focus on one kind of variable—biological factors. The evidence sug- gests that biological abnormalities, perhaps inherited and perhaps triggered by life stress, cause bipolar disorders. Whatever roles other factors may play, the primary one appears to lie in this realm.
C li n i C al C h o i C e s Now that you’ve read about disorders of mood, try the interactive case study for this chapter. See if you are able to identify John’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for John? Go to LaunchPad to access Clinical Choices.
Depressive and Bipolar Disorders : 219
There is no question that investigations into depressive and bipolar disorders have been fruitful and enlightening. And it is more than reasonable to expect that important research findings and insights will continue to unfold in the years ahead. Now that clinical researchers have gathered so many important pieces of the puzzle, they must put the pieces together into a still more meaningful picture that will sug- gest even better ways to predict, prevent, and treat these disorders.
KEY TERMS depression, p. 183
mania, p. 183
depressive disorders, p. 183
unipolar depression, p. 183
bipolar disorders, p. 184
anhedonia, p. 186
major depressive disorder, p. 187
persistent depressive disorder, p. 187
premenstrual dysphoric disorder, p. 187
disruptive mood dysregulation disorder, p. 187
norepinephrine, p. 189
serotonin, p. 189
cortisol, p. 190
melatonin, p. 190
seasonal affective disorder, p. 191
Brodmann Area 25, p. 191
electroconvulsive therapy (ECT), p. 192
MAO inhibitors, p. 193
tyramine, p. 193
tricyclics, p. 193
selective serotonin reuptake inhibitors (SSRIs), p. 194
vagus nerve stimulation, p. 195
transcranial magnetic stimulation (TMS), p. 195
deep brain stimulation (DBS), p. 196
symbolic loss, p. 196
behavioral activation, p. 200
learned helplessness, p. 201
attribution, p. 201
cognitive triad, p. 202
automatic thoughts, p. 202
rumination, p. 204
cognitive therapy, p. 204
interpersonal psychotherapy (IPT), p. 206
couple therapy, p. 208
hypomanic episode, p. 212
bipolar I disorder, p. 212
bipolar II disorder, p. 212
cyclothymic disorder, p. 213
ions, p. 215
lithium, p. 215
mood stabilizing drugs, p. 215
second messengers, p. 217
neuroprotective proteins, p. 217
adjunctive psychotherapy, p. 217
QuickQuiz
1. What is the difference between depres- sive disorders and bipolar disorders? pp. 183–184
2. What are the key symptoms of depres- sion and mania? pp. 184–188, 212
3. Describe the role of norepinephrine and serotonin in unipolar depression. pp. 189–191
4. Describe Freud and Abraham’s psycho- dynamic theory of depression and the evidence that supports it. pp. 196–197
5. How do behaviorists describe the role of rewards in depression? p. 198
6. How might learned helplessness be related to human depression? pp. 200–202
7. What kinds of negative thinking may lead to mood problems? pp. 202–204
8. How do sociocultural theorists ac- count for unipolar depression? pp. 205, 208–210
9. What roles do biological and genetic factors seem to play in bipolar disor- ders? pp. 214–215
10. Discuss the leading treatments for uni- polar depression and bipolar disorders. How effective are these various ap- proaches? pp. 192–198, 200, 204–208, 210, 215–217
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T he war in Iraq never ended for Jonathan Michael Boucher. Not when he flew home from Baghdad, not when he moved to Saratoga Springs for a fresh start and, especially, not when nighttime arrived.
Tortured by what he saw as an 18-year-old Army private during the 2003 inva- sion and occupation, Boucher was diagnosed with post-traumatic stress disorder (PTSD) and honorably discharged from the military less than two years later.
On May 15, three days before his 24th birthday, the young veteran committed suicide in his apartment’s bathroom, stunning friends and family. . . . There was no note. . . .
Johnny Boucher joined the Army right after graduating from East Lyme High School in Connecticut in 2002 because he was emotionally moved by the Sept. 11, 2001, terrorist attacks. “He felt it was his duty to do what he could for America,” his father, Steven Boucher, 50, said.
Shortly after enlisting, the 6-foot-2-inch soldier deployed with the “Wolf Pack”— 1st Battalion, 41st Field Artillery—and fought his way north in Iraq. He landed with his unit at Baghdad International Airport and was responsible for helping guard it. The battalion earned a Presidential Unit Citation for “exceptional bravery and hero- ism in the liberation of Baghdad.”
But it was during those early months of the war that Johnny Boucher had the evils of combat etched into his mind. The soldier was devastated by seeing a young Iraqi boy holding his dead father, who had been shot in the head. Later, near the airport, the soldier saw four good friends in his artillery battery killed in a vehicle accident minutes after one of them relieved him from duty, his father said.
Boucher tried to rescue the soldiers. Their deaths and other things his son saw deeply impacted his soul after he returned because he was sensitive about family and very patriotic, Steven Boucher said. . . .
But when the sun set, memories of combat and lost friends rose to the top, caus- ing the former artilleryman severe nightmares. Sometimes he would curl up in a ball and weep, causing his parents to try to comfort him. . . . “At nighttime, he was just haunted,” Steven Boucher said. . . . “Haunted, I think, by war.” Bitterness about the war had crept in, and the troubled former soldier started drinking to calm himself. . . .
Supported by a huge family he adored . . . Johnny Boucher recently got his own apartment on Franklin Street and appeared to be getting back on track. He seemed to be calm and enjoying life. But it was difficult to tell, and he was still fearful of sleep, his father said. They had plans for a hike, a birthday party and attending his brother Jeffrey’s graduation. . . . Then, without warning, Johnny Boucher was gone. He hanged himself next to a Bible, his Army uniform and a garden statue of an angel, said his mother, who discovered him after he failed to show up to work for two days. . . .
Yusko, 2008
Salmon spawn and then die, after an exhausting upstream swim to their breed- ing ground. Lemmings rush to the sea and drown. But only humans know- ingly take their own lives. The actions of salmon and lemmings are instinctual responses that may even help their species survive in the long run. Only in the human act of suicide do beings act for the specific purpose of putting an end to their lives.
Suicide has been recorded throughout history. The Old Testament described King Saul’s suicide: “There Saul took a sword and fell on it.” The ancient Chinese, Greeks, and Romans also provided examples. In more recent times, suicides by such celebrated individuals as writer Ernest Hemingway, actress
7
T o p i c o v e r v i e w
What Is Suicide? How Is Suicide Studied? Patterns and Statistics
What Triggers a Suicide? Stressful Events and Situations Mood and Thought Changes Alcohol and Other Drug Use Mental Disorders Modeling: The Contagion of Suicide
What Are the Underlying Causes of Suicide? The Psychodynamic View Durkheim’s Sociocultural View The Biological View
Is Suicide Linked to Age? Children Adolescents The Elderly
Treatment and Suicide What Treatments Are Used After Suicide Attempts? What Is Suicide Prevention? Do Suicide Prevention Programs Work?
Putting It Together: Psychological and Biological Insights Lag Behind
Suicide
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Marilyn Monroe, rock star Kurt Cobain, and comedian Robin Williams have both shocked and fascinated the public.
Today suicide is one of the leading causes of death in the world. By the time you finish reading this page and the next, someone in the United States will have killed himself or herself (AFSP, 2014). In fact, at least 100 Americans will have taken their own lives by this time tomorrow.
It has been estimated that 1 million people die by suicide each year, more than 38,000 in the United States alone (AFSP, 2014; CDC, 2013) (see Table 7-1). Around 25 million other people throughout the world—as many as 1 million in the United States—make unsuccessful attempts to kill themselves; such attempts are called parasuicides. Actually, it is difficult to obtain accurate figures on suicide, and many investigators believe that estimates are often low. For one thing, suicide can be difficult to distinguish from unintentional drug overdoses, automobile crashes, drownings, and other accidents (Björkenstam et al., 2014). Many apparent “accidents” are probably intentional. For another, since suicide is frowned on in our society, relatives and friends often refuse to acknowledge that loved ones have taken their own lives.
Suicide is not officially classified as a mental disorder, although DSM-5’s framers have proposed that a category called suicidal behavior disorder be studied for possible inclusion in future revisions of DSM-5 (APA, 2013). Regardless of whether suicidal acts themselves represent a distinct disorder, psychological dysfunctioning—a breakdown of coping skills, emotional tur-
moil, a distorted view of life—usually plays a role in such acts. For example, the young combat veteran about whom you read at the beginning of this chapter had intense feelings of depression, developed a severe drinking problem, and displayed posttraumatic stress disorder.
What Is Suicide? Not every self-inflicted death is a suicide. A man who crashes his car into a tree after falling asleep at the steering wheel is not trying to kill himself. Thus Edwin Shneidman (2005, 1993, 1963), a pioneer in this field, defined suicide as an inten- tioned death—a self-inflicted death in which one makes an intentional, direct, and conscious effort to end one’s life.
Intentioned deaths may take various forms. Consider the following examples. All three of these people intended to die, but their motives, concerns, and actions differed greatly:
Dave was a successful man. By the age of 50 he had risen to the vice presidency of a small but profitable investment firm. He had a caring wife and two teenage sons who respected him. They lived in an upper-middle-class neighborhood, had a spa- cious house, and enjoyed a life of comfort.
In August of his fiftieth year, everything changed. Dave was fired. Just like that. The economy had gone bad once again, the firm’s profits were down, and the presi- dent wanted to try new, fresher investment strategies and marketing approaches. Dave had been “old school.” He didn’t fully understand today’s investors—didn’t know how to reach out to them with Web-based advertising, engage them online in the investment process, or give his firm a high-tech look. Dave’s boss wanted to try a younger person.
The experience of failure, loss, and emptiness was overwhelming for Dave. He looked for another position, but found only low-paying jobs for which he was over- qualified. Each day as he looked for work Dave became more depressed, anxious, and desperate. He thought of trying to start his own investment company or to be a
table: 7-1
Most Common Causes of Death in the United States
Rank Cause Deaths Per Year
1 Heart disease 597,689
2 Cancer 574,743
3 Chronic respiratory diseases 138,080
4 Stroke 129,476
5 Accidents 120,859
6 Alzheimer’s 83,494
7 Diabetes 69,071
8 Kidney disease 50,476
9 Pneumonia and influenza 50,097
10 Suicide 38,364
Information from: CDC, 2013
▶▶ parasuicide A suicide attempt that does not result in death.
▶▶ suicide A self-inflicted death in which the person acts intentionally, directly, and consciously.
Suicide : 223
consultant of some kind, but in the cold of night, he knew he was just fooling himself with such notions. He kept sinking, withdrew from others, and felt increasingly hopeless.
Six months after losing his job, Dave began to consider ending his life. The pain was too great, the humiliation unending. He hated the present and dreaded the future. Throughout February he went back and forth. On some days he was sure he wanted to die. On other days, an enjoyable evening or uplifting conversation might change his mind temporarily. On a Monday late in February he heard about a job possibility, and the anticipation of the next day’s interview seemed to lift his spirits. But Tuesday’s interview did not go well. He knew there’d be no job offer. He went home, took a recently purchased gun from his locked desk drawer, and shot himself.
Demaine never truly recovered from his mother’s death. He was only seven years old and unprepared for such a loss. His father sent him to live with his grandparents for a time, to a new school with new kids and a new way of life. In Demaine’s mind, all these changes were for the worse. He missed the joy and laughter of the past. He missed his home, his father, and his friends. Most of all he missed his mother.
He did not really understand her death. His father said that she was in heaven now, at peace, happy. Demaine’s unhappiness and loneliness continued day after day and he began to put things together in his own way. He believed he would be happy again if he could join his mother. He felt she was waiting for him, waiting for him to come to her. The thoughts seemed so right to him; they brought him com- fort and hope. One evening, shortly after saying good night to his grandparents, Demaine climbed out of bed, went up the stairs to the roof of their apartment house, and jumped to his death. In his mind he was joining his mother in heaven.
Tya and Noah had met on a speed date. On a lark, Tya and a friend had registered at the speed date event, figuring, “What’s the worst thing that can happen?” On the night of the big event, Tya talked to dozens of guys, none of whom appealed to her—except for Noah! He was quirky. He was witty. And he seemed as turned off by the whole speed date thing as she was. His was the only name that she put on her list. As it turned out, he also put her name down on his list, and a week later each of them received an email with contact information about the other. A flurry of email exchanges followed, and before long, they were going together. She marveled at her luck. She had beaten the odds. She had had a successful speed date experience.
It was Tya’s first serious relationship; it became her whole life. Thus she was truly shocked and devastated when, on the one-year anniversary of their speed date, Noah told her that he no longer loved her and was leaving her for someone else.
As the weeks went by, Tya was filled with two competing feelings—depression and anger. Several times she texted or called Noah, begged him to reconsider, and pleaded for a chance to win him back. At the same time, she hated him for putting her through such misery.
Tya’s friends became more and more worried about her. At first they sympathized with her pain, assuming it would soon lift. But as time went on, her depression and anger worsened, and Tya began to act strangely. Always a bit of a drinker, she started to drink heavily and to mix her drinks with various kinds of drugs.
One night Tya went into her bathroom, reached for a bottle of sleeping pills, and swallowed a handful of them. She wanted to make her pain go away, and she wanted Noah to know just how much pain he had caused her. She continued swallowing pill after pill, crying and swearing as she gulped them down. When she began to feel drowsy, she decided to call her close friend Dedra. She was not sure why she was calling, perhaps to say good-bye, to explain her actions, or to make sure that Noah was told; or perhaps to be talked out of it. Dedra pleaded and reasoned with her and tried to motivate her to live. Tya was trying to listen, but she became less and less coherent. Dedra hung up the phone and quickly called Tya’s neighbor and the police. When reached by her neighbor, Tya was already in a coma. Seven hours later, while her friends and family waited for news in the hospital lounge, Tya died.
Legitimate protest or attempted suicide? Civil rights activist Irom Sharmila, seen here at a press conference in New Delhi, has been on a hunger strike for almost 15 years to protest an Indian law that suspends many human rights protections. A form of attempted suicide? Not in Sharmila’s mind, but the Indian government has charged her with attempted suicide and man- dated that she be force-fed through a tube.
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Shocking Comparison Each year, more deaths in the United States result from suicide (38,364) than from motor vehicle crashes (33,687) (CDC, 2013).
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While Tya seemed to have mixed feelings about her death, Dave was clear in his wish to die. Whereas Demaine viewed death as a trip to heaven, Dave saw it as an end to his existence. Such differences can be important in efforts to understand and treat suicidal persons. Accord- ingly, Shneidman distinguished four kinds of people who intentionally end their lives: the death seeker, death initiator, death ignorer, and death darer.
Death seekers clearly intend to end their lives at the time they attempt suicide. This singleness of purpose may last only a short time. It can change to confusion the very next hour or day, and then return again in short order. Dave, the middle- aged investment counselor, was a death seeker. He had many misgivings about suicide and was ambivalent about it for weeks, but on Tuesday night he was a death seeker—clear in his desire to die and acting in a manner that virtually guaranteed a fatal outcome.
Death initiators also clearly intend to end their lives, but they act out of a belief that the process of death is already under way and that they are simply hastening the process. Some expect that they will die in a matter of days or weeks. Many sui- cides among the elderly and very sick fall into this category. Robust novelist Ernest Hemingway was profoundly concerned about his failing body as he approached his sixty-second birthday—a concern that some observers believe was at the center of his suicide.
Death ignorers do not believe that their self-inflicted death will mean the end of their existence. They believe they are trading their present lives for a better or hap- pier existence. Many child suicides, like Demaine’s, fall into this category, as do those of adult believers in a hereafter who commit suicide to reach another form of life. In 1997, for example, the world was shocked to learn that 39 members of an unusual cult named Heaven’s Gate had committed suicide at an expensive house outside San Diego. It turned out that these members had acted out of the belief that their deaths would free their spirits and enable them to ascend to a “higher kingdom.”
Death darers experience mixed feelings, or ambivalence, about their intent to die, even at the moment of their attempt, and they show this ambivalence in the act itself. Although to some degree they wish to die, and they often do die, their risk-taking behavior does not guarantee death. The person who plays Russian roulette—that is, pulls the trigger of a revolver randomly loaded with one bullet—is a death darer. Tya might be considered a death darer. Although her unhappiness and anger were great, she was not sure that she wanted to die. Even while taking pills, she called her friend, reported her actions, and listened to her friend’s pleas.
When people play indirect, covert, partial, or unconscious roles in their own deaths, Shneidman (2001, 1993, 1981) classified them in a suicide-like category called subintentional deaths. Traditionally, clinicians have cited drug, alcohol, or tobacco use; promiscuous sexual behavior; recurrent physical fighting; and medi- cation mismanagement as behaviors that may contribute to subintentional deaths ( Juan et al., 2011).
In recent years, another behavioral pattern, self-injury or self-mutilation, has been added to this list—for example, cutting or burning oneself or banging one’s head. Although this pattern is not officially classified as a mental disorder, the framers of DSM-5 proposed that a category called nonsuicidal self-injury be studied for possible inclusion in future revisions of the DSM (APA, 2013).
Self-injurious behavior is more common than previously recognized, particu- larly among teenagers and young adults, and it may be on the increase (Rodav, Levy, & Hamdan, 2014). It appears that this behavior becomes addictive in nature. The pain brought on by self-injury seems to offer some relief from emotional suf- fering, the behavior serves as a temporary distraction from problems, and the scars
Death darers? A sky surfer tries to ride the perfect cloud, high above the hustle and bustle of the city below. Are thrill seek- ers daredevils searching for new highs, as many of them claim, or are some actually death darers?
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▶▶ subintentional death A death in which the victim plays an indirect, hidden, partial, or unconscious role.
Suicide : 225
that result may document the person’s distress (Wilkinson & Goodyer, 2011). More generally, self-injury may help a person deal with chronic feelings of emptiness and boredom. Although self-injury and the other risky behaviors mentioned earlier may indeed represent an indirect attempt at suicide (Victor & Klonsky, 2014), the true intent behind them is unclear, so, other than the commentary in MediaSpeak, these behaviors are not included in the discussions of this chapter.
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YouTube videos are spreading word of a self- destructive be- havior already disturbingly common among many teenagers and young adults—“cutting” and other forms of self-injury that stop short of sui- cide, a new study reports.
As many as one in five young men and women are believed to have engaged at least once in what psychologists call nonsui- cidal self-injury. Now the behavior is being depicted in hundreds of YouTube clips—most of which don’t carry any warnings about the content—that show explicit videos and photographs of people injur- ing themselves, usually by cutting. They also depict burning, hitting and biting oneself, picking at one’s skin, disturbing wounds and embedding objects under the skin. Most of the injuries are inflicted on the wrists and arms and, less commonly, on the legs, torso or other parts of the body.
Some of the videos weave text, music and photography together, which may glamorize self-harming behaviors even more, the paper’s authors warn.
And the videos are popular. Many viewers rated the videos positively, selecting them as favorites more than 12,000 times, according to the new study, . . . whose authors reviewed the 100 most-viewed videos on self-harm.
Stephen P. Lewis, assistant professor of psychol- ogy at the University of Guelph in Ontario and the paper’s lead author, calls the YouTube depictions of self-harm “an alarming new trend,” especially consider- ing how popular Internet use is among the population
MediaSpeak videos of Self-injury Find an Audience
By Roni Caryn Rabin, New York Times
that engages most in self-injury already: teenagers and young adults.
“The risk is that these videos normalize self-injury, and foster a virtual community for some people in which self-injury is accepted, and the message of getting help is not necessar- ily conveyed,” Dr. Lewis said. “There’s another risk, which is the phenomenon of ‘triggering,’ when someone who has a history of self-injury then watches a video or sees a picture, his or her urge to self-injure might actually increase in the moment.”
Only about one in four of the 100 most-viewed videos sent a
clear message against self-injury, the paper’s analysis showed, and about the same proportion had an en- couraging message that suggested the behavior could
be overcome. About half the videos had a sad, melancholic tone, while about half described the behavior in a straightforward and factual manner.
About a quarter of the videos con- veyed a mixed message about self- injury, while 42 percent were deemed
neutral and 7 percent were clearly favorable toward self-injury. Only 42 percent of the videos warned view- ers about the content.
February 22, 2011, “VITAL SIGNS; Behavior: Videos of Self- Injury Find an Audience,” Rabin, Roni Caryn. From New York Times, 2/22/2011 © 2011 The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribu- tion, or retransmission of this content without express written permission is prohibited.
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Self-mutilation online The self-inflicted knife wounds of this patient are evident. The phenomenon of self-injury is growing and now extends even to the Internet and social networks.
why do you think certain
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: chapter 7226
How Is Suicide Studied? Suicide researchers face a major obstacle: the people they study are no longer alive. How can investigators draw accurate conclusions about the intentions, feelings, and circumstances of those who can no longer explain their actions? Two research methods attempt to deal with this problem, each with only partial success.
One strategy is retrospective analysis, a kind of psychological autopsy in which clinicians and researchers piece together data from the suicide vic- tim’s past (Schwartz, 2011). Relatives, friends, therapists, or physicians may remember past statements, conversations, and behaviors that shed light on a suicide. Retrospective information may also be provided by the suicide notes that some victims leave behind (Cerel et al., 2015). However, such sources of information are not always available or reliable (Kelleher & Campbell, 2011; Wurst et al., 2011).
Because of these limitations, many researchers also use a second strategy— studying people who survive their suicide attempts. It is estimated that there are 12 nonfatal suicide attempts for every fatal suicide (AFSP, 2014). However, it may be that people who survive suicide attempts differ in important ways from those who do not. Many of them may not really have wanted to die, for example. Nevertheless, suicide researchers have found it useful to study sur- vivors of suicide attempts, and this chapter shall consider those who attempt suicide and those who commit suicide as more or less alike.
Patterns and Statistics Suicide happens within a larger social setting, and researchers have gathered many statistics regarding the social contexts in which such deaths take place. They have found, for example, that suicide rates vary from country to country
(Kirkcaldy et al., 2010). South Korea, Russia, Hungary, Germany, Austria, Finland, Denmark, China, and Japan have very high rates—more than 20 suicides annually per 100,000 persons; conversely, Egypt, Mexico, Greece, and Spain have relatively low rates, fewer than 5 per 100,000. The United States and Canada fall in between, each with a suicide rate of 12.1 per 100,000 persons; England has a rate of 9 per 100,000 (AFSP, 2014; CDC, 2013).
Religious affiliation and beliefs may help account for these national differences (Foo et al., 2014). For example, countries that are largely Catholic, Jewish, or Muslim tend to have low suicide rates. Perhaps in these coun- tries, strict prohibitions against suicide or a strong religious tradition deter many people from committing suicide. Yet there are exceptions to this tentative rule. Austria, a largely Roman Catholic country, has one of the highest suicide rates in the world.
Research is beginning to suggest that religious doctrine may not help prevent suicide as much as the degree of an individual’s devoutness. Regardless of their par- ticular persuasion, very religious people seem less likely to commit suicide (Cook, 2014; Güngörmüs et al., 2014). Similarly, it seems that people who have a greater reverence for life are less prone to consider or attempt self-destruction (Lee, 1985).
The suicide rates of men and women also differ. Three times as many women attempt suicide as men, yet men succeed at more than four times the rate of women (AFSP, 2014; CDC, 2013). Around the world 19 of every 100,000 men kill them- selves each year; the suicide rate for women is 4 per 100,000 (Levi et al., 2003).
Although various explanations have been proposed for this gender difference, a popular one points to the different methods used by men and women (Stack &
what factors besides religious
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Retrospective analysis The very public retrospective analysis of the 1994 suicide of rock star Kurt Cobain, leader of the grunge band Nirvana, was given new impetus in 2002 with the publication of Journals—a collection of notebook pages in which Cobain had writ- ten about his thoughts and concerns, bouts with depression, and drug addiction during the final years of his life.
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Wasserman, 2009). Men tend to use more violent methods, such as shooting, stabbing, or hanging themselves, whereas women use less violent methods, such as drug overdose. Guns are used in 56 percent of the male suicides in the United States, compared with 31 percent of the female suicides (CDC, 2014).
Suicide is also related to social environment and marital status (You et al., 2011). In one study, around half of the individuals who had committed suicide were found to have no close personal friends (Maris, 2001), although they may be active on Internet and social networks. Fewer still had close relationships with parents and other family members. In a related vein, research has revealed that divorced persons have a higher suicide rate than married or cohabitating individuals (Roskar et al., 2011).
Finally, in the United States at least, suicide rates seem to vary according to race (see Figure 7-1). The overall suicide rate of white Americans is more than twice as high as that of African Ameri- cans, Hispanic Americans, and Asian Americans (AFSP, 2014; CDC, 2013). A major exception to this pattern is the very high suicide rate of American Indians, which is at least 20 percent higher than that of white Americans (Herne et al., 2014; SPRC, 2013). Although the extreme poverty of many American Indians may partly explain their high suicide rate, studies show that factors such as alcohol use, modeling, and the availability of guns may also play a role (Lanier, 2010). In addition to differences across racial groups, researchers have found that suicide rates sometimes differ within groups. Among Hispanic Americans, for example, Puerto Ricans are significantly more likely to attempt suicide than any other Hispanic American group (Baca-Garcia et al., 2011).
Some of these statistics on suicide have been questioned. Analyses suggest, for example, that the actual rate of suicide may be 15 percent higher for African Ameri- cans and 6 percent higher for women than usually reported (Barnes, 2010; Phillips & Ruth, 1993). People in these groups are more likely than others to use methods of suicide that can be mistaken for causes of accidental death, such as poisoning, drug overdose, single-car crashes, and pedestrian accidents.
➤ Summing Up What IS SUICIDe? Suicide is a self-inflicted death in which a person makes an intentional, direct, and conscious effort to end his or her life. Four kinds of peo- ple who intentionally end their lives have been distinguished: the death seeker, the death initiator, the death ignorer, and the death darer.
Two major strategies are used in the study of suicide: retrospective analysis and the study of people who survive suicide attempts. Suicide ranks among the top 10 causes of death in Western societies. Rates vary from country to country. One reason seems to be cultural differences in religious affiliation, beliefs, and degree of devoutness. Suicide rates also vary according to race, gender, and marital status.
What Triggers a Suicide? Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the basic motivation for the suicide, they can precipitate it. Common triggering factors include stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling.
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figure 7-1 Suicide, race, and gender In the United States, American Indians have the highest suicide rates among both males and females. (Information from: CDC, 2014, 2010; SPRC, 2013.)
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Deal Breaker If clients state an intention to com- mit suicide, therapists may break the doctor–patient confidentiality agree- ment that usually governs treatment discussions.
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Stressful Events and Situations Researchers have counted more stressful events in the recent lives of suicide attempters than in the lives of nonattempters (McFeeters et al., 2014; Pompili et al., 2011). At the beginning of this chapter, for example, you read about a young man who committed suicide upon returning to civilian life, after experiencing the enor- mous stressors of combat in Iraq. However, the stressors that help lead to suicide do not need to be as horrific as those tied to combat. Common forms of immediate stress seen in cases of suicide are the loss of a loved one through death, divorce, or rejection (Roskar et al., 2011); loss of a job (Milner el al., 2014); significant financial loss (Houle & Light, 2014); and stress caused by hurricanes or other natural disasters, even among very young children. People may also attempt suicide in response to long-term rather than recent stress. Four such stressors are particularly common— social isolation, serious illness, an abusive environment, and occupational stress.
Social Isolation As you saw in the cases of Dave, Demaine, and Tya, people from loving families or supportive social systems may commit suicide. However, those without such social supports are particularly vulnerable to suicidal thinking and actions. Researchers have found a heightened risk for suicidal behavior among those who feel little sense of “belongingness,” believe that they have limited or no social support, live alone, and have ongoing conflicts with other people (You et al., 2011).
Serious Illness People whose illnesses cause them great pain or severe disabil- ity may try to commit suicide, believing that death is unavoidable and imminent (Schneider & Shenassa, 2008). They may also believe that the suffering and problems caused by their illnesses are more than they can endure. Studies suggest that as many as one-third of those who die by suicide have been in poor physical health during the months prior to their suicidal acts (MacLean et al., 2011; Conwell et al., 1990).
Abusive or Repressive Environment Victims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. For example, some prisoners of war, inmates of concentration camps, abused spouses, abused children, and prison inmates try to end their lives (Fazel et al., 2011). Like those who have serious illnesses, these people may feel that they can endure no more suffering and believe that there is no hope for improvement in their condition.
Occupational Stress Some jobs create feelings of tension or dissatisfaction that may trigger suicide attempts. Research has found particularly high suicide rates among psychiatrists and psychologists, physicians, nurses, dentists, lawyers, police officers, farmers, and unskilled laborers (Milner et al., 2013; Kleespies et al., 2011). Such correlations do not necessarily mean that occupational pressures directly cause suicidal actions. Perhaps unskilled workers are responding to financial insecurity rather than job stress when they attempt suicide. Similarly, rather than reacting to the emotional strain of their work, suicidal psychiatrists and psychologists may have long-standing emotional problems that stimulated their career interest in the first place.
Mood and Thought Changes Many suicide attempts are preceded by a change in mood. The change may not be severe enough to warrant a diagnosis of a mental disorder, but it does represent a sig- nificant shift from the person’s past mood. The most common change is an increase in sadness (Kim et al., 2015). Also common are increases in feelings of anxiety, ten- sion, frustration, anger, or shame (Reisch et al., 2010). In fact, Shneidman (2005, 2001) believed that the key to suicide is “psychache,” a feeling of psychological pain
Famous prison suicide People around the country expressed outrage when they learned that Ariel Castro, shown here at his 2013 trial, had kidnapped three young women in Cleveland, Ohio, and imprisoned them in his house for more than a decade, repeatedly raping them. Sentenced to 1,000 years with- out parole for his crimes, Castro killed himself by hanging just a month into his sentence. Around 5.5 percent of all prison deaths are due to suicide (Smith, 2013).
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that seems intolerable to the person. A study of 88 patients found that those who scored higher on a measure called the Psychological Pain Assessment Scale were indeed more likely than others to commit suicide (Pompili et al., 2008).
Suicide attempts may also be preceded by shifts in patterns of thinking. People may become preoccupied with their problems, lose perspective, and see suicide as the only effective solution to their difficulties (Shneidman, 2005, 2001). They often develop a sense of hopelessness—a pessimistic belief that their present circum- stances, problems, or mood will not change. Some clinicians believe that a feeling of hopelessness is the single most likely indicator of suicidal intent, and they take special care to look for signs of hopelessness when they assess the risk of suicide (Rosellini & Bagge, 2014).
Many people who attempt suicide fall victim to dichotomous thinking, viewing problems and solutions in rigid either/or terms (Shneidman, 2005, 2001, 1993). Indeed, Shneidman said that the “four-letter word” in suicide is “only,” as in “suicide was the only thing I could do” (Maris, 2001). In the following statement a woman who survived her leap from a building describes her dichotomous thinking at the time. She saw death as the only alternative to her pain:
I was so desperate. I felt, my God, I couldn’t face this thing. Everything was like a terrible whirlpool of confusion. And I thought to myself: There’s only one thing to do. I just have to lose consciousness. That’s the only way to get away from it. The only way to lose consciousness, I thought, was to jump off something good and high. . . .
(Shneidman, 1987, p. 56)
Alcohol and Other Drug Use Studies indicate that as many as 70 percent of the people who attempt suicide drink alcohol just before they do so (Crosby et al., 2009; McCloud et al., 2004). Autop- sies reveal that about one-quarter of these people are legally intoxicated (Flavin et al., 1990). It may be that the use of alcohol lowers a person’s fears of committing suicide, releases underlying aggressive feelings, or impairs his or her judgment and problem-solving ability. Research shows that the use of other kinds of drugs may have a similar tie to suicide, particularly in teenagers and young adults (Darke et al., 2005). A high level of heroin, for example, was found in the blood of Kurt Cobain at the time of his suicide in 1994 (Colburn, 1996).
Mental Disorders Although people who attempt suicide may be troubled or anxious, they do not necessarily have a psychological disorder. Nevertheless, the majority of all suicide attempters do have such a disorder (Singhal et al., 2014; Nock et al., 2013). Research suggests that as many as 70 percent of all suicide attempters had been experienc- ing severe depression, 20 percent chronic alcoholism, and 10 percent schizophrenia. Correspondingly, as many as 25 percent of people with each of these disorders try to kill themselves. People who are both depressed and dependent on alcohol seem particularly prone to suicidal impulses (Nenadic´-Šviglin et al., 2011). It is also the case that many people with borderline personality disorder, a pattern that you will read about in Chapter 13, try to harm themselves or make suicidal gestures as part of their disorder (Amore et al., 2014).
As you saw in Chapter 6, people with major depressive disorder often have suicidal thoughts. Indeed, one review has found that treatments for depression consistently reduce the rate of suicidal thinking, attempts, and completions among
Acting happy Fans of megastar, comedian, and actor Robin Williams were shocked when he committed suicide by hanging in 2014. Close friends reported that Williams had been battling depression and the early stages of Parkinson’s disease for some time—a painful emotional state that he managed to conceal from the public with his joyful performances. Williams’ autopsy also revealed a type of neurocognitive disorder called Lewy body disease.
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patients (Sakinofsky, 2011). Even when depressed people are showing improve- ments in mood, however, they may remain at high risk for suicide. In fact, among those who are severely depressed, the risk of suicide may actually increase as their mood improves and they have more energy to act on their suicidal wishes. Recall, for example, the combat veteran whose case opened this chapter. Just before he committed suicide, he had seemed to be calm and enjoying life again, according to family members and friends.
Severe depression also may play a key role in suicide attempts made by those with serious physical illnesses (Werth, 2004). A study of 44 patients with terminal illnesses revealed that fewer than one-quarter of them had thoughts of suicide or wished for an early death and that those who did were all suffering from major depressive disorder (Brown et al., 1986).
A number of the people who drink alcohol or use drugs just before a suicide attempt actually have a long history of abusing such substances (Kim et al., 2015; Ries, 2010). The basis for the link between substance-related disorders and suicide is not clear. Perhaps the tragic lifestyle of many persons with these disorders or their sense of being hopelessly trapped by a substance leads to suicidal thinking. Alter- natively, a third factor—psychological pain, for instance, or desperation—may cause both substance abuse and suicidal thinking (Sher et al., 2005). Such people may be caught in a downward spiral: they are driven toward substance use by psychologi- cal pain or loss, only to find themselves caught in a pattern of substance abuse that aggravates rather than solves their problems (Maris, 2001).
People with schizophrenia, as you will see in Chapter 12, may hear voices that are not actually present (hallucinations) or hold beliefs that are clearly false and perhaps bizarre (delusions). The popular notion is that when such people kill themselves, they must be responding to an imagined voice commanding them to do so or to a delusion that suicide is a grand and noble gesture. Research indicates, however, that suicides by people with schizophrenia more often reflect feelings of demoralization or fears of further mental deterioration (Meltzer, 2011). Many young and unemployed people with schizophrenia who have had relapses over several years come to believe that the disorder will forever disrupt their lives. Still others seem to be disheartened by their substandard living conditions. Suicide is the leading cause of premature death among people with schizophrenia.
Modeling: The Contagion of Suicide It is not unusual for people, particularly teenagers, to try to commit suicide after observing or reading about someone else who has done so (Hagihara et al., 2014). Perhaps they have been struggling with major problems and the other person’s suicide seems to reveal a possible solution, or perhaps they have been thinking about suicide and the other person’s suicide seems to give them permission or finally persuades them to act. Either way, one suicidal act apparently serves as a model for another. Suicides by family members and friends, those by celebrities, other highly publicized suicides, and those by coworkers or colleagues are particularly common triggers.
Family Members and Friends A recent suicide by a family member or friend increases the likelihood that a person will attempt suicide (Ali et al., 2011). Of course, the death of a family member or friend, especially when self-inflicted, is a life-changing event, and suicidal thoughts or attempts may be tied largely to that trauma or sense of loss. Indeed, such losses typically have a lifelong impact on surviving relatives and friends, including a heightened risk of suicide that can con- tinue for years (Roy, 2011). However, even when researchers factor out these issues, they find increases in the risk of suicide among the relatives and friends of people who recently committed suicide (Ali et al., 2011). This additional risk factor is often called the social contagion effect.
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Suicides by Rock Musicians: Post–Kurt Cobain Jason Thirsk, punk band Pennywise (1996)
Rob Pilatus, pop band Milli Vanilli (1998)
Wendy O. Williams, punk singer (1998)
Screaming Lord Sutch, British rock singer (1999)
Herman Brood, Dutch rock singer (2001)
Elliott Smith, rock singer (2003)
Robert Quine, punk guitarist (2004)
Dave Schulthise, bassist for the Dead Milkmen (2004)
Derrick Plourde, rock drummer (2005)
Vince Welnick, keyboardist for the Tubes and the Grateful Dead (2006)
Brad Delp, lead singer for rock band Boston (2007)
Johnny Lee Jackson, rapper (2008)
Vic Chesnutt, singer-songwriter (2009)
Mark Linkous, singer-songwriter/musi- cian (2010)
Ronnie Montrose, guitarist (2012)
Bob Welch, guitarist for Fleetwood Mac (2012)
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Celebrities Research suggests that suicides by entertainers, political figures, and other well-known people are regularly followed by unusual increases in the num- ber of suicides across the nation (Queinec et al., 2011). During the week after the suicide of Marilyn Monroe in 1963, for example, the national suicide rate rose 12 percent (Phillips, 1974).
Other Highly Publicized Cases Suicides with bizarre or unusual aspects often receive intense coverage by the news media. Such highly publicized accounts may lead to similar suicides (Hagihara et al., 2014). During the year after a widely publicized, politically motivated suicide by self-burning in England, for example, 82 other people set themselves on fire, with equally fatal results (Ashton & Donnan, 1981). Inquest reports revealed that most of those people had histories of emotional problems and that none of the suicides had the political motivation of the publicized suicide. The imitators seemed to be responding to their own problems in a manner triggered by the suicide they had observed or read about.
Some clinicians argue that more responsible report- ing could reduce this frightening impact of highly pub- licized suicides (Sullivan et al., 2015). A careful approach to reporting was seen in the media’s coverage of the suicide of Kurt Cobain. MTV’s repeated theme on the evening of the suicide was “Don’t do it!” In fact, thou- sands of upset, frightened, and in some cases suicidal young people called MTV and other radio and televi- sion stations in the hours after Cobain’s death. Some of the stations responded by posting the phone numbers of suicide prevention centers, presenting interviews with suicide experts, and offering counseling services and advice directly to callers. Perhaps because of such efforts, the usual rate of suicide both in Seattle, where Cobain lived, and elsewhere held steady during the weeks that followed (Colburn, 1996).
Coworkers and Colleagues The word-of-mouth publicity that attends suicides in a school, workplace, or small community may trigger suicide attempts. The suicide of a recruit at a U.S. Navy training school, for example, was followed within two weeks by another and also by an attempted suicide at the school. To head off what threatened to become a suicide epidemic, the school began a program of staff education on suicide and group therapy sessions for recruits who had been close to the suicide victims (Grigg, 1988). Today, a number of schools, for individu- als of all ages, put into action programs of this kind after a student commits suicide ( Joshi et al., 2015). Such postsuicide programs are often referred to by clinicians as postvention.
➤ Summing Up What trIggerS a SUICIDe? Many suicidal acts are triggered by the current events or conditions in a person’s life. The acts may be triggered by recent stressors, such as loss of a loved one and job loss, or long-term stressors, such as social isolation, serious illness, an abusive environment, and job stress. They may also be preceded by changes in mood or thought, particularly increases in one’s sense of hopelessness. In addition, the use of alcohol or other kinds of substances, mental disorders, or news of another’s suicide may precede suicide attempts.
Eye of the storm In a celebrated case, the British press blamed the music of the emo group My Chemical Romance for the suicide of a 13-year-old girl in 2008. For years, the lyr- ics and melodies of various songs have been pointed to as negative influences, particularly on teenagers, that can contribute to suicide attempts. However, little research has been conducted on this issue and lawsuits making such claims have typically been dismissed.
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What Are the Underlying Causes of Suicide? Most people faced with difficult situations never try to kill themselves. In an effort to understand why some people are more prone to suicide than others, theorists have proposed more fundamental explanations for self-destructive actions than the immediate triggers considered in the previous section. The leading theories come from the psychodynamic, sociocultural, and biological perspectives. As a group,
however, these hypotheses have received limited research support and fail to address the full range of suicidal acts. Thus the clinical field cur- rently lacks a satisfactory understanding of suicide.
The Psychodynamic View Many psychodynamic theorists believe that suicide results from depres- sion and from anger at others that is redirected toward oneself. This theory was first stated by Wilhelm Stekel at a meeting in Vienna in 1910, when he proclaimed that “no one kills himself who has not wanted to kill another or at least wished the death of another” (Shneidman, 1979). Agreeing with this notion, influential psychiatrist Karl Menninger called suicide “murder in the 180th degree.”
As you read in Chapter 6, Freud (1917) and Abraham (1916, 1911) proposed that when people experience the real or symbolic loss of a loved one, they uncon- sciously incorporate the person into their own identity and feel toward themselves as they had felt toward the other. For a short while, negative feelings toward the lost loved one are experienced as self-hatred. Anger toward the loved one may turn into intense anger against oneself and finally into depression. Suicide is thought to be an extreme expression of this self-hatred (Campbell, 2010). The following description of a suicidal patient demonstrates how such forces may operate:
A 27-year-old conscientious and responsible woman took a knife to her wrists to punish herself for being tyrannical, unreliable, self-centered, and abusive. She was perplexed and frightened by this uncharacteristic self-destructive episode and was enormously relieved when her therapist pointed out that her invective described her recently deceased father much better than it did herself.
(Gill, 1982, p. 15)
In support of Freud’s view, researchers have often found a relationship between childhood losses—real or symbolic—and later suicidal behaviors (Alonzo et al., 2014). A classic study of 200 family histories, for example, found that early parental loss was much more common among suicide attempters (48 percent) than among nonsuicidal individuals (24 percent) (Adam et al., 1982). Common forms of loss were death of the father and divorce or separation of the parents. Similarly, a study of 343 depressed individuals found that those who had felt rejected or neglected as children by their parents were more likely than other people to attempt suicide as adults (Ehnvall et al., 2008).
Late in his career, Freud proposed that human beings have a basic “death instinct.” He called this instinct Thanatos and said that it opposes the “life instinct.” According to Freud, while most people learn to redirect their death instinct by aim- ing it toward others, suicidal people, caught in a web of self-anger, direct it squarely toward themselves.
Sociological findings are consistent with this explanation of suicide. National suicide rates have been found to drop in times of war (Maris, 2001), when, one could argue, people are encouraged to direct their self-destructive energy against
Murder–suicide in the air Nowhere is the link between homicidal and suicidal behavior more evident than in cases of murder– suicide. On March 24, 2015, Andreas Lubitz, a depressed 27-year-old copilot, deliberately crashed a Germanwings Airbus A320 (above) into the French Alps, killing himself and 149 passengers and crew members. Around 2 percent of all suicides occur in the context of murder–suicide, usually involving spouses or lovers.
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The Economics of Suicide The annual cost of suicide deaths in the United States is $34 billion (lost wages and work productivity).
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“the enemy.” In addition, in many parts of the world, societies with high rates of homicide tend to have low rates of suicide, and vice versa (Bills & Li, 2005). How- ever, research has failed to establish that suicidal people are in fact dominated by
intense feelings of anger. Although hostility is an important element in some suicides, several studies find that other emotional states are even more prevalent (Conner & Weisman, 2011).
By the end of his career, Freud himself expressed dissatisfaction with his theory of
suicide. Other psychodynamic theorists have also challenged his ideas over the years, yet themes of loss and self-directed aggression generally remain at the center of most psychodynamic explanations (King, 2003).
Durkheim’s Sociocultural View Toward the end of the nineteenth century, Emile Durkheim (1897), a sociolo- gist, developed a broad theory of suicidal behavior. Today this theory continues to be influential and is often supported by research (Fernquist, 2007). According to Durkheim, the probability of suicide is determined by how attached a person is to such social groups as the family, religious institutions, and community. The more thoroughly a person belongs, the lower the risk of suicide. Conversely, people who have poor relationships with their society are at higher risk of killing themselves. He defined several categories of suicide, including egoistic, altruistic, and anomic suicide.
Egoistic suicides are committed by people over whom society has little or no control. These people are not concerned with the norms or rules of society, nor are they integrated into the social fabric. According to Durkheim, this kind of suicide is more likely in people who are isolated, alienated, and nonreligious. The larger the number of such people living in a society, the higher that society’s suicide rate.
Altruistic suicides, in contrast, are committed by people who are so well integrated into the social structure that they intentionally sacrifice their lives for its well-being. Soldiers who threw themselves on top of a live grenade to save others, Japanese kamikaze pilots who crashed their planes into enemy ships during World War II, and Buddhist monks and nuns who protested the Vietnam War by setting themselves on fire may have been committing altruistic suicide (Leenaars, 2004; Stack, 2004). According to Durkheim, societies that encourage people to sacrifice themselves for others and to preserve their own honor (as East Asian societies do) are likely to have higher suicide rates.
Anomic suicides, another category proposed by Durkheim, are those committed by people whose social environment fails to provide stable structures, such as family and religion, to support and give meaning to life. Such a societal condition, called anomie (literally, “without law”), leaves people without a sense of belonging. Unlike egoistic suicide, which is the act of a person who rejects the structures of a society, anomic suicide is the act of a person who has been let down by a disorganized, inadequate, often decaying society.
Durkheim argued that when societies go through periods of anomie, their sui- cide rates increase. Historical trends support this claim. Periods of economic depres- sion may bring about some degree of anomie in a country, and national suicide rates tend to rise during such times (Noh, 2009; Maris, 2001). Periods of population change and increased immigration, too, tend to bring about a state of anomie, and again suicide rates rise (Kposowa et al., 2008).
A major change in a person’s immediate surroundings, rather than general soci- etal problems, can also lead to anomic suicide. People who suddenly inherit a great deal of money, for example, may go through a period of anomie as their relationships with social, economic, and occupational structures are changed. Thus Durkheim
Altruistic suicide? A clay sculpture of a suicide bomber is displayed at a Baghdad art gallery. Some sociologists believe that the acts of such bombers fit Durkheim’s definition of altruistic suicide, arguing that the bombers believe they are sacrificing their lives for the well-being of their society. Other theorists, however, point out that many such bombers seem indifferent to the innocent lives they are destroying and categorize the bombers instead as mass murderers motivated by hatred rather than by feelings of altruism (Humphrey, 2006).
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predicted that societies with more opportunities for change in individual wealth or status would have higher suicide rates; this prediction is also supported by research (Cutright & Fernquist, 2001; Lester, 2000, 1985). Conversely, people who are removed from society and sent to a prison environment may experience anomie. As you read earlier, research con- firms that such people have a heightened suicide rate (Fazel et al., 2011).
Although today’s sociocultural theorists do not always embrace Durkheim’s particular ideas, most agree that social structure and cultural stress often play major roles in suicide. In fact, the sociocultural view pervades the study of suicide. Recall the ear- lier discussion of the many studies linking suicide to broad factors such as religious affiliation, marital status, gender, race, and societal stress. You will also see the impact of such factors when you read about
the ties between suicide and age. Despite the influence of sociocultural theories such as Durkheim’s, these theo-
ries cannot by themselves explain why some people who face particular societal pressures commit suicide while the majority do not. Durkheim himself concluded that the final explanation probably lies in the interaction between societal and indi- vidual factors.
The Biological View For years, biological researchers have relied largely on family pedigree studies to support their position that biological factors contribute to suicidal behavior. They repeatedly have found higher rates of suicide among the parents and close relatives of suicidal people than among those of nonsui- cidal people (Petersen et al., 2014; Roy, 2011). Such findings may suggest that genetic, and so biological, factors are at work.
In the past three decades, laboratory studies have offered more direct support for a bio- logical view of suicide. One promising line of research focuses on serotonin. The activity level of this neurotransmitter has often been found to be low in people who commit suicide (Fabio Di Narzo et al., 2014; Mann & Currier, 2007). An early hint of this relationship came from a study by psychiatric researcher Marie Asberg and her colleagues (1976). They studied 68 depressed patients and found that 20 of the patients had particularly low levels of serotonin activity. It turned out that 40 percent of the research participants with such serotonin levels attempted suicide, compared with 15 percent of those with higher serotonin levels. The researchers interpreted this to mean that low serotonin activity may be “a predictor of suicidal acts.” Later studies found that suicide attempters with low serotonin activity are 10 times more likely to make a repeat attempt and succeed than are suicide attempters with higher serotonin activity (Roy, 1992).
At first glance, these and related studies may appear to tell us only that depressed people often attempt suicide. After all, depression is itself related to low serotonin activity. On the other hand, there is evidence of low serotonin activity even among suicidal people who have no history of depression (Mann & Currier, 2007). That is, low serotonin activity also seems to play a role in suicide separate from depression.
How, then, might low serotonin activity increase the likelihood of suicidal behavior? One possibility is that it contributes to aggressive and impulsive behaviors
Not just another bridge This man, one of only 26 people to survive jumping off the Golden Gate Bridge, returns to the site of his suicide attempt—made at the age of 19. The bridge is believed to be the site of more jumping suicides than any other location in the world—with an estimated 1,400 suicides since the bridge opened in 1937.
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Most Common Killings More suicides (38,364) than homicides (18,000) are committed in the United States each year (CDC, 2011).
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(Preti, 2011). It has been found, for example, that serotonin activ- ity is lower in aggressive men than in nonaggressive men and that serotonin activity is often low in those who commit such aggressive acts as arson and murder (Oquendo et al., 2006, 2004; Stanley et al., 2000). Such findings suggest that low serotonin activity helps produce aggressive feelings and impulsive behavior. In people who are clinically depressed, low serotonin activity may produce aggressive tendencies that cause them to be particularly vulnerable to suicidal thoughts and acts. Even in the absence of a depressive disorder, however, people with low serotonin activity may develop such aggressive feelings that they, too, are dangerous to themselves or to others. Still other research indicates that low serotonin activity combined with key psychosocial factors (such as childhood traumas) may be the strongest suicide predictor of all (Moberg et al., 2011).
➤ Summing Up What are the UnDerlyIng CaUSeS of SUICIDe? The leading explanations for suicide come from the psychodynamic, sociocultural, and biological models. Each has received only limited support. Psychodynamic theorists believe that suicide usually results from depression and self-directed anger. Emile Durkheim’s sociocultural theory defines three categories of suicide, based on the person’s relationship with society: egoistic, altruistic, and anomic suicides. And biological theorists suggest that the activity of the neurotransmitter sero- tonin is particularly low in people who commit suicide.
Is Suicide Linked to Age? Although people of all ages may try to kill themselves, the likelihood of committing suicide steadily increases with age up through middle age, then decreases during the early stages of old age, and then increases again beginning at age 85 (see Figure 7-2 on page 237). Currently, 1 of every 100,000 people under 15 years of age in the United States kills himself or herself each year, compared with 11 of every 100,000 people between 15 and 24 years old, 19 of every 100,000 between 45 and 64 years old, 15 of every 100,000 between 65 and 84, and 18 of every 100,000 people over age 85 (AFSP, 2014; CDC, 2013). The exceptional rate of suicide among those who are middle-aged is a recent phenomenon and is not fully understood. Up until 2006, that rate had been considerably lower than the current rate and always lower than that of elderly people.
Clinicians have paid particular attention to self-destructive behavior in three age groups: children, adolescents, and the elderly. Although the features and theories of suicide discussed throughout this chapter apply to all age groups, each group faces unique problems that may play key roles in the suicidal acts of its members.
Children Although suicide is infrequent among children, it has been increasing over the past several decades (Dervic et al., 2008). Indeed, more than 6 percent of all deaths among children between the ages of 10 and 14 years are caused by suicide (Arias et al., 2003). Boys outnumber girls by as much as 5 to 1. In addition, it has been estimated that 1 of every 100 children tries to harm himself or herself, and many thousands of children are hospitalized each year for deliberately self-destructive
Is aggression the key? Biological theorists believe that heightened feelings of aggression and impulsivity, produced by low serotonin activity, are key factors in suicide. In 2007, professional wrestling champion Chris Benoit (right) killed his wife and son and then hanged himself, a tragedy that seemed con- sistent with this theory. In addition, toxicology reports found steroids, drugs known to help cause aggression and impulsivity, in Benoit’s body.
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Additional Punishment Up through the nineteenth century, the bodies of suicide victims in France and England were sometimes dragged through the streets on a frame, head downward, the way criminals were dragged to their executions.
In the United States, the last prosecu- tion for attempted suicide occurred in 1961; the prosecution was not successful.
(Wertheimer, 2001; Fay, 1995)
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acts, such as stabbing, cutting, burning, or shooting themselves; overdosing; or jumping from high places (Fortune & Hawton, 2007).
Researchers have found that suicide attempts by the very young are com- monly preceded by such behavioral patterns as running away from home; accident- proneness; aggressive acting out; temper tantrums; self-criticism; social withdrawal and loneliness; extreme sensitivity to criticism by others; low tolerance of frustration; sleep problems; dark fantasies, daydreams, or hal- lucinations; marked personality change; and overwhelming interest in death and suicide (Soole et al., 2015; Wong et al., 2011; Dervic et al., 2008). Studies further have linked child suicides to the recent or anticipated loss of a loved one, family stress and a parent’s unemployment, abuse by parents, victimization by peers (for example, bullying), and a clinical level of depression (van Geel et al., 2014; Renaud et al., 2008).
Most people find it hard to believe that children fully comprehend the meaning of a suicidal act. They argue that because a child’s thinking is so lim- ited, children who attempt suicide fall into Shneidman’s category of “death ignorers,” like Demaine, who sought to join his mother in heaven. Many child suicides, however, appear to be based on a clear understanding of death and on a clear wish to die (Pfeffer, 2003). In addition, suicidal thinking among even normal children is apparently more common than most people once believed. Clinical interviews with schoolchildren have revealed that between 6 and 33 percent have thought about suicide (Riesch et al., 2008; Culp et al., 1995). Small wonder that many of today’s elementary schools have tried to develop
tools and procedures for better identifying and assessing suicide risk among their students (Miller, 2011; Whitney et al., 2011).
Adolescents
Dear Mom, Dad, and everyone else, I’m sorry for what I’ve done, but I loved you all and I always will, for eternity.
Please, please, please don’t blame it on yourselves. It was all my fault and not yours or anyone else’s. If I didn’t do this now, I would have done it later anyway. We all die some day, I just died sooner.
Love, John
(Berman, 1986)
The suicide of John, age 17, was not an unusual occurrence. Suicidal actions become much more common after the age of 13 than at any earlier age. According to offi- cial records, approximately 1,400 teenagers (age 13 to 18), or 7 of every 100,000, commit suicide in the United States each year (Nock et al., 2013). In addition, at least 12 percent of teenagers have persistent suicidal thoughts and 4 percent make suicide attempts (Nock et al., 2013). Because fatal illnesses are uncommon among the young, suicide has become the third leading cause of death in this age group, after accidents and homicides (CDC, 2015). Around 10 percent of all adolescent deaths are the result of suicide.
More than half of teenage suicides have been tied to clinical depression (see PsychWatch on page 238), low self-esteem, and feelings of hopelessness, but many teenagers who try to kill themselves also appear to struggle with anger and impul- siveness or to have serious alcohol or drug problems (Orri et al., 2014; Renaud et al., 2008). Some also have deficiencies in their ability to sort out and solve problems.
Teenagers who consider or attempt suicide are often under great stress. They may be dealing with long-term pressures such as poor (or missing) relationships
Student stress The intense training and testing that characterize Japan’s educational system produce high levels of stress in many students. This child, wearing a headband that translates to “Struggle to Pass,” partici- pates in summer juku, a camp where children receive special academic training, extra les- sons, and exam practice 11 hours a day.
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Therapeutic Failure More than 55% of suicidal teens actu- ally started therapy before the onset of their suicidal behaviors, but it failed to prevent their actions (Nock et al., 2013).
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with parents, family conflict, inadequate peer relationships, and social isola- tion (Orri et al., 2014; Capuzzi & Gross, 2008). Alternatively, their actions also may be triggered by more immediate stress, such as a parent’s unem- ployment or medical illness, financial setbacks for the family, or a social loss such as a breakup with a boyfriend or girlfriend (Orbach & Iohan, 2007). Stress at school seems to be a particularly common problem for teenagers who attempt suicide. Some have trouble keeping up at school, while others may be high achievers who feel pressured to be perfect and to stay at the top of the class (Frazier & Cross, 2011; Miller, 2011).
Some theorists believe that the period of adolescence itself produces a stressful climate in which suicidal actions are more likely. Adolescence is often marked by conflicts, depressed feelings, tensions, and difficulties at home and school. Adolescents tend to react to events more sensitively, angrily, dramatically, and impulsively than individuals in other age groups; thus the likelihood of their engaging in suicidal acts during times of stress is higher (Greening et al., 2008). Finally, the eagerness of adolescents to imitate others, including others who attempt suicide, may set the stage for suicidal action (Apter & Wasserman, 2007). One pioneering study found that 93 percent of adolescent suicide attempters had known someone who had attempted suicide (Conrad, 1992).
Teen Suicides: Attempts Versus Completions Far more teenagers attempt suicide than actually kill themselves—most experts believe that the ratio is 25 to 1 (AFSP, 2014), although estimates range as high as 200 to 1. The unusually large number of unsuccessful teenage suicides may mean that adolescents are less certain than middle-age and elderly people who make such attempts. While some do indeed wish to die, many may simply want to make others understand how desperate they are, or they may want to get help or teach others a lesson (Apter & Wasserman, 2007). Up to half of teenagers who make a suicide attempt try again in the future, and as many as 14 percent eventually die by suicide (Horwitz et al., 2014; Wong et al., 2008).
Why is the rate of suicide attempts so high among teenagers (as well as among young adults)? Several explanations, most pointing to societal factors, have been proposed. First, as the number and proportion of teenagers and young adults in the general population have risen, the competition for jobs, college positions, and aca- demic and athletic honors has intensified for them, leading increasingly to shattered dreams and ambitions (Holinger & Offer, 1993, 1991, 1982). Other explanations point to weakening ties in the family (which may produce feelings of alienation and rejection in many of today’s young people) and to the easy availability of alcohol and other drugs and the pressure to use them among teenagers and young adults (Brent, 2001; Cutler et al., 2001).
The mass media coverage of suicides by teenagers and young adults may also contribute to the high rate of suicide attempts among the young (Gerard et al., 2012). The detailed descriptions of teenage suicide that the media and the arts often offer may serve as models for young people who are contemplating suicide (Cheng et al., 2007). In one of the most famous examples of this phenomenon, just days after the highly publicized suicides of four adolescents in a New Jersey town in 1987, dozens of teenagers across the United States took similar actions (at least 12 of them fatal)—two in the same garage just one week later.
It is worth noting here that a number of pro-suicide forums and chat rooms have popped up on the Internet in recent
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figure 7-2 Suicide and age In the United States, suicide rates keep rising up to the age of 64, then fall during the first two decades of old age, then rise again among people over the age of 84. (Information from: AFSP, 2014.)
Telling his story College student Bryce Mackie watches as his film, Eternal High, is played for a group of mental health profes- sionals in Ohio. He made the film in high school, chronicling his struggle with bipolar disorder and suicidal thoughts.
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years. Some pro-suicide Web sites celebrate former users who have committed suicide, others help set up appointments for joint or partner suicides, and several offer specific instructions about suicide methods and locations and writing suicide notes (Daine et al., 2013; Davey, 2010). Although such sites are growing in number and influence, they do not appear to be a major factor in the rise of teenage suicide attempts—at least not yet. One study found that pro-suicide sites were visited by suicidal people relatively infrequently, whereas sites dedicated to suicide-related information, preven- tion, or treatment were visited very often (Kemp & Collings, 2011).
Teen Suicides: Multicultural Issues Teenage suicide rates vary by ethnic- ity in the United States. Around 7.5 of every 100,000 white American teenagers commit suicide each year, compared with 5 of every 100,000 African American teens and 5 of every 100,000 Hispanic American teens (Goldston et al., 2008; NAHIC, 2006). Although these numbers certainly indicate that white American teens are more prone to suicide, the rates of the three groups are in fact becoming
PsychWatch
A major controversy in the clinical field is whether antidepressant drugs are highly dangerous for depressed children and teenagers. Throughout the 1990s, most psychia- trists believed that antidepressants— particularly the second-generation antidepressants—were safe and effec- tive for children and adolescents, just as they seemed to be for adults, and they prescribed those medications readily (Cooper et al., 2014). How- ever, after reviewing a large number of clinical reports and studying 3,300 patients on antidepressants, the U.S. Food and Drug Administration (FDA) con- cluded in 2004 that the drugs produce a real, though small, increase in the risk of suicidal behavior for certain children and adolescents, especially during the first few months of treatment, and it ordered that all antidepressant containers carry “black box” warnings stating that the drugs “increase the risk of suicidal think- ing and behavior in children.” In 2007 the FDA expanded this warning to include young adults.
Although many clinicians have been pleased by the FDA order, others worry that it may be ill-advised (Isacsson & Rich, 2014; Haliburn, 2010). They argue that while the drugs may indeed increase the risk of suicidal thoughts and attempts
in as many as 2 to 3 percent of young patients, the risk of suicide is actually reduced in the vast majority of children and teenagers who take the drugs (Christiansen et al., 2015; Mulder, 2010). To support this argument, they point out that the overall rate of teenage suicides decreased by 30 percent in the decade leading up to 2004, as the number of antidepressant prescriptions provided to children and teenagers was soaring (Isacsson & Rich, 2014; Isacsson et al., 2010).
The critics of the black box warnings also point to the initial effect that the warnings had on prescription patterns and teenage suicide rates in the United States and other countries. Some stud- ies suggest that during the first two years
following the institution of the black box warnings, the number of anti- depressant prescriptions fell 22 percent in the United States and the Netherlands, while the rate of teenage suicides rose 14 percent in the United States, the largest suicide rate increase since 1979 (Fawcett, 2007). Although other studies chal- lenge these numbers (Wheeler et al., 2008), it is certainly possible that black box warnings were indirectly depriving many young patients of a medication that they truly needed
to help fight depression and head off sui- cide. Antidepressant prescriptions for de- pressed teenagers now seem to be rising again, and the effect of this trend reversal on teenage suicide rates certainly awaits careful scrutiny.
A major outgrowth and benefit of the black box controversy is that the FDA re- cently has expanded its interest in suicidal side effects to drugs other than antide- pressants. It now requires pharmaceutical companies to test for suicidal side effects in certain newly developed drugs, such as those for obesity and epilepsy, before such drugs receive FDA approval (Carey, 2008; Harris, 2008). In the past, lethal ef- fects of this kind never came to light until well after drugs had been approved and used by millions of patients.
The Black Box controversy: Do Antidepressants cause Suicide?
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closer (Baca-Garcia et al., 2011). This closing trend may reflect increas- ingly similar pressures on young African, Hispanic, and white Ameri- cans—competition for grades and college opportunities, for example, is now intense for all three groups (Barnes, 2010). The growing suicide rates for young African and Hispanic Americans may also be linked to their rising unemployment, the many anxieties and economic pressures of inner-city life, and the rage many feel over racial inequities in our society (Baca-Garcia et al., 2011; Barnes, 2010). Recent studies further indicate that 4.5 of every 100,000 Asian American teens now commit suicide each year.
The highest teenage suicide rate of all is displayed by American Indians. Currently, more than 15 of every 100,000 American Indian teenagers commit suicide each year, double the rate of white American teenagers and triple that of other minority teenagers. Clinical theorists attribute this extraordinarily high rate to factors such as the extreme poverty faced by most American Indian teens, their limited educational and employment opportunities, their particularly high rate of alcohol abuse, and the geographical isolation of those who live on reservations (Alcántara & Gone, 2008; Goldston et al., 2008). In addition, it appears that certain American Indian reservations have extreme suicide rates—called cluster suicides—and that teenagers who live in such communities are unusually likely to be exposed to suicide, to have their lives disrupted, to observe suicidal models, and to be at risk for suicide contagion (Bender, 2006; Chekki, 2004).
The Elderly More than 15 of every 100,000 people over the age of 65 in the United States com- mit suicide, a rate that rises to 18 per 100,000 among the very elderly, as you read earlier (AFSD, 2014). Elderly people commit over 19 percent of all suicides in the
United States, yet they account for only 14 percent of the total population (U.S. Census Bureau, 2014).
Many factors contribute to this high suicide rate. As people grow older, all too often they become ill, lose close friends and relatives, lose control over their lives, and lose status in our society (Draper, 2014; O’Riley et al., 2014). Such experiences may result in feelings of hopelessness, loneliness, depres-
sion, “burdensomeness,” or inevitability among aged persons and so increase the likelihood that they will attempt suicide (Kim et al., 2014; Cukrowicz et al., 2011). One study found that two-thirds of particularly elderly individuals (those over 80 years old) who committed suicide had been hospitalized for medical reasons within two years preceding the suicide (Erlangsen et al., 2005), and another found a height- ened rate of vascular or respiratory illnesses among elderly people who attempted suicide (Levy et al., 2011). Still other research has shown that the suicide rate of elderly people who have recently lost a spouse is particularly high (Ajdacic-Gross et al., 2008).
Elderly people are typically more determined than younger people in their decision to die and give fewer warnings, so their success rate is much higher (Dennis & Brown, 2011). An estimated one of every four elderly persons who attempts suicide succeeds (AFSD, 2014). Given the determination of aged persons and their physical decline, some people argue that older persons who want to die are clear in their thinking and should be allowed to carry out their wishes (see InfoCentral on the next page). However, clinical depression appears to play an important role in as many as 60 percent of suicides by the elderly, suggesting that more elderly people who are suicidal should be receiving treatment for their depressive disorders (Levy
Continuing trend The rate of suicide among American Indians is much higher than the national average. Here a memorial is held for a young suicide victim at a middle school on the Fort Peck Indian Reservation in Poplar, Montana.
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Why do people often view the suicides of elderly or chronically sick people as less tragic than that of young or healthy people?
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In Their Words “What an amount of good nature and humor it takes to endure the gruesome business of growing old.”
Sigmund Freud, 1937
InfoCentral
THE RIGHT TO COMMIT SUICIDE In ancient Greece, citizens with a grave illness or mental anguish could obtain official permission from the Senate to take their own lives (Humphry & Wickett, 1986). In contrast, most Western coun- tries have traditionally discouraged suicide, based on their belief in
the “sanctity of life” (Dickens et al., 2008). Today, however, a person’s “right to commit suicide” is receiving more and more support from the public, particularly in connection with ending great pain and terminal illness (Breitbart et al., 2011; Werth, 2004, 2000).
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WHO SUPPORTS THE RIGHT OF TERMINALLY ILL PATIENTS TO COMMIT SUICIDE?
EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE Euthanasia, also called “mercy killing,” is the practice of killing someone who is terminally sick or badly injured to stop the suffering. Euthanasia is not necessarily initiated by the patient. Physician- assisted suicide is a particular form of euthanasia, in which a physician helps a patient to end his or her life, in response to the patient’s request.
Should physicians provide indirect or direct assistance? Physicians may advise patients about how to end their life (indirect assistance) or may actually end a patient’s life (direct assistance). Many people who support physician-assisted suicide remain un- comfortable with the prospect of a doctor directly inducing a patient’s death.
In 1997 Oregon passed the first U.S. law to legalize physician- assisted suicide. Since then, more than 500 Oregonians have used this law to end their lives.
In 2001 the Netherlands legalized physician- assisted suicide and euthanasia. It is the only country where both are legal. (Onwuteaka-Philipsen et al., 2012; Schadenberg, 2012).
3 percent of all deaths in the Netherlands are the result of euthanasia and/or physician- assisted suicide. (Onwuteaka-Philipsen et˜al., 2012; Schadenberg, 2012).
Some studies from Belgium and the Netherlands show significant num- bers of deaths by euthanasia “without explicit request or consent.” (Onwuteaka- Philipsen et al., 2012; Schadenberg, 2012).
Switzerland, where assisted suicide was made legal in 1942, is the only country where nonphysicians may assist. (Thomasson, 2012).
Many terminally ill foreigners—particularly from Germany, France, and Britain—travel to Switzerland to commit suicide. (Thomasson, 2012)
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Jack Kevorkian, the Michigan physician who claimed to have assisted in the deaths of 130 progressively ill patients, was convicted of second-degree murder and sentenced to prison after he administered a lethal injection to a terminally ill patient on a 60 Minutes broadcast in 2008.
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et al., 2011). In fact, research suggests that treating depression in older persons helps reduce their risk of suicide markedly (Draper, 2014).
The suicide rate among the elderly in the United States is lower in some minor- ity groups ( Joe et al., 2014; Alcántara & Gone, 2008). Although American Indians have the highest overall suicide rate, for example, the rate among elderly American Indians is relatively low. The aged are held in high esteem by American Indians and are looked to for the wisdom and experience they have acquired over the years, and this may help account for their low suicide rate. Such high regard is in sharp contrast to the loss of status often experienced by elderly white Americans.
Similarly, the suicide rate is only one-third as high among elderly African Americans as among elderly white Americans ( Joe et al., 2014; Barnes, 2010). One reason for this low suicide rate may be the pressures faced by African Americans, of whom it is sometimes said: “only the strongest survive” (Seiden, 1981). Those who reach an advanced age often have overcome significant adversity, and many feel proud of what they have accomplished. Because reaching old age is not in itself a form of success for white Americans, their attitude toward aging may be more negative. Another possible explanation is that aged African Americans have successfully over- come the rage that prompts many suicides in younger African Americans.
➤ Summing Up IS SUICIDe lInkeD to age? The likelihood of suicide varies with age. It is uncommon among children, although it has been increasing in that group dur- ing the past several decades. Suicide by adolescents is more common than sui- cide by children, but the numbers have been decreasing over the past decade. Adolescent suicide has been linked to clinical depression, anger, impulsiveness, major stress, and adolescent life itself. Suicide attempts by this age group are numerous. The high attempt rate among adolescents and young adults may be related to the growing number and proportion of young people in the general population, the weakening of family ties, the increased availability and use of drugs among young people, and the broad media coverage of suicide attempts
The power of respect Elderly people are held in high esteem in many traditional societ- ies because of the store of knowledge they have accumulated. Perhaps not so coinciden- tally, suicides among the elderly seem to be less common in these cultures than in those of many industrialized nations.
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Attitudes Toward Suicide Hispanic and African Americans have certain beliefs that may make them less likely to attempt suicide. Both groups hold stronger moral objections to sui- cide than other groups do. In addition, Hispanic Americans have firmer beliefs about the need to cope and survive and feel more responsibility to their families (Oquendo et al., 2005). And African Americans have higher degrees of orthodox religious belief and personal devotion and express more concern about giving others the power to end one’s life (MacDonald, 1998; Neeleman et al., 1998).
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by the young. The rate of suicide among American Indian teens is twice as high as that among white American teens and three times as high as those of African, Hispanic, and Asian American teens.
In Western societies, the elderly are more likely to commit suicide than people in most other age groups. The loss of health, friends, control, and status may produce feelings of hopelessness, loneliness, depression, or inevitability in this age group.
Treatment and Suicide Treatment of suicidal people falls into two major categories: treatment after suicide has been attempted and suicide prevention. Treatment may also be beneficial to relatives and friends of those who commit or attempt to commit suicide. Their feelings of loss, guilt, or anger after a suicide fatality or attempt can be intense (Kramer et al., 2015), but the discussion here is limited to the treatment afforded suicidal people themselves.
What Treatments Are Used After Suicide Attempts? After a suicide attempt, most victims need medical care. Close to one-half million people in the United States are admitted to a hospital each year for injuries resulting from efforts to harm themselves (AFSP, 2014). Some are left with severe injuries, brain damage, or other medical problems. Once the physical damage is treated, psy- chotherapy or drug therapy may begin, on either an inpatient or outpatient basis.
Unfortunately, even after trying to kill themselves, many suicidal people fail to receive systematic follow-up care (Stanley et al., 2015). In some cases, health care professionals are at fault for this lack of follow-up. In others, the person who has attempted suicide refuses therapy. According to one review, the average number of therapy sessions attended by teenagers who receive follow-up care is 8; around 18 percent of such teens stop treatment against their therapists’ advice (Spirito et al., 2011).
The goals of therapy for those who have attempted suicide are to keep the individuals alive, reduce their psychological pain, help them achieve a nonsuicidal state of mind, provide them with hope, and guide them to develop better ways of handling stress (Rudd & Brown, 2011). Various therapies have been employed, including drug, psychodynamic, cognitive-behavioral, group, and family therapies (Baldessarini & Tondo, 2011, 2007; Spirito et al., 2011). Research indicates that cognitive-behavioral therapy may be particularly helpful (Rudd et al., 2015; Brown et al., 2011, 2010). This approach focuses largely on the painful thoughts, sense of hopelessness, dichotomous thinking, poor coping skills, weak problem-solving abili- ties, and other cognitive and behavioral features that characterize suicidal people.
What Is Suicide Prevention? During the past 60 years, emphasis around the world has shifted from suicide treat- ment to suicide prevention. In some respects this change is most appropriate: the last opportunity to keep many potential suicide victims alive comes before their first attempt.
The first suicide prevention program in the United States was founded in Los Angeles in 1955; the first in England, called the Samaritans, was started in 1953. There are now hundreds of suicide prevention centers in the United States and England. In addition, many of today’s mental health centers, hospital emergency rooms, pastoral counseling centers, and poison control centers include suicide prevention programs among their services.
Working with suicide Pedestrians and police work to rescue a young woman who had attempted to drown herself in a river in 2010. Police departments across the world typically provide special crisis intervention training so that officers can develop the skills to help suicidal individuals.
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There are also hundreds of suicide hotlines, 24-hour-a-day telephone services, in the United States. Callers reach a counselor, typically a paraprofessional—a person trained in counseling but without a formal degree—who provides services under the supervision of a mental health professional.
Suicide prevention programs and hotlines respond to suicidal people as individu- als in crisis—that is, under great stress, unable to cope, feeling threatened or hurt, and interpreting their situations as unchangeable. Thus the programs offer crisis intervention: they try to help suicidal people see their situations more accurately, make better decisions, act more constructively, and overcome their crises (Lester, 2011). Because crises can occur at any time, the centers advertise their hotlines and also welcome people who walk in without appointments (see MindTech).
MindTech
Crisis Texting Suicide hotlines and drop-in centers have dominated the field of suicide prevention for decades. Over the past year or so, however, texting has emerged as an
additional tool in the fight against self destruction. More and more therapists are conducting crisis intervention sessions via text, especially with young people. There are some limitations to this form of coun- seling, but there are also advantages, including the following (Kaufman, 2014):
(1) While it is difficult to create the personal connection that even a phone con- versation with a counselor can provide, most people under 20 are very familiar— and comfortable—with texting as a form of communication (Momtaz, 2014).
(2) If a person’s crisis involves an abusive situation with a family member, the per- son does not need to wait until he or she is alone to communicate with a counselor. The texter can be in the same room with their abuser, who might not be any the wiser (Lublin, 2014).
(3) Similarly, a person in crisis who might be out in public does not need to wait until alone to seek help. He or she can still look “cool” to peers or friends while receiving desperately needed assistance (Weichman, 2014).
(4) A session conducted by text can be interrupted and picked back up more naturally than a phone conversation. Likewise, a counselor can hand over a session to another expert with less interruption of flow than there would be in a phone conversation.
(5) Because texts are retained, the person in crisis can go back and reread the texts during difficult moments in the future and revisit the advice and coping mechanisms discussed (Weichman, 2014). Also, saved texts may provide valuable data for researchers studying suicide trends and may lead to unanticipated treatment insights.
One nonprofit service, the Crisis Text Line in New York, has been offering text counseling since the fall of 2013, in partnership with a number of hotlines across the United States (Kaufman, 2014; Lubin, 2014). In the first half year of operation, it exchanged nearly a million texts with 19,000 teenagers, with only minimal advertis- ing. Google now links users to the Crisis Text Line’s contact information whenever they do searches for suicide-related topics.
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▶▶ suicide prevention program A pro- gram that tries to identify people who are at risk of killing themselves and to offer them crisis intervention.
▶▶ crisis intervention A treatment approach that tries to help people in a psychological crisis to view their situation more accurately, make better decisions, act more constructively, and overcome the crisis.
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Some prevention centers and hotlines reach out to par- ticular suicidal populations. The Trevor Lifeline, for example, is a nationwide, around-the-clock hotline available for LGBTQ (lesbian, gay, bisexual, transgender, and questioning) teenagers who are thinking about suicide. This hotline is one of several services offered by the Trevor Foundation, a wide-reaching organization dedicated to providing support, guidance, and information and promoting acceptance of LGBTQ teens.
The public sometimes confuses suicide prevention centers and hotlines with online chat rooms and forums (message boards) to which some suicidal people turn. However, chat rooms and forums operate quite differently, and in fact, most of them do not seek out suicidal people or try to prevent suicide. Typically, these sites are not prepared to deal with suicidal people, do not offer face-to-face support, do not involve professionals or paraprofessionals, and do not have ways of keeping out inappropriate users.
Today, suicide prevention takes place not only at preven- tion centers and hotlines but also in therapists’ offices. Suicide experts encourage all therapists to look for and address signs of suicidal thinking in their clients, regardless of the broad reasons that the clients are seeking treatment (McGlothlin, 2008). With this in mind, a number of guidelines have been developed to help therapists effec- tively uncover, assess, prevent, and treat suicidal thinking and behavior in their daily work (de Beurs et al., 2015; Van Orden et al., 2008; Shneidman & Farberow, 1968).
Although specific techniques vary from therapist to therapist and from prevention center to prevention center, the approach developed originally by the Los Angeles Suicide Prevention Center continues to reflect the goals and techniques of many clinicians and organizations. During the initial contact at the center, the counselor has several tasks:
establish a Positive relationship As callers must trust counselors in order to confide in them and follow their suggestions, counselors try to set a positive and comfortable tone for the discussion. They convey that they are listening, understanding, interested, nonjudgmental, and available.
Understand and Clarify the Problem Counselors first try to understand the full scope of the caller’s crisis and then help the person see the crisis in clear and constructive terms. In particular, they try to help callers see the central issues and the transient nature of their crises and recognize the alternatives to suicide.
assess Suicide Potential Crisis workers at the Los Angeles Suicide Prevention Center fill out a questionnaire, often called a lethality scale, to estimate the caller’s potential for suicide. It helps them determine the degree of stress the caller is under, the caller’s relevant personality characteristics, how detailed the suicide plan is, the severity of symptoms, and the coping resources available to the caller.
assess and Mobilize the Caller’s resources Although they may view themselves as ineffectual, helpless, and alone, people who are suicidal usually have many strengths and resources, including relatives and friends. It is the counselor’s job to recognize, point out, and activate those resources.
formulate a Plan Together the crisis worker and caller develop a plan of action. In essence, they are agreeing on a way out of the crisis, an alternative to suicidal action. Most plans include a series of follow-up counseling sessions over the next few days or weeks, either in person at the center or by phone. Each plan also requires the caller to take certain actions and make certain changes in his or her personal life. Coun- selors usually negotiate a no-suicide contract with the caller—a promise not to attempt suicide, or at least a promise to reestablish contact if the caller again considers suicide. Although such contracts are popular, their effectiveness has been called into question
Raising public awareness In order to better educate the public about suicide’s far reach, many organizations now hold special remembrances. Here the organization Active Minds sponsors an exhibit of 1,100 backpacks at Montclair State University in New Jersey. The backpacks represent the number of col- lege students who die by suicide each year.
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Still at Risk Approximately 4 percent of all suicides are committed by people who are in- patients at mental hospitals or other psychiatric facilities.
Suicide : 245
(Rudd et al., 2006). In addition, if callers are in the midst of a suicide attempt, coun- selors try to find out their whereabouts and get medical help to them immediately.
Although crisis intervention may be sufficient treatment for some suicidal people, longer-term therapy is needed for most (Lester et al., 2007). If a crisis intervention center does not offer this kind of therapy, its counselors will refer the clients elsewhere.
Yet another way to help prevent suicide may be to reduce the public’s access to common means of suicide (Anestis & Anestis, 2015; Lester, 2011). In 1960, for example, around 12 of every 100,000 people in Britain killed themselves by inhaling coal gas (which contains carbon monoxide). In the 1960s, Britain replaced coal gas with natural gas (which contains no carbon monoxide) as an energy source, and by the mid-1970s the rate of coal gas suicide fell to 0 (Maris, 2001). In fact, England’s overall rate of suicide dropped as well. On the other hand, the Netherlands’ drop in gas-induced suicides was compensated for by an increase in other methods, par- ticularly drug overdoses.
Similarly, ever since Canada passed a law in the 1990s restricting the availabil- ity of and access to certain firearms, there has been a decrease in firearm suicides across the country (Leenaars, 2007). Some studies suggest that this decrease has not been displaced by increases in other kinds of suicides; other studies, however, have found an increase in the use of other suicide methods (Caron et al., 2008). Thus, although many clinicians hope that measures such as gun control, safer medications, better bridge barriers, and car emission controls will lower suicide rates, there is no guarantee that they will.
Do Suicide Prevention Programs Work? It is difficult for researchers to measure the effectiveness of suicide prevention pro- grams (Sanburn, 2013; Lester, 2011). There are many kinds of programs, each with its own procedures and each serving populations that vary in number, age, and the like. Communities with high suicide risk factors, such as a high elderly population or economic problems, may continue to have higher suicide rates than other communities regardless of the effectiveness of their local prevention centers.
Do suicide prevention centers reduce the number of suicides in a community? Clinical researchers do not know (Sanburn, 2013). Stud- ies comparing local suicide rates before and after the establishment of community prevention centers have yielded different findings. Some find a decline in a community’s suicide rates, others no change, and still others an increase (De Leo & Evans, 2004; Leenaars & Lester, 2004). Of course, even an increase may represent a positive impact, if it is lower than the larger society’s overall increase in suicidal behavior.
Do suicidal people contact prevention centers? Apparently only a small percentage do (Sanburn, 2013). Moreover, the typical caller to an urban prevention center appears to be young, African American, and female, whereas the greatest number of suicides are committed by older white men (Maris, 2001). A key problem is that people who are suicidal do not necessarily admit to or talk about their feelings in discussions with others, even professionals (Stolberg et al., 2002).
Prevention programs do seem to reduce the number of suicides among those high-risk people who do call. One study identified 8,000 high-risk individuals who contacted the Los Angeles Suicide Prevention Center (Farberow & Litman, 1970). Approximately 2 percent of these callers later committed suicide, compared with the 6 percent suicide rate usually found in similar high-risk groups. Clearly, centers need to be more visible and available to people who are thinking of suicide. The growing number of advertisements and
A different kind of military threat Con- cerned about the growing number of suicides by military personnel, the U.S. Army has dis- tributed this antisuicide poster to soldiers in military bases around the country. The fear and pain of repeated military deployments has apparently been a major factor in the serious rise of depression and suicidal actions among members of the military (Nock et al., 2014).
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announcements on the Web, television, radio, and billboards indicate movement in this direction.
Many theorists have called for more effective public education about suicide as the ultimate form of prevention, and a number of suicide edu- cation programs have emerged. Most of these programs take place in schools and concentrate on students and their teachers ( Joshi et al., 2015; Schilling et al., 2014). There are also a growing number of online sites that provide education about suicide—targeting troubled persons, their family members, and friends (Lai et al., 2014). These offerings agree with the following statement by Shneidman:
The primary prevention of suicide lies in education. The route is through teaching one another and . . . the public that suicide can happen to anyone, that there are verbal and behavioral clues that can be looked for . . . and that help is available. . . .
In the last analysis, the prevention of suicide is everybody’s business.
(Shneidman, 1985, p. 238)
➤ Summing Up treatMent anD SUICIDe Treatment may follow a suicide attempt. When it does, therapists try to help the person achieve a nonsuicidal state of mind and develop better ways of handling stress and solving problems.
Over the past 60 years, emphasis has shifted to suicide prevention. Suicide prevention programs include 24-hour-a-day hotlines and walk-in centers staffed largely by paraprofessionals. During their initial contact with a suicidal person, counselors try to establish a positive relationship, understand and clarify the prob- lem, assess the potential for suicide, assess and mobilize the caller’s resources, and formulate a plan for overcoming the crisis. Beyond such crisis intervention, most suicidal people also need longer-term therapy. In a still broader attempt at prevention, suicide education programs for the public are on the increase.
PUTTING IT...together Psychological and Biological Insights Lag Behind Once a mysterious and hidden problem that was hardly acknowledged by the public and barely investigated by professionals, suicide today is the focus of much attention. During the past 40 years in particular, investigators have learned a great deal about this life-or-death problem.
In contrast to most other problems covered in this textbook, suicide has received much more examination from the sociocultural model than from any other. Socio- cultural theorists have, for example, highlighted the importance of societal change and stress, national and religious affiliation, marital status, gender, race, and the mass media. The insights and information gathered by psychological and biological researchers have been more limited.
Although sociocultural factors certainly shed light on the general background and triggers of suicide, they typically leave us unable to predict that a given person will attempt suicide. Clinicians do not yet fully understand why some people kill themselves while others in similar circumstances manage to find better ways of addressing their problems. Psychological and biological insights must catch up to the sociocultural insights if clinicians are truly to understand suicide.
why might some schools
be reluctant to offer suicide
education programs?
B e t w e e n t h e L i n e s
Clinical Encounters Suicide is the most common clinical emergency encountered in mental health practice (Stolberg et al., 2002; Beutler et al., 2000).
Suicidal behavior or thinking is the most common reason for admission to a men- tal hospital. Around two-thirds of pa- tients who are admitted have aroused concern that they will harm themselves (Miret et al., 2011; Jacobson, 1999).
B e t w e e n t h e L i n e s
Highest National Suicide Rates Lithuania (31.5 per 100,000 people)
South Korea (31)
Kazakhstan (26.9)
Belarus (25.3)
Japan (24.4)
Russia (23.5)
Guyana (22.9)
Ukraine (22.6)
(WhO, 2011)
Suicide : 247
Treatments for suicide also pose some difficult problems. Clinicians have yet to develop clearly successful therapies for suicidal people. Although suicide prevention programs certainly show the clinical field’s commitment to helping those who are suicidal, it is not yet clear how much such programs actually reduce the overall risk or rate of suicide.
At the same time, the growth in the amount of research on suicide offers great promise. And perhaps most promising of all, clinicians are now enlisting the public in the fight against this problem. They are calling for broader public education about suicide—for programs aimed at both young and old. It is reasonable to expect that the current commitment will lead to a better understanding of suicide and to more successful interventions. Such goals are of importance to everyone. Although suicide itself is typically a lonely and desperate act, the impact of such acts is very broad indeed.
KEY TERMS parasuicide, p. 222
suicidal behavior disorder, p. 222
suicide, p. 222
death seeker, p. 224
death initiator, p. 224
death ignorer, p. 224
death darer, p. 224
subintentional death, p. 224
nonsuicidal self injury, p. 224
retrospective analysis, p. 226
hopelessness, p. 229
dichotomous thinking, p. 229
postvention, p. 231
Thanatos, p. 232
egoistic suicide, p. 233
altruistic suicide, p. 233
anomic suicide, p. 233
serotonin, p. 234
suicide prevention program, p. 242
suicide hotline, p. 243
paraprofessional, p. 243
crisis intervention, p. 243
suicide education program, p. 246
QuickQuiz
1. Define suicide and subintentional death. Describe four different kinds of people who attempt suicide. What is nonsuicidal self-injury? pp. 222–225
2. What techniques do researchers use to study suicide? p. 226
3. How do statistics on suicide vary ac- cording to country, religion, gender, marital status, and race? pp. 226–227
4. What kinds of immediate and long- term stressors have been linked to suicide? pp. 227–228
5. What other conditions or events may help trigger suicidal acts? pp. 228–231
6. How do psychodynamic, sociocultural, and biological theorists explain sui- cide, and how well supported are their theories? pp. 232–235
7. Compare the risk, rate, and causes of suicide among children, adolescents, and elderly persons. pp. 235–241
8. How do theorists explain the high rate of suicide attempts by adolescents and young adults? pp. 236–239
9. Describe the nature and goals of treat- ment given to people after they have attempted suicide. Do such people often receive this treatment? p. 242
10. Describe the principles of suicide pre- vention programs. What procedures are used by counselors in these programs? How effective are the programs? pp. 242–246
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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I t was Wednesday. The big day. Midterms in history and physics back to back, beginning at 11:30, and an oral presentation in psych at 3:30. Jarell had been preparing for, and dreading, this day for weeks, calling it “D-Day” to his friends. He had been up until 3:30 a.m. the night before, studying, trying to nail everything
down. It seemed like he had fallen asleep only minutes ago, yet here it was 9:30 a.m. and the killer day was under way.
As soon as he woke, Jarell felt a tight pain grip his stomach. He also noticed buzzing in his ears, a lightheadedness, and even aches throughout his body. He wasn’t surprised, given the day he was about to face. One test might bring a few butterflies of anxiety; two and a presentation were probably good for a platoon of dragonflies.
As he tried to get going, however, Jarell began to suspect that this was more than butterflies. His stomach pain soon turned to spasms, and his lightheadedness be- came outright dizziness. He could barely make it to the bathroom without falling. Thoughts of breakfast made him nauseous. He knew he couldn’t keep anything down.
Jarell began to worry, even panic. This was hardly the best way to face what was in store for him today. He tried to shake it off, but the symptoms stayed. Finally, his roommate convinced him that he had better go to a doctor. At 10:30, just an hour before the first exam, he entered the big brick building called “Student Health.” He felt embarrassed, like a wimp, but what could he do? Persevering and taking two tests under these conditions wouldn’t prove anything—except maybe that he was foolish.
Psychological factors may contribute to somatic, or bodily, illnesses in a variety of ways. The physician who sees Jarell has some possibilities to sort out. Jarell could be faking his pain and dizziness to avoid taking some tough tests. Alter- natively, he may be imagining his illness, that is, faking to himself. Or he could be overreacting to his pain and dizziness. Then again, his physical symptoms could be both real and significant, yet triggered by stress: whenever he feels extreme pressure, such as a person can feel before an important test, Jarell’s gastric juices may become more active and irritate his intestines, and his blood pressure may rise and cause him to become dizzy. Finally, he may be coming down with the flu. Even this “purely medical” problem, however, could be linked to psychological factors. Perhaps weeks of constant worry about the exams and presentation have weakened Jarell’s body so that he was not able to fight off the flu virus. Whatever the diagnosis, Jarell’s state of mind is affecting his body. The physician’s view of the role played by psychological factors will in turn affect the treatment Jarell receives.
You have observed throughout the book that psychological disorders fre- quently have physical causes. Abnormal neurotransmitter activity, for example, contributes to generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. Is it surprising, then, that bodily illnesses may have psychologi- cal causes? Today’s clinicians recognize the wisdom of Socrates’ fourth century b.c.e. assertion: “You should not treat body without soul.”
The idea that psychological factors may contribute to somatic illnesses has ancient roots, yet it had few proponents before the twentieth century. It
8
T o p I c o v e r v I e w
Factitious Disorder
Conversion Disorder and Somatic Symptom Disorder Conversion Disorder Somatic Symptom Disorder What Causes Conversion and Somatic Symptom Disorders? How Are Conversion and Somatic Symptom Disorders Treated?
Illness Anxiety Disorder
Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions Traditional Psychophysiological Disorders New Psychophysiological Disorders
Psychological Treatments for Physical Disorders Relaxation Training Biofeedback Meditation Hypnosis Cognitive Interventions Support Groups and Emotion Expression Combination Approaches
Putting It Together: Expanding the Boundaries of Abnormal Psychology
Disorders Featuring Somatic Symptoms
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was particularly unpopular during the Renaissance, when medicine began to be a physical science and scientists became committed to the pursuit of objective “fact” (Conti, 2014). At that time, the mind was considered the territory of priests and philosophers, not of physicians and scientists. By the seventeenth century, French philosopher René Descartes went so far as to claim that the mind, or soul, is totally separate from the body—a position called mind-body dualism. Over the course of the twentieth century, however, numerous studies convinced medical and clinical researchers that psychological factors such as stress, worry, and perhaps even uncon- scious needs can contribute in major ways to bodily illness.
DSM-5 lists a number of psychological disorders in which bodily symptoms or concerns are the primary features of the disorders. These include factitious disorder, in which patients intentionally produce or feign physical symptoms; conversion disorder, which is characterized by medically unexplained physical symptoms that affect voluntary motor or sensory functioning; somatic symptom disorder, in which people become disproportionately concerned, distressed, and disrupted by bodily symp- toms; illness anxiety disorder, in which people who are anxious about their health become preoccupied with the notion that they are seriously ill despite the absence of bodily symptoms; and psychological factors affecting other medical conditions, disorders in which psychological factors adversely affect a person’s general medical condition.
Factitious Disorder Like Jarell, people who become physically sick usually go to a physician. Sometimes, however, the physician cannot find a medical cause for the problem and may sus- pect that other factors are involved. Perhaps the patient is malingering—intentionally feigning illness to achieve some external gain, such as financial compensation or deferment from military service (Crighton et al., 2014).
Alternatively, a patient may intentionally produce or feign physical symptoms from a wish to be a patient; that is, the motivation for assuming the sick role may be the role itself (Baig et al., 2015). Physicians would then decide that the patient is manifesting factitious disorder (see Table 8-1). Consider, for example, the symp- toms of this lab technician:
A 29-year-old female laboratory technician was admitted to the medical service via the emergency room because of bloody urine. The patient said that she was being treated for lupus erythematosus by a physician in a different city. She also men- tioned that she had had Von Willebrand’s disease (a rare hereditary blood disorder) as a child. On the third day of her hospitalization, a medical student mentioned to the resident that she had seen this patient several weeks before at a different hospital in the area, where the patient had been admitted for the same problem. A search of the patient’s belongings revealed a cache of anticoagulant medication. When confronted with this information she refused to discuss the matter and hur- riedly signed out of the hospital against medical advice.
(Spitzer et al., 1981, p. 33)
Factitious disorder is known popularly as Munchausen syndrome, a label derived from the exploits of Baron von Münchhausen, an eighteenth-century cavalry officer who journeyed from tavern to tavern in Europe telling fantastical tales about his sup- posed military adventures (Ayoub, 2010). People with factitious disorder often go to extremes to create the appearance of illness (APA, 2013). Many give themselves medications secretly. Some, like the woman just described, inject drugs to cause bleeding (Mucha et al., 2014). Still others use laxatives to produce chronic diarrhea.
table: 8-1
Dx Checklist
Factitious Disorder Imposed on Self 1. False creation of physical or
psychological symptoms, or deceptive production of injury or disease, even without external rewards for such ailments.
2. Presentation of oneself as ill, damaged, or hurt.
Factitious Disorder Imposed on Another
1. False creation of physical or psychological symptoms, or deceptive production of injury or disease, in another person, even without external rewards for such ailments.
2. Presentation of another person (victim) as ill, damaged, or hurt.
(Information from: APA, 2013)
▶▶ factitious disorder A disorder in which a person feigns or induces physical symptoms, typically for the purpose of assuming the role of a sick person.
Disorders Featuring Somatic Symptoms : 251
High fevers are especially easy to create. In a classic study of patients with prolonged mysterious fever, more than 9 percent were eventually diagnosed with factitious disorder (Feldman et al., 1994).
People with factitious disorder often research their supposed ailments and are impressively knowledgeable about medicine (Miner & Feldman, 1998). Many eagerly undergo painful testing or treatment, even surgery (McDermott et al., 2012). When confronted with evidence that their symptoms are factitious, they typically deny the charges and leave the hospital; they may enter another hospital the same day.
Clinical researchers have had a hard time determining the prevalence of facti- tious disorder, since patients with the disorder hide the true nature of their problem (Kenedi, Sames, & Paice, 2013). Overall, the pattern appears to be more common in women than men. Men, however, may more often have severe cases. The disorder usually begins during early adulthood.
Factitious disorder seems to be particularly common among people who (1) re- ceived extensive treatment for a medical problem as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, laboratory technician, or medical aide. A number have poor social support, few enduring social relation- ships, and little family life (McDermott et al., 2012; Feldman et al., 1994).
The precise causes of factitious disorder are not understood (Lawlor & Kirakowski, 2014), although clinical reports have pointed to factors such as depression, unsup- portive parental relationships during childhood, and an extreme need for social sup- port that is not otherwise available (McDermott et al., 2012; Ozden & Canat, 1999; Feldman et al., 1995, 1994). Nor have clinicians been able to develop dependably effective treatments for this disorder.
Psychotherapists and medical practitioners often report feel- ings of annoyance or anger toward people with factitious disorder, feeling that these people are, at the very least, wasting their time. Yet people with the disorder feel they have no control over the problem, and they often experience great distress.
In a related pattern, factitious disorder imposed on another, known popularly as Munchausen syndrome by proxy, parents or caretakers make up or pro- duce physical illnesses in their children, leading in some cases to repeated painful
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In Their Words “I would rather have anything wrong with my body than something wrong with my head.”
Sylvia plath, The Bell Jar
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diagnostic tests, medication, and surgery (Koetting, 2015; Ayoub, 2010). If the chil- dren are removed from their parents and placed in the care of others, their symptoms disappear (see PsychWatch).
➤ Summing Up FACTITIOUS DISORDER People with factitious disorder feign or induce physical disorders, typically for the purpose of assuming the role of a sick person. The disorder is neither well understood nor well treated. In a related pattern, facti tious disorder imposed on another, a parent fabricates or induces a physical ill ness in his or her child.
PsychWatch
Tanya, a mere 8 years old, had been hospitalized 127 times over the past five years and undergone 28 different medical procedures—from removal of her spleen to exploratory surgery of her intes- tines. Two months ago, her mother was arrested, charged with child endangerment. When Tanya’s grandmother gently tried to talk to the girl about her mother’s arrest (or, as she put, “Mommy’s going away”), Tanya was upset and confused. “I miss Mommy so much. She’s the best person in the world. She spent all her time with me in the hospital. She made the doctors pay attention to me. They say Mommy was making me feel bad, putting bad stuff in my tube. But there’s no way Mommy made me feel bad.”
Cases like Tanya’s have horrified the public and called attention to Munchausen syndrome by proxy. This form of factitious disorder is caused by a caregiver who uses various techniques to induce symptoms in a child—giving the child drugs, tampering with medica tions, contaminating a feeding tube, or even smothering the child, for example. The illness can take almost any form, but the most common symptoms are bleed ing, seizures, asthma, comas, diarrhea, vomiting, “accidental” poisonings, infec tions, fevers, and sudden infant death syndrome.
Between 6 and 30 percent of the vic tims of Munchausen syndrome by proxy die as a result of their symptoms, and
8 percent of those who survive are perma nently disfigured or physically impaired (Flaherty & Macmillan, 2013; Ayoub, 2006). Psychological, educational, and physical development are also affected (Bass & Glaser, 2014; Schreier et al., 2010).
The syndrome is very hard to diagnose and may be more common than clinicians once thought (Ashraf & Thevasagayam, 2014; Feldman, 2004). The parent (usu ally the mother) seems to be so devoted and caring that others sympathize with and admire her. Yet the physical problems disappear when the child and parent are separated (Koetting, 2015; Scheuerman et al., 2013). In many cases, siblings of the sick child are also victimized (Ayoub, 2010, 2006).
What kind of parent carefully inflicts pain and illness on her own child? The typical Munchau sen mother is emotionally needy: she craves the attention and praise she receives for her de voted care of her sick child (Asraf & Thevasagayam, 2014; Noeker, 2004). She may have little social support outside the medical system. Often the mothers have a medical background of some kind—perhaps having worked for merly in a doctor’s office. A num ber have medically unexplained physical problems of their own (Bass & Glaser, 2014). Typically
they deny their actions, even in the face of clear evidence, and refuse to undergo therapy (Bluglass, 2001).
Law enforcement authorities ap proach Munchausen syndrome by proxy as a crime—a carefully planned form of child abuse (Flaherty & Macmillan, 2013; Schreier et al., 2010). They almost always require that the child be separated from the mother (Koetting, 2015; Ayoub, 2010, 2006). At the same time, a parent who re sorts to such actions is seriously disturbed and greatly in need of clinical help. Thus clinical researchers and practitioners must now work to develop clearer insights and more effective treatments for such parents and their young victims.
Munchausen Syndrome by proxy
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Disorders Featuring Somatic Symptoms : 253
Conversion Disorder and Somatic Symptom Disorder When a bodily ailment has an excessive and disproportionate impact on the per- son, has no apparent medical cause, or is inconsistent with known medical diseases, physicians may suspect a conversion disorder or a somatic symptom disorder. Consider the plight of Brian:
Brian was spending Saturday sailing with his wife, Helen. The water was rough but well within what they considered safe limits. They were having a wonderful time and really didn’t notice that the sky was getting darker, the wind blowing harder, and the sailboat becoming more difficult to control. After a few hours of sailing, they found themselves far from shore in the middle of a powerful and dangerous storm.
The storm intensified very quickly. Brian had trouble controlling the sailboat amidst the high winds and wild waves. He and Helen tried to put on the safety jackets they had neglected to wear earlier, but the boat turned over before they were finished. Brian, the better swimmer of the two, was able to swim back to the overturned sailboat, grab the side, and hold on for dear life, but Helen simply could not overcome the rough waves and reach the boat. As Brian watched in horror and disbelief, his wife disappeared from view.
After a time, the storm began to lose its strength. Brian managed to right the sail- boat and sail back to shore. Finally he reached safety, but the personal consequences of this storm were just beginning. The next days were filled with pain and further hor- ror: the Coast Guard finding Helen’s body . . . texts, emails, and conversations with family members and friends . . . self-blame . . . grief . . . and more. Compounding this horror, the accident had left Brian with a severe physical impairment—he could not walk properly. He first noticed this terrible impairment when he sailed the boat back to shore, right after the accident. As he tried to run from the sailboat to get help, he could hardly make his legs work. By the time he reached the nearby beach restaurant, all he could do was crawl. Two patrons had to lift him to a chair, and after he told his story and the authorities were alerted, he had to be taken to a hospital.
At first Brian and the hospital physician assumed that he must have been hurt during the accident. One by one, however, the hospital tests revealed nothing—no broken bones, no spinal damage, nothing. Nothing that could explain such severe impairment.
By the following morning, the weakness in his legs had become near paralysis. Because the physicians could not pin down the nature of his injuries, they decided to keep his activities to a minimum. He was not allowed to talk long with the police. To his deep regret, he was not even permitted to attend Helen’s funeral.
The mystery deepened over the following days and weeks. As Brian’s paralysis continued, he became more and more withdrawn, unable to see more than a few friends and family members and unable to take care of the many unpleasant tasks attached to Helen’s death. He could not bring himself to return to work or get on with his life. Texting, emailing, and phone conversations slowly came to a halt. At most, he was able to go online and surf the Internet. Almost from the beginning, Brian’s paralysis had left him self-absorbed and drained of emotion, unable to look back and unable to move forward.
Conversion Disorder Eventually, Brian received a diagnosis of conversion disorder (see Table 8-2). People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases (APA, 2013). In short, they have neurological-like symptoms—for example, paralysis, blindness, or loss of feeling—that have no neurological basis.
table: 8-2
Dx Checklist
Conversion Disorder 1. Presence of at least one symptom
or deficit that affects voluntary or sensory function.
2. Symptoms are found to be inconsistent with known neurological or medical disease.
3. Significant distress or impairment.
(Information from: APA, 2013)
▶▶ conversion disorder A disorder in which a person’s bodily symptoms affect his or her voluntary motor and sensory functions, but the symptoms are inconsis- tent with known medical diseases.
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Conversion disorder often is hard, even for physicians, to distinguish from a genuine medical problem (Ali et al., 2015; Parish & Yutzy, 2011). In fact, it is always possible that a diagnosis of conversion disorder is a mistake and that the patient’s problem has an undetected neurological or other medical cause (de Schipper et al., 2014). Because conversion disorders are so similar to “genuine” medical ailments, physicians sometimes rely on oddities in the patient’s medical picture to help dis- tinguish the two (Boone, 2011). The symptoms of a conversion disorder may, for example, be at odds with the way the nervous system is known to work. In a con- version symptom called glove anesthesia, numbness begins sharply at the wrist and extends evenly right to the fingertips. As Figure 8-1 shows, real neurological damage is rarely as abrupt or evenly spread out.
The physical effects of a conversion disorder may also differ from those of the corresponding medical problem (Ali et al., 2015; Scheidt et al., 2014). For example, when paralysis from the waist down, or paraplegia, is caused by damage to the spinal cord, a person’s leg muscles may atrophy, or waste away, unless physical therapy is applied. The muscles of people whose paralysis is the result of a conversion disorder, in contrast, do not usually atrophy. Perhaps those with a conversion disorder exercise their muscles without being aware that they are doing so. Similarly, people with conversion blindness have fewer accidents than people who are organically blind, an indication that they have at least some vision even if they are unaware of it.
Unlike people with factitious disorder, those with conversion disorder do not consciously want or purposely produce their symptoms. Like Brian, they almost always believe that their problems are genuinely medical (Lahman et al., 2010). This pattern is called “conversion” disorder because clinical theorists used to believe that individuals with the disorder are converting psychological needs or conflicts into their neurological-like symptoms. Although some theorists still believe that con- version is at work in the disorder, others prefer alternative kinds of explanations, as you’ll see later.
Conversion disorder usually begins between late childhood and young adulthood; it is diagnosed at least twice as often in women as in men (Raj et al., 2014). It typi- cally appears suddenly, at times of extreme stress, and lasts a matter of weeks (Kukla et al., 2010). Some research suggests that people who develop the disorder tend to be generally suggestible (see MindTech on the next page); many are highly susceptible to hypnotic procedures, for example (Parish & Yutzy, 2011; Roelofs et al., 2002). It is thought to be a rare problem, occurring in at most 5 of every 1,000 persons.
figure 8-1 Glove anesthesia In this conversion symp- tom (left), the entire hand, extending from the fingertips to the wrist, becomes numb. Actual physical damage (right) to the ulnar nerve, in contrast, causes anesthesia in the ring finger and little finger and beyond the wrist part- way up the arm; damage to the radial nerve causes loss of feeling only in parts of the ring, middle, and index fingers and the thumb and partway up the arm. (Information from: Gray, 1959.)
▶▶ somatic symptom disorder A disorder in which people become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing, and their lives are greatly and disproportionately disrupted by the symptoms.
Area affected by ulnar nerve
Area affected by radial nerve
Glove anesthesia
Radial nerve
Ulnar nerve
Disorders Featuring Somatic Symptoms : 255
Somatic Symptom Disorder People with somatic symptom disorder become excessively distressed, con- cerned, and anxious about bodily symptoms that they are experiencing, and their lives are greatly disrupted by the symptoms (APA, 2013) (see Table 8-3 on the next page). The symptoms last longer but are less dramatic than those found in conver- sion disorder. In some cases, the somatic symptoms have no known cause; in others,
MindTech
Can Social Media Spread “Mass Hysteria”? In Chapter 1, you read about outbreaks during the Middle Ages of mass madness, also called mass hysteria or mass psychogenic illness, in which large numbers of people would share psychological
or physical maladies that had no apparent cause (see page 9). Periodic outbreaks of mysterious illnesses are not a thing of the past. In fact, the number of such cases currently seems to be on the increase (Vitelli, 2013). Most of today’s clinicians consider these outbreaks to be a form of conversion disorder.
New Zealand sociologist Robert Bartholomew (2014) has been studying mass psychogenic illnesses that date back over 400 years, and he argues that social media is a major factor in the current increase. One notable 2011 outbreak in Le Roy, New York, dem- onstrates the suggestive role played by social media (Vitelli, 2013; Dominus, 2012). A local high school student began having facial spasms. After several weeks, others started having similar symptoms, and eventually 18 girls from the high school were affected. Apparently, a number of these teenagers began to show symptoms after they saw a YouTube video featuring a girl from a nearby town who had significant tics. Doctors eventu- ally concluded that this was an example of mass psychogenic illness.
An unusual aspect of the Le Roy case that further points to the likely role of social media is that in addition to the 18 high school girls, a 36-year-old woman with no connection to the teenage girls also began having the same symptoms dur- ing the same period of time (NBC, 2012). She stated that she first saw the facts of the case on a Facebook post.
This case mirrors others in recent years, such as an outbreak of hiccups and vocal tics in early 2013 among teenagers in Danvers, Massachusetts, and the case of 400 garment workers in a Bangladesh factory who had severe gastrointestinal symptoms for which there was ultimately no physical explanation (Vitelli, 2013). In these and other cases, the symptoms seemed to be spread, at least in part, by social media exposure.
Bartholomew (2014) believes that due to the power of social media, future outbreaks of mass psychogenic illness may be more numerous, wide ranging, and severe than any yet recorded. He observes that in the distant past “the local priests, who were . . . summoned to [treat mass psychogenic illnesses], faced a daunting task . . . but they were fortunate in one regard: they did not have to contend with mobile phones, Twitter, and Facebook.”
In what ways could social
media itself help to prevent
or reduce cases of mass
psychogenic illness?
Sc ie
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So ur
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Coming around again? This lithograph depicts Saint Vitus’ Dance, a widespread form of mass psychogenic illness during the Middle Ages, characterized by rapid, uncoordinated, jerking movements of the face, feet, and hands. Similar symptoms were on display in Le Roy, New York, in 2011, during an outbreak of mass psychogenic illness attributed to the impact of social media.
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the cause can be identified. Either way, the person’s concerns are disproportionate to the seriousness of the bodily problems.
Two patterns of somatic symptom disorder have received particular attention. In one, sometimes called a somatization pattern, the individual experiences a large and varied number of bodily symptoms. In the other, called a predominant pain pattern, the person’s primary bodily problem is the experience of pain.
Somatization Pattern Sheila baffled medical specialists with the wide range of her symptoms:
Sheila reported having abdominal pain since age 17, necessitating exploratory surgery that yielded no specific diagnosis. She had several pregnancies, each with severe nausea, vomiting, and abdominal pain; she ultimately had a hysterectomy for a “tipped uterus.” Since age 40 she had experienced dizziness and “blackouts,” which she eventually was told might be multiple sclerosis or a brain tumor. She continued to be bedridden for extended periods of time, with weakness, blurred vision, and difficulty urinating. At age 43 she was worked up for a hiatal hernia be- cause of complaints of bloating and intolerance of a variety of foods. She also had additional hospitalizations for neurological, hypertensive, and renal workups, all of which failed to reveal a definitive diagnosis.
(Spitzer et al., 1994, 1981, pp. 185, 260)
Like Sheila, people with a somatization pattern of somatic symptom disorder expe- rience many long-lasting physical ailments—ailments that typically have little or no physical basis. This pattern, first described by Pierre Briquet in 1859, is also known as Briquet’s syndrome. A sufferer’s ailments often include pain symptoms (such as headaches or chest pain), gastrointestinal symptoms (such as nausea or diarrhea), sexual symptoms (such as erectile or menstrual difficulties), and neurological-type symptoms (such as double vision or paralysis).
People with a somatization pattern usually go from doctor to doctor in search of relief. They often describe their many symptoms in dramatic and exaggerated terms. Most also feel anxious and depressed (Taycan et al., 2014; Dimsdale & Creed, 2010). The pattern typically lasts for many years, fluctuating over time but rarely disappearing completely without therapy (Parish & Yutzy, 2011; Abbey, 2005).
table: 8-3
Dx Checklist
Somatic Symptom Disorder 1. Person experiences at least one
upsetting or repeatedly disruptive physical (somatic) symptom.
2. Person experiences an unreason able number of thoughts, feel ings, and behaviors regarding the nature or implications of the physical symptoms, including one of the following:
(a) Repeated, excessive thoughts about their seriousness.
(b) Continual high anxiety about their nature or health implications.
(c) Disproportionate amounts of time and energy spent on the symptoms or their health implications.
3. Physical symptoms usually continue to some degree for more than 6 months.
(Information from: APA, 2013)
“I can’t watch. It makes me sick.” These fans are “watching” the 2010 World Cup match between Spain and Germany. The stress of big games in soccer and other sports causes many fans to develop a range of physical symptoms, such as fainting, throwing up, stomach pain, headaches, and chest pains. No wonder these people closed their eyes as the tension mounted. ©
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Disorders Featuring Somatic Symptoms : 257
Between 0.2 and 2.0 percent of all women in the United States may experience a somatization pattern in any given year, compared with less than 0.2 percent of men (North, 2005; APA, 2000). The pattern often runs in families; as many as 20 percent of the close female relatives of women with the pattern also develop it. It usually begins between adolescence and young adulthood.
Predominant Pain Pattern If the primary feature of somatic symptom disorder is pain, the person is said to have a predominant pain pattern. Patients with conversion disorder or another pattern of somatic symptom disorder may also experience pain, but it is the key symptom in this pattern. The source of the pain may be known or unknown. Either way, the concerns and disruption produced by the pain are disproportionate to its severity and seriousness.
Although the precise prevalence has not been determined, this pattern appears to be fairly common (Nickel et al., 2010). It may begin at any age, and women seem more likely than men to experience it (APA, 2000). Often it develops after an accident or during an illness that has caused genuine pain, which then takes on a life of its own. For example, Laura, a 36-year-old woman, reported pains that went far beyond the usual symptoms of her tubercular disease, called sarcoidosis:
Before the operation I would have little joint pains, nothing that really bothered me that much. After the operation I was having severe pains in my chest and in my ribs, and those were the type of problems I’d been having after the operation, that I didn’t have before. . . . I’d go to an emergency room at night, 11:00, 12:00, 1:00 or so. I’d take the medicine, and the next day it stopped hurting, and I’d go back again. In the meantime this is when I went to the other doctors, to complain about the same thing, to find out what was wrong; and they could never find out what was wrong with me either. . . .
. . . At certain points when I go out or my husband and I go out, we have to leave early because I start hurting. . . . A lot of times I just won’t do things because my chest is hurting for one reason or another. . . . Two months ago when the doctor checked me and another doctor looked at the x-rays, he said he didn’t see any signs of the sarcoid then and that they were doing a study now, on blood and various things, to see if it was connected to sarcoid. . . .
(Green, 1985, pp. 60–63)
What Causes Conversion and Somatic Symptom Disorders? For many years, conversion and somatic symptom disorders were referred to as hysterical disorders. This label was meant to convey the prevailing belief that exces-
sive and uncontrolled emotions underlie the bodily symptoms found in these disorders.
Work by Ambroise-Auguste Liébault and Hippolyte Bernheim in the late nineteenth century helped foster the notion that such psychological factors were at the root of hys- terical disorders. These researchers founded
the Nancy School in Paris for the study and treatment of mental disorders. There they were able to produce hysterical symptoms in normal people—deafness, paraly- sis, blindness, and numbness—by hypnotic suggestion, and they could remove the symptoms by the same means (see Chapter 1). If hypnotic suggestion could both produce and reverse physical dysfunctioning, they concluded, hysterical disorders might themselves be caused by psychological processes.
Why do the terms “hysteria”
and “hysterical” currently have
such negative connotations in
our society?
B e t W e e N t h e L I N e S
More Wealth, Less Pain 37% Percentage of low-income people
with chronic neck or back pain
26% Percentage of high-income people with chronic neck or back pain
32% Percentage of low-income people with chronic knee or leg pain
19% Percentage of high-income people with chronic knee or leg pain
(Brown, 2012)
B e t W e e N t h e L I N e S
DSM-5 Controversy: Overreactions to Medical Illnesses? According to DSM-5, even people whose physical symptoms are caused by significant medical problems may qualify for a diagnosis of somatic symp- tom disorder if they are overly anxious or upset by their medical problems. Critics worry that many patients who are understandably upset by the de- velopment of cancer, heart disease, or other serious diseases will incor- rectly receive a diagnosis of somatic symptom disorder.
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Today’s leading explanations for conversion and somatic symptom disorders come from the psychodynamic, behavioral, cognitive, and multicultural models. None has received much research support, however, and the disorders are still poorly understood.
The Psychodynamic View As you read in Chapter 1, Freud’s theory of psychoanalysis began with his efforts to explain hysterical symptoms. Indeed, he was one of the few clinicians of his day to treat patients with these symptoms seriously, as people with genuine problems. After studying hypnosis in Paris, Freud became interested in the work of an older physician, Josef Breuer (1842–1925). Breuer had successfully used hypnosis to treat a woman he called Anna O., who suffered from hysterical deafness, disorganized speech, and paralysis (Ellenberger, 1972). On the
basis of this and similar cases, Freud (1894) came to believe that hysterical disorders represented a conversion of underlying emo- tional conflicts into physical symptoms and concerns.
Observing that most of his patients with hysterical disorders were women, Freud centered his explanation of such disorders on the needs of girls during their phallic stage (ages 3 through 5). At that time in life, he believed, all girls develop a pattern of desires called the Electra complex: each girl experiences sexual feelings for her father and at the same time recognizes that she must compete with her mother for his affection. However, aware of her mother’s more powerful position and of cultural taboos, the child typically represses her sexual feelings and rejects these early desires for her father.
Freud believed that if a child’s parents overreact to her sexual feelings—with strong punishments, for example—the Electra conflict will be unresolved and the child may reexperience sexual anxiety throughout her life. Whenever events trigger
sexual feelings, she may feel an unconscious need to hide them from both herself and others. Freud concluded that some women hide their sexual feelings by uncon- sciously converting them into physical symptoms and concerns.
Most of today’s psychodynamic theorists take issue with parts of Freud’s expla- nation of conversion and somatic symptom disorders (Nickel et al., 2010), but they continue to believe that sufferers of the disorders have unconscious conflicts carried forth from childhood, which arouse anxiety, and that they convert this anxiety into “more tolerable” physical symptoms (Brown et al., 2005).
Psychodynamic theorists propose that two mechanisms are at work in these disorders—primary gain and secondary gain. People derive primary gain when their bodily symptoms keep their internal conflicts out of awareness. During an argument, for example, a man who has underlying fears about expressing anger may develop a conversion paralysis of the arm, thus preventing his feelings of rage from reaching consciousness. People derive secondary gain when their bodily symp- toms further enable them to avoid unpleasant activities or to receive sympathy from others. When, for example, a conversion paralysis allows a soldier to avoid combat duty or conversion blindness prevents the breakup of a relationship, secondary gain may be at work. Similarly, the conversion paralysis of Brian, the man who lost his wife in the boating accident, seemed to help him avoid many painful duties after the accident, such as attending her funeral and returning to work.
The Behavioral View Behavioral theorists propose that the physical symptoms of conversion and somatic symptom disorders bring rewards to sufferers (see Table 8-4). Perhaps the symptoms remove those with the disorders from an unpleasant relationship, or perhaps the symptoms bring attention from other people ( Witthöft & Hiller, 2010). In response to such rewards, the sufferers learn to display the bodily
Electra complex goes awry Freud argued that a hysterical disorder may result when par ents overreact to their daughter’s early displays of affection for her father, by repeatedly pun ishing her, for example. The child may go on to exhibit sexual repression in adulthood and convert sexual feelings into physical ailments.
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▶▶ primary gain In psychodynamic theory, the gain people derive when their somatic symptoms keep their internal conflicts out of awareness.
▶▶ secondary gain In psychodynamic theory, the gain people derive when their somatic symptoms elicit kindness from others or provide an excuse to avoid unpleasant activities.
Disorders Featuring Somatic Symptoms : 259
symptoms more and more prominently. Behaviorists also hold that people who are familiar with an illness will more readily adopt its physical symptoms. In fact, stud- ies find that many sufferers develop their bodily symptoms after they or their close relatives or friends have had similar medical problems (Marshall et al., 2007).
Clearly, the behavioral focus on the role of rewards is similar to the psychody- namic notion of secondary gain. The key difference is that psychodynamic theorists view the gains as indeed secondary—that is, as gains that come only after underlying conflicts produce the disorders. Behaviorists view them as the primary cause of the development of the disorders.
Like the psychodynamic explanation, the behavioral view of conversion and somatic symptom disorders has received little research support. Even clinical case reports only occasionally support this position. In many cases the pain and upset that surround the disorders seem to outweigh any rewards the symptoms might bring.
The Cognitive View Some cognitive theorists propose that conversion and somatic symptom disorders are forms of commu- nication, providing a means for people to express emotions that would otherwise be difficult to convey (Koo et al., 2014; Hal- lquist et al., 2010). Like their psychodynamic colleagues, these theorists hold that the emotions of people with the disorders are being converted into physical symptoms. They suggest, however, that the purpose of the conversion is not to defend against anxi- ety but to communicate extreme feelings—anger, fear, depres- sion, guilt, jealousy—in a “physical language” that is familiar and comfortable for the person with the disorder.
According to this view, people who find it particularly hard to recognize or express their emotions are candidates for conver- sion and somatic symptom disorders. So are those who “know” the language of physical symptoms through firsthand experience with a genuine physical ailment. Because children are less able to express their emotions verbally, they are particularly likely to develop physical symptoms as a form of communica- tion (Shaw et al., 2010). Like the other explanations, this cognitive view has not been widely tested or supported by research.
The Multicultural View Most Western clinicians believe that it is inappropri- ate to produce or focus excessively on somatic symptoms in response to personal
table: 8-4
Disorders That Have Somatic Symptoms
Disorder
Voluntary Control of Symptoms?
Symptoms Linked to Psychosocial Factor?
An Apparent Goal?
Malingering Yes Maybe Yes
Factitious disorder Yes Yes No*
Conversion disorder No Yes Maybe
Somatic symptom disorder No Yes Maybe
Illness anxiety disorder No Yes No
Psychophysiological disorder No Yes No
Physical illness No Maybe No
*Except for medical attention.
The positive side of swearing Famous English soccer player Wayne Rooney yells out in pain after being struck by a ball in the groin. Research indicates that swearing can help reduce pain, and not just pain on display in conversion and somatic symptom disorders, but even pain like Rooney’s (Stephens et al., 2009).
M ar
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/P re
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io n
vi a
A P
Im ag
es
: chapter 8260
distress (Shaw et al., 2010; So, 2008; Escobar, 2004). That is, in part, why conversion and somatic symptom dis- orders are included in DSM-5. Some theorists believe, however, that this position reflects a Western bias—a bias that sees somatic reactions as an inferior way of dealing with emotions (Moldavsky, 2004; Fábrega, 1990).
In fact, the transformation of personal distress into somatic complaints is the norm in many non-Western cultures (Draguns, 2006; Kleinman, 1987). In such cul- tures, the formation of such complaints is viewed as a socially and medically correct—and less stigmatizing— reaction to life’s stressors. Studies have found very high rates of stress-caused bodily symptoms in non-Western medical settings throughout the world, including those in China, Korea, Japan, and Arab countries (Zhou et al., 2015; Matsumoto & Juang, 2008). People throughout Latin America seem to display the most somatic reac- tions (Escobar, 2004, 1995; Escobar et al., 1998, 1992). Even within the United States, Hispanic Americans display more somatic reactions in the face of stress than do other populations.
The lesson to be learned from such multicultural findings is not that somatic reactions to stress are superior to psychological ones or vice versa, but rather, once again, that both bodily and psychological reactions to life events are often influenced by one’s culture. Overlooking this point can lead to knee-jerk mislabels or misdiagnoses.
How Are Conversion and Somatic Symptom Disorders Treated? People with conversion and somatic symptom disorders usually seek psychotherapy only as a last resort. They believe that their problems are completely medical and at first reject all suggestions to the contrary (Lahmann et al., 2010). When a physi- cian tells them that their symptoms or concerns have a psychological dimension, they often go to another physician. Eventually, however, many patients with these disorders do consent to psychotherapy, psychotropic drug therapy, or both (Raj et al., 2014).
Many therapists focus on the causes of these disorders (the trauma or anxiety tied to the physical symptoms) and apply insight, exposure, and drug therapies (Ali et al., 2015; Boone, 2011). Psychodynamic therapists, for example, try to help those with somatic symptoms become conscious of and resolve their underlying fears, thus eliminating the need to convert anxiety into physical symptoms (Nickel et al., 2010; Hawkins, 2004). Alternatively, behavioral therapists use exposure treatments. They expose clients to features of the horrific events that first triggered their physi- cal symptoms, expecting that the clients will become less anxious over the course of repeated exposures and more able to face those upsetting events directly rather than through physical channels (Stuart et al., 2008). And biological therapists use antianxiety drugs or certain antidepressant drugs to help reduce the anxiety of cli- ents with conversion and somatic symptom disorders (Raj et al., 2014).
Other therapists try to address the physical symptoms of these disorders rather than the causes, using techniques such as suggestion, reinforcement, or confronta- tion (Ali et al., 2015; Parish & Yutzy, 2011). Those who employ suggestion offer emotional support to patients and tell them persuasively (or hypnotically) that their physical symptoms will soon disappear (Hallquist et al., 2010; Lahmann et al., 2010). Therapists who take a reinforcement approach arrange for the removal of rewards for
Mind over matter The opposite of somatic symptom disorder are instances in which people “ignore” pain or other physical symp toms. Here a London performance artist smiles comfortably while her skin is pierced with sharp hooks that help suspend her from the ceiling above. Her action was part of a protest to end shark finning—the practice of cutting off a shark’s fin and throwing its stillliving body back into the sea so that the fin can be used in the production of shark fin soup (a food delicacy) and other goods.
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B e t W e e N t h e L I N e S
Diagnostic Confusion Many medical problems with vague or confusing symptoms—multiple sclerosis, hyperparathyroidism, lupus, and chronic fatigue syndrome are examples— frequently have been misdiagnosed as conversion or somatic symptom disor- der. In the past, whiplash was regularly misdiagnosed in this way (Shaw et al., 2010; Ferrari, 2006; Nemecek, 1996).
Disorders Featuring Somatic Symptoms : 261
a client’s “sickness” symptoms and an increase of rewards for healthy behaviors (Raj et al., 2014; North, 2005). And therapists who take a confrontational approach try to force patients out of the sick role by straightforwardly telling them that their bodily symptoms are without medical basis (Sjolie, 2002). Researchers have not fully evalu- ated the effects of these particular approaches on conversion and somatic symptom disorders (Martlew, Pulman, & Marson, 2014; Boone, 2011).
➤ Summing Up CONVERSION DISORDER AND SOMATIC SYMPTOM DISORDER Conversion disorder involves bodily symptoms that affect voluntary motor and sensory functions, but the symptoms are inconsistent with known medical diseases. Diagnosticians are sometimes able to distinguish conversion disorder from a “true” medical problem by observing oddities in the patient’s medical picture. In somatic symptom disorder, people become excessively distressed, con cerned, and anxious about bodily symptoms that they are experiencing, and their lives are greatly and disproportionately disrupted by the symptoms.
Freud developed the initial psychodynamic view of conversion and somatic symptom disorders, proposing that the disorders represent a conversion of underlying emotional conflicts into physical symptoms. According to behavior ists, the physical symptoms of these disorders bring rewards to the sufferer, and such reinforcement helps maintain the symptoms. Some cognitive theorists propose that the disorders are forms of communication and that people express their emotions through their physical symptoms. Treatments for these disorders include insight, exposure, and drug therapies and may include techniques such as suggestion, reinforcement, or confrontation.
Illness Anxiety Disorder People with illness anxiety disorder, previously known as hypochondriasis, are chronically anxious about their health and are convinced that they have or are developing a serious medical illness, despite the absence of somatic symptoms (see Table 8-5). They repeatedly check their body for signs of illness and misinterpret various bodily events as signs of serious medical problems. Typically the events are merely normal bodily changes, such as occasional coughing, sores, or sweating. Those with illness anxiety disorder persist in such misinterpretations no matter what friends, relatives, and physicians say. Many of these individuals recognize that their concerns are excessive, but many do not.
Although illness anxiety disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers. Between 1 and 5 percent of all people experience the disorder (Weck et al., 2015; Abramowitz & Braddock, 2011). Their symptoms tend to rise and fall over the years. Physicians report see- ing many cases (Dimsdale et al., 2011). As many as 7 percent of all patients seen by primary care physicians may display the disorder.
Theorists typically explain illness anxiety disorder much as they explain various anxiety disorders (see Chapter 4). Behaviorists, for example, believe that the ill- ness fears are acquired through classical conditioning or modeling (Marshall et al., 2007). Cognitive theorists suggest that people with the disorder are so sensitive to and threatened by bodily cues that they come to misinterpret them (Witthöft & Hiller, 2010).
People with illness anxiety disorder usually receive the kinds of treatments that are used to treat obsessive-compulsive disorder (see pages 139–142). Studies reveal, for example, that clients with the disorder often improve considerably when given
table: 8-5
Dx Checklist
Illness Anxiety Disorder 1. Person is preoccupied with
thoughts about having or getting a significant illness. In reality, person has no or, at most, mild somatic symptoms.
2. Person has easily triggered, high anxiety about health.
3. Person displays unduly high number of healthrelated behaviors (e.g., keeps focusing on body) or dysfunctional healthavoidance behaviors (e.g., avoids doctors).
4. Person’s concerns continue to some degree for at least 6 months.
(Information from: APA, 2013)
▶▶ illness anxiety disorder A disorder in which people are chronically anxious about and preoccupied with the notion that they have or are developing a seri- ous medical illness, despite the absence of somatic symptoms. Previously known as hypochondriasis.
: chapter 8262
the same antidepressant drugs that are helpful in cases of obsessive-compulsive disor- der (Bouman, 2008). Many clients also improve when treated with the behavioral approach of exposure and response prevention (Weck et al., 2015). In this approach, the therapists repeatedly point out bodily variations to the clients while, at the same time, preventing them from seeking their usual medical attention. In addition, cognitive therapists guide the clients to identify, challenge, and change their beliefs about illness that are helping to maintain their disorder.
➤ Summing Up ILLNESS ANXIETY DISORDER People with illness anxiety disorder are chroni cally anxious about and preoccupied with the notion that they have or are developing a serious medical illness, despite the absence of substantial somatic symptoms. Theorists explain this disorder much as they do anxiety disorders. Treatment includes drug, behavioral, and cognitive approaches originally developed for obsessivecompulsive disorder.
Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions About 85 years ago, clinicians identified a group of physical illnesses that seemed to be caused or worsened by an interaction of biological, psychological, and sociocultural factors (Dunbar, 1948; Bott, 1928). Early editions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders, but DSM-5 labels them as psychological factors affecting other medical conditions (see Table 8-6). The more familiar term “psychophysiological” will be used in this chapter.
It is important to recognize that significant medical symptoms and conditions are involved in psychophysiological disorders and that the disorders often result in seri- ous physical damage (APA, 2013). They are different from the factitious, conversion, and illness anxiety disorders that are accounted for primarily by psychological factors.
Traditional Psychophysiological Disorders Before the 1970s, clinicians believed that only a limited number of illnesses were psy- chophysiological. The best known and most common of these disorders were ulcers, asthma, insomnia, chronic headaches, high blood pressure, and coronary heart disease. Recent research, however, has shown that many other physical illnesses—including bacterial and viral infections—may also be caused by an interaction of psychosocial and physical factors. Let’s look first at the traditional psychophysiological disorders and then at the illnesses that are newer to this category.
Ulcers are lesions (holes) that form in the wall of the stomach or of the duo- denum, resulting in burning sensations or pain in the stomach, occasional vomiting, and stomach bleeding. More than 25 million people in the United States have ulcers at some point during their lives, and ulcers cause an estimated 6,500 deaths each year (Stratemeier & Vignogna, 2014). Ulcers often are caused by an interaction of stress factors, such as environmental pressure or intense feelings of anger or anxiety (see Figure 8-2), and physiological factors, such as the bacteria H. pylori (Marks, 2014; Fink, 2011).
Asthma causes the body’s airways (the trachea and bronchi) to narrow periodi- cally, making it hard for air to pass to and from the lungs. The resulting symptoms are shortness of breath, wheezing, coughing, and a terrifying choking sensation. Some 235 million people in the world—25 million in the United States alone—currently
table: 8-6
Dx Checklist
Psychological Factors Affect- ing Other Medical Conditions 1. The presence of a medical
condition.
2. Psychological factors negatively affect the medical condition by:
• Affecting the course of the medical condition.
• Providing obstacles for the treatment of the medical condition.
• Posing new health risks.
• Triggering or worsening the medical condition.
(Information from: APA, 2013)
▶▶ psychophysiological disorders Dis- orders in which biological, psychological, and sociocultural factors interact to cause or worsen a physical illness. Also known as psychological factors affecting other medical conditions.
▶▶ ulcer A lesion that forms in the wall of the stomach or of the duodenum.
▶▶ asthma A medical problem marked by narrowing of the trachea and bronchi, which results in shortness of breath, wheezing, coughing, and a choking sensation.
▶▶ insomnia Difficulty falling or staying asleep.
▶▶ muscle contraction headache A headache caused by a narrowing of muscles surrounding the skull. Also known as tension headache.
▶▶ migraine headache A severe, near- paralyzing headache that occurs on one side of the head.
Disorders Featuring Somatic Symptoms : 263
suffer from asthma (WHO, 2013; Akinbami et al., 2011), and most were children or young teenagers at the time of the first attack. Seventy percent of all cases appear to be caused by an interaction of stress factors, such as environmental pressures or anxiety, and physiological factors, such as allergies to specific substances, a slow- acting sympathetic nervous system, or a weakened respiratory system (CDC, 2013; Dhabhar, 2011).
Insomnia, difficulty falling asleep or maintaining sleep, plagues more than one-third of the population each year (Heffron, 2014). Although many of us have temporary bouts of insomnia that last a few nights or so, a large number of people—10 percent of the popu- lation—have insomnia that lasts months or years (see InfoCentral on the next page). Chronic insomniacs feel as though they are almost constantly awake. They often are very sleepy during the day and may have difficulty functioning. Their problem may be caused by a combination of psychosocial factors, such as high levels of anxiety or depression, and physiological problems, such as an overactive arousal system or certain medical ailments (Trauer et al., 2015; Belleville et al., 2011).
Chronic headaches are frequent intense aches of the head or neck that are not caused by another physical disorder. There are two major types. Muscle contraction, or tension, headaches are marked by pain at the back or front of the head or the back of the neck. These occur when the muscles surrounding the skull tighten, narrowing the blood vessels. Approximately 45 million Americans suffer from such headaches (CDC, 2010).
Migraine headaches are extremely severe, often nearly para- lyzing headaches that are located on one side of the head and are sometimes accompanied by dizziness, nausea, or vomiting. Migraine headaches are thought by some medical theorists to develop in two phases: (1) blood vessels in the brain narrow, so that the flow of blood to parts of the brain is reduced, and (2) the same blood vessels later expand, so that blood flows through them rapidly, stimulating many neuron endings and causing pain. Twenty-three million people in the United States suffer from migraines.
Research suggests that chronic headaches are caused by an interaction of stress factors, such as environmental pressures or general feelings of helplessness, anger, anxiety, or depression, and physiological factors, such as abnormal activity of the
Percentage Who Perform Activity When Stressed
A ct
iv it
y
Watch TV, read, or listen to music
82%
Talk to family or friends
71%
Pray or meditate 62%
Exercise 55%
Eat 37%
Smoke, drink, or take drugs
26%
Take medication 12%
Hurt self 1%
Tweet 8%
Use cell phone to call, text, take photos, or play games
68%
Play video games 72%
Go on the Internet 77%
figure 8-2 What do people do to relieve stress? According to surveys, most of us go on the Internet, watch television, read, or listen to music. Tweeting is on the rise. (Information from: IWS, 2011; Pew Research Center, 2011, 2010; MHA, 2008; NPD Group, 2008.)
More than head pain Beyond intense head pain, the symptoms of migraine headaches may range from dizziness, nausea, and vomiting to physical ailments that virtually paralyze the individual. Here soccer star Freddie Ljungberg is taken from the Major League Soccer AllStar game to a nearby hospital in 2009. A longtime migraine sufferer, he lost his vision temporarily as a consequence of a migraine that he devel oped during the game.AP
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InfoCentral
SLEEP AND SLEEP DISORDERS Sleep is a naturally recurring state that features altered conscious- ness, suspension of voluntary bodily functions, muscle relaxation, and reduced perception of environmental stimuli. Researchers have acquired much data about the stages, cycles, brain waves, and
mechanics of sleep, but they do not fully understand its precise purpose. We do know, however, that humans and other animals need sleep to survive and function properly.
0 3 6 9
12 15
Infants
ho ur
s
Toddlers Preschoolers School children
Teens College age
Adults
Sleep people NEED
Sleep people GET
15 13 13 12 12 10.5 10.5 9.5 9.5 7.5 8 6.5 8 7
SLEEP-AWAKE DISORDERS
Sleep-awake disorders are syndromes characterized by significant and repeated disruptions in the quantity, quality, timing, or nature of a person’s sleep (APA, 2013).
HOW MUCH DAILY SLEEP DO PEOPLE NEED VERSUS GET?
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26%
emotion Happy 21%
Unhappy 46%
26% 22%
gender Men Women
age
22% 29%
$
Po or
p eo
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32%
W ea
lth y
pe op
le
22%
25%
All adults
18 -2
9
21%
30 -4
9
30%
50 -6
9
26%
70 +
22%
0 10 20 30 40 50
0 10 20 30 40 50
0 10 20 30 40 50
0 10 20 30 40 50
0 10 20 30 40 50
WHO HAD TROUBLE FALLING ASLEEP LAST NIGHT?
raceage 0 2 4 6 8
10
20-39 40-49 50-59 60-69 70-79 80+
1.8% 4.9% 6.0% 5.5% 5.7% 7.0% 4.7% 2.5% 2.0%
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Total Adults
4.1%U.S. doctors prescribe sleeping medications for
Insomnia disorder: severe difficulty falling asleep or
maintaining sleep at least three nights
per week
Hypersomnolence disorder: need
for extra sleep, and excessive sleepiness
Narcolepsy: repeated sudden and irrepressible
need to sleep during waking hours
Sleep apnea disorder: frequent
awakenings each night due to peri-
odic deprivation of oxygen to the brain
during sleep
Circadian rhythm disorder: mismatch between a person’s sleep-wake pattern and the sleep-wake
schedule of most other people
Parasomnias: disorders
featuring frequent sleepwalking
episodes, sleep terrors, or
nightmares (APA, 2013)
10%
2%
.03%
9%
3%
4%
Tips for a good night’s sleep • Go to bed at the same time each night and awaken at
the same time each morning.
• Avoid large meals before bedtime.
• Do not drink caffeine or alcohol before bedtime.
• Do not smoke tobacco before bedtime.
• Read or listen to soothing music before bedtime.
• Avoid viewing electronic media before bedtime.
• Create a cool, dark, and quiet bedroom atmosphere.
• If you cannot sleep, perform an interesting or pro- ductive activity until you feel sleepy.
% of people afflicted
Mild insomnia One-fourth of all adults regularly suf- fer from some degree of insomnia.
25%
(CDC, 2014; National Sleep Foundation, 2014; Gallup, 2013)
(CDC, 2013)
gender Men Women
5.8% 3.5% 0 2 4 6 8
10
Nodded oˆ while driving during past month
(CDC, 2013)
(CDC, 2014; Oelschlager, 2014)
problems 0 5
10 15 20 25 Difficulty concentrating
Forgetfulness Inability to work on hobbies Difficulty driving Inability to perform financial duties Inability to work effectively
23 .2
%
18 .2
%
13 .3
%
11 .3
%
10 .5
%
8. 6%
Sleeplessness-produced problems
Disorders Featuring Somatic Symptoms : 265
neurotransmitter serotonin, vascular problems, or muscle weakness (Bruffaerts et al., 2015; Young & Skorga, 2011; Engel, 2009).
Hypertension is a state of chronic high blood pressure. That is, the blood pumped through the body’s arteries by the heart produces too much pressure against the artery walls. Hypertension has few outward signs, but it interferes with the proper functioning of the entire cardiovascular system, greatly increasing the likeli- hood of stroke, heart disease, and kidney problems. It is estimated that 75 million people in the United States have hypertension, thousands die directly from it annu- ally, and millions more perish because of illnesses caused by it (CDC, 2014, 2011). Around 10 percent of all cases are caused by physiological abnormalities alone; the rest result from a combination of psychological and physiological factors and are called essential hypertension. Some of the leading psychosocial causes of essential hypertension are constant stress, environmental danger, and general feelings of anger or depression. Physiological factors include obesity, smoking, poor kidney function, and an unusually high proportion of the gluey protein collagen in a person’s blood vessels (Hu et al., 2015; Brooks et al., 2011).
Coronary heart disease is caused by a blocking of the coronary arteries, the blood vessels that surround the heart and are responsible for carrying oxygen to the heart muscle. The term actually refers to several problems, including blockage of the
coronary arteries and myocardial infarction (a “heart attack”). In the United States, nearly 18 million people have some form of coronary heart disease. It is the leading cause of death for both men and women in the nation, accounting for 600,000 deaths each year, around 40 percent of all deaths (CDC, 2014; AHA, 2011). The majority of all cases
of coronary heart disease are related to an interaction of psychosocial factors, such as job stress or high levels of anger or depression, and physiological factors, such as high cholesterol, obesity, hypertension, smoking, or lack of exercise (Rhéaume et al., 2015; Bekkouche et al., 2011).
What Factors Contribute to Psychophysiological Disorders? Over the years, clinicians have identified a number of variables that may generally contribute to the development of psychophysiological disorders. The variables can be grouped as biological, psychological, and sociocultural factors.
Biological Factors You saw in Chapter 5 that one way the brain activates body organs is through the operation of the autonomic nervous system (ANS ), the net- work of nerve fibers that connect the central nervous system to the body’s organs. Defects in this system are believed to contribute to the development of psychophysiological disorders (Lundberg, 2011; Hugdahl, 1995). If one’s ANS is stimulated too easily, for example, it may overreact to situations that most people find only mildly stressful, eventually damaging certain organs and causing a psychophysiological disorder. Other more specific biological problems may also contribute to psychophysiological disorders. A person with a weak gastrointestinal system, for example, may be a prime candidate for an ulcer, whereas someone with a weak respiratory system may develop asthma readily.
In a related vein, people may display “favored” biological reac- tions that raise their chances of developing psychophysiological disorders. Some individuals perspire in response to stress, others develop stomachaches, and still others have a rise in blood pressure (Lundberg, 2011). Research has indicated, for example, that some people are particularly likely to have temporary rises in blood pres- sure when stressed (Su et al., 2014). It may be that they are prone to develop hypertension.
Studying sleep Clinicians and researchers use special techniques to assess and learn about sleep and sleep disorders. This man is undergoing a polysomnographic examina tion, a procedure that measures a person’s physiological activity during sleep, including measurements of lung, heart, and brain activity.
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What jobs and/or lifestyles
in our society might be
particularly stressful and
traumatizing?
▶▶ hypertension Chronic high blood pressure.
▶▶ coronary heart disease Illness of the heart caused by a blockage in the coronary arteries.
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Psychological Factors According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors and thus increase their chances of developing psychophysiological disorders ( Williams et al., 2011). Researchers have found, for example, that men with a repressive coping style (a reluctance to express discomfort, anger, or hostility) tend to have a particularly sharp rise in blood pressure and heart rate when they are stressed (Trapp et al., 2014).
Another personality style that may contribute to psychophysiological disorders is the Type A personality style, an idea introduced a half- century ago by two cardiologists, Meyer Friedman and Ray Rosenman (1959). People with this style are said to be consistently angry, cynical, driven, impatient, competitive, and ambitious. They interact with the world in a way that, according to Friedman and Rosenman, produces continual stress and often leads to coronary heart disease. People with a Type B personality style, by contrast, are thought to be more relaxed,
less aggressive, and less concerned about time and thus are less likely to develop cardiovascular deterioration.
The link between the Type A personality style and coronary heart disease has been supported by many studies. In one well-known investigation of more than 3,000 people, Friedman and Rosenman (1974) separated healthy men in their for- ties and fifties into Type A and Type B categories and then followed their health over the next eight years. More than twice as many Type A men developed coronary heart disease. Later studies found that Type A functioning correlates similarly with heart disease in women (Haynes et al., 1980).
Recent studies indicate that the link between the Type A personality style and heart disease may not be as strong as the earlier studies suggested. These studies do suggest, however, that several of the characteristics that supposedly make up the Type A style, particularly hostility and time urgency, may indeed be strongly related to heart disease (Allan, 2014; Williams et al., 2013).
sociocultural Factors: the Multicultural PersPective Adverse social con- ditions may set the stage for psychophysiological disorders (Su et al., 2014). Such conditions produce ongoing stressors that trigger and interact with the biological and personality factors just discussed. One of society’s most negative social conditions, for example, is poverty. In study after study, it has been found that relatively wealthy people have fewer psychophysiological disorders, better health in general, and better health outcomes than poor people (Singh & Siahpush, 2014; Chandola & Marmot, 2011). One obvious reason for this relationship is that poorer people typically experi- ence higher rates of crime, unemployment, overcrowding, and other negative stress- ors than wealthier people. In addition, they typically receive inferior medical care.
The relationship between race and psychophysiological and other health prob- lems is complicated. On the one hand, as one might expect from the economic trends just discussed, African Americans have more such problems than do white Americans. African Americans have, for example, higher rates of high blood pressure, diabetes, and asthma (Wang et al., 2014; CDC, 2011). They are also more likely than white Americans to die of heart disease and stroke. Certainly, economic factors may help explain this racial difference. Many African Americans live in poverty; those who do often must contend with the high rates of crime and unemployment that often result in poor health conditions (Greer et al., 2014).
Research further suggests that the high rate of psychophysiological and other medical disorders among African Americans probably extends beyond economic factors. Consider, for example, the finding that 42 percent of African Americans have high blood pressure, compared with 29 percent of white Americans (CDCP, 2011). Although this difference may be explained in part by the dangerous environments
“I’m sure it’s nothing.”
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▶▶ Type A personality style A person- ality pattern characterized by hostility, cynicism, drivenness, impatience, com- petitiveness, and ambition.
▶▶ Type B personality style A person- ality pattern in which a person is more relaxed, less aggressive, and less con- cerned about time.
Disorders Featuring Somatic Symptoms : 267
in which so many African Americans live and the unsatisfying jobs at which so many must work (Gilbert et al., 2011), other factors may also be operating. A physiological predisposition among African Ameri- cans may, for example, increase their risk of developing high blood pressure. Or it may be that repeated experiences of racial discrimina- tion constitute special stressors that help raise the blood pressure of African Americans (Dolezsar et al., 2014) (see Figure 8-3). In fact, some recent investigations have found that the more discrimination people experience over a one-year period, the greater their daily rise in blood pressure (Smart-Richman et al., 2010).
Looking at the health picture of African Americans, one might expect to find a similar trend among Hispanic Americans. After all, a high percentage of Hispanic Americans also live in poverty, are exposed to discrimination, are affected by high rates of crime and unemployment, and receive inferior medical care (BLS, 2015; Travis & Meltzer, 2008). However, despite such disadvantages, the health of Hispanic Americans is, on average, at least as good and often better than that of both white Americans and African Americans (CDC, 2015). As you can see in Table 8-7, for example, Hispanic Americans have lower rates of high blood pressure, high cholesterol, asthma, and cancer than white Americans or African Americans do.
The relatively positive health picture for Hispanic Americans in the face of clear economic disadvantage has been referred to in the clinical field as the “Hispanic Health Paradox.” Generally, researchers are puzzled by this pattern, but a few expla- nations have been offered. It may be, for example, that the strong emphasis on social relationships, family support, and religiousness that often characterize Hispanic American cultures increase health resilience among their members (Dubowitz et al., 2010; Gallo et al., 2009), or Hispanic Americans may have a physiological predispo- sition that improves their likelihood of having better health outcomes.
New Psychophysiological Disorders Clearly, biological, psychological, and sociocultural factors combine to produce psy- chophysiological disorders. In fact, the interaction of such factors is now considered the rule of bodily functioning, not the exception. As the years have passed, more and more illnesses have been added to the list of traditional psychophysiological disorders, and researchers have found many links between psychosocial stress and a wide range of physical illnesses. Let’s look at how these links were established and then at psychoneuroimmunology, the area of study that ties stress and illness to the body’s immune system.
61%
54%
79%
42%43%
31%
63%
33%
“It is hard for young Black persons to get ahead
because they face so much
discrimination.”
“Black youth receive a poorer
education on average than white youth.”
“The police discriminate much more
against Black youth than
against white youth.”
“Racism will not be
eliminated during my lifetime.”
African American respondents White American respondents
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figure 8-3 How much discrimination do racial minority teenagers face? It depends on who’s being asked the question. In a recent survey of 1,590 teenagers and young adults, African American respondents were more likely than white American respondents to recognize that African American teens experience various forms of discrimination. (Information from: Black Youth Project, 2011.)
table: 8-7
Dx Checklist
Prevalence of Medical Disorders Among U.S. Racial Groups
High Blood Pressure
High Cholesterol Diabetes Asthma Cancer
African Americans 42% 24% 16% 13% 5%
White Americans 29% 30% 11% 11% 8%
Hispanic Americans 21% 20% 11% 9% 3%
(Information from: CDCP, 2011; Mendes, 2010)
: chapter 8268
Are Physical Illnesses Related to Stress? Back in 1967 two research- ers, Thomas Holmes and Richard Rahe, developed the Social Readjustment Rating Scale, which assigns numerical values to the stresses that most people experience at some time in their lives (see Table 8-8). Answers given by a large sample of participants indicated that the most stressful event on the scale is the death of a spouse, which receives a score of 100 life change units (LCUs). Lower on the scale is retirement (45 LCUs), and still lower is a minor violation of the law (11 LCUs). This scale gave researchers a yardstick for measuring the total amount of stress a person faces over a period of time. If, for example, in the course of a year a woman started a new business (39 LCUs), sent her son off to college (29 LCUs), moved to a new house (20 LCUs), and had a close friend die (37 LCUs), her stress score for the year would be 125 LCUs, a considerable amount of stress for such a period of time.
With this scale in hand, Holmes and Rahe (1989, 1967) examined the relation- ship between life stress and the onset of illness. They found that the LCU scores of sick people during the year before they fell ill were much higher than those of healthy people. If a person’s life changes totaled more than 300 LCUs over the course of a year, he or she was particularly likely to develop serious health problems.
Using the Social Readjustment Rating Scale or similar scales, studies have since linked stresses of various kinds to a wide range of physical conditions, from trench mouth and upper respiratory infections to cancer (Baum et al., 2011; Rook et al., 2011) (see MediaSpeak on page 270). Overall, the greater the amount of life stress, the greater the likelihood of illness. Researchers even have found a relationship between traumatic stress and death. Widows and widowers, for example, display an increased risk of death during their period of bereavement (Moon et al., 2014; Möller et al., 2011).
table: 8-8
Most Stressful Life Events
Adults: Social Readjustment Rating Scale*
1. Death of spouse
2. Divorce
3. Marital separation
4. Jail term
5. Death of close family member
6. Personal injury or illness
7. Marriage
8. Fired at work
9. Marital reconciliation
10. Retirement
11. Change in health of family member
12. Pregnancy
*Full scale has 43 items. (Reprinted from Journal of Psychosomatic Research,
Vol. 11, Holmes, T. H., & Rahe, R. H., The Social Readjustment Rating Scale, 213-218, Copyright
1967, with permission from Elsevier.)
Students: Undergraduate Stress Questionnaire†
1. Death (family member or friend)
2. Had a lot of tests
3. It’s finals week
4. Applying to graduate school
5. Victim of a crime
6. Assignments in all classes due the same day
7. Breaking up with boy/girlfriend
8. Found out boy/girlfriend cheated on you
9. Lots of deadlines to meet
10. Property stolen
11. You have a hard upcoming week
12. Went into a test unprepared
†Full scale has 83 items. (Information from: Crandall, C. S., Preisler, J. J., & Aussprung, J.
(1992). Measuring life event stress in the lives of college students: The Undergraduate Stress Questionnaire (USQ). Journal of
Behavioral Medicine, 15(6), 627–662.)
▶▶ psychoneuroimmunology The study of the connections between stress, the body’s immune system, and illness.
▶▶ immune system The body’s network of activities and cells that identify and destroy antigens and cancer cells.
▶▶ antigen A foreign invader of the body, such as a bacterium or virus.
▶▶ lymphocytes White blood cells that circulate through the lymph system and bloodstream, helping the body identify and destroy antigens and cancer cells.
Disorders Featuring Somatic Symptoms : 269
One shortcoming of Holmes and Rahe’s Social Readjustment Rating is that it does not take into consideration the particular life stress reactions of specific populations. For example, in their development of the scale, the researchers sampled white Americans predominantly. Few of the respondents were African Americans or Hispanic Americans. But since their ongoing life experiences often differ in key ways, might not members of minority groups and white Americans differ in their stress reactions to various kinds of life events? Research indicates that indeed they do (Bennett & Olugbala, 2010; Johnson, 2010). One study found, for example, that African Americans experience greater stress than white Americans in response to a major personal injury or illness, a major change in work responsibilities, or a major change in living conditions (Komaroff et al., 1989, 1986). Similarly, studies have shown that women and men differ in their reactions to a number of life changes (APA, 2010; Wang et al., 2007).
Finally, college students may face stressors that are different from those listed in the Social Readjustment Rating Scale. Instead of having marital difficulties, being fired, or applying for a job, a college student may have trouble with a roommate, fail a course, or apply to graduate school. When researchers use special scales to measure life events in this population, they find the expected relationships between stressful events and illness (Anders et al., 2012; Hurst et al., 2012) (see Table 8-8 again).
Psychoneuroimmunology How do stressful events result in a viral or bacte- rial infection? Researchers in an area of study called psychoneuroimmunology seek to answer this question by uncovering the links between psychosocial stress, the immune system, and health. The immune system is the body’s network of activi- ties and cells that identify and destroy antigens—foreign invaders, such as bacteria, viruses, fungi, and parasites—and cancer cells. Among the most important cells in this system are billions of lymphocytes, white blood cells that circulate through the lymph system and the bloodstream. When antigens strike, lymphocytes spring into action to help the body overcome the invaders.
One group of lymphocytes, called helper T-cells, identifies antigens and then multiplies and triggers the production of other kinds of immune cells. Another group, natural killer T-cells, seeks out and destroys body cells that have already been infected by viruses, thus helping to stop the spread of a viral infection. A third group of lymphocytes, B-cells, produces antibodies, protein molecules that recognize and bind to antigens, mark them for destruction, and prevent them from causing infection.
Researchers now believe that stress can interfere with the activity of lympho- cytes, slowing them down and thus increasing a person’s susceptibility to viral and
Student stress-busters: East and West According to research, frequent testing is the second most stressful life event for high school and college students. To reduce such stress, college applicants from Beijing give one another head massages in preparation for China’s college entrance exams (left). In the meantime, students at a dorm at Northwestern University in the United States try to blow off steam by performing “primal screams” during their final exam period (right).
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B e t W e e N t h e L I N e S
The Immune System at Work Marital Stress During and after marital spats, women typically release more stress hormones than men, and so have poorer immune functioning (Gouin et al., 2009; Kiecolt-Glaser et al., 1996).
Virtues of Laughter After watching a humorous video, research partici- pants who laughed at the film showed decreases in stress and improve- ments in natural killer cell activity (Bennett, 1998).
: chapter 8270
75%10:00 AM
The first time it was an ear, nose and throat doctor. I had an emergency visit for an ear infection, which was causing a level of pain I hadn’t experienced since giving birth. He looked at the list of drugs I was taking for my bipolar disorder and closed my chart.
“I don’t feel comfortable prescribing anything,” he said. “Not with everything else you’re on.” He said it was probably safe to take Tylenol and politely but firmly indicated it was time for me to go. The next day my eardrum ruptured and I was left with minor but per manent hearing loss.
Another time I was lying on the examining table when a gastroenter ologist I was seeing for the first time looked at my list of drugs and shook her finger in my face. “You better get yourself together psychologically,” she said, “or your stomach is never going to get any better.” . . .
I was surprised when, after one of these runins, my psychopharmacolo gist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medi cal care than “normal” people. . . . I never knew it until I started poking around, but this particular kind of dis criminatory doctoring has a name. It’s called “diagnos tic overshadowing.” . . . [P]eople with a serious mental illness—including bipolar disorder, major depression, schizophrenia and schizoaffective disorder—end up with wrong diagnoses and are undertreated.
That is a problem, because if you are given one of these diagnoses you probably also suffer from one or more chronic physical conditions: though no one quite knows why, migraines, irritable bowel syndrome and mitral valve prolapse often go hand in hand with bipo lar disorder. . . .
It’s little wonder that many people with a serious mental illness don’t seek medical attention when they need it. As a result, many of us end up in emergency rooms—where doctors, confronted with an endless
MediaSpeak when Doctors Discriminate
By Juliann Garey, New York Times, August 10, 2013
stream of drug addicts who come to their door look ing for an easy fix—are often all too willing to equate mental illness with drugseeking behavior and refuse to prescribe pain medication. . . .
Indeed, given my experience over the last two de cades, I shouldn’t have been surprised by the statistics I found in . . . a review of studies . . . . The takeaway: people who suffer from a serious mental illness and use the public health care system die 25 years earlier than those without one.
True, suicide is a big factor, ac counting for 30 to 40 percent of early deaths. But 60 percent die of pre ventable or treatable conditions. First on the list is, unsurprisingly, cardio vascular disease. Two studies showed that patients with both a mental ill ness and a cardiovascular condition received about half the number of followup interventions, like bypass surgery or cardiac catheterization, after having a heart attack than did the “normal” cardiac patients.
The report also contains a list of policy recommendations, including designating patients with serious mental illnesses as a highpriority population; coordinating and in
tegrating mental and physical health care for such people; education for health care workers and patients; and a qualityimprovement process that . . . ensures appropriate prevention, screening and treatment services. . . .
We can only hope that humanizing programs like this . . . become a requirement for all health care work ers. Maybe then “first, do no harm” will apply to every one, even the mentally ill.
August 11, 2013, “OPINION; When Doctors Discriminate,” Carey, Juliann. From New York Times, 8/11/2013 © 2013 The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission is prohibited.
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Disorders Featuring Somatic Symptoms : 271
bacterial infections (Dhabhar, 2014, 2011). In a landmark study, inves- tigator Roger Bartrop and his colleagues (1977) in New South Wales, Australia, compared the immune systems of 26 people whose spouses had died eight weeks earlier with those of 26 matched control group participants whose spouses had not died. Blood samples revealed that lymphocyte functioning was much lower in the bereaved people than in the controls. Still other studies have shown slow immune functioning in people who are exposed to long-term stress. For example, research- ers have found poorer immune functioning among those who provide ongoing care for a relative with Alzheimer’s disease (Fonareva & Oken, 2014; Kiecolt-Glaser et al., 2002, 1996).
These studies seem to be telling a remarkable story. During periods when healthy people happened to have unusual levels of stress, they remained healthy on the surface, but their stressors apparently slowed their immune systems so that they became susceptible to illness. If stress affects our capacity to fight off illness, it is no wonder that researchers have repeatedly found a relationship between life stress and illnesses of various kinds. But why and when does stress interfere with the immune system? Several factors influence whether stress will result in a slowdown of the system, including biochemi- cal activity, behavioral changes, personality style, and degree of social support.
BiocheMical activity Excessive activity of the neurotransmitter norepinephrine apparently contributes to slowdowns of the immune system. Remember from Chapter 5 that stress leads to increased activity by the sympathetic nervous system, including an increase in the release of norepinephrine throughout the brain and body. Research indicates that if stress continues for an extended time, norepineph- rine eventually travels to receptors on certain lymphocytes and gives them an inhibi- tory message to stop their activity, thus slowing down immune functioning (Dhabhar, 2014; Lekander, 2002).
In a similar manner, corticosteroids—that is, cortisol and other so-called stress hormones—apparently contribute to poorer immune system functioning. Recall that when a person is under stress, the adrenal glands release corticosteroids (see page 152). As in the case of norepinephrine, if stress continues for an extended time, the stress hormones eventually travel to receptor sites located on certain lympho- cytes and give an inhibitory message, again causing a slowdown of the activity of the lymphocytes (Dhabhar, 2014; Groër et al., 2010).
Recent research has further indicated that another action of the corticosteroids is to trigger an increase in the production of cytokines, proteins that bind to recep- tors throughout the body. At moderate levels of stress, the cytokines, another key player in the immune system, help combat infection. But as stress continues and more corticosteroids are released, the growing production and spread of cytokines lead to chronic inflammation throughout the body, contributing at times to heart disease, stroke, and other illnesses (Dhabhar, 2014; Brooks et al., 2011).
Behavioral changes Stress may set in motion a series of behavioral changes that indirectly affect the immune system. Some people under stress may, for example, become anxious or depressed, perhaps even develop an anxiety or mood disorder. As a result, they may sleep badly, eat poorly, exercise less, or smoke or drink more—behaviors known to slow down the immune system (Brooks et al., 2011; Kibler et al., 2010).
Personality style According to research, people who generally respond to life stress with optimism, constructive coping, and resilience—that is, people who welcome challenges and are willing to take control in their daily encounters— experience better immune system functioning and are
First line of defense How do lymphocytes meet up with invading antigens? The lympho cytes are first alerted by macrophages, big white blood cells in the immune system that recognize an antigen, engulf it, break it down, and hand off its dissected parts to the lympho cytes. Here a macrophage stretches its long “arms” (pseudopods) to detect and capture the suspected antigens.
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Everyone Is vulnerable to stress A male koala receives a swab test at the Sydney Wild life World in Australia to detect an oftenfatal disease called chlamydiosis. Chlamydiosis is caused by a virus that often breaks out in koalas when their immune systems are weak ened during times of stress, such as when they are forced to find a new habitat. Fewer than 100,000 koalas are now left in Australia, down from millions of them two centuries ago.
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better prepared to fight off illness (Kim, Chopik, & Smith, 2014; Williams et al., 2011). Some studies have found, for example, that people with “hardy” or resilient personalities remain healthy after stressful events, while those whose personalities are less hardy seem more susceptible to illness (Bonanno & Mancini, 2012; Ouellette & DiPlacido, 2001). Researchers have even dis- covered that men with a general sense of hopelessness die at above-average rates from heart disease and other causes (Kangelaris et al., 2010; Everson et al., 1996). Similarly, a growing body of research suggests that people who are spiritual tend to be healthier than people without spiritual beliefs, and a few studies have linked spirituality to better immune system functioning ( Jackson & Bergeman, 2011; Cadge & Fair, 2010).
In related work, researchers have found a relationship between certain personality characteristics and a person’s ability to cope effectively with cancer (Baum et al., 2011; Floyd et al., 2011). They have found, for example, that patients with certain forms of cancer who display a helpless coping style and who cannot easily express their feelings, particularly anger, tend to have a poorer quality of life in the face of their disease than patients who do express their emotions. A few investigators have even suggested a relation- ship between personality and cancer outcome, but this claim has not been supported clearly by research (Pillay et al., 2014; Kern & Friedman, 2011; Urcuyo et al., 2005).
social suPPort Finally, people who have few social supports and feel lonely tend to have poorer immune functioning in the face of stress than people who do not feel lonely (Hicks, 2014; Cohen, 2002). In a pioneering study, medical students were given the UCLA Loneliness Scale and then divided into “high” and “low” loneli- ness groups (Kiecolt-Glaser et al., 1984). The high-loneliness group showed lower lymphocyte responses during a final exam period.
Other studies have found that social support and affiliation may actually help protect people from stress, poor immune system functioning, and subsequent illness or help speed up recovery from illness or surgery (Hicks, 2014; Rook et al., 2011). Similarly, some studies have suggested that patients with certain forms of cancer who receive social support in their personal lives or supportive therapy often have better immune system functioning and more successful recoveries than patients without such supports (Dagan et al., 2011; Kim et al., 2010).
➤ Summing Up PSYCHOPHYSIOLOGICAL DISORDERS Psychophysiological disorders are those in which biological, psychosocial, and sociocultural factors interact to cause or worsen a physical problem. Factors linked to these disorders are biological fac tors, such as defects in the autonomic nervous system or particular organs; psy chological factors, such as particular needs, attitudes, or personality styles; and sociocultural factors, such as aversive social conditions and cultural pressures.
For years, clinical researchers singled out a limited number of physical ill nesses as psychophysiological. These traditional psychophysiological disor ders include ulcers, asthma, insomnia, chronic headaches, hypertension, and coronary heart disease. Recently many other psychophysiological disorders have been identified. Indeed, scientists have linked many physical illnesses to stress and have developed a new area of study called psychoneuroimmunology. Stress can slow lymphocyte activity, thereby interfering with the immune sys tem’s ability to protect against illness during times of stress. Factors that seem to affect immune functioning include norepinephrine and corticosteroid activity, behavioral changes, personality style, and social support.
Attitude is key During a fourmonth period in 2012, standup comedian Tig Notaro developed breast cancer and underwent a double mastec tomy, lost her mother, developed pneumonia, and also went through other significant life changes. Shortly after, she changed her comedy act to include descriptions of her ordeal and disease process. Her presentations have enter tained and enthralled audiences and catapulted her career to new heights. They also appear to have played a role in helping her to fight her medical problems and regain her health.
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New Pop-Culture Diagnosis Phantom cell phone vibration syn- drome: a false sense that one’s cell phone is vibrating (Archer, 2013)
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Psychological Treatments for Physical Disorders As clinicians have discovered that stress and related psychological and sociocultural factors may contribute to physical disorders, they have applied psychological treat- ments to more and more medical problems. The most common of these interventions are relaxation training, biofeedback, meditation, hypnosis, cognitive interventions, support groups, and therapies to increase awareness and expression of emotions. The field of treatment that combines psychological and physical approaches to treat or prevent medical problems is known as behavioral medicine.
Relaxation Training As you saw in Chapter 4, people can be taught to relax their muscles at will, a pro- cess that sometimes reduces feelings of anxiety. Given the positive effects of relax- ation on anxiety and the nervous system, clinicians believe that relaxation training can help prevent or treat medical illnesses that are related to stress.
Relaxation training, often in combination with medication, has been widely used in the treatment of high blood pressure (Moffatt et al., 2010). It has also been of some help in treating headaches, insomnia, asthma, diabetes, pain, certain vascular diseases, and the undesirable effects of certain cancer treatments (McKenna et al., 2015; Nezu et al., 2011).
Biofeedback As you also saw in Chapter 4, patients given biofeedback training are connected to machinery that gives them continuous readings about their involuntary body activi- ties. This information enables them gradually to gain control over those activities. Somewhat helpful in the treatment of anxiety disorders, the procedure has also been applied to a growing number of physical disorders.
In a classic study, electromyograph (EMG) feedback was used to treat 16 patients who had facial pain caused in part by tension in their jaw muscles (Dohrmann & Laskin, 1978). In an EMG procedure, electrodes are attached to a person’s muscles so that the muscle contractions are detected and converted into a tone (see pages 118–119). Changes in the pitch and volume of the tone indicate changes in muscle tension. After “listening” to EMG feedback repeatedly, the 16 patients in this study learned how to relax their jaw muscles at will and later reported that they had less facial pain.
EMG feedback has also been used successfully in the treatment of headaches and muscular disabilities caused by strokes or accidents. Still other forms of biofeedback training have been of some help in the treatment of heartbeat irregularities, asthma, high blood pressure, stuttering, and pain (McKenna et al., 2015; Freitag, 2013; Young & Kemper, 2013).
Meditation Although meditation has been practiced since ancient times, Western health care professionals have only recently become aware of its effectiveness in relieving physi- cal distress. Meditation is a technique of turning one’s concentration inward, achiev- ing a slightly changed state of consciousness, and temporarily ignoring all stressors. In the most common approach, meditators go to a quiet place, assume a comfortable posture, utter or think a particular sound (called a mantra) to help focus their atten- tion, and allow their mind to turn away from all outside thoughts and concerns. Many people who meditate regularly report feeling more peaceful, engaged, and creative. Meditation has been used to help manage pain and to treat high blood pressure, heart problems, asthma, skin disorders, diabetes, insomnia, and even viral infections (Manchanda & Madan, 2014; Stein, 2003; Andresen, 2000).
The power of distraction Researchers at a medical center in New Jersey had this 10year old girl and other young patients play with handheld Game Boys while waiting for their anesthesia to take effect before their surgery. Such gameplaying was found to be more effective at relaxing the young patients than antianxiety drugs or holding hands with parents. Additional research suggests that patients who are more relaxed often have better surgical outcomes.
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One form of meditation that has been used in particular by patients suffering from severe pain is mindfulness meditation (Barker, 2014; Kabat-Zinn, 2005). Here, as you read in Chapters 2 and 4, meditators pay attention to the feelings, thoughts, and sensations that are flowing through their mind during meditation, but they do so with detachment and objectivity and, most importantly, without judgment. By just being mindful but not judgmental of their feelings and thoughts, including feelings of pain, they are less inclined to label them, fixate on them, or react negatively to them.
Hypnosis As you saw in Chapter 1, people who undergo hypnosis are guided by a hypnotist into a sleeplike, suggestible state during which they can be directed to act in unusual ways, feel unusual sensations, remember seemingly forgotten events, or forget remembered events. With training, some people are even able to induce their own hypnotic state (self-hypnosis). Hypnosis is now used as an aid to psychotherapy and to help treat many physical conditions.
Hypnosis seems to be particularly helpful in the control of pain ( Jensen et al., 2014, 2011). One case study describes a patient who underwent dental surgery under hypnotic suggestion. After a hypnotic state was induced, the dentist suggested to the patient that he was in a pleasant and relaxed setting listening to a friend describe his own success at under- going similar dental surgery under hypnosis. The dentist then proceeded to perform a successful 25-minute operation (Gheorghiu & Orleanu, 1982). Although only some people are able to go through surgery while anesthetized by hypnosis alone, hypnosis combined with chemical forms of anesthesia is apparently helpful to many patients (Lang, 2010). Beyond its use in the control of pain, hypnosis has been used suc- cessfully to help treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection (Becker, 2015; McBride, Vlieger, & Anbar, 2014; Modlin, 2002).
Fighting HIV on all fronts As part of his treatment at the Wellness Center in San Francisco, this man meditates and writes letters to his HIV virus.
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The hypnotic way Hypnosis is now widely used in medical procedures, particularly to help reduce and control pain. At the Cliniques Universitaires SaintLuc Hospital in Brussels, a surgeon prepares a patient for her thyroid procedure while anesthesiologist Dr. Fabienne Roelants hypnotizes the patient. Onethird of all thyroidremoval surgeries and onequarter of all breast cancer surgeries at the hospital are con ducted using a combination of hypnosis and a local anesthetic rather than general anesthesia.
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Cognitive Interventions People with physical ailments have sometimes been taught new attitudes or cogni- tive responses toward their ailments as part of treatment (Hampel et al., 2014; Syrjala et al., 2014). For example, an approach called self-instruction training, or stress inocula- tion training, has helped patients cope with severe pain (D’Arienzo, 2010; Meichen- baum, 1993, 1977, 1975). In this training, therapists teach people to identify and eventually rid themselves of unpleasant thoughts that keep emerging during pain episodes (so-called negative self-statements, such as “Oh no, I can’t take this pain”) and to replace them with coping self-statements instead (for example, “When pain comes, just pause; keep focusing on what you have to do”).
Support Groups and Emotion Expression If anxiety, depression, anger, and the like contribute to a person’s physical ills, inter- ventions to reduce these negative emotions should help reduce the ills. Thus it is not surprising that some medically ill people have profited from support groups and from therapies that guide them to become more aware of and express their emotions and needs (Bell et al., 2010; Hsu et al., 2010). Research suggests that the discussion, or even the writing down, of past and present emotions or upsets may help improve a person’s health, just as it may help one’s psychological functioning (Kelly & Barry, 2010; Smyth & Pennebaker, 2001). In one study, asthma and arthritis patients who wrote down their thoughts and feelings about stressful events for a handful of days showed lasting improvements in their conditions. Similarly, stress-related writing was found to be beneficial for patients with either HIV or cancer (Corter & Petrie, 2011; Petrie et al., 2004).
Combination Approaches Studies have found that the various psychological interventions for physical prob- lems tend to be equally effective (Devineni & Blanchard, 2005). Relaxation and biofeedback training, for example, are equally helpful (and more helpful than place- bos) in the treatment of high blood pressure, headaches, and asthma. Psychological interventions are, in fact, often most helpful when they are combined with other psychological interventions and with medical treatments ( Jensen et al., 2014, 2011; Hembree & Foa, 2010). In a classic study, ulcer patients who were given relaxation, self-instruction, and assertiveness training along with medication were found to be less anxious and more comfortable, to have fewer symptoms, and to have a bet- ter long-term outcome than patients who received medication only (Brooks & Richardson, 1980). Combination interventions have also been helpful in changing Type A patterns and in reducing the risk of coronary heart disease among people who display Type A kinds of behavior (Ladwig et al., 2014; Harlapur et al., 2010).
Clearly, the treatment picture for physical illnesses has been changing dramati- cally. While medical treatments continue to dominate, today’s medical practitioners are traveling a course far removed from that of their counterparts in centuries past.
➤ Summing Up PSYCHOLOGICAL TREATMENTS FOR PHYSICAL DISORDERS Behavioral medi cine combines psychological and physical interventions to treat or prevent med ical problems. Psychological approaches such as relaxation training, biofeedback training, meditation, hypnosis, cognitive techniques, support groups, and thera pies that heighten the awareness and expression of emotions and needs are increasingly being included in the treatment of various medical problems.
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Strictly a Coincidence? On February 17, 1673, French actor- playwright Molière collapsed onstage and died while performing in Le Malade Imaginaire (The Hypochondriac).
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Room with a View According to one hospital’s records of individuals who underwent gallbladder surgery, those in rooms with a good view from their window had shorter hospitalizations and needed fewer pain medications than those in rooms with- out a good view (Ulrich, 1984).
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KEY TERMS
mind-body dualism, p. 250
malingering, p. 250
factitious disorder, p. 250
Munchausen syndrome, p. 250
Munchausen syndrome by proxy, p. 251
conversion disorder, p. 253
somatic symptom disorder, p. 253
Electra complex, p. 258
primary gain, p. 258
secondary gain, p. 258
illness anxiety disorder, p. 261
psychophysiological disorder, p. 262
psychological factors affecting other medical conditions, p. 262
ulcer, p. 262
asthma, p. 262
insomnia, p. 263
muscle contraction headaches, p. 263
migraine headaches, p. 263
hypertension, p. 265
coronary heart disease, p. 265
Type A personality style, p. 266
Type B personality style, p. 266
Social Readjustment Rating Scale, p. 268
psychoneuroimmunology, p. 269
immune system, p. 269
antigen, p. 269
lymphocyte, p. 269
cytokines, p. 271
behavioral medicine, p. 273
relaxation training, p. 273
biofeedback training, p. 273
meditation, p. 273
hypnosis, p. 274
self-instruction training, p. 275
PUTTING IT...together Expanding the Boundaries of Abnormal Psychology Once considered outside the field of abnormal psychology, bodily ailments and physical illnesses are now seen as problems that fall squarely within its boundaries. Just as physical factors have long been recognized as playing a role in abnormal mental functioning, psychological conditions are now considered important con- tributors to abnormal physical functioning. In fact, many of today’s clinicians believe
that psychological and sociocultural factors contribute to some degree to the onset and course of virtually all physical ailments.
The number of studies devoted to this relationship has risen steadily during the past 40 years. What researchers once saw as a vague connec- tion between stress and physical illness is now understood as a complex interaction of many variables. Such factors as life changes, a person’s particular psychological state, social support, biochemical activity, and slowing of the immune system are all recognized as contributors to dis- orders once considered purely physical.
Insights into the treatment of physical illnesses have been accumulat- ing just as rapidly. Psychological approaches such as relaxation training and cognitive therapy are being applied to more and more physical ills,
usually in combination with traditional medical treatments. Small wonder that many practitioners are convinced that such treatment combinations will eventually be the norm in treating the majority of physical ailments.
One of the most exciting aspects of these recent developments is the field’s growing emphasis on the interrelationship of the social environment, the brain, and the rest of the body. Researchers have observed repeatedly that mental disorders are often best understood and treated when sociocultural, psychological, and biological factors are all taken into consideration. They now know that this interaction also helps explain medical problems. We are reminded that the brain is part of the body and that both are part of a social context. For better and for worse, the three are intertwined.
C li n i C al C h o i C e s Now that you’ve read about disorders featuring somatic symptoms, try the interactive case study for this chapter. See if you are able to identify Joanne’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Joanne? Go to LaunchPad to access Clinical Choices.
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QuickQuiz
1. What are the symptoms of factitious disorder, conversion disorder, and so- matic symptom disorder? pp. 250–257
2. How do practitioners distinguish con- version disorder from a “genuine” medical problem? What are two dif- ferent patterns of somatic symptom disorder? pp. 254, 256–257
3. What are the leading explanations and treatments for conversion and somatic symptom disorder? How well does re- search support them? pp. 257–261
4. What are the symptoms, causes, and treatments of illness anxiety disorder? pp. 261–262
5. What are the specific causes of ulcers, asthma, insomnia, headaches, hyper- tension, and coronary heart disease? pp. 262–265
6. What kinds of biological, psychologi- cal, and sociocultural factors appear to contribute to psychophysiological disorders? pp. 265–267
7. What kind of relationship has been found between life stress and physical illnesses? What scale has helped re- searchers investigate this relationship? pp. 268–269
8. Describe the connection between stress, the immune system, and physi-
cal illness. Explain the specific roles played by various types of lymphocytes. pp. 269–271
9. Discuss how immune system function- ing at times of stress may be affected by a person’s biochemical activity, be- havioral changes, personality style, and social support. pp. 271–272
10. What psychological treatments have been used to help treat physical ill- nesses? To which specific illnesses has each been applied? pp. 273–275
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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S hani, age 15: I walked into the kitchen when no one was around, took a slice of bread out of the packet, toasted it, spread butter on it, took a deep breath and bit. Guilty. I spat it in the trash and tossed the rest of it in and walked away. Seconds later I longed for the toast, walked back to the trash, popped open the
lid and sifted around in the debris. I found it and contemplated, for minutes, whether to eat it. I brought it close to my nose and inhaled the smell of melted butter. Guilty. Guilty for trashing it. Guilty for craving it. Guilty for tasting it. I threw it back in the trash and walked away. No is no, I told myself. No is no.
. . . And no matter how hard I would try to always have The Perfect Day in terms of my food, I would feel the guilt every second of every day. . . . It was my desire to escape the guilt that perpetuated my compulsion to starve.
In time I formulated a more precise list of “can” and “can’t” in my head that dic- tated what I was allowed or forbidden to consume. . . . It became my way of life. My manual. My blueprint. But more than that, it gave me false reassurance that my life was under control. I was managing everything because I had this list in front of me telling me what—and what not—to do. . . .
In the beginning, starving was hard work. It was not innate. Day by day I was slowly lured into another world, a world that was . . . as rewarding as it was challenging. . . .
That summer, despite the fact that I had lost a lot of weight, my mother agreed to let me go to summer camp with my fifteen-year-old peers, after I swore to her that I would eat. I broke that promise as soon as I got there. . . . At breakfast time when all the teens raced into the dining hall to grab cereal boxes and bread loaves and jelly tins and peanut butter jars, I sat alone cocooned in my fear. I fingered the plastic packet of a loaf of white sliced bread, took out a piece and tore off a corner, like I was marking a page in a book, onto which I dabbed a blob of peanut butter and jelly the size of a Q-tip. That was my breakfast. Every day. For three weeks.
I tried to get to the showers when everyone else was at the beach so nobody would see me. I heard girls behind me whispering, “That’s the girl I told you about that looks so disgusting.” Someone invariably walked in on me showering and covered her mouth with her hand like I was a dead body. I wished I could disappear into the drain like my hair that was falling out in chunks. . . .
[Upon returning to school] I was labeled the “concentration camp victim.” On my return, over the months everyone watched my body shrink as though it were being vacuum packed in slow motion. . . . At my lowest weight my hipbones protruded like knuckle bones under my dress and I had to minimize the increments of the belt holes until there was so much extra belt material dangling down that I did away with the belt completely. My shoes were too big for my feet; my ankles were so thin that I wore three pairs of socks at a time and still my shoes would slide off my heels. And my panties were so baggy I secured them with safety pins on the sides so they wouldn’t fall down. . . .
On the home front things were worse than ever. . . . I locked my door and forbade anyone from entering. Even so, my mother and I had screaming matches every day, with her trying to convince me that “your body needs food as fuel” and me retaliat- ing with “I’m not hungry.” . . .
For nine months my mother stood by, forbidden to interfere, while I starved myself. She had no idea what was going on, nor did I. . . . She watched me transform from an innocent, soft, kind, loving girl into a reclusive, vicious, aggressive, defiant teenager. . . . And there was nothing she could say or do to stop me. She knew that if my weight continued to drop radically that she might lose me. But despite all her desperate attempts to reach out to me . . . she had no way of getting through to me. . . .
(Raviv, 2010)
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T O P I C O V E R V I E W
Anorexia Nervosa The Clinical Picture Medical Problems
Bulimia Nervosa Binges Compensatory Behaviors Bulimia Nervosa Versus Anorexia Nervosa
Binge-Eating Disorder
What Causes Eating Disorders? Psychodynamic Factors: Ego Deficiencies Cognitive Factors Depression Biological Factors Societal Pressures Family Environment Multicultural Factors: Racial and Ethnic Differences Multicultural Factors: Gender Differences
How Are Eating Disorders Treated? Treatments for Anorexia Nervosa Treatments for Bulimia Nervosa Treatments for Binge-Eating Disorder
Putting It Together: A Standard for Integrating Perspectives
Eating Disorders
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It has not always done so, but Western society today equates thinness with health and beauty. In fact, in the United States thinness has become a national obsession. Most of us are as preoccupied with how much we eat as with the taste and nutritional value of our food. Thus it is not surprising that during the past three decades we have also witnessed an increase in two eating disorders that have at their core a mor- bid fear of gaining weight. Sufferers of anorexia nervosa, like Shani, are convinced that they need to be extremely thin, and they lose so much weight that they may starve themselves to death. People with bulimia nervosa go on frequent eating binges, during which they uncontrollably consume large quantities of food, and then force themselves to vomit or take other extreme steps to keep from gaining weight. A third eating disorder, binge-eating disorder, in which people frequently go on eating binges but do not force themselves to vomit or engage in other such behaviors, also appears to be on the rise. People with binge-eating disorder do not fear weight gain to the same degree as those with anorexia nervosa and bulimia nervosa, but they do have many of the other features found in those disorders (Alvarenga et al., 2014).
The news media have published many reports about eating disorders. One rea- son for the surge in public interest is the frightening medical consequences that can result from the disorders. The public first became aware of such consequences in 1983 when Karen Carpenter died from medical problems related to anorexia. Carpenter, the 32-year-old lead singer of the soft-rock brother-and-sister duo called the Carpenters, had been enormously successful and was admired by many as a wholesome and healthy model to young women everywhere. Another reason for the current concern is the disproportionate prevalence of anorexia nervosa and bulimia nervosa among adolescent girls and young women.
Anorexia Nervosa Shani, 15 years old and in the ninth grade, displays many symptoms of anorexia nervosa (APA, 2013). She purposely maintains a significantly low body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and is excessively influenced by her weight and shape in her self-evaluations (see Table 9-1).
Like Shani, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. First they tend to cut out sweets and fattening snacks; then, increasingly, they elimi- nate other foods. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which you will read about in more detail in the section on bulimia nervosa.
Ninety to 95 percent of all cases of anorexia nervosa occur in females. Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years. Between 0.5 and 4.0 percent of all females in Western countries develop the disor- der in their lifetime, and many more display at least some of its symptoms (Ekern, 2014; Stice et al., 2013). It seems to be on the increase in North America, Europe, and Japan.
Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet (APA, 2015; Stice & Presnell, 2010). The esca- lation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (APA, 2015;
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Dx Checklist
Anorexia Nervosa
1. Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people of similar age and gender.
2. Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight.
3. Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight.
(Information from: APA, 2013.)
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▶▶ anorexia nervosa A disorder marked by the pursuit of extreme thinness and by extreme weight loss.
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Wilson et al., 2003). Although most people with the disorder recover, between 2 and 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation or from suicide (Suokas et al., 2013; Forcano et al., 2010).
The Clinical Picture Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation. People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (Herzig, 2004). Many report that their dreams are filled with images of food and eating (Knudson, 2006).
This preoccupation with food may in fact be a result of food depriva- tion rather than its cause. In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious objectors were put on a semi- starvation diet for six months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food.
Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Boone et al., 2014; Siep et al., 2011). In addition, they are likely to overestimate their actual proportions. While most women in Western society over- estimate their body size, the estimates of those with anorexia nervosa are particularly high. In one of her classic books on eating disorders, Hilde Bruch, a pioneer in this field, recalled the self-perceptions of a 23-year-old patient:
I look in a full-length mirror at least four or five times daily and I really cannot see myself as too thin. Sometimes after several days of strict dieting, I feel that my shape is tolerable, but most of the time, odd as it may seem, I look in the mirror and believe that I am too fat.
(Bruch, 1973)
This tendency to overestimate body size has been tested in the laboratory (Delinsky, 2011). In a popular assessment technique, research participants look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size. The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the individuals with anorexia nervosa overestimated their body size, stopping the lens when the image was larger than they actually were.
The distorted thinking of anorexia nervosa also takes the form of certain mal- adaptive attitudes and misperceptions (Alvarenga et al., 2014). Sufferers tend to hold such beliefs as “I must be perfect in every way,” “I will become a better person if I deprive myself,” and “I can avoid guilt by not eating.”
Laboratory starvation Thirty-six conscientious objectors who were put on a semistarvation diet for six months developed many of the symptoms seen in anorexia nervosa and bulimia nervosa (Keys et al., 1950).
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A New Word In 2015 the Oxford Dictionaries added a new word, “hangry,” which means bad-tempered or irritable as a result of hunger.
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People with anorexia nervosa also have certain psychological problems, such as depression, anxiety, low self-esteem, and insomnia or other sleep disturbances (Forsén Mantilla et al., 2014; Holm-Denoma et al., 2014). A number grapple with substance abuse (Mann et al., 2014). And many display obsessive-compulsive pat- terns (Degortes et al., 2014). They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well. Many, for example, exercise compulsively, prioritizing exercise over most other activities in their lives (Fairburn et al., 2008). In some research, people with anorexia nervosa and others with obsessive-compulsive disorder score equally high for obsessiveness and compulsiveness. Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder (Boone et al., 2014).
Medical Problems The starvation habits of anorexia nervosa cause medical problems (Faje et al., 2014; Suokas et al., 2014). Women develop amenorrhea, the absence of menstrual cycles. Other problems include lowered body temperature, low blood pressure, body swell- ing, reduced bone mineral density, and slow heart rate. Metabolic and electrolyte imbalances also may occur and can lead to death by heart failure or circulatory col- lapse. The poor nutrition of people with anorexia nervosa may also cause skin to become rough, dry, and cracked; nails to become brittle; and hands and feet to be cold and blue. Some people lose hair from the scalp, and some grow lanugo (the fine, silky hair that covers some newborns) on their trunk, extremities, and face. Shani, the young woman whose self-description opened this chapter, recalls how her body deteriorated as her disorder was progressing: “Nobody knew that I was always cold no matter how many layers I wore, that my hair came out in thick wads whenever I wet it or washed it, that I stopped menstruating, [and] that my hipbones hurt to lie on my stomach and my coccyx hurt to sit on the floor” (Raviv, 2010).
➤ Summing Up ANOREXIA NERVOSA Rates of eating disorders have increased dramatically as thinness has become a national obsession. People with anorexia nervosa pursue extreme thinness and lose dangerous amounts of weight. They may follow a pattern of restricting-type anorexia nervosa or binge-eating/purging- type anorexia nervosa. The central features of anorexia nervosa are a drive for thinness, intense fear of weight gain, and disturbed body perception and other cognitive disturbances. Ninety to 95 percent of all cases occur among females. Most sufferers develop significant medical problems, including amenorrhea.
Bulimia Nervosa People with bulimia nervosa—a disorder also known as binge-purge syndrome— engage in repeated episodes of uncontrollable overeating, or binges. A binge epi- sode takes place over a limited period of time, often two hours, during which the person eats much more food than most people would eat during a similar time span (APA, 2013). In addition, people with this disorder repeatedly perform inappropri- ate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively (see Table 9-2). Lindsey, a woman who has since recovered from bulimia nervosa, describes a morning during her disorder:
Turning point When soft-rock star Karen Carpenter (right) received an award from fellow musician Emmylou Harris at the 1977 Billboard Music Awards, few people paid much atten- tion to her symptoms. Carpenter’s 1983 death helped change the public’s view of anorexia nervosa.
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▶▶ amenorrhea The absence of menstrual cycles.
▶▶ bulimia nervosa A disorder marked by frequent eating binges that are fol- lowed by forced vomiting or other extreme compensatory behaviors to avoid gaining weight. Also known as binge-purge syndrome.
▶▶ binge An episode of uncontrollable eating during which a person ingests a very large quantity of food.
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Today I am going to be really good and that means eating certain predetermined portions of food and not taking one more bite than I think I am allowed. I am very careful to see that I don’t take more than Doug does. I judge by his body. I can feel the tension building. I wish Doug would hurry up and leave so I can get going!
As soon as he shuts the door, I try to get involved with one of the myriad of re- sponsibilities on the list. I hate them all! I just want to crawl into a hole. I don’t want to do anything. I’d rather eat. I am alone, I am nervous, I am no good, I always do everything wrong anyway, I am not in control, I can’t make it through the day, I just know it. It has been the same for so long.
I remember the starchy cereal I ate for breakfast. I am into the bathroom and onto the scale. It measures the same, but I don’t want to stay the same! I want to be thinner! I look in the mirror, I think my thighs are ugly and deformed looking. I see a lumpy, clumsy, pear-shaped wimp. There is always something wrong with what I see. I feel frustrated trapped in this body and I don’t know what to do about it.
I float to the refrigerator knowing exactly what is there. I begin with last night’s brownies. I always begin with the sweets. At first I try to make it look like nothing is missing, but my appetite is huge and I resolve to make another batch of brown- ies. I know there is half of a bag of cookies in the bathroom, thrown out the night before, and I polish them off immediately. I take some milk so my vomiting will be smoother. I like the full feeling I get after downing a big glass. I get out six pieces of bread and toast one side in the broiler, turn them over and load them with patties of butter and put them under the broiler again till they are bubbling. I take all six pieces on a plate to the television and go back for a bowl of cereal and a banana to have along with them. Before the last toast is finished, I am already preparing the next batch of six more pieces. Maybe another brownie or five, and a couple of large bowlfuls of ice cream, yogurt or cottage cheese. My stomach is stretched into a huge ball below my ribcage. I know I’ll have to go into the bathroom soon, but I want to postpone it. I am in never-never land. I am waiting, feeling the pressure, pacing the floor in and out of the rooms. Time is passing. Time is passing. It is get- ting to be time.
I wander aimlessly through each of the rooms again tidying, making the whole house neat and put back together. I finally make the turn into the bathroom. I brace my feet, pull my hair back and stick my finger down my throat, stroking twice, and get up a huge pile of food. Three times, four and another pile of food. I can see everything come back. I am glad to see those brownies because they are SO fatten- ing. The rhythm of the emptying is broken and my head is beginning to hurt. I stand up feeling dizzy, empty and weak. The whole episode has taken about an hour.
(Hall & Cohn, 2010, p. 1; Hall, 1980, pp. 5–6)
Like anorexia nervosa, bulimia nervosa usually occurs in females, again in 90 to 95 percent of the cases (ANAD, 2015; Sanftner & Tantillo, 2011). It begins in adolescence or young adulthood (most often between 15 and 20 years of age) and often lasts for years, with periodic letup (Stice et al., 2013). The weight of people with bulimia nervosa usually stays within a normal range, although it may fluctuate markedly within that range. Some people with this disorder, however, become seri- ously underweight and may eventually qualify for a diagnosis of anorexia nervosa instead (see Figure 9-1 on the next page).
Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media. Indeed, according to global studies, 25 to 50 percent of all students report periodic binge eating or self-induced vomiting (Ekern, 2014; McDermott & Jaffa, 2005). Only some of these individuals, however, qualify for a diagnosis of buli- mia nervosa. Surveys in several Western countries suggest that as many as 5 percent
table: 9-2
Dx Checklist
Bulimia Nervosa
1. Repeated binge-eating episodes.
2. Repeated performance of ill- advised compensatory behaviors (e.g., forced vomiting) to prevent weight gain.
3. Symptoms take place at least weekly for a period of 3 months.
4. Inappropriate influence of weight and shape on appraisal of oneself.
(Information from: APA, 2013.)
B e t W e e N t h e L I N e S
In Their Words “To be born woman is to know— Although they do not talk of it at school—Women must labour to be beautiful.”
W. B. Yeats, 1904
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of women develop the full syndrome (Ekern, 2014; Touchette et al., 2011). Among college students the rate may be much higher (Zerbe, 2008).
Binges People with bulimia nervosa may have between 1 and 30 binge episodes per week (Fairburn et al., 2008). In most cases, they carry out the binges in secret. The person eats massive amounts of food very rapidly, with minimal chewing—usually sweet, high-calorie foods with a soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. Binge eaters consume an average of 3,400 calories during an episode. Some individuals consume as many as 10,000 calories.
Binges are usually preceded by feelings of great tension. The person feels irritable, “unreal,” and powerless to control an overwhelming need to eat “forbid- den” foods. During the binge, the person feels unable to stop eating (APA, 2013). Although the binge itself may be experienced as pleasurable in the sense that it relieves the unbearable tension, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fears of gaining weight and being discovered (Sanftner & Tantillo, 2011; Goss & Allan, 2009).
Compensatory Behaviors After a binge, people with bulimia nervosa try to compensate for and undo its effects. Many resort to vomiting, for example. But vomiting actually fails to pre- vent the absorption of half of the calories consumed during a binge. Furthermore, repeated vomiting affects one’s general ability to feel satiated; thus it leads to greater hunger and more frequent and intense binges. Similarly, the use of laxatives or diuretics largely fails to undo the caloric effects of bingeing (Fairburn et al., 2008).
Vomiting and other compensatory behaviors may temporarily relieve the uncomfortable physical feelings of fullness or reduce the feelings of anxiety and self- disgust attached to binge eating (Stewart & Williamson, 2008). Over time, however, a cycle develops in which purging allows more bingeing, and bingeing necessitates more purging. The cycle eventually causes people with the disorder to feel power- less and disgusted with themselves (Sanftner & Tantillo, 2011; Hayaki et al., 2002). Most recognize fully that they have an eating disorder. Lindsey, the woman we met
Binge-eating disorder
Binge-eating/pu r ging-typ e ano r exia ne r v os a disorder
Restricting-type anorexia
nervosa disorder
Normal-weight bulimia nervosa disorder
Obesity
figure 9-1 Overlapping patterns of anorexia nervosa, bulimia nervosa, and obesity Some people with anorexia nervosa binge and purge their way to weight loss, and some obese people binge eat. However, most peo- ple with bulimia nervosa are not obese, and most overweight people do not binge eat.
B e t W e e N t h e L I N e S
Royal Bulimia? During her three years as queen of England, Anne Boleyn, King Henry VIII’s second wife, displayed a habit, first observed during her coronation ban- quet, of vomiting during meals. In fact, she assigned a lady-in-waiting the task of holding up a sheet when the queen looked likely to vomit (Shaw, 2004).
Eating Disorders : 285
earlier, recalls how the pattern of binge eating, purging, and self-disgust took hold while she was a teenager in boarding school.
Every bite that went into my mouth was a naughty and selfish indulgence, and I be- came more and more disgusted with myself. . . .
The first time I stuck my fingers down my throat was during the last week of school. I saw a girl come out of the bathroom with her face all red and her eyes puffy. She had always talked about her weight and how she should be dieting even though her body was really shapely. I knew instantly what she had just done and I had to try it. . . .
I began with breakfasts which were served buffet-style on the main floor of the dorm. I learned which foods I could eat that would come back up easily. When I woke in the morning, I had to make the decision whether to stuff myself for half an hour and throw up before class, or whether to try and make it through the whole day without overeating. . . . I always thought people noticed when I took huge portions at mealtimes, but I figured they assumed that because I was an athlete, I burned it off. . . . Once a binge was under way, I did not stop until my stomach looked pregnant and I felt like I could not swallow one more time.
That year was the first of my nine years of obsessive eating and throwing up. . . . I didn’t want to tell anyone what I was doing, and I didn’t want to stop. . . . [Though] being in love or other distractions occasionally lessened the cravings, I always re- turned to the food.
(Hall & Cohn, 2010, p. 55; Hall, 1980, pp. 9–12)
As with anorexia nervosa, a bulimic pattern typically begins during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (APA, 2015; Stice & Presnell, 2010; Couturier & Lock, 2006). Studies of both animals and humans have found that normal research partici- pants placed on very strict diets also develop a tendency to binge (Pankevich et al., 2010; Eifert et al., 2007). Some of the participants in the conscientious objector
Eating for sport Many people go on occa- sional eating binges. In fact, sometimes binges are officially endorsed, as you see in this photo from the annual Nathan’s Famous Interna- tional Hot Dog Eating Contest in Brooklyn’s Coney Island, New York. However, people are considered to have an eating disorder only when the binges recur, the pattern endures, and the issues of weight or shape dominate self-evaluation.Cu
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The Diet Business Americans spend an estimated $61 bil- lion each year on weight- reduction foods, products, and services (PRWEB, 2013).
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“starvation study,” for example, later binged when they were allowed to return to regular eating, and a number of them continued to be hungry even after large meals (Keys et al., 1950).
Bulimia Nervosa Versus Anorexia Nervosa Bulimia nervosa is similar to anorexia nervosa in many ways. Both disorders typically begin after a period of dieting by people who are fearful of becoming obese; driven to become thin; preoccupied with food, weight, and appearance; and struggling with depression, anxiety, obsessiveness, and the need to be perfect (Boone et al., 2014; Holm-Denoma et al., 2014). People with either of the disorders have a heightened risk of suicide attempts (Suokas et al., 2014). Substance abuse may accompany either disorder, perhaps beginning with the excessive use of diet pills (Mann et al., 2014). People with either disorder believe that they weigh too much and look too heavy regardless of their actual weight or appearance (Boone et al., 2014) (see InfoCentral on the next page). And both disorders are marked by disturbed attitudes toward eating (Alvarenga et al., 2014).
Yet the two disorders also differ in important ways. Although people with either disorder worry about the opinions of others, those with bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships (Zerbe, 2010, 2008). They also tend to be more sexually experienced and active than people with anorexia nervosa (Gonidakis et al., 2014). Particularly troublesome, they are more likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively or controlling their impulses and strong emotions (Boone et al., 2014; Lilenfeld, 2011). As many as one-third of those with bulimia nervosa display the characteristics of a personality disorder, particularly borderline personality disorder, which you will be looking at more closely in Chapter 13 (Reas et al., 2013).
Another difference is the nature of the medical complications that accom- pany the two disorders (Corega et al., 2014; Mitchell & Crow, 2010). Only half of women with bulimia nervosa are amenorrheic or have very irregular menstrual periods, compared with almost all of those with anorexia nervosa. On the other hand, repeated vomiting bathes teeth and gums in hydrochloric acid, leading some women with bulimia nervosa to have serious dental problems, such as breakdown of enamel and even loss of teeth. Moreover, frequent vomiting or chronic diarrhea (from the use of laxatives) can cause dangerous potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart damage.
Across the generations When famous television journalist Katie Couric interviewed popular singer Demi Lovato in 2012, it turned out that the two had an important thing in common—eating disorders. Lovato has spoken openly for years about her body image issues and eating struggles, but not until this interview did Couric reveal that she had experienced similar problems in the past. She noted, “I wrestled with bulimia all through college and for two years after that.” AP
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Sending a (Bad) Message • Prior to 1995, eating problems were
rare in the Fiji Islands in the South Pacific.
• Soon after satellite television began beaming Western shows and fashions to the islands in 1995, Fijian teen- age girls who regularly watched TV became increasingly likely to feel “too big or fat,” to diet regularly, and to vomit to control weight.
• As more and more young Fijians have participated on Facebook and other forms of online social networking in recent years, the prevalence of eating disorders among teenagers there has further risen dramatically.
(Becker et al., 2011, 2010, 2007, 2003, 2002, 1999)
287InfoCentral
BODY DISSATISFACTION People who evaluate their weight and shape negatively are experi- encing body dissatisfaction. Around 73% of all girls and women are dissatisfied with their bodies, compared with 56% of all boys and men (Mintem et al., 2014). The vast majority of dissatisfied females believe they are overweight; in contrast, half of dissatisfied males
consider themselves overweight and half consider themselves un- derweight. The factors most closely tied to body dissatisfaction are perfectionism and unrealistic expectations (Wade & Tiggemann, 2013). Body dissatisfaction is the single most powerful contributor to dieting and to the development of eating disorders.
PEOPLE WITH HIGH BODY DISSATISFACTION ARE MORE PRONE TO…
0 .10 .20 .30 .40 .50 .60
Unfavorable peer comparisons
Low self-esteem
Negative parental attitude about
weight
Unfavorable media
comparisons
.55
.52
.30
.26
BODY DISSATISFACTION CORRELATES WITH...
(Van Vonderen & Kinnally, 2012)
Overall Appearance
56%
43.9%
Stomach
63%
71%
Weight
52%
66%
Hips/Thighs
29%
61%
Women Men
ADULTS AND BODY DISSATISFACTION
ADOLESCENTS AND BODY DISSATISFACTION Females of all ages tend to be dissatis�ed with their bodies, but the biggest leap in dissatisfaction occurs when girls transition from early to mid-adolescence (Mäkinen et al., 2012).
Dissatisfaction
Weight
Hips
Thighs
Waist
Weight
Hips
Thighs
Waist
13 years old
15 years old
18 years old
16% 30% 22%
9% 25% 27%
18% 42% 39%
7% 17% 25%
17% 25% 20%
12% 2% 4%
10% 9% 6%
21% 11% 10%
GIRLS
(Weinshenker, 2014; Rosenblum & Lewis, 1999)
BOYS
SOCIAL MEDIA AND BODY DISSATISFACTION • The more time teenage girls spend
on social media, the higher their body dissatisfaction.
• 86% of teens say that social network sites hurt their body con�dence.
(PROUD2BME, 2013; Tiggemann & Slater, 2013)
NEGATIVE BODY THOUGHTS
97% of women have at least one negative thought about their bodies each day. On average, a woman has 13 negative body thoughts each day. Examples of negative body thoughts:
(Dreisbach, 2011)
(Weinshenker, 2014; Garner, 1997)
• Eating disorders • Depressive disorders • Anxiety disorders • Body dysmorphic disorder • Problems in interpersonal relationships • Dif�culties at work
(Marques et al., 2012; Dyl et al., 2006; Ohring et al., 2002)
“I hate my thighs, my stomach, and my arms.”
“I’m obese. All the pretty girls are size 2.”
“I look disgusting.”
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➤ Summing Up BulImIA NERVOSA People with bulimia nervosa go on frequent eating binges and then force themselves to vomit or perform other inappropriate compensa- tory behaviors. The binges are often in response to increasing tension and are followed by feelings of guilt and self-blame.
Compensatory behavior is at first reinforced by the temporary relief from uncomfortable feelings of fullness or the reduction of feelings of anxiety, self- disgust, and loss of control attached to bingeing. Over time, however, suffer- ers generally feel disgusted with themselves, depressed, and guilty. People with bulimia nervosa may have mood swings or have difficulty controlling their impulses. Some display a personality disorder. Many develop significant medi- cal problems.
Binge-Eating Disorder Like those with bulimia nervosa, people with binge-eating disorder engage in repeated eating binges during which they feel no control over their eating (APA, 2013). However, they do not perform inappropriate compensatory behavior (see Table 9-3). As a result of their frequent binges, around two-thirds of people with binge-eating disorder become overweight or even obese (Brauhardt et al., 2014).
Binge-eating disorder was first identified more than 50 years ago as a pattern common among many overweight people (Stunkard, 1959). It is important to rec- ognize, however, that most overweight people do not engage in repeated binges; their weight results from frequent overeating and/or a combination of biological, psychological, and sociocultural factors (ANAD, 2014).
Between 2 and 7 percent of the population have binge-eating disorder (Brownley et al., 2015; Smink et al., 2013). The binges that characterize this pattern are similar to those seen in bulimia nervosa, particularly the amount of food eaten and the sense of loss of control experienced during the binge. Moreover, like people with bulimia nervosa or anorexia nervosa, those with binge-eating disorder typically are preoc- cupied with food, weight, and appearance; base their evaluation of themselves largely on their weight and shape; misperceive their body size and are extremely dissatisfied with their body; struggle with feelings of depression, anxiety, and perfectionism; may abuse substances; and typically first develop the disorder in adolescence or young adulthood (Brauhardt et al., 2014; Pearl et al., 2014). On the other hand, although they aspire to limit their eating, people with binge-eating disorder are not as driven to thinness as those with anorexia nervosa and bulimia nervosa. Also, unlike the other eating disorders, binge-eating disorder does not necessarily begin with efforts at extreme dieting, nor are there large gender differences in the prevalence of binge- eating disorder (Davis, 2015; Grucza et al., 2007).
➤ Summing Up BINgE-EAtINg DISORDER People with binge-eating disorder have frequent binge-eating episodes but do not display inappropriate compensatory behav- iors. Although most overweight people do not have binge-eating disorder, two-thirds of those with binge-eating disorder become overweight. Between 2 and 7 percent of the population display binge-eating disorder. Unlike anorexia nervosa and bulimia nervosa, this disorder is more evenly distributed among males and females and people of different races.
table: 9-3
Dx Checklist
Binge-Eating Disorder
1. Recurrent binge-eating episodes.
2. Binge-eating episodes include at least three of these features: • Unusually fast eating • Absence of hunger • Uncomfortable fullness • Secret eating due to sense of shame • Subsequent feelings of self-disgust, depression, or severe guilt.
3. Significant distress.
4. Binge-eating episodes take place at least weekly over the course of 3 months.
5. Absence of excessive compensatory behaviors.
(Information from: APA, 2013.)
▶▶ binge-eating disorder A disorder marked by frequent binges but not extreme compensatory behaviors.
▶▶ multidimensional risk perspective A theory that identifies several kinds of risk factors that are thought to combine to help cause a disorder. The more fac- tors present, the greater the risk of developing the disorder.
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What Causes Eating Disorders? Most of today’s theorists and researchers use a multidimensional risk perspective to explain eating disorders. That is, they identify several key factors that place a per- son at risk for these disorders ( Jacobi & Fittig, 2010). The more of these factors that are present, the more likely it is that a person will develop an eating disorder. As you will see, most of the factors that have been cited and investigated center on anorexia nervosa and bulimia nervosa. Binge-eating disorder, identified as a clinical syndrome more recently, is only now being broadly investigated. Which of these factors are also at work in this “newer” disorder will probably become clearer in the coming years.
Psychodynamic Factors: Ego Deficiencies Hilde Bruch, a pioneer in the study and treatment of eating disorders, was men- tioned earlier in this chapter. Bruch developed a largely psychodynamic theory of the disorders. She argued that disturbed mother–child interactions lead to serious ego deficiencies in the child (including a poor sense of independence and control) and to severe perceptual disturbances that jointly help produce disordered eating (Bruch, 2001, 1991, 1962).
According to Bruch, parents may respond to their children either effectively or ineffectively. Effective parents accurately attend to their children’s biological and emotional needs, giving them food when they are crying from hunger and com- fort when they are crying out of fear. Ineffective parents, by contrast, fail to attend to their children’s needs, deciding that their children are hungry, cold, or tired without correctly interpreting the children’s actual condition. They may feed their children when their children are anxious rather than hungry or comfort them when they are tired rather than anxious. Children who receive such parenting may grow up con- fused and unaware of their own internal needs, not knowing for themselves when they are hungry or full and unable to identify their own emotions.
Because they cannot rely on internal signals, these children turn instead to exter- nal guides, such as their parents. They seem to be “model children,” but they fail to develop genuine self-reliance and “experience themselves as not being in control of their behavior, needs, and impulses, as not owning their own bodies” (Bruch, 1973, p. 55). Adolescence increases their basic desire to establish independence, yet they feel unable to do so. To overcome their sense of helplessness, they seek exces- sive control over their body size and shape and over their eating habits. Helen, an 18-year-old patient of Bruch’s, described such needs and efforts:
There is a peculiar contradiction—everybody thinks you’re doing so well and every- body thinks you’re great, but your real problem is that you think that you are not good enough. You are afraid of not living up to what you think you are expected to do. You have one great fear, namely that of being ordinary, or average, or com- mon—just not good enough. This peculiar dieting begins with such anxiety. You want to prove that you have control, that you can do it. The peculiar part of it is that it makes you feel good about yourself, makes you feel “I can accomplish some- thing.” It makes you feel “I can do something nobody else can do.”
(Bruch, 1978, p. 128)
Clinical reports and research have provided some support for Bruch’s theory (Holtom-Viesel & Allan, 2014; Schultz & Laessle, 2012). Clinicians have observed that the parents of teenagers with eating disorders do tend to define their children’s
Wrong message Supermodel Kate Moss arrives at a New York City fashion gala. Asked during a 2009 online interview whether she had any life mottos, Moss set off a firestorm by replying, “Nothing tastes as good as skinny feels.” Noting that this phrase often appears on pro-anorexia Web sites, many critics accused the model of giving legitimacy to the pro-Ana movement. Moss countered that her answer had been misrepresented and clarified that she does not support self-starvation as a lifestyle choice.
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needs rather than allow the children to define their own needs (Ihle et al., 2005; Steiner et al., 1991). When Bruch interviewed the mothers of 51 children with anorexia nervosa, many proudly recalled that they had always “anticipated” their young child’s needs, never permitting the child to “feel hungry” (Bruch, 1973).
Research has also supported Bruch’s belief that peo- ple with eating disorders perceive internal cues, includ- ing emotional cues, inaccurately (Lavender et al., 2014; Fairburn et al., 2008). When research participants with an eating disorder are anxious or upset, for example, many of them mistakenly think they are also hungry (see Figure 9-2), and they respond as they might respond to hunger—by eating. In fact, people with eating disorders are often described by clinicians as alexithymic, mean- ing they have great difficulty putting descriptive labels on their feelings (D’Agata et al., 2015; Zerbe, 2010, 2008). And finally, studies support Bruch’s argument that people with eating disorders rely excessively on the opinions, wishes, and views of others. They are more likely than other people to worry about how others view them, to seek approval, to be conforming, and to
feel a lack of control over their lives (Amianto et al., 2011; Travis & Meltzer, 2008).
Cognitive Factors If you look closely at Bruch’s explanation of eating disorders, you’ll see that it contains several cognitive ideas. She held, for example, that as a result of ineffective parenting, people with eating disorders improperly label their internal sensations and needs, generally feel little control over their lives, and, in turn, want to have excessive levels of control over their body size, shape, and eating habits. According to cognitive theorists, these deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating, namely, people with anorexia nervosa and bulimia nervosa judge themselves—often exclusively—based on their shape and weight and their ability to control them (Fairburn et al., 2015, 2008; Murphy et al., 2010). This “core pathology,” say cognitive theorists, gives rise to all other aspects of the disorders, including the repeated efforts to lose weight and the preoccupation with thoughts about shape, weight, and eating.
As you saw earlier in the chapter, research indicates that people with eating disorders do indeed display such cognitive deficiencies (Siep et al., 2011). Although studies have not clarified that such deficiencies are the cause of eating disorders, many cognitive-behavioral therapists proceed from this assumption and center their treatment for the disor- ders on correcting the clients’ cognitive distortions and accompanying behaviors. As you’ll soon see, cognitive-behavioral therapies of this kind are among the most widely used of all treatments for eating disorders (Fairburn et al., 2015, 2008).
Depression Many people with eating disorders, particularly those with bulimia nervosa, have symptoms of depression (Harrington et al., 2015). This finding has led some theo- rists to suggest that depressive disorders set the stage for eating disorders.
Bo r edo m 23%
Dep r essio n 47%
29%
Anxiety 44%
33%
L o v e 36%
35%
Happiness
P ercentage Who Eat the F oo d
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figure 9-2 When do people seek junk food? Apparently, when they feel bad. People who eat junk food when they are feeling bad outnumber those who eat nutritional food under similar circumstances. In contrast, more people seek nutritional food when they are feeling good. (Information from: Isasi et al., 2013; Haberman, 2007; Rowan, 2005; Hudd et al., 2000; Lyman, 1982.)
how might you explain the
finding that eating disorders
tend to be less common in
cultures that restrict a
woman’s freedom to make
decisions about her life?
▶▶ hypothalamus A part of the brain that helps regulate various bodily functions, including eating and hunger.
▶▶ lateral hypothalamus (lH) A brain region that produces hunger when activated.
▶▶ ventromedial hypothalamus (VmH) A brain region that depresses hunger when activated.
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Their claim is supported by four kinds of evidence. First, many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general popula- tion. Second, the close relatives of people with eating disorders seem to have a higher rate of depressive disorders than do close relatives of people without such disorders. Third, as you will soon see, many people with eating disorders, particularly bulimia nervosa, have low activity of the neurotransmitter serotonin, similar to the serotonin abnormalities found in people with depression. And finally, people with eating disorders are often helped by some of the same anti- depressant drugs that reduce depression. Of course, although such findings suggest that depression may help cause eating disorders, other explanations are possible. For example, the pressure and pain of having an eating disorder may cause depression.
Biological Factors Biological theorists suspect that certain genes may leave some people particularly susceptible to eating disorders (Starr & Kreipe, 2014). Consistent with this idea, relatives of people with eating disorders are up to six times more likely than other people to develop the disorders themselves (Thornton et al., 2011; Strober et al., 2001, 2000). Moreover, if one identical twin has anorexia nervosa, the other twin also develops the disorder in as many as 70 percent of cases; in contrast, the rate for fraternal twins, who are genetically less similar, is 20 percent. Similarly, in the case of bulimia nervosa, identical twins display a concordance rate of 23 percent, compared with a rate of 9 percent among fraternal twins (Thornton et al., 2011; Kendler et al., 1995, 1991).
One factor that has interested investigators is the possible role of serotonin. Several research teams have found a link between eating disorders and the genes responsible for the production of this neurotransmitter, and still others have mea- sured low serotonin activity in many people with eating disorders (Phillips et al., 2014; Starr & Kreipe, 2014). Thus some theorists suspect that abnormal serotonin activity causes the bodies of some people to crave and binge on high-carbohydrate foods (Kaye et al., 2013, 2011, 2005).
Other biological researchers explain eating disorders by pointing to the hypo- thalamus, a part of the brain that regulates many bodily functions (Berthoud, 2012). Researchers have located two separate areas in the hypothalamus that help control eating. One, the lateral hypothalamus (LH), produces hunger when it is activated. When the LH of a laboratory animal is stimulated electrically, the animal eats, even if it has been fed recently. In contrast, another area, the ventromedial hypothalamus (VMH), reduces hunger when it is activated. When the VMH is electrically stimulated, laboratory animals stop eating.
These areas of the hypothalamus and related brain structures are apparently activated by chemicals from the brain and body, depending on whether the person is eating or fasting (Schwartz, 2014; Petrovich, 2011). Two such brain chemicals are the natural appetite suppressants cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1) (Dossat et al., 2015; Turton et al., 1996). When one team of researchers collected and injected GLP-1 into the brains of rats, the chemical traveled to recep- tors in the hypothalamus and caused the rats to reduce their food intake almost entirely even though they had not eaten for 24 hours. Conversely, when “full” rats were injected with a substance that blocked the reception of GLP-1 in the hypo- thalamus, they more than doubled their food intake.
Some researchers believe that the hypothalamus, related brain areas, and chemi- cals such as CCK and GLP-1, working together, comprise a “weight thermostat”
“What do you eat for anxiety?”
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Smoking, Eating, and Weight 75 percent of people who quit smoking gain weight.
Nicotine, a stimulant substance, suppresses appetites and increases metabolic rate, perhaps because of its impact on the lateral hypothalamus.
(Kroemer et al., 2013; higgins & George, 2007)
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of sorts in the body, which is responsible for keeping an individual at a particular weight level called the weight set point. Genetic inheritance and early eating practices seem to determine each person’s weight set point (Yu et al., 2015; Sullivan et al., 2011). When a person’s weight falls below his or her particular set point, the LH and certain other brain areas are activated and seek to restore the lost weight by producing hunger and lowering the body’s metabolic rate, the rate at which the body expends energy. When a person’s weight rises above his or her set point, the VMH and certain other brain areas are activated, and they try to remove the excess weight by reducing hunger and increasing the body’s metabolic rate.
According to the weight set point theory, when people diet and fall to a weight below their weight set point, their brain starts trying to restore the lost weight. Hypothalamic and related brain activity produce a preoccupation with food and a desire to binge. They also trigger bodily changes that make it harder to lose weight and easier to gain weight, however little is eaten (Yu et al., 2015; Higgins & George, 2007). Once the brain and body begin conspiring to raise weight in this way, diet- ers actually enter into a battle against themselves. Some people apparently manage to shut down the inner “thermostat” and control their eating almost completely. These people move toward restricting-type anorexia nervosa. For others, the battle spirals toward a binge-purge or binge-only pattern. Although the weight set point explanation has received considerable debate in the clinical field, it remains widely accepted by theorists and practitioners.
Societal Pressures Eating disorders are more common in Western countries than in other parts of the world. Thus, many theorists believe that Western standards of female attractiveness are partly responsible for the emergence of the disorders (MacNeill & Best, 2015). Western standards of female beauty have changed throughout history, with a notice- able shift in preference toward a thin female frame in recent decades (Gilbert et al., 2005). One study that tracked the height, weight, and age of contestants in the Miss America Pageant from 1959 through 1978 found an average decline of 0.28 pound per year among the contestants and 0.37 pound per year among winners (Garner et al., 1980). The researchers also examined data on all Playboy magazine centerfold models over the same time period and found that the average weight, bust, and hip measurements of these women had decreased steadily. More recent studies of Miss America contestants and Playboy centerfolds indicate that these trends have contin- ued (Rubinstein & Caballero, 2000).
Because thinness is especially valued in the subcultures of performers, fashion models, and certain athletes, members of these groups are likely to be particularly concerned and/or crit- icized about their weight. For example, after undergoing an inpatient treatment program for eating disorders, the popular singer and rapper Kesha recently wrote, “The music industry has set unrealistic expectations for what a body is supposed to look like, and I started becoming overly critical of my own body because of that” (Sebert, 2014).
Studies have found that performers, models, and athletes are indeed more prone than others to anorexia nervosa and bulimia nervosa (Arcelus, Witcomb, & Mitchell, 2014; Martinsen & Sundgot-Borgen, 2013). In fact, many famous young women from these fields have publicly acknowledged grossly disordered eating patterns over the years. Surveys of athletes at colleges around the United States reveal that more than 9 percent of female college athletes suffer from an eating disorder and at least another 33 percent display eating behaviors that put them at risk for such disorders (Ekern, 2014; Kerr et al., 2007). A full 20 percent of surveyed gymnasts appear to have an eating disorder (Van Durme et al., 2012).
Laboratory obesity Biological theorists believe that certain genes leave some individu- als particularly susceptible to eating disorders. To help support this view, researchers have cre- ated mutant (“knockout”) mice—mice without certain genes. The mouse on the left is missing a gene that helps produce obesity, and it is thin. In contrast, the mouse on the right, which retains that gene, is obese.
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▶▶ weight set point The weight level that a person is predisposed to maintain, controlled in part by the hypothalamus.
▶▶ enmeshed family pattern A family system in which members are overinvolved with each other’s affairs and overconcerned about each other’s welfare.
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Attitudes toward thinness may also help explain economic dif- ferences in the rates of eating disorders. In the past, women in the upper socioeconomic classes expressed more concern about thinness and dieting than women of the lower socioeconomic classes (Margo, 1985). Correspondingly, anorexia nervosa and bulimia nervosa were more common among women higher on the socioeconomic scale (Foreyt et al., 1996; Rosen et al., 1991). In recent years, however, diet- ing and preoccupation with thinness have increased to some degree in all socioeconomic classes, as has the prevalence of these eating disorders (Starr & Kreipe, 2014; Ernsberger, 2009).
Western society not only glorifies thinness but also creates a climate of prejudice against overweight people (Puhl et al., 2015). Whereas slurs based on ethnicity, race, and gender are considered unacceptable, cruel jokes about obesity are standard fare on the Web and television and in movies, books, and magazines. Research indi- cates that the prejudice against obese people is deep-rooted (Grilo et al., 2005). Prospective parents who were shown pictures of a chubby child and a medium-weight or thin child rated the former as less friendly, energetic, intelligent, and desirable than the latter. In another study, preschool children who were given a choice between a chubby and a thin rag doll chose the thin one, although they could not say why.
Given these trends, it is not totally surprising that a recent survey of 248 ado- lescent girls directly tied eating disorders and body dissatisfaction to social net- working, Internet activity, and television browsing (Latzer, Katz, & Spivak, 2011) (see MindTech on the next page). The survey found that the respondents who spent more time on Facebook were more likely to display eating disorders, have negative body image, eat in dysfunctional ways, and want to diet. Those who spent more time on fashion and music Web sites and those who viewed more gossip- and leisure- related television programs showed similar tendencies.
Family Environment Families may play an important role in the development and maintenance of eating disorders (Hoste, Lebow, & Le Grange, 2014). Research suggests that as many as half of the families of people with anorexia nervosa or bulimia nervosa have a long his- tory of emphasizing thinness, physical appearance, and dieting. In fact, the mothers in these families are more likely to diet themselves and to be generally perfection- istic than are the mothers in other families (Zerbe, 2008; Woodside et al., 2002).
Abnormal interactions and forms of communication within a family may also set the stage for an eating disorder (Holtom-Viesel, & Allan, 2014). Family sys- tems theorists argue that the families of people who develop eating disorders are often dysfunctional to begin with and that the eating disorder of one member is a reflection of the larger problem. Influential family theorist Salvador Minuchin, for example, believes that what he calls an enmeshed family pattern often leads to eating disorders (Olson, 2011; Minuchin et al., 2006).
In an enmeshed system, family members are overinvolved in each other’s affairs and overconcerned with the details of each other’s lives. On the positive side, enmeshed families can be affectionate and loyal. On the negative side, they can be clingy and foster dependency. Parents are too involved in the lives of their children, allowing little room for individuality and independence. Minuchin argues that ado- lescence poses a special problem for these families. The teenager’s normal push for independence threatens the family’s apparent harmony and closeness. In response, the family may subtly force the child to take on a “sick” role—to develop an eating disorder or some other illness. The child’s disorder enables the family to maintain its
Models and mannequins Mannequins were once made extra-thin to show the lines of the clothing for sale to best advantage. Today the shape of the ideal woman is indis- tinguishable from that of a mannequin (right), and a growing number of young women try to achieve this ideal.
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Teasing and Eating When it comes to eating disorders, teasing is no laughing matter (Hilbert et al., 2013; Neumark-Sztainer et al., 2007). In one study, researchers found that adolescents who were teased about their weight by family members were twice as likely as nonteased teens of similar weight to become overweight within five years and 1.5 times more likely to become binge eaters and use extreme weight control measures.
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appearance of harmony. A sick child needs her family, and family members can rally to protect her. Some case studies have supported such family systems explanations, but systematic research fails to show that particular family patterns consistently set the stage for the development of eating disorders (Holtom-Viesel & Allan, 2014). In fact, the families of people with either anorexia nervosa or bulimia nervosa vary widely.
MindTech
Dark Sites of the Internet Clinicians, researchers, and other mental health practitioners try to combat psychological disorders—in person, in journals and books, and online. Unfortunately, today there are also other—more negative—forces operating
that run counter to the work of mental health professionals. Among the most com- mon are so-called dark sites of the Internet—sites with the goal of promoting behav- iors that the clinical community, and most of society, consider abnormal and destructive. Pro- anorexia sites are a prime example of this phe- nomenon (Wooldridge et al., 2014).
The Eating Disorders Association reports that there are more than 500 pro-anorexia Internet sites, with names such as “Dying to Be Thin” and “Starving for Perfection” (Borzekowski et al., 2010). These sites are commonly called pro-Ana sites, using a girl named Ana as the personification of this eating disorder. Some of the sites view anorexia nervosa (and bulimia nervosa) as lifestyles rather than psychological disorders;
others present themselves as nonjudgmental sites for people with anorexic features. Either way, the sites are enormously popular and appear to greatly outnumber “pro- recovery” Web sites. This worries professionals and parents alike, although it is not yet clear how influential the sites actually are (Delforterie et al., 2014).
Many users of the sites exchange tips on how they can starve themselves and disguise their weight loss from family, friends, and doctors (Christodoulou, 2012). The sites may also offer support and feedback about starvation diets. Many of the sites offer mottos, emo- tional messages, and photos and videos of extremely thin actresses and models as “thinspiration” (Mathis, 2014).
The pro-Ana movement and its messages actually appear throughout the Internet—for example, on Web
forums; social networks such as Facebook, Tumblr, and Live Journal; and video platforms such as YouTube, Vimeo, and Veoh (Syed-Abdul et al, 2013). Most online enterprises try to seek out and delete pro-Ana material and groups, taking the position that such messages promote self-harm (Peng, 2008). However, despite such efforts, the sites—and their pro-Ana messages—continue to flourish.
Many people worry that pro-Ana sites place vulnerable people at great risk, and they have called for more active efforts to ban these sites. Others argue, however, that despite their potential dangers, the sites represent basic freedoms that should not be violated—freedom of speech, for example, and perhaps even the freedom to do oneself harm.
Besides promoting eating
disorders, might there be
other ways in which pro-ana
sites are potentially harmful
to regular visitors?
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Multicultural Factors: Racial and Ethnic Differences In the popular 1995 movie Clueless, Cher and Dionne, wealthy teenage friends of different races, have similar tastes, beliefs, and values about everything from boys to schoolwork. In particular, they have the same kinds of eating habits and beauty ideals, and they are even similar in weight and physical form. But does the story of these young women reflect the realities of white American and African American females in our society?
In the early 1990s, the answer to this question appeared to be a resounding no. Most studies conducted up to the time of the movie’s release indicated that the eat- ing behaviors, values, and goals of young African American women were consider- ably healthier than those of young white American women (Lovejoy, 2001; Cash & Henry, 1995; Parker et al., 1995). A widely publicized 1995 study at the University of Arizona, for example, found that the eating behaviors and attitudes of young African American women were more positive than those of young white American women. It found, specifically, that nearly 90 percent of the white American respon- dents were dissatisfied with their weight and body shape, compared with around 70 percent of the African American teens.
The study also suggested that white American and African American adolescent girls had different ideals of beauty. The white American teens, asked to define the “perfect girl,” described a girl of 5' 7" weighing between 100 and 110 pounds— proportions that mirror those of so-called supermodels. Attaining a perfect weight, many said, was the key to being happy and popular. In contrast, the African Ameri- can respondents emphasized personality traits over physical characteristics. They defined the “perfect” African American girl as smart, fun, easy to talk to, not con- ceited, and funny; she did not necessarily need to be “pretty,” as long as she was well groomed. The body dimensions the African American teens described were more attainable for the typical girl; they favored fuller hips, for example. Moreover, the African American respondents were less likely than the white American respondents to diet for extended periods.
Unfortunately, research conducted over the past decade suggests that body image concerns, dysfunctional eating patterns, and anorexia nervosa and bulimia nervosa are on the rise among young African American women as well as among women of other minority groups (Starr & Kreipe, 2014; Gilbert, 2011). For example, a sur- vey conducted by Essence—the largest-circulation magazine geared toward African Americans—and studies by several teams of researchers have found that the risk of today’s African American women developing these eating disorders is approaching
Dangerous profession The fashion world was shocked when 21-year-old Brazilian model Ana Carolina Reston died in 2006 of compli- cations from anorexia nervosa. Told during a 2004 casting call that she was “too fat,” Reston began restricting her diet to only apples and tomatoes, culminating in a generalized infec- tion and eventually death. The 5'8" model weighed 88 pounds at the time of her death.
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SPARK Movement Members of SPARK Movement, a group of high school girls dedi- cated to changing how female shapes and weight are portrayed in the media, recently conducted a mock fashion show on the streets of New York City. The group called on the edi- tors of Teen Vogue magazine to stop altering the bodies and faces of girls displayed in the magazine’s photos.©
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that of white American women. Similarly, African American women’s attitudes about body image, weight, and eating are closing in on those of white American women (Annunziato et al., 2007). In the Essence survey, 65 percent of African American respondents reported dieting, 39 percent said that food controlled their lives, 19 percent avoided eating when hungry, 17 percent used laxatives, and 4 per- cent vomited to lose weight.
The shift in the eating behaviors and eating problems of African American women appears to be partly related to their acculturation (Kroon Van Diest et al., 2014). One study compared African American women at a predominately white American university with those at a predominately African American university. Those at the former school had significantly higher depression scores, and those scores were positively correlated with eating problems (Ford, 2000).
Still other studies indicate that Hispanic American female adolescents and young adults engage in disordered eating behaviors and express body dissatisfaction at rates about equal to those of white American women (Blow & Cooper, 2014; Levine & Smolak, 2010). Moreover, those who consider themselves more oriented to white American culture have particularly high rates of anorexia nervosa and bulimia ner- vosa (Cachelin et al., 2006). These eating disorders also appear to be on the increase among young Asian American women and young women in several Asian countries (Pike et al., 2013; Stewart & Williamson, 2008). In one Taiwanese study, for example, 65 percent of the underweight girls aged 10 to 14 years said they wished they were thinner (Wong & Huang, 2000).
Multicultural Factors: Gender Differences Males account for only 5 to 10 percent of all people with anorexia nervosa and bulimia nervosa. The reasons for this striking gender difference are not entirely clear, but Western society’s double standard for attractiveness is, at the very least, one rea- son. Our society’s emphasis on a thin appearance is clearly aimed at women much more than men, and some theorists believe that this difference has made women much more inclined to diet and more prone to eating disorders. Surveys of college men have, for example, found that the majority select “muscular, strong and broad shoulders” to describe the ideal male body and “thin, slim, slightly underweight” to describe the ideal female body (Mayo & George, 2014; Toro et al., 2005).
Salt-N-Pepa: Behind the scenes When the pioneering female rap group Salt-N-Pepa suddenly disbanded in 2002, it was viewed by most as a “typical” band breakup. In fact, however, one of the performers, Cheryl “Salt” James (shown here), had been suffering from bulimia nervosa. She quit performing in order to recover from the disorder and to escape the pressures of her fame, including, in her words, “the pressure to be beautiful and management telling me ‘You’re gaining weight.’” With James now recovered, the group has reunited and is touring again. Sc
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Climate Control Women who live in warmer climates (where more revealing clothing is worn) have lower weight, engage in more binge eating and purging, and have more body image concerns than women who live in cooler climates (Sloan, 2002).
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A second reason for the different rates of anorexia nervosa and bulimia nervosa between men and women may be the different methods of weight loss favored by the two genders. According to some clinical observations, men are more likely to use exercise to lose weight, whereas women more often diet (Gadalla, 2009; Toro et al., 2005). And, as you have read, dieting often precedes the onset of these eating disorders.
Why do some men develop anorexia nervosa or bulimia nervosa? In a num- ber of cases, the disorder is linked to the requirements and pressures of a job or sport (Morgan, 2012; Thompson & Sherman, 2011). According to one study, 37 percent
of men with these eating disorders had jobs or played sports for which weight control was important, compared with 13 percent of women with such disorders (Braun, 1996). The highest rates of male eating disorders have been found among jockeys, wrestlers, distance runners, body builders, and swim-
mers. Jockeys commonly spend hours before a race in a sauna, shedding up to seven pounds of weight, and may restrict their food intake, abuse laxatives and diuretics, and force vomiting (Kerr et al., 2007).
For other men who develop anorexia nervosa or bulimia nervosa, body image appears to be a key factor, just as it is in women (Mayo & George, 2014; Mond et al., 2014). Many report that they want a “lean, toned, thin” shape similar to the ideal female body, rather than the muscular, broad-shouldered shape of the typical male ideal (Morgan, 2012; Hildebrandt & Alfano, 2009).
Still other men seem to be caught up in a different kind of eating disorder, called reverse anorexia nervosa or muscle dysmorphobia. Men with this disorder are very mus- cular but still see themselves as scrawny and small and therefore continue to strive for a “perfect” body through extreme measures such as excessive weight lifting or the abuse of steroids (Lin & DeCusati, 2015; Morgan, 2012). People with muscle
Not for women only A growing number of today’s men are developing eating disorders. Some of them aspire to a very lean body shape, such as that displayed by a new breed of ultra-thin male models (left), and develop anorexia nervosa or bulimia nervosa. Others want the ultramuscu- lar look displayed by bodybuilders (above) and develop a new kind of eating disorder called muscle dysmorphobia. The men in this latter category inaccurately consider themselves to be scrawny and small and keep striving for a “perfect” body through excessive weight lifting and abuse of steroids.
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Saintly Restraint During the Middle Ages, restrained eating, prolonged fasting, or purg- ing by a number of female saints was greatly admired and was even counted among their miracles. Catherine of Siena sometimes pushed twigs down her throat to bring up food, Mary of Oignies and Beatrice of Nazareth vom- ited from the mere smell of meat, and Columba of Rieti died of self-starvation (Brumberg, 1988).
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dysmorphobia typically feel shame about their bodies, and many have a history of depression, anxiety, and self-destructive compulsive behavior. About one-third of them also engage in related dysfunctional behaviors such as binge eating.
➤ Summing Up WHAt CAuSES EAtINg DISORDERS? Most theorists now use a multidimen- sional risk perspective to explain anorexia nervosa and bulimia nervosa and to identify several key contributing factors. These factors include ego deficiencies; cognitive factors; depression; biological factors such as activity of the hypothal- amus, biochemical activity, and the body’s weight set point; society’s emphasis on thinness and bias against obesity; family environment; racial and ethnic dif- ferences; and gender differences. Which of these factors are also involved in binge-eating disorder is not yet clear.
How Are Eating Disorders Treated? Today’s treatments for eating disorders have two goals. The first is to correct the dangerous eating pattern as quickly as possible. The second is to address the broader psychological and situational factors that have led to and maintain the eating prob- lem. Family and friends can also play an important role in helping to overcome the disorder.
Treatments for Anorexia Nervosa The immediate aims of treatment for anorexia nervosa are to help people regain their lost weight, recover from malnourishment, and eat normally again. Therapists must then help them to make psychological and perhaps family changes to lock in those gains.
How Are Proper Weight and Normal Eating Restored? A variety of treatment methods are used to help patients with anorexia nervosa gain weight quickly and return to health within weeks. In the past, treatment almost always took place in a hospital, but now it is often offered in day hospitals or outpatient settings (Raveneau et al., 2014; Keel & McCormick, 2010).
In life-threatening cases, clinicians may need to force tube and intravenous feedings on a patient who refuses to eat (Rocks et al., 2014; Touyz & Carney, 2010). Unfor- tunately, this use of force may cause the client to distrust the clinician. In contrast, clinicians using behavioral weight-restoration approaches offer rewards whenever patients eat properly or gain weight and offer no rewards when they eat improperly or fail to gain weight (Tacón & Caldera, 2001).
Perhaps the most popular weight-restoration technique in recent years has been a combination of supportive nursing care, nutritional counseling, and a relatively high- calorie diet—often called a nutritional rehabilitation program (Leclerc et al., 2013). Here nurses gradually increase a patient’s diet over the course of several weeks to more than 3,000 calories a day (Zerbe, 2010, 2008; Herzog et al., 2004). The nurses educate patients about the program, track their progress, provide encouragement, and help them recognize that their weight gain is under control and will not lead to obesity. In some programs, the nurses also use motivational interviewing, an intervention in which they motivate clients to actively make and follow through on constructive choices regarding their eating behaviors and their lives (Dray et al., 2014). Studies
“Normal Barbie” For years, the ultra-slim measurements and proportions of the widely popular Barbie doll have introduced women to an unattainable ideal at a very young age. Hoping to demonstrate instead that “average is beautiful,” artist Nickolay Lamm recently designed a Normal Barbie (right), using the CDC measurements of the average 19-year-old American woman. Normal Barbie turns out to be shorter, curvier, and bustier than the doll sit- ting on store shelves around the world.
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find that patients in nursing-care programs usually gain the necessary weight over 8 to 12 weeks.
How Are Lasting Changes Achieved? Clinical researchers have found that people with anorexia nervosa must overcome their underlying psychologi- cal problems in order to create lasting improvement. Therapists typically use a combination of education, psychotherapy, and family therapy to help reach this broader goal (Knatz et al., 2015; Wade & Watson, 2012). Psychotropic drugs have also been helpful in some cases, but research has found that such medications are typically of limited benefit over the long-term course of anorexia nervosa (Starr & Kreipe, 2014).
Cognitive-Behavioral therapy A combination of behavioral and cognitive inter- ventions is included in most treatment programs for anorexia nervosa. Such tech- niques are designed to help clients appreciate and change the behaviors and thought processes that help keep their restrictive eating going (Fairburn & Cooper, 2014; Evans & Waller, 2011). On the behavioral side, clients are typically required to moni- tor (perhaps by keeping a diary) their feelings, hunger levels, and food intake and the ties between these variables. On the cognitive side, they are taught to identify their “core pathology”—the deep-seated belief that they should in fact be judged by their shape and weight and by their ability to control these physical character- istics. The clients may also be taught alternative ways of coping with stress and of solving problems.
The therapists who use these approaches are particularly careful to help patients with anorexia nervosa recognize their need for independence and teach them more appropriate ways to exercise control (Pike et al., 2010). The therapists may also teach them to identify better and trust their internal sensations and feelings (Wilson, 2010). In the following session, a therapist tries to help a 15-year-old client recognize and share her feelings:
Patient: I don’t talk about my feelings; I never did. Therapist: Do you think I’ll respond like others? Patient: What do you mean? Therapist: I think you may be afraid that I won’t pay close attention to what you feel
inside, or that I’ll tell you not to feel the way you do—that it’s foolish to
A story of two billboards In 1995, the Calvin Klein clothing brand posed young teenagers in sexually suggestive clothing ads (left). A public uproar forced the company to remove the ads from magazines and billboards across the United States, but by then, a point had been made—that extreme thinness was in vogue for female fashion and, indeed, for females of all ages. In contrast, the Nolita clothing brand launched a major ad campaign against excessive thinness in 2007, displaying anti-anorexia billboards throughout Italy (right). Here two young women stare at one such billboard—that of an emaciated naked woman appearing beneath the words “No Anorexia.” The billboard model, Isabelle Caro, died in 2010 of complications from anorexia nervosa.
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Fashion Downsizing In 1968, the average fashion model was 8 percent thinner than the typical woman. Today, models are 23 percent thinner (Tashakova, 2011; Derenne & Beresin, 2006).
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feel frightened, to feel fat, to doubt yourself, considering how well you do in school, how you’re appreciated by teachers, how pretty you are.
Patient: (Looking somewhat tense and agitated) Well, I was always told to be po- lite and respect other people, just like a stupid, faceless doll. (Affecting a vacant, doll-like pose)
Therapist: Do I give you the impression that it would be disrespectful for you to share your feelings, whatever they may be?
Patient: Not really; I don’t know. Therapist: I can’t, and won’t, tell you that this is easy for you to do. . . . But I can prom-
ise you that you are free to speak your mind, and that I won’t turn away.
(Strober & Yager, 1985, pp. 368–369)
Finally, cognitive-behavioral therapists help clients with anorexia nervosa change their attitudes about eating and weight (Fairburn & Cooper, 2014; Evans & Waller, 2012) (see Table 9-4). The therapists may guide clients to identify, challenge, and change maladaptive assumptions, such as “I must always be perfect” or “My weight and shape determine my value” (Fairburn et al., 2015, 2008). They may also educate clients about the body distortions typical of anorexia nervosa and help them see that their own assessments of their size are incorrect.
Although cognitive-behavioral techniques are often of great help to clients with anorexia nervosa, research suggests that the techniques typically must be supple- mented by other approaches to bring about better results (Zerbe, 2010, 2008). Fam- ily therapy, for example, is often included in treatment.
Changing Family interaCtions Family therapy can be an invaluable part of treatment for anorexia nervosa, particularly for children and adolescents with the disorder. As in other family therapy situations, the therapist meets with the family as a whole, points out troublesome family patterns, and helps the members make appropriate changes. In particular, family therapists may try to help the person with anorexia nervosa separate her feelings and needs from those of other members of her
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Sample Items from the Eating Disorder Inventory
For each item, decide if the item is true about you ALWAYS (A), USUALLY (U), OFTEN (O), SOMETIMES (S), RARELY (R), or NEVER (N). Circle the letter that corresponds to your rating.
A U O S R N I eat when I am upset.
A U O S R N I stuff myself with food.
A U O S R N I think about dieting.
A U O S R N I think that my thighs are too large.
A U O S R N I feel extremely guilty after overeating.
A U O S R N I am terrified of gaining weight.
A U O S R N I get confused as to whether or not I am hungry.
A U O S R N I have the thought of trying to vomit in order to lose weight.
A U O S R N I think my buttocks are too large.
A U O S R N I eat or drink in secrecy.
(Information from: Clausen et al., 2011; Garner, 2005, 1991; Garner, Olmsted, & Polivy, 1984.)
Calling for more assertive action According to many people, efforts to change the negative impact of the fashion industry and media on women have been woefully ineffec- tive to date. Thus a feminist movement has emerged to more aggressively fight society’s “obsession with female thinness.” The move- ment’s slogan, “Riots Not Diets,” has already caught fire and now adorns bags, T-shirts, patches, cookies, glassware, and many other objects around the world.
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family. Although the role of family in the development of anorexia nervosa is not yet clear, research strongly suggests that family therapy (or at least parent counseling) can be helpful in the treatment of this disorder (Knatz et al., 2015; Ambresin et al., 2014).
Mother: I think I know what [Susan] is going through: all the doubt and in- security of growing up and establishing her own identity. (Turning to the patient, with tears) If you just place trust in yourself, with the support of those around you who care, everything will turn out for the better.
Therapist: Are you making yourself available to her? Should she turn to you, rely on you for guidance and emotional support?
Mother: Well, that’s what parents are for. Therapist: (Turning to patient) What do you think? Susan: (To mother) I can’t keep depending on you, Mom, or everyone else.
That’s what I’ve been doing, and it gave me anorexia. . . . Therapist: Do you think your mom would prefer that there be no secrets be-
tween her and the kids—an open door, so to speak? Older sister: Sometimes I do. Therapist: (To patient and younger sister) How about you two? Susan: Yeah. Sometimes it’s like whatever I feel, she has to feel. Younger sister: Yeah.
(Strober & Yager, 1985, pp. 381–382)
What Is the Aftermath of Anorexia Nervosa? The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa, although the road to recovery can be difficult. The course and outcome of this disorder vary from person to person, but researchers have noted certain trends.
On the positive side, weight is often quickly restored once treatment for the disorder begins, and treatment gains may continue for years (Isomaa & Isomaa, 2014; Haliburn, 2005). As many as 85 percent of patients continue to show improvement— either full or partial—when they are inter- viewed several years or more after their initial recovery (Isomaa & Isomaa, 2014; Brewerton & Costin, 2011).
Another positive note is that most females with anorexia nervosa menstru- ate again when they regain their weight, and other medical improvements follow (Mitchell & Crow, 2010). Also encourag- ing is that the death rate from anorexia nervosa seems to be falling (van Son et al., 2010). Earlier diagnosis and safer and faster weight-restoration techniques may account for this trend. Deaths that do occur are usually caused by suicide, starva- tion, infection, gastrointestinal problems, or electrolyte imbalance.
Miss America speaks out Kirsten Haglund is crowned Miss America at the January 2008 pageant. During her one-year reign, Haglund openly acknowledged her past struggles with anorexia nervosa. In recent years, she has con- tinued to travel and speak about body image issues and eating disorders. She also has started a foundation to provide treatment ser- vices for women who have eating disorders.Do
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Another New Word In 2015, the Oxford Dictionaries also added the word “fat-shame,” a verb meaning to humiliate someone by mak- ing mocking or critical comments about their overweight appearance.
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On the negative side, as many as 25 percent of persons with anorexia nervosa remain seriously troubled for years (Isomaa & Isomaa, 2014; Steinhausen, 2009). Furthermore, recovery, when it does occur, is not always permanent. At least one- third of recovered patients have recurrences of anorexic behavior, usually triggered by new stresses, such as marriage, pregnancy, or a major relocation (Stice et al., 2013; Fennig et al., 2002). Even years later, many who have recovered continue to express concerns about their weight and appearance. Some still restrict their diets to a degree, feel anxiety when they eat with other people, or hold some distorted ideas about food, eating, and weight (Isomaa & Isomaa, 2014; Fairburn et al., 2008).
About half of those who have suffered from anorexia nervosa continue to have certain emotional problems—particularly depression, obsessiveness, and social anxiety—years after treatment. Such problems are particularly common in those who had not reached a fully normal weight by the end of treatment (Bodell & Mayer, 2011; Steinhausen, 2002).
The more weight persons have lost and the more time that passes before they enter treatment, the poorer the recovery rate (Fairburn et al., 2008). People who had psychological or sexual problems before the onset of the disorder tend to have a poorer recovery rate than those without such a history (Zerwas et al., 2013; Amianto et al., 2011). People whose families are dysfunctional have less positive treatment outcomes (Holtom-Viesel & Allan, 2014). Teenagers seem to have a better recovery rate than older patients (Richard, 2005).
Treatments for Bulimia Nervosa Treatment programs for bulimia nervosa are often offered in eating disorder clin- ics (Henderson et al., 2014). Such programs share the immediate goals of helping clients to eliminate their binge-purge patterns and establish good eating habits and the more general goal of eliminating the underlying causes of bulimic patterns. The programs emphasize education as much as therapy (Fairburn & Cooper, 2014). Cognitive-behavioral therapy is particularly helpful in cases of bulimia nervosa— perhaps even more helpful than in cases of anorexia nervosa (Fairburn & Cooper, 2014; Wonderlich et al., 2014). And antidepressant drug therapy, which is of limited help to people with anorexia nervosa, appears to be quite effective in many cases of bulimia nervosa (Starr & Kreipe, 2014).
Cognitive-Behavioral Therapy When treating clients with bulimia ner- vosa, cognitive-behavioral therapists employ many of the same techniques that they use to help treat people with anorexia nervosa. However, they tailor the techniques to the unique features of bulimia (for example, bingeing and purging behavior) and to the specific beliefs at work in bulimia nervosa.
Behavioral teChniques Therapists often instruct clients with bulimia nervosa to keep diaries of their eating behavior, changes in sensations of hunger and fullness, and the ebb and flow of other feelings (Stewart & Williamson, 2008). This helps the clients to observe their eating patterns more objectively and recognize the emotions and situations that trigger their desire to binge.
One team of researchers studied the effectiveness of an online version of the diary technique (Shapiro et al., 2010). They had 31 clients with bulimia nervosa, each an outpatient in a 12-week cognitive-behavioral therapy program, send nightly texts to their therapists, reporting on their bingeing and purging urges and episodes. The clients received feedback messages, including reinforcement and encourage- ment for the treatment goals they had been able to reach that day. The clinical researchers reported that by the end of therapy, the clients showed significant decreases in binges, purges, other bulimic symptoms, and feelings of depression.
Cognitive-behavioral therapists may also use the behavioral technique of expo- sure and response prevention to help break the binge-purge cycle. As you read
B e t W e e N t h e L I N e S
Celebrities Who Acknowledge Having Had Eating Disorders Kesha, singer
Demi Lovato, singer
Nicole “Snooki” Polizzi, reality star
Alanis Morissette, singer
Ashlee Simpson, singer
Kate Winslet, actress
Lady Gaga, singer/songwriter
Mary-Kate Olsen, actress
Kelly Clarkson, singer
Jessica Alba, actress
Elton John, singer
Paula Abdul, dancer/entertainer
Fiona Apple, singer
Daniel Johns, rock singer (Silverchair)
Karen Elson, model
Cynthia French, singer
Princess Diana, British royalty
Kate Beckinsale, actress
Zina Garrison, tennis star
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in Chapter 4, this approach consists of exposing people to situations that would ordinarily raise anxiety and then prevent- ing them from performing their usual compulsive responses until they learn that the situations are actually harmless and their compulsive acts unnecessary. For bulimia nervosa, the therapists require cli- ents to eat particular kinds and amounts of food and then prevent them from vom- iting to show that eating can be a harmless and even constructive activity that needs no undoing (Wilson, 2010). Typically the therapist sits with the client while the client eats the forbidden foods and stays until the urge to purge has passed. Stud- ies find that this treatment often helps reduce eating-related anxieties, bingeing, and vomiting.
Cognitive teChniques Beyond such behavioral techniques, a primary focus of cognitive-behavioral therapists is to help clients with bulimia nervosa recognize and change their maladaptive attitudes toward food, eating, weight, and shape (Waller et al., 2014; Wonderlich et al., 2014). The therapists typically teach the clients to identify and challenge the negative thoughts that regularly precede their urge to binge—“I have no self-control”; “I might as well give up”; “I look fat” (Fairburn & Cooper, 2014; Fairburn, 1985). They may also guide clients to recognize, question, and eventually change their perfectionistic standards, sense of helplessness, and low self-concept (see PsychWatch on the next page). Cognitive-behavioral approaches seem to help as many as 65 per- cent of patients stop bingeing and purging (Poulsen et al., 2014; Eifert et al., 2007).
Other Forms of Psychotherapy Because of its effectiveness in the treat- ment of bulimia nervosa, cognitive-behavioral therapy is often tried first, before other therapies are considered. If clients do not respond to it, other approaches with promising but less impressive track records may then be tried. A common alternative is interpersonal psychotherapy, the treatment described in Chapter 6 that is used to help improve interpersonal functioning (Fairburn et al., 2015; Kass et al., 2013). Psychody- namic therapy has also been used in cases of bulimia nervosa, but only a few research studies have tested and supported its effectiveness (Poulsen et al., 2014; Tasca et al., 2014). The various forms of psychotherapy—cognitive-behavioral, interpersonal, and psychodynamic—are often supplemented by family therapy (Ambresin et al., 2014; Starr & Kreipe, 2014).
Cognitive-behavioral, interpersonal, and psychodynamic therapy may each be offered in either an individual or a group therapy format, including self-help groups. Research suggests that group formats are at least somewhat helpful for as many as 75 percent of people with bulimia nervosa (Valbak, 2001).
Antidepressant Medications During the past 15 years, antidepressant drugs—all forms of antidepressant drugs—have been used to help treat bulimia ner- vosa (Starr & Kreipe, 2014). In contrast to people with anorexia nervosa, those with bulimia nervosa are often helped considerably by these drugs. According to research, the drugs help as many as 40 percent of patients, reducing their binges by an average of 67 percent and vomiting by 56 percent. Once again, drug therapy seems to work best in combination with other forms of therapy, particularly cognitive-behavioral
New efforts at prevention A number of innovative educational programs have been developed to help promote healthy body images and prevent eating disorders. Here, a first-year Winona State University student swings a maul over her shoulder and into bathroom scales as part of Eating Disorders Awareness Week. The scale smashing is an annual event.
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therapy (Stewart & Williamson, 2008). Alternatively, some therapists wait to see whether cognitive-behavioral therapy or another form of psychotherapy is effective before trying antidepressants (Wilson, 2010, 2005).
What Is the Aftermath of Bulimia Nervosa? Left untreated, bulimia nervosa can last for years, sometimes improving temporarily but then returning. Treatment, however, produces immediate, significant improvement in approximately 40 percent of clients: they stop or greatly reduce their bingeing and purging, eat properly, and maintain a normal weight (Isomaa & Isomaa, 2014; Richard, 2005). Another 40 percent show a moderate response—at least some decrease in binge eating and purging. As many as 20 percent show little immediate improvement. Follow-up studies, conducted years after treatment, suggest that as many as 85 per- cent of people with bulimia nervosa have recovered, either fully or partially (Isomaa & Isomaa, 2014; Brewerton & Costin, 2011).
PsychWatch
In a November 2010 review of the New York City Ballet production of The Nutcracker, New York Times critic Alastair Macauley wrote that Jenifer Ringer, the 37-year-old dancer who played the part of the Sugar Plum Fairy, “looked as if she’d eaten one sugar plum too many” (Macauley, 2010). That harsh critique of the dancer’s weight and body set off a storm of protest throughout the country. Many regarded the review- er’s comments as cruel, an example of the absurd aesthetic standards by which women are judged in our society—even a lithe and graceful ballet artist. The reviewer defended his position, arguing, “If you want to make your appearance irrelevant to criticism, do not choose ballet as a career” (Macauley, 2010). But, in the eyes of most observers, he had gone too far.
About the only person who re- acted calmly in the face of this up- roar was the dancer herself, Jenifer Ringer. She even noted that “as a dancer, I do put myself out there to be criticized, and my body is part of my art form” (Ringer, 2010). It turns out that the 2010 flak was hardly the first time that Ringer’s weight and appearance had been described in unflattering terms. In a 2014
autobiography, she has revealed that her body had been an object of criticism throughout much of her professional life.
Ringer began with the City Ballet as a teenager in 1989, and by 1995 she was soloing. According to her memoir, she was also developing bulimia nervosa
while her career was on the rise. She fell into a pattern of overeating and over- exercising to compensate. As she puts it, “I had lost any sense of a center for self- esteem and self-worth” (Ringer, 2014).
Decades before Macauley’s 2010 critique, many of Ringer’s dance men- tors were urging her to lose weight. She
recalls how legendary choreographer Jerome Robbins exhorted her, “Come on. You just need to get the weight off. Just do it. We need you” (Ringer, 2014). In fact, after a warning from a ballet master that she must “stop eat- ing cheesecake,” Ringer‘s contract with the ballet company was not renewed in 1997 (Ringer, 2014). She left dance at that time for a brief stint as an office worker.
After overcoming her eating dis- order and regaining her self-esteem, Ringer rejoined the City Ballet in 1998. The next 16 years of dance repre- sented a personal and professional triumph for her—a triumph that those harsh and unfair words in 2010 could not penetrate. By then, she was no longer an insecure person who judged herself and her body by the standards of others. Rather, as she states in her memoir, “I didn’t feel I was heavy, and someone else’s opinion of me had no power over me unless I allowed it” (Ringer, 2014).
The Sugar Plum Fairy
Unfair critique Ballet dancer Jenifer Ringer performs with partner Jared Angle in The Nutcracker.
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Relapse can be a problem even among people who respond successfully to treat- ment (Stice et al., 2013; Olmsted et al., 2005). As with anorexia nervosa, relapses are usually triggered by a new life stress (Liu, 2007; Abraham & Llewellyn-Jones, 1984).
One study found that close to one-third of those who had recovered from bulimia nervosa relapsed within two years of treatment, usually within six months (Olmsted et al., 1994). Relapse is more likely among people who had longer histories of bulimia nervosa before treatment, had vomited more frequently during their disorder, continued to vomit at the end of treatment, had histories of
substance abuse, and continue to be lonely or to distrust others after treatment (Vall & Wade, 2015; Brewerton & Costin, 2011; Fairburn et al., 2004).
Treatments for Binge-Eating Disorder Given the key role of binges in both bulimia nervosa and binge-eating disorder (bingeing without purging), today’s treatments for binge-eating disorder are often similar to those for bulimia nervosa. In particular, cognitive-behavioral therapy, other forms of psychotherapy, and antidepressant medications have been provided—with some success—to help reduce or eliminate the binge-eating patterns and to change disturbed thinking such as being overly concerned with weight and shape (Fischer et al., 2014; Fairburn, 2013). Of course, many people with binge-eating disorder also are overweight, a problem that requires additional kinds of intervention and is often resis- tant to long-term improvement (Grilo et al., 2014; Claudino & Morgan, 2012).
Now that binge-eating disorder has been identified and is receiving considerable study, it is likely that specialized treatment programs that target the disorder’s unique issues will emerge in the coming years (Grilo et al., 2014). In the meantime, relatively little is known about the aftermath of this disorder (Claudino & Morgan, 2012). In one follow-up study of hospitalized patients with severe symptoms, one-third of those who had been treated still displayed the disorder 12 years after hospitalization, and 36 percent were still significantly overweight (Fichter et al., 2008). As with the other eating disorders, many of those who initially recover from binge-eating disorder continue to have a relatively high risk of relapse (ANAD, 2014).
➤ Summing Up HOW ARE EAtINg DISORDERS tREAtED? The first step in treating anorexia nervosa is to increase calorie intake and quickly restore the person’s weight, using a strategy such as supportive nursing care. The second step is to deal with the underlying psychological and family problems, often using a combination of education, cognitive-behavioral approaches, and family therapy. As many as 90 percent of people who are successfully treated for anorexia nervosa continue to show full or partial improvements years later. However, some of them relapse along the way.
Treatments for bulimia nervosa focus first on stopping the binge-purge pat- tern and then on addressing the underlying causes of the disorder. Often sev- eral treatment strategies are combined, including education, psychotherapy
The Biggest Loser phenomenon Contestant Hannah Curlee proudly observes the results of her weigh-in on the 2011 season finale of the popular reality show The Biggest Loser. In this TV series, overweight contestants compete to lose the most weight for cash prizes. Most overweight people do not display binge-eating disorder, but most people with the disorder are overweight.
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(particularly cognitive-behavioral therapy), and antidepressant medications. As many as 75 percent of those who receive treatment eventually improve either fully or partially. Relapse can be a problem and may be precipitated by a new stress. Similar treatments are used to help people with binge-eating disorder. These individuals, however, may also require interventions to address their excessive weight.
PUTTING IT...together A Standard for Integrating Perspectives You have observed throughout this book that it is often useful to consider socio- cultural, psychological, and biological factors jointly when trying to explain or treat various forms of abnormal functioning. Nowhere is the argument for combining these perspectives more powerful than in the case of eating disorders. According to the multidimensional risk perspective embraced by many theorists, varied factors act together to spark the development of eating disorders, particularly anorexia nervosa and bulimia nervosa. One case may result from societal pressures, autonomy issues, the physical and emotional changes of adolescence, and hypothalamic overactivity,
while another case may result from family pressures, depression, and the effects of dieting. No wonder that the most helpful treatment programs for eating disorders combine sociocultural, psychological, and biologi- cal approaches. When the multidimensional risk perspective is applied to eating disorders, it demonstrates that scientists and practitioners who follow very different models can work together productively in an at- mosphere of mutual respect.
Research on eating disorders keeps revealing new surprises that force clinicians to adjust their theories and treatment programs. For example, researchers have learned that people with eating disorders sometimes feel strangely positive about their symptoms (Williams & Reid, 2010).
One recovered patient said, “I still miss my bulimia as I would an old friend who has died” (Cauwels, 1983, p. 173). Given such feelings, many therapists now help clients work through grief reactions over their lost symptoms, reactions that may emerge as the clients begin to overcome their eating disorders (Zerbe, 2008).
While clinicians and researchers seek more answers about eating disorders, cli- ents themselves have begun to take an active role in the identification and treatment of the disorders. A number of patient-run organizations now provide information, education, and support through Web sites, national telephone hot lines, schools, professional referrals, newsletters, workshops, and conferences (Musiat & Schmidt, 2010; Sinton & Taylor, 2010).
KEY TERMS anorexia nervosa, p. 280
restricting-type anorexia nervosa, p. 280
amenorrhea, p. 282
bulimia nervosa, p. 282
binge, p. 282
compensatory behavior, p. 284
binge-eating disorder, p. 288
multidimensional risk perspective, p. 289
effective parents, p. 289
hypothalamus, p. 291
lateral hypothalamus (LH), p. 291
ventromedial hypothalamus (VMH), p. 291
cholecystokinin (CCK), p. 291
glucagon-like peptide-1 (GLP-1), p. 291
weight set point, p. 292
enmeshed family pattern, p. 293
supportive nursing care, p. 298
C li n i C al C h o i C e s Now that you’ve read about eating disorders, try the interactive case study for this chapter. See if you are able to identify Jenny’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Jenny? Go to LaunchPad to access Clinical Choices.
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QuickQuiz
1. What are the symptoms and main fea- tures of anorexia nervosa and bulimia nervosa? pp. 280–286
2. How are people with anorexia nervosa similar to those with bulimia nervosa? How are they different? p. 286
3. What are the symptoms and main fea- tures of binge-eating disorder? How is this disorder different from bulimia nervosa? p. 288
4. According to Hilde Bruch, how might parents’ failure to attend appropriately to their baby’s internal needs and emo- tions contribute to the later development of an eating disorder? pp. 289–290
5. How might a person’s hypothalamus and weight set point contribute to the development of an eating disorder? pp. 291–292
6. What evidence suggests that sociocul- tural pressures and factors may set the stage for eating disorders? pp. 292–298
7. When clinicians treat people with anorexia nervosa, what are their short- term and long-term goals? What ap- proaches do they use to accomplish them? pp. 298–301
8. How well do people with anorexia nervosa recover from their disorder? What factors affect a person’s recovery?
What risks and problems may linger after recovery? pp. 301–302
9. What are the key goals and approaches used in the treatment of bulimia ner- vosa, and how successful are they? What factors affect a person’s recovery? What risks and problems may linger after recovery? pp. 302–305
10. How are treatments for binge-eating disorder similar to and different from treatments for bulimia nervosa? p. 305
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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“I am Duncan. I am an alcoholic.” The audience settled deeper into their chairs at these familiar words. Another chronicle of death and rebirth would shortly begin [at] Alcoholics Anonymous. . . .
“I must have been just past my 15th birthday when I had that first drink that everybody talks about. And like so many of them . . . it was like a miracle. With a little beer in my gut, the world was transformed. I wasn’t a weakling anymore, I could lick almost anybody on the block. And girls? Well, you can imagine how a couple of beers made me feel like I could have any girl I wanted. . . .
“Though it’s obvious to me now that my drinking even then, in high school, and after I got to college, was a problem, I didn’t think so at the time. After all, everybody was drinking and getting drunk and acting stupid, and I didn’t really think I was differ- ent. . . . I guess the fact that I hadn’t really had any blackouts and that I could go for days without having to drink reassured me that things hadn’t gotten out of control. And that’s the way it went, until I found myself drinking even more—and more often— and suffering more from my drinking, along about my third year of college. . . .
“My roommate, a friend from high school, started bugging me about my drinking. It wasn’t even that I’d have to sleep it off the whole next day and miss class, it was that he had begun to hear other friends talking about me, about the fool I’d made of myself at parties. He saw how shaky I was the morning after, and he saw how dif- ferent I was when I’d been drinking a lot—almost out of my head was the way he put it. And he could count the bottles that I’d leave around the room, and he knew what the drinking and carousing was doing to my grades. . . . [P]artly because I really cared about my roommate and didn’t want to lose him as a friend, I did cut down on my drinking by half or more. I only drank on weekends—and then only at night. . . . And that got me through the rest of college and, actually, through law school as well. . . .
“Shortly after getting my law degree, I married my first wife, and . . . for the first time since I started, my drinking was no problem at all. I would go for weeks at a time without touching a drop. . . .
“My marriage started to go bad after our second son, our third child, was born. I was very much career- and success-oriented, and I had little time to spend at home with my family. . . . My traveling had increased a lot, there were stimulating people on those trips, and, let’s face it, there were some pretty exciting women available, too. So home got to be little else but a nagging, boring wife and children I wasn’t very interested in. My drinking had gotten bad again, too, with being on the road so much, having to do a lot of entertaining at lunch when I wasn’t away, and trying to soften the hassles at home. I guess I was putting down close to a gallon of very good scotch a week, with one thing or another.
“And as that went on, the drinking began to affect both my marriage and my career. With enough booze in me and under the pressures of guilt over my failure to carry out my responsibilities to my wife and children, I sometimes got kind of rough physi- cally with them. I would break furniture, throw things around, then rush out and drive off in the car. I had a couple of wrecks, lost my license for two years because of one of them. Worst of all was when I tried to stop. By then I was totally hooked, so every time I tried to stop drinking, I’d experience withdrawal in all its horrors . . . with the vomiting and the ‘shakes’ and being unable to sit still or to lie down. And that would go on for days at a time. . . .
“Then, about four years ago, with my life in ruins, my wife given up on me and the kids with her, out of a job, and way down on my luck, [Alcoholics Anonymous] and I found each other. . . . I’ve been dry now for a little over two years, and with luck and support, I may stay sober. . . .”
(Spitzer et al., 1983, pp. 87–89)
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T O P I C O V E R V I E W
Depressants Alcohol Sedative-Hypnotic Drugs Opioids
Stimulants Cocaine Amphetamines Stimulant Use Disorder
Hallucinogens, Cannabis, and Combinations of Substances Hallucinogens Cannabis Combinations of Substances
What Causes Substance Use Disorders? Sociocultural Views Psychodynamic Views Cognitive-Behavioral Views Biological Views
How Are Substance Use Disorders Treated? Psychodynamic Therapies Behavioral Therapies Cognitive-Behavioral Therapies Biological Treatments Sociocultural Therapies
Other Addictive Disorders Gambling Disorder Internet Gaming Disorder: Awaiting Official Status
Putting It Together: New Wrinkles to a Familiar Story
Substance Use and Addictive Disorders
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Human beings enjoy a remarkable variety of foods and drinks. Every substance on earth probably has been tried by someone, somewhere, at some time. We also have discovered substances that have interesting effects—both medical and pleasurable— on our brains and the rest of our bodies. We may swallow an aspirin to quiet a headache, an antibiotic to fight an infection, or a tranquilizer to calm us down. We may drink coffee to get going in the morning or wine to relax with friends. We may smoke cigarettes to soothe our nerves. However, many of the substances we con- sume can harm us or disrupt our behavior or mood. The misuse of such substances has become one of society’s biggest problems; it has been estimated that the cost of substance misuse is more than $600 billion each year in the United States alone ( Johnston et al., 2014).
Not only are numerous substances available in our society, but new ones are also introduced almost every day. Some are harvested from nature, others derived from natural substances, and still others produced in the laboratory. Some, such as anti- anxiety drugs, require a physician’s prescription for legal use. Others, such as alcohol and nicotine, are legally available to adults. Still others, such as heroin, are illegal under all circumstances. In 1962, only 4 million people in the United States had ever used marijuana, cocaine, heroin, or another illegal substance; today the number has climbed to more than 100 million (SAMHSA, 2014). In fact, 24 million people have used illegal substances within the past month. Almost 24 percent of all high school seniors have used an illegal drug within the past month ( Johnston et al., 2014).
A drug is defined as any substance other than food that affects our bodies or minds. It need not be a medicine or be illegal. The term “substance” is now fre-
quently used in place of “drug,” in part because many people fail to see that such substances as alcohol, tobacco, and caffeine are drugs, too. When a person ingests a substance—whether it be alcohol, cocaine, marijuana, or some form of medication— trillions of powerful molecules surge through the bloodstream and into the brain. Once there, the molecules set off a series of biochemical events that disturb the normal operation of the brain and body. Not surprisingly, then, substance misuse may lead to various kinds of abnormal functioning.
Substances may cause temporary changes in behavior, emo- tion, or thought; this cluster of changes is called substance intoxication in DSM-5. As Duncan found out, for example, an excessive amount of alcohol may lead to alcohol intoxication, a temporary state of poor judgment, mood changes, irritability, slurred speech, and poor coordination. Similarly, drugs such as LSD may produce hallucinogen intoxication, sometimes called hallucinosis, which consists largely of perceptual distortions and hallucinations.
Some substances can also lead to long-term problems. Peo- ple who regularly ingest them may develop substance use disorders, patterns of maladaptive behaviors and reactions brought about by the repeated use of substances (Higgins et al., 2014; APA, 2013). People with a substance use dis- order may come to crave a particular substance and rely on it excessively, resulting in damage to their family and social relationships, poor functioning at work, and/or danger to themselves or others (see Table 10-1). In many cases, people with such a disorder also become physically dependent on the substance, developing a tolerance for it and experiencing with- drawal reactions. When people develop tolerance, they need increasing doses of the substance to produce the desired effect. Withdrawal reactions consist of unpleasant and sometimes
table: 10-1
Dx Checklist
Substance Use Disorder
1. Individual displays a maladaptive pattern of substance use leading to significant impairment or distress.
2. Presence of at least 2 of the following symptoms within a 1-year period:
(a) Substance is often taken in larger amounts or over a longer period than intended.
(b) Unsuccessful efforts or persistent desire to reduce or control substance use.
(c) Much time spent trying to obtain, use, or recover from the effects of substance.
(d) Failure to fulfill major role obligations at work, school, or home as a result of repeated substance use.
(e) Continued use of substance despite persistent social or interpersonal problems caused by it.
(f ) Cessation or reduction of important social, occupational, or recreational activities because of substance use.
(g) Continuing to use substance in situations where use poses physical risks.
(h) Continuing to use substance despite awareness that it is causing or worsening a physical or psychological problem.
( i ) Craving for substance.
( j ) Tolerance effects.
(k) Withdrawal reactions.
(Information from: APA, 2013)
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dangerous symptoms—cramps, anxiety attacks, sweating, nausea—that occur when the person suddenly stops taking or cuts back on the substance. Duncan, who described his problems to fellow members at an Alcoholics Anonymous meeting, was caught in a form of substance use disorder called alcohol use disorder. When he was a college student and later a lawyer, alcohol damaged his family, social, academic, and work life. He also built up a toler- ance for alcohol over time and had withdrawal symptoms such as vomiting and shaking when he tried to stop using it.
In any given year, 8.9 percent of all teens and adults in the United States, over 23 million people, have a substance use disorder (SAMHSA, 2014; NSDUH, 2013). American Indians have the highest rate of substance use disorders in the United States (21.8 percent), while Asian Americans have the lowest (3.2 percent). White Americans, Hispanic Americans, and African Americans have rates close to 9 percent (see Figure 10-1). Only 11 percent (around 2.5 million people) of all those with substance use disorders receive treat- ment from a mental health professional (Belendiuk & Riggs, 2014; NSDUH, 2013).
The substances people misuse fall into several categories: depressants, stimulants, hallucinogens, and cannabis. In this chapter you will read about some of the most problematic substances and the abnormal patterns they may produce. In addition, at the end of the chapter, you’ll read about gambling disorder, a problem that DSM-5 lists as an additional addictive disorder. By listing this behavioral pattern alongside the substance use disorders, DSM-5 is suggesting that this problem has addictive-like symptoms and causes that share more than a passing similarity to those at work in substance use disorders.
Depressants Depressants slow the activity of the central nervous system. They reduce tension and inhibitions and may interfere with a person’s judgment, motor activity, and concentration. The three most widely used groups of depressants are alcohol, sedative- hypnotic drugs, and opioids.
Alcohol The World Health Organization estimates that 2 billion people worldwide consume alcohol. In the United States more than half of all residents at least from time to time drink beverages that contain alcohol (SAMHSA, 2014). Purchases of beer, wine, and liquor amount to tens of billions of dollars each year in the United States alone.
When people consume five or more drinks on a single occasion, it is called a binge-drinking episode. Twenty-three percent of people in the United States over the age of 11, most of them male, binge-drink each month (SAMHSA, 2014). Around 6.5 percent of people over 11 years of age binge-drink at least five times each month. They are considered heavy drinkers. Among heavy drinkers, males outnumber females by at least 3 to 2.
All alcoholic beverages contain ethyl alcohol, a chemical that is quickly absorbed into the blood through the lining of the stomach and the intestine. The ethyl alco- hol immediately begins to take effect as it is carried in the bloodstream to the central nervous system (the brain and spinal cord), where it acts to depress, or slow, func- tioning by binding to various neurons. One important group of neurons to which ethyl alcohol binds are those that normally receive the neurotransmitter GABA. As you saw in Chapter 4, GABA carries an inhibitory message—a message to stop firing—when it is received at certain neurons. When alcohol binds to receptors on those neurons, it apparently helps GABA to shut down the neurons, thus helping to relax the drinker (Filip et al., 2014; Nace, 2011, 2005).
figure 10-1 How do races differ in substance use disorders? In the United States, American Indians are much more likely than members of other ethnic or cultural groups to have substance use disorders. (Information from: NSDUH, 2013.)
21.8%
3.2%
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American Indians
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8.8%Hispanic Americans
White Americans
8.9%African Americans
Asian Americans
▶▶ substance intoxication A cluster of temporary undesirable behavioral or psychological changes that develop during or shortly after the ingestion of a substance.
▶▶ substance use disorder A pattern of long-term maladaptive behaviors and reactions brought about by repeated use of a substance.
▶▶ tolerance The brain and body’s need for ever larger doses of a drug to pro- duce earlier effects.
▶▶ withdrawal Unpleasant, sometimes dangerous reactions that may occur when people who use a drug regularly stop tak- ing or reduce their dosage of the drug.
▶▶ alcohol Any beverage containing ethyl alcohol, including beer, wine, and liquor.
: chapter 10312
At first ethyl alcohol depresses the areas of the brain that control judgment and inhibition; people become looser, more talkative, and often more friendly. As their inner control breaks down, they may feel relaxed, confident, and happy. When more alcohol is absorbed, it slows down additional areas in the cen- tral nervous system, leaving drinkers less able to make sound judgments, their speech less careful and less coherent, and their memory weaker. Many people become highly emotional and perhaps loud and aggressive.
Motor difficulties increase as a person continues drinking, and reaction times slow. People may be unsteady when they stand or walk and clumsy in performing even simple activities. They may drop things, bump into doors and furniture, and misjudge distances. Their vision becomes blurred, particularly their peripheral, or side, vision, and they have trouble hearing. As a result, people who have drunk too much alcohol may have great difficulty driving or solving simple problems.
The extent of the effect of ethyl alcohol is determined by its concentration, or proportion, in the blood. Thus a given amount of alcohol has less effect on a large person than on a small one. Gender also affects the concentration of alcohol in the blood. Women have less of the stomach enzyme alcohol
dehydrogenase, which breaks down alcohol in the stomach before it enters the blood. So women become more intoxicated than men on equal doses of alcohol (Hart & Ksir, 2014).
Levels of impairment are closely related to the concentration of ethyl alcohol in the blood. When the alcohol concentration reaches 0.06 percent of the blood volume, a person usually feels relaxed and comfortable. By the time it reaches 0.09 percent, however, the drinker crosses the line into intoxication. If the level goes as high as 0.55 percent, the drinker will likely die. Most people lose consciousness before they can drink enough to reach this level; nevertheless, more than 1,000 people in the United States die each year from too high a blood alcohol level (Hart & Ksir, 2014).
The effects of alcohol subside only when the alcohol concentration in the blood declines. Most of the alcohol is broken down, or metabolized, by the liver into car- bon dioxide and water, which can be exhaled and excreted. The average rate of this metabolism is 25 percent of an ounce per hour, but different people’s livers work at different speeds; thus rates of “sobering up” vary. Despite popular belief, only time and metabolism can make a person sober. Drinking black coffee, splashing cold water on one’s face, or “pulling oneself together” cannot hurry the process.
Alcohol Use Disorder Though legal, alcohol is actually one of the most dangerous of recreational drugs, and its reach extends across the life span. In fact, around 28 percent of middle school students admit to some alcohol use, while 39 percent of high school seniors drink alcohol each month (most to the point of intoxication) and 2.2 percent report drinking every day ( Johnston et al., 2014). Alcohol misuse is also a major problem on college campuses (see PsychWatch on the next page).
Surveys indicate that over a one-year period, 6.8 percent of all adults in the United States display alcohol use disorder, known in popular terms as alcoholism (NSDUH, 2013). Men with this disorder outnumber women by at least 2 to 1. Many teenagers also experience the disorder ( Johnston et al., 2014).
Substance misuse and sports fans A problem that has received growing attention in recent years is excessive drinking by fans at sports events. While two soccer players were jumping for a high ball at this 2002 playoff game in Athens, Greece, fans—many of them intoxicated—ripped out plastic seats, threw flares on the field, and hurled coins and rocks at the players.
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The current prevalence of alcoholism is around 7.6 percent for white Ameri- cans, 5.1 percent for Hispanic Americans, and 4.5 percent for African Americans (NSDUH, 2013). American Indians, particularly men, tend to display a higher rate of alcohol use disorder than any of these groups. Overall, 8.5 percent of them experience the disorder, although specific prevalence rates differ widely across the various American Indian reservation communities. Generally, Asians in the United States and elsewhere have a lower rate of alcoholism (1.7 percent) than do people from other cultures. As many as half of these individuals have a deficiency of alcohol dehydrogenase, the chemical responsible for breaking down alcohol, so they react quite negatively to even a modest intake of alcohol. Such reactions in turn help prevent extended use (Tsuang & Pi, 2011).
PsychWatch
Drinking large amounts of alcohol in a short time, or binge drinking, is a serious problem on college cam- puses, as well as in many other settings (SAMHSA, 2014; NSDUH, 2013). Studies show that 40 percent of college students binge-drink at least once each year, one-third of them six times or more per month. In many circles, alcohol use is an accepted part of college life, but consider some of the following statistics (Abbey et al., 2014; Statistic Brain, 2012; Howland et al., 2010; NCASA, 2007; Abbey, 2002):
➤ Alcohol-related arrests account for 83 percent of all campus arrests.
➤ More than half of all sexual assaults on college campuses involve the heavy consumption of alcohol.
➤ Alcohol may be a factor in nearly 40 percent of academic problems and 28 percent of all instances of dropping out of college.
➤ Approximately 700,000 students each year are physically or emotionally traumatized or assaulted by a student drinker.
➤ Half of college students say “drinking to get drunk” is an important reason for drinking.
➤ Binge drinking often has a lingering ef- fect on mood, memory, brain function- ing, and heart functioning.
➤ Binge drinking is tied to 1,700 deaths and 500,000 injuries, every year.
➤ The number of female binge drinkers among college students has increased 31 percent over the past decade.
These findings have led some educa- tors to describe binge drinking as “the number one public health hazard” for full-time college students, and many re- searchers and clinicians have turned their attention to it. Researchers at the Harvard School of Public Health, for example, have surveyed more than 50,000 students at 120 college campuses around the United States (Wechsler & Nelson, 2008; Wechsler et al., 2004, 1995, 1994). One of their surveys found that the students most likely to binge-drink were those who lived in a fraternity or sorority house, pursued a party-centered lifestyle, and engaged in high-risk behaviors such as substance mis- use or having multiple sex partners. Other
surveys have also suggested that students who were binge drinkers in high school were more likely to binge-drink in college.
Efforts to change such patterns have begun. For example, some universities now provide substance-free dorms: 36 percent of the residents in such dorms continue to be occasional binge drinkers, according to one study, compared with 75 percent of those who live in a fraternity or sorority house (Wechsler et al., 2002). This and other current research efforts are promising. However, most people in the clinical field agree that much more work is needed to help us fully understand, pre- vent, and treat what has become a major societal problem.
College Binge Drinking: An Extracurricular Crisis
Testing the limits College binge drinking, which involves behaviors similar to that shown here, has led to a number of deaths in recent years.
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CliniCal PiCture Generally speaking, people with alcohol use disorder drink large amounts regularly and rely on it to enable them to do things that would otherwise make them anxious (McCrady, 2014). Eventually the drinking interferes with their social behavior and ability to think and work. They may have frequent arguments with family members or friends, miss work repeatedly, and even lose their jobs. MRI scans of chronic heavy drinkers have revealed damage in various regions of their brains and, correspondingly, impairments in their memory, speed of thinking, attention skills, and balance (Sifferlin, 2014).
Individually, people’s patterns of alcoholism vary. Some drink large amounts of alcohol every day and keep drinking until intoxicated. Others go on periodic binges of heavy drinking that can last weeks or months. They may remain intoxicated for days and later be unable to remember anything about the period. Still others may limit their excessive drinking to weekends, evenings, or both.
toleranCe and WithdraWal For many people, alcohol use disorder includes the symptoms of tolerance and withdrawal reactions (McCrady, 2014). As their bod- ies build up a tolerance for alcohol, they need to drink ever larger amounts to feel its effects. In addition, they have withdrawal symptoms when they stop drinking. Within hours their hands, tongue, and eyelids begin to shake; they feel weak and nauseated; they sweat and vomit; their heart beats rapidly; and their blood pres- sure rises. They may also become anxious, depressed, unable to sleep, or irritable (APA, 2013).
A small percentage of people with alcohol use disorder go through a particularly dramatic withdrawal reaction called delirium tremens (“the DTs”). It con- sists of terrifying visual hallucinations that begin within a few days after they stop or reduce their drinking. Some people see small, frightening animals chasing or crawling on them or objects dancing about in front of their eyes. Like most other alcohol withdrawal symptoms, the DTs usually run their course in two to three days. However, people who have severe withdrawal reactions such as this may also have seizures, lose consciousness, suffer a stroke, or even die. Today certain medical procedures can help prevent or reduce such extreme reactions.
What Is the Personal and Social Impact of Alcoholism? Alcohol- ism destroys millions of families, social relationships, and careers (see MindTech on the next page). Medical treatment, lost productivity, and losses due to deaths from
alcoholism cost society many billions of dollars annually. The disorder also plays a role in more than one-third of all suicides, homicides, assaults, rapes, and accidental deaths, including 30 percent of all fatal automobile accidents in the United States (NIAAA, 2015; Gifford et al., 2010). Altogether, intoxicated drivers are responsible for 10,000 deaths each year. More than 11 percent of all adults have driven while intoxicated at least once in the past year (SAMHSA, 2014).
Alcoholism has serious effects on the 30 million children of people with this disorder. Home life for these children is likely to include much conflict and perhaps sexual or other forms of abuse. In turn, the children themselves have higher rates of psychological problems (Kelley et al., 2014; Watt, 2002). Many have low self-esteem, poor communication skills, poor sociability, and marital problems.
Long-term excessive drinking can also seriously damage a person’s physical health (Nace, 2011, 2005). It so overworks the liver that people may develop an irreversible condition called cirrhosis, in which the liver becomes scarred and dys- functional. Cirrhosis accounts for more than 36,000 deaths
Simulating alcohol’s effects A 16-year-old student weaves her way through an obstacle course while wearing a pair of goggles that produce alcohol-like impairment. The exercise is part of a DUI-prevention program at her New Mexico high school, designed to give students hands-on experience with alcohol’s effects on vision and balance.
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DSM-5 Controversy: Is All Drug Misuse the Same? DSM-5 has combined two past disor- ders, substance abuse (excessive and chronic reliance on drugs) and substance dependence (excessive reliance accom- panied by tolerance and withdrawal symptoms) into a single category— substance use disorder. Critics worry that clinicians may now fail to recognize and address the different prognoses and treatment needs of people who abuse substances and those who de- pend on substances.
Substance Use and Addictive Disorders : 315
each year (CDC, 2015). Alcohol use disorder may also damage the heart and lower the immune system’s ability to fight off cancer, bacterial infections, and AIDS.
Long-term excessive drinking also causes major nutritional problems. Alcohol makes people feel full and lowers their desire for food, yet it has no nutritional value. As a result, chronic drinkers become malnourished, weak, and prone to disease. Their vitamin and mineral deficiencies may also cause problems. An alcohol-related
MindTech
Neknomination Goes Viral Binge drinking and other risky alcohol-related behaviors have long been associated with peer pressure. But in the past few years, a popular new “game”—made possible by the Internet and social
media—has taken the impact of peer pressure to new heights. In early 2013, an online drinking game called Neknominate
(or Neknomination), believed to have originated in Australia, emerged on Internet sites like YouTube and Facebook (Wilkinson and Soares, 2014). In this game, a person records a video of himself or herself drinking an entire bottle of hard liquor (known in Australia as “necking”) and then challenges (“nominates”) a friend by name to post his or her own drink- ing video, one that will top the level and danger of the initial drinking act, and to then pass the challenge on to another person ( James, 2014).
In most cases, the drink being consumed in the videos has an unusually high alcohol content, to make the “achievement” all the more “impressive.” Some of the videos also involve people exhibiting other dangerous or reckless behavior along with the drinking, such as driving while drinking, stripping in public, shoplifting, or consuming motor oil or even small animals both alive and dead (Wilkinson and Soares, 2014).
Given the nature of the game, you may not be surprised that Neknominate was tied with a number of deaths within a very short period after its emergence, as it spread to Great Britain, Canada, the United States, and other parts of the world ( James, 2014). In February 2014, for example, five unrelated men, three in England
and two in Ireland, died while making vid- eos of themselves completing Neknominate challenges.
A public outcry regarding the practice of Neknominate has emerged, with politicians, doctors, and others calling on Facebook and You Tube to ban discussions or presentations of the game. Facebook, however, has declined
to ban discussions or postings associated with it, stating that its policy is only to ban content that is directly harmful, not to censor content that discusses potentially dangerous or offensive behavior (Wilkinson and Soares, 2014). The practice and uproar surrounding Neknominate has begun to die down a bit in recent months— while many Neknominate players have moved on to other high-risk Internet crazes such as Punch4Punch, in which people video themselves punching each other until one gives up.
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▶▶ delirium tremens (DTs) A dramatic withdrawal reaction that some people who are dependent on alcohol have. It consists of confusion, clouded conscious- ness, and terrifying visual hallucinations.
What psychological factors,
besides peer pressure, might
induce a person to participate
in an activity as risky as
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: chapter 10316
deficiency of vitamin B (thiamine), for example, may lead to Korsakoff ’s syn- drome, a disease marked by extreme confusion, memory loss, and other neurologi- cal symptoms. People with Korsakoff ’s syndrome cannot remember the past or learn new information and may make up for their memory losses by confabulating— reciting made-up events to fill in the gaps.
Women who drink during pregnancy place their fetuses at risk (Bakoyiannis et al., 2014; Hart & Ksir, 2014; Gifford et al., 2010). Excessive alcohol use during pregnancy may cause a baby to be born with fetal alcohol syndrome, a pattern of abnormalities that can include intellectual disability disorder, hyperactivity, head and face deformities, heart defects, and slow growth. It has been estimated that in the overall population, around 1 of every 1,000 babies is born with this syndrome. The rate may increase to as many as 29 of every 1,000 babies of women who are problem drinkers. If all alcohol-related birth defects (known as fetal alcohol spectrum disorder) are counted, the rate becomes 80 to 200 such births per 1,000 heavy- drinking women. In addition, heavy drinking early in pregnancy often leads to a miscarriage. According to surveys, 8.5 percent of pregnant American women have drunk alcohol during the past month and 2.7 percent of pregnant women have had binge-drinking episodes (SAMHSA, 2014; NSDUH, 2013).
Sedative-Hypnotic Drugs Sedative-hypnotic drugs, also called anxiolytic (meaning “anxiety-reducing”) drugs, produce feelings of relaxation and drowsiness. At low dosages, the drugs have a calming or sedative effect. At higher dosages, they are sleep inducers, or hypnot- ics. For the first half of the twentieth century, a group of drugs called barbiturates were the most widely prescribed sedative-hypnotic drugs. Although still prescribed by some physicians, these drugs have been largely replaced by benzodiazepines, which are generally safer and less likely to lead to intoxication, tolerance effects, and withdrawal reactions (Filip et al., 2014).
As Chapter 4 noted, benzodiazepines, developed in the 1950s, are the most popular sedative-hypnotic drugs available. Xanax, Ativan, and Valium are just three of the dozens of these compounds in clinical use. Altogether, 130 million prescrip- tions are written annually for benzodiazepines (Grohol, 2012). Like alcohol, they calm people by binding to receptors on the neurons that receive GABA and by increasing GABA’s activity at those neurons (Filip et al., 2014). Benzodiazepines relieve anxiety without making people as drowsy as other kinds of sedative- hypnotics. They are also less likely to slow a person’s breathing, so they are less likely to cause death during sleep in the event of an overdose.
When benzodiazepines were first discovered, they seemed so safe and effective that physicians prescribed them generously, and their use spread. Eventually, how- ever, it became clear that in high enough doses the drugs can, like barbiturates, cause intoxication and lead to sedative-hypnotic use disorder, a pattern marked by craving for the drugs, tolerance effects, and withdrawal reactions. Over a one-year period, 0.03 percent of all adults in the United States display this disorder, and as many as 1 percent develop the pattern over the course of their lives (SAMHSA, 2014).
Opioids Opioids include opium—taken from the sap of the opium poppy—and the drugs derived from it, such as heroin, morphine, and codeine. Opium itself has been in use for thousands of years. In the past it was used widely in the treatment of medical disorders because of its ability to reduce both physical and emotional pain. Eventu- ally, however, physicians discovered that the drug was addictive.
In 1804 a new substance, morphine, was derived from opium. Named after Morpheus, the Greek god of sleep, this drug relieved pain even better than
▶▶ Korsakoff’s syndrome An alcohol- related disorder marked by extreme confusion, memory impairment, and other neurological symptoms.
▶▶ fetal alcohol syndrome A cluster of problems in a child, including low birth weight, irregularities in the head and face, and intellectual deficits, caused by excessive alcohol intake by the mother during pregnancy.
▶▶ sedative-hypnotic drug A drug used in low doses to reduce anxiety and in higher doses to help people sleep. Also called an anxiolytic drug.
▶▶ barbiturates Addictive sedative- hypnotic drugs that reduce anxiety and help people sleep.
▶▶ benzodiazepines The most common group of sedative-hypnotic drugs, which includes Valium and Xanax.
▶▶ opioid Opium or any of the drugs derived from opium, including morphine, heroin, and codeine.
▶▶ opium A highly addictive substance made from the sap of the opium poppy.
▶▶ morphine A highly addictive sub- stance derived from opium that is particularly effective in relieving pain.
▶▶ heroin One of the most addictive sub- stances derived from opium.
▶▶ endorphins Neurotransmitters that help relieve pain and reduce emotional tension. They are sometimes referred to as the body’s own opioids.
Substance Use and Addictive Disorders : 317
opium did and initially was considered safe. However, wide use of the drug eventually revealed that it, too, could lead to addiction. So many wounded soldiers in the United States received morphine injec- tions during the Civil War that morphine addiction became known as “soldiers’ disease.”
In 1898, morphine was converted into yet another new pain reliever, heroin. For several years heroin was viewed as a wonder drug and was used as a cough medicine and for other medical purposes. Eventually, however, physicians learned that heroin is even more addictive than the other opioids. By 1917, the U.S. Congress had concluded that all drugs derived from opium were addictive, and it passed a law making opioids illegal except for medical purposes.
Still other drugs have been derived from opium, and synthetic (laboratory-blended) opioids such as methadone have also been devel- oped (Dilts & Dilts, 2011, 2005). All these opioid drugs—natural and synthetic— are known collectively as narcotics. Each drug has a different strength, speed of action, and tolerance level. Morphine, codeine, and oxycodone (the key ingredient in OxyContin and Percocet) are medical narcotics usually prescribed to relieve pain. In contrast to these narcotics, heroin is illegal in the United States in all circumstances.
Most narcotics are smoked, inhaled, snorted, injected by needle just beneath the skin (“skin popped”), or injected directly into the bloodstream (“mainlined”), the most powerful form of intake. An injection quickly brings on a rush—a spasm of warmth and ecstasy that is some- times compared with orgasm. The brief spasm is followed by several hours of a pleasant feeling called a high or nod. During a high, the drug user feels relaxed, happy, and unconcerned about food, sex, or other bodily needs.
Opioids create these effects by depressing the central nervous system, particu- larly the centers that help control emotion. The drugs attach to brain receptor sites that ordinarily receive endorphins—neurotransmitters that help relieve pain and reduce emotional tension. When neurons at these receptor sites receive opioids, they produce pleasurable and calming feelings just as they would do if they were receiv- ing endorphins. In addition to reducing pain and tension, opioids cause nausea, narrowing of the pupils (“pinpoint pupils”), and constipation.
Opioid Use Disorder Heroin use exemplifies the kinds of prob- lems posed by opioids. After taking heroin repeatedly for just a few weeks, users may develop opioid use disorder. Their use of heroin interferes significantly with their social and occupational functioning, and their lives center around the drug. They may also build a tolerance for heroin and experience a withdrawal reaction when they stop taking it (Hart & Ksir, 2014). At first the withdrawal symptoms are anxiety, restlessness, sweating, and rapid breathing; later they include severe twitching, aches, fever, vomiting, diarrhea, loss of appetite, high blood pressure, and weight loss of up to 15 pounds (due to loss of bodily fluids). These symptoms usually peak by the third day, gradually subside, and disappear by the eighth day. A person in heroin withdrawal can either wait out the symp- toms or end withdrawal by taking the drug again.
Such people soon need heroin just to avoid going into withdrawal, and they must continually increase their doses in order to achieve even that relief. The temporary high becomes less intense and less important. Heroin users may spend much of their time planning their next dose, in
Purer blend Heroin, derived from poppies such as this one in a poppy field in southern Afghanistan, is purer and stronger today than it was three decades ago (65 percent pure versus 5 percent pure).
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Injecting heroin Opioids may be taken by mouth, inhaled, snorted, injected just beneath the surface of the skin, or injected intra- venously. Here, one addict injects another with heroin inside one of the many so-called shooting galleries where addicts gather in downtown San Juan, Puerto Rico.
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many cases turning to criminal activities, such as theft and prostitution, to support the expensive “habit” (Cadet et al., 2014; Koetzle, 2014).
Surveys suggest that more than 1 percent of adults in the United States display an opioid use disorder within a given year (SAMHSA, 2014; NSDUH, 2013). Most of these persons (80 percent) are addicted to the pain-reliever opioids such as oxy- codone and morphine (see Figure 10-2). Around 20 percent of those with opioid
use disorder (a half-million people) are addicted to heroin. The rate of opioid dependence dropped considerably dur- ing the 1980s, rose in the early 1990s, fell in the late 1990s, and now seems to be relatively high once again. The actual number of opioid-dependent people may be even higher, however, as many people are reluctant to admit an illegal activity.
What Are the Dangers of Opioid Use? Once again, heroin provides a good example of the dangers of opioid use. The most immediate danger of heroin use is an overdose, which closes down the respiratory center in the brain, almost paralyzing breathing and in many cases caus- ing death (Christensen, 2014). Death is particularly likely during sleep, when a person is unable to fight this effect
by consciously working to breathe. People who resume heroin use after having avoided it for some time often make the fatal mistake of taking the same dose they had built up to before. Because their bodies have been without heroin for some time, however, they can no longer tolerate this high level (Gray, 2014). Each year approximately 2 percent of those addicted to heroin and other opioids die under the drug’s influence, usually from an overdose.
Heroin users run other risks as well. Drug dealers often mix heroin with a cheaper drug or even a deadly substance such as cyanide or battery acid. In addi- tion, dirty needles and other unsterilized equipment spread infections such as AIDS, hepatitis C, and skin abscesses (NIDA, 2014; Dilts & Dilts, 2011). In some areas of the United States, the HIV infection rate among active heroin users is reported to be as high as 60 percent.
➤ Summing Up SUbSTanCe MiSUSe anD DepreSSanTS Repeated and excessive use of cer- tain substances (or drugs) can lead to substance use disorders. Many people with such disorders also develop a tolerance for the substance in question and/ or have unpleasant withdrawal symptoms when they abstain from it.
Depressants are substances that slow the activity of the central nervous sys- tem. Repeated and excessive use of these substances can lead to problems such as alcohol use disorder, sedative-hypnotic use disorder, or opioid use dis- order. Alcoholic beverages contain ethyl alcohol, which is carried by the blood to the central nervous system, depressing its function. Intoxication occurs when the concentration of alcohol in the bloodstream reaches 0.09 percent. Among other actions, alcohol increases the activity of the neurotransmitter GABA at key sites in the brain. Sedative-hypnotic drugs, which produce feelings of relaxation and drowsiness, include barbiturates and benzodiazepines. These drugs also increase the activity of GABA. Opioids include opium and drugs derived from it, such as morphine and heroin, as well as laboratory-made opioids. They all reduce tension and pain and cause other reactions. Opioids operate by binding to neurons that ordinarily receive endorphins.
figure 10-2 Where do people obtain pain killers for nonmedical use? More than half get the drugs from friends or relatives, and more than 20 percent obtain them from a doctor. Fewer than 5 percent buy them from a drug dealer. (Information from: SAMHSA, 2014; NSDUH, 2013.)
Obtained free from a friend or relative 54%
Prescribed by one or more physicians 22%
Bought or stolen from friend or relative 15%
Bought from a drug dealer or stranger 4%
Bought online 0.2% Other 5%
B e t W e e N t h e L I N e S
Nonmedical Use of Pain Relievers In the United States, the largest increase in illicit drug use during the past few years has been the nonmedical use of medications, mostly pain relievers (SAMHSA, 2014).
Substance Use and Addictive Disorders : 319
Stimulants Stimulants are substances that increase the activity of the central nervous system, resulting in increased blood pressure and heart rate, more alertness, and sped-up behavior and thinking. Among the most troublesome stimulants are cocaine and amphetamines, whose effects on people are very similar. When users report different effects, it is often because they have ingested different amounts of the drugs. Two other widely used and legal stimulants are caffeine and nicotine (see InfoCentral on the next page).
Cocaine Cocaine—the central active ingredient of the coca plant, found in South America— is the most powerful natural stimulant now known (Acosta et al., 2011, 2005). The drug was first separated from the plant in 1865. Native people of South America, however, have chewed the leaves of the plant since prehistoric times for the energy and alertness the drug offers. Processed cocaine is an odorless, white, fluffy powder. For recreational use, it is most often snorted so that it is absorbed through the mucous membrane of the nose. Some users prefer the more powerful effects of injecting cocaine intravenously or smoking it in a pipe or cigarette.
For years people believed that cocaine posed few problems aside from intoxica- tion and, on occasion, temporary psychosis (see Table 10-2). Only later did research- ers come to appreciate its many dangers (Haile, 2012). Their insights came after society witnessed a dramatic surge in the drug’s popularity and in problems related to its use. In the early 1960s, an estimated 10,000 people in the United States had tried cocaine. Today 28 million people have tried it, and 1.6 million—most of them teenagers or young adults—are using it currently (SAMHSA, 2014; NSDUH, 2013). In fact, 1.1 percent of all high school seniors have used cocaine within the past month and almost 2.6 percent have used it within the past year ( Johnston et al., 2014).
Cocaine brings on a euphoric rush of well-being and confidence. Given a high enough dose, this rush can be almost orgasmic, like the one produced by heroin. At first cocaine stimulates the higher centers of the central nervous system, making
table: 10-2
risks and Consequences of Drug Misuse
Potential Intoxication
Addiction Potential
Risk of Organ Damage or Death
Risk of Severe Social or Economic Consequences
Risk of Severe or Long-Lasting Mental and Behavioral Change
Opioids High High Moderate High Low to moderate
Sedative-hypnotics Barbiturates Benzodiazepines
Moderate Moderate
Moderate to high Moderate
Moderate to high Low
Moderate to high Low
Low Low
Stimulants (cocaine, amphetamines) High High Moderate Low to moderate Moderate to high
Alcohol High Moderate High High High
Cannabis High Low to moderate Low Low to moderate Low
Mixed drugs High High High High High
Information from: Hart & Ksir, 2014; APA, 2013; Hart et al., 2010.
▶▶ cocaine An addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.
InfoCentral
0 10 20 30 40 50
33 %
21 %
23 %
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33 .7
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29 .4
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25 .5
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18 .6
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38 .1
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27 .0
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48 .4
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29 .2
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27 .2
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19 .2
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SMOKING, TOBACCO, AND NICOTINE Around 27% percent of all Americans over the age of 11 regularly smoke tobacco—a total of 70 million people (NSDUH, 2013).
Similarly, 22% of the world population over 11 smoke regularly—a total of 1.1 billion people (WHO, 2014).
Common Aids for Quitting
RAPID SMOKING — Puf�ng frequently and rapidly until becoming ill.
NICOTINE GUM — Releases nicotine when chewed.
NICOTINE PATCH — Releases nicotine through the skin.
NICOTINE LOZENGES — Dissolves in the mouth and releases nicotine.
NASAL SPRAY — Delivers aerosol nicotine into the nostrils.
ANTIDEPRESSANTS (BUPROPION AND NORTRIPTYLINE) — Reduce craving for nicotine.
SELF-HELP GROUPS —Offer psychological support.
WHO SMOKES REGULARLY IN THE UNITED STATES?
WHY DO PEOPLE CONTINUE TO SMOKE? Between 50% and 75% of smokers keep smoking because they are addicted to nicotine, the active substance in tobacco (WHO, 2014). Nicotine is a stimulant of the central nervous system that acts on the same neurotransmitters and reward centers in the brain as amphetamines and cocaine. It is as addictive as those drugs and heroin (Hart & Ksir, 2014). Smokers addicted to nicotine are said to have tobacco use disorder (APA, 2013).
QUITTING SMOKING More and more smokers try to quit each year. One reason is that many studies have identi�ed the severe health dangers smoking poses. Another is the outstanding job that health agencies have done spreading the word about these dangers. With the declining acceptability of smoking, a market for products and techniques to help people kick the habit has emerged.
Gettin g the Message Teens who believe that smoking is harmful
U.S. smokers with tobacco use disorder 32.5 million
Worldwide smokers with tobacco use disorder 770 million
13.5% 15.1%
population (over 11 years old)
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Most Popular New Aid: e-Cigarettes Smoking an e-cigarette, a battery-operated cigarette, is called vaping.
Tobacco Cigarette vs. e-Cigarette
10 mg of nicotine 0.34 mg of nicotine
Smoke poses biggest danger No actual burning or smoke
Very addictive Mildly addictive
$35 billion annual earnings $1 billion annual earnings (CDC, 2014; Grif�n, 2014; Schroeder & Hoffman, 2014; Bullen et al., 2013)
Smoker exhales a cloud of vapor
SMOKING AND HEALTH
438,000 Annual U.S.
deaths caused by smoking-
related diseases
5 million Annual
worldwide deaths caused by smoking-
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42,000 Annual
U.S. deaths caused by
secondhand cigarette
smoke
479,000 Annual
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caused by secondhand
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(CDC, 2014)
LED end glows when smoker inhales
Heater vaporizes nicotine
Substance Use and Addictive Disorders : 321
users feel excited, energetic, talkative, and even euphoric. As more is taken, it stimu- lates other centers of the central nervous system, producing a faster pulse, higher blood pressure, faster and deeper breathing, and further arousal and wakefulness.
Cocaine apparently produces these effects largely by increasing supplies of the neurotransmitter dopamine at key neurons throughout the brain (Haile, 2012). Excessive amounts of dopamine travel to receiving neurons throughout the central nervous system and overstimulate them. Cocaine appears to also increase the activ- ity of the neurotransmitters norepinephrine and serotonin in some areas of the brain (Hart & Ksir, 2014).
High doses of the drug produce cocaine intoxication, whose symptoms are poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behav- ior, anxiety, and confusion. Some people have hallucinations, delusions, or both.
A young man described how, after free-basing, he went to his closet to get his clothes, but his suit asked him, “What do you want?” Afraid, he walked toward the door, which told him, “Get back!” Retreating, he then heard the sofa say, “If you sit on me, I’ll kick your ass.” With a sense of impending doom, intense anxiety, and momentary panic, the young man ran to the hospital where he received help.
(Allen, 1985, pp. 19–20)
As the stimulant effects of cocaine subside, the user goes through a depression- like letdown, popularly called crashing, a pattern that may also include headaches, dizziness, and fainting (NIH, 2015; Acosta et al., 2011, 2005). For occasional users, the aftereffects usually disappear within 24 hours, but they may last longer for people who have taken a particularly high dose. These people may sink into a stupor, deep sleep, or, in some cases, coma.
Ingesting Cocaine In the past, cocaine use and impact were limited by the drug’s high cost. Moreover, cocaine was usually snorted, a form of inges- tion that has less powerful effects than either smoking or injection (Haile, 2012). Since 1984, however, the availability of newer, more powerful, and sometimes cheaper forms of cocaine has produced an enormous increase in the use of the drug. For example, many people now ingest cocaine by free- basing, a technique in which the pure cocaine basic alkaloid is chemically separated, or “freed,” from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe.
Millions more people use crack, a powerful form of free-base cocaine that has been boiled down into crystalline balls. It is smoked with a special pipe and makes a crackling sound as it is inhaled (hence the name). Crack is sold in small quantities at a fairly low cost, which has resulted in crack epidemics among people who previously could not have afforded cocaine, primarily those in poor, urban areas (Acosta et al., 2011, 2005). Around 1.1 percent of high school seniors report having used crack within the past year, down from a peak of 2.7 percent in 1999 ( Johnston et al., 2014).
What Are the Dangers of Cocaine? Aside from cocaine’s harmful effects on behavior, cognition, and emotion, the drug poses serious physical dangers (NIH, 2015; Paczynski & Gold, 2011). The growth in the use of the powerful forms of cocaine has caused the annual number of cocaine-related emergency room incidents in the United States to multiply more than 125 times since 1982, from around 4,000 cases to 505,000 (SAMHSA, 2013). Cocaine use has also been linked to many suicides (San Nicolas & Lemos, 2015).
Smoking crack Crack, a powerful form of freebase cocaine, is produced by boiling cocaine down into crystalline balls and is smoked with a crack pipe.
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▶▶ free-basing A technique for ingesting cocaine in which the pure cocaine basic alkaloid is chemically separated from pro- cessed cocaine, vaporized by heat from a flame, and inhaled with a pipe.
▶▶ crack A powerful, ready-to-smoke free- base cocaine.
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The greatest danger of cocaine use is an overdose. Excessive doses have a strong effect on the respiratory center of the brain, at first stimulating it and then depress- ing it to the point where breathing may stop. Cocaine can also create major, even fatal, heart irregularities or brain seizures that bring breathing or heart functioning to a sudden stop (Acosta et al., 2011, 2005). In addition, pregnant women who use cocaine run the risk of having a miscarriage and of having children with predispo- sitions to later drug use and with abnormalities in immune functioning, attention and learning, thyroid size, and dopamine and serotonin activity in the brain (Minnes et al., 2014; Kosten et al., 2008).
Amphetamines Amphetamines are stimulant drugs that are manufactured in the laboratory. Some common examples are amphetamine (Benzedrine), dextroamphetamine (Dexe- drine), and methamphetamine (Methedrine). First produced in the 1930s to help treat asthma, amphetamines soon became popular among people trying to lose weight; athletes seeking an extra burst of energy; soldiers, truck drivers, and pilots trying to stay awake; and students studying for exams through the night (Haile, 2012). Physicians now know the drugs are far too dangerous to be used so casually, and they prescribe them much less freely.
Amphetamines are most often taken in pill or capsule form, although some people inject the drugs intravenously or smoke them for a quicker, more powerful effect. Like cocaine, amphetamines increase energy and alertness and reduce appe- tite when taken in small doses; produce a rush, intoxication, and psychosis in high doses; and cause an emotional letdown as they leave the body. Also like cocaine, amphetamines stimulate the central nervous system by increasing the release of the neurotransmitters dopamine, norepinephrine, and serotonin throughout the brain, although the actions of amphetamines differ somewhat from those of cocaine (Hart & Ksir, 2014; Haile, 2012).
One kind of amphetamine, methamphetamine (nicknamed crank), has surged in popularity in recent years and so warrants special focus. Almost 6 percent of all people over the age of 11 in the United States have used metham- phetamine at least once. Around 0.2 percent use it currently (NSDUH, 2013). It is available in the form of crystals (also known by the street names ice and crystal meth), which users smoke.
Most of the nonmedical methamphetamine in the United States is made in small “stovetop laboratories,” which typically operate for a few days in a remote area and then move on to a new—safer—location (Hart & Ksir, 2014). Such laboratories have been around since the 1960s, but they have increased eightfold—in number, production, and in being confiscated by authorities—over the past decade. A major health concern is that the secret laboratories expel dangerous fumes and residue (Burgess, 2001).
Since 1989, when the media first began reporting about the dangers of smoking methamphetamine crystals, the rise in usage has been dra- matic. Correspondingly, methamphetamine-linked emergency room visits are increasing in hospitals throughout all parts of the country (SAMHSA, 2013).
Methamphetamine is about as likely to be used by women as men. Around 40 percent of current users are women (NSDUH, 2013). The drug is particularly popular today among biker gangs, rural Americans, and urban gay communities and has gained wide use as a “club drug,” the term for those drugs that regularly find their way to all-night dance parties, or “raves” (Hart & Ksir, 2014; Hopfer, 2011).
Like other kinds of amphetamines, methamphetamine increases activ- ity of the neurotransmitters dopamine, serotonin, and norepinephrine,
Methamphetamine dependence: spreading the word This powerful ad shows the degenerative effects of metham- phetamine addiction on a woman over a four-year period—from age 36 in the top photo to age 40 in the bottom one.
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▶▶ amphetamine A stimulant drug that is manufactured in the laboratory.
▶▶ methamphetamine A powerful amphetamine drug that has surged in popularity in recent years, posing major health and law enforcement problems.
▶▶ hallucinogen A substance that causes powerful changes primarily in sensory perception, including strengthening perceptions and producing illusions and hallucinations. Also called a psychedelic drug.
▶▶ LSD (lysergic acid diethylamide) A hallucinogenic drug derived from ergot alkaloids.
Substance Use and Addictive Disorders : 323
producing increased arousal, attention, and related effects (Yu et al., 2015; Acosta et al., 2011, 2005). It can have serious negative effects on a user’s physical, mental, and social life. Of particular concern is that it damages nerve endings. But users focus more on methamphetamine’s immediate positive impact, including percep- tions by many that it makes them feel hypersexual and uninhibited (Washton & Zweben, 2008; Jefferson, 2005).
Stimulant Use Disorder Regular use of either cocaine or amphetamines may lead to stimulant use disorder. The stimulant comes to dominate the person’s life, and the person may remain under the drug’s effects much of each day and function poorly in social relation- ships and at work. Regular stimulant use may also cause problems in short-term memory and attention (Lundqvist, 2010). People may develop tolerance and with- drawal reactions to the drug—in order to gain the desired effects, they must take higher doses, and when they stop taking it, they may go through deep depression, fatigue, sleep problems, irritability, and anxiety (Barr et al., 2011). These withdrawal symptoms can last for weeks or even months after drug use has ended. In a given year, 0.4 percent of all people over the age of 11 display stimulant use disorder that is centered on cocaine, and 0.2 percent display stimulant use disorder centered on amphetamines (SAMHSA, 2014; NSDUH, 2013).
➤ Summing Up STiMULanTS Stimulants, including cocaine, amphetamines, caffeine, and nico- tine, are substances that increase the activity of the central nervous system. Abnormal use of cocaine or amphetamines can lead to stimulant use disorder. Stimulants produce their effects by increasing the activity of dopamine, norepi- nephrine, and serotonin in the brain.
Hallucinogens, Cannabis, and Combinations of Substances Other kinds of substances may also cause problems for their users and for society. Hallucinogens produce delusions, hallucinations, and other sensory changes. Cannabis produces sensory changes, but it also has depressant and stimulant effects, and so it is considered apart from hallucinogens in DSM-5. And many people take combina- tions of substances.
Hallucinogens Hallucinogens are substances that cause powerful changes in sensory perception, from strengthening a person’s normal perceptions to inducing illusions and hallu- cinations. They produce sensations so out of the ordinary that they are sometimes called “trips.” The trips may be exciting or frightening, depending on how a per- son’s mind interacts with the drugs. Also called psychedelic drugs, the hallucinogens include LSD, mescaline, psilocybin, and MDMA (Ecstasy) (see PsychWatch on page 325). Many of these substances come from plants or animals; others are produced in laboratories.
LSD (lysergic acid diethylamide), one of the most famous and most pow- erful hallucinogens, was derived by Swiss chemist Albert Hoffman in 1938 from a group of naturally occurring drugs called ergot alkaloids. During the 1960s, a decade
Cocaine and the heart Pop icon Whitney Houston died in her bathtub on February 11, 2012. The coroner’s report ruled that the cause of her death was accidental drowning caused in part by heart disease and her abuse of cocaine and perhaps other drugs. The suspicion is that her long-term use of cocaine helped produce her heart problems (Dolak & Murphy, 2012).
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of social rebellion and experimentation, millions of people turned to the drug as a way of expanding their experience. Within two hours of being swallowed, LSD brings on a state of hallucinogen intoxication, sometimes called hallucinosis, marked by a general strengthening of perceptions, particularly visual perceptions, along with psychological changes and physical symptoms. People may focus on small details— the pores of the skin, for example, or individual blades of grass. Colors may seem enhanced or take on a shade of purple. People may have illusions in which objects seem distorted and appear to move, breathe, or change shape. A person under the influence of LSD may also hallucinate—seeing people, objects, or forms that are not actually present.
Hallucinosis may also cause one to hear sounds more clearly, feel tingling or numbness in the limbs, or confuse the sensations of hot and cold. Some people have been badly burned after touching flames that felt cool to them under the influence of LSD. The drug may also cause different senses to cross, an effect called synesthesia. Colors, for example, may be “heard” or “felt.”
LSD can also induce strong emotions, from joy to anxiety or depression. The perception of time may slow dramatically. Long-forgotten thoughts and feelings may resurface. Physical symptoms can include sweating, palpitations, blurred vision, tremors, and poor coordination. All of these effects take place while the user is fully awake and alert, and they wear off in about six hours.
It seems that LSD produces these symptoms primarily by binding to some of the neurons that normally receive the neurotrans- mitter serotonin, changing the neurotransmitter’s activity at those sites (Advokat et al., 2014). These neurons ordinarily help the brain send visual information and control emotions (as you saw in Chapter 6); thus LSD’s activity there produces various visual and emotional symptoms.
More than 14 percent of all people in the United States have used LSD or another hallucinogen at some point in their lives. Around 0.4 percent, or 1.1 million people, are currently using them (NSDUH, 2013). Although people do not usually develop tolerance to LSD or have with- drawal symptoms when they stop taking it, the drug poses dangers for both one- time and long-term users. It is so powerful that any dose, no matter how small, is likely to produce enormous perceptual, emotional, and behavioral reactions. Some- times the reactions are extremely unpleasant—a so-called bad trip (when LSD users injure themselves or others, for instance, usually they are in the midst of a bad trip). Witness, for example, this description of a young woman who took LSD during the 1960s, when so many people thought of the drug as a problem-free mind expander, only to learn about its dark side through personal use:
A 21-year-old woman was admitted to the hospital along with her lover. He had had a number of LSD experiences and had convinced her to take it to make her less constrained sexually. About half an hour after ingestion of approximately 200 microgm., she noticed that the bricks in the wall began to go in and out and that light affected her strangely. She became frightened when she realized that she was unable to distinguish her body from the chair she was sitting on or from her lover’s body. Her fear became more marked after she thought that she would not get back into herself. At the time of admission she was hyperactive and laughed inappropri- ately. Her stream of talk was illogical and affect labile. Two days later, this reaction had ceased.
(Frosch, Robbins, & Stern, 1965)
Lingering popularity Although less popu- lar than in the 1960s, LSD continues to be a drug of some favor, especially among younger people, at many raves, rock concerts, and simi- lar events. This participant at the 2012 Boom Festival, a gathering of boomers who share “the universal spirit of psychedelic trance,” wrote a message on his back that leaves no doubt about how important the drug is to him.
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Substance Use and Addictive Disorders : 325
Another danger is the long-term effect that LSD may have (Lerner et al., 2014; Weaver & Schnoll, 2008). Some users eventually develop psychosis or a mood or anxiety disorder. And a number have flashbacks—a recurrence of the sensory and emotional changes after the LSD has left the body. Flashbacks may occur days or even months after the last LSD experience.
PsychWatch
You probably know of the drug MDMA (3,4-methylenedioxymeth-amphetamine) by its common street name, Ecstasy. This laboratory-produced drug is technically a stimulant, similar to amphetamines, but it also produces hal- lucinogenic effects and so is often consid- ered a hallucinogenic drug (Litjens et al., 2014; McDowell, 2011, 2005). MDMA was developed as far back as 1910, but only in the past 25 years has it gained life as a club drug. Today, in the United States alone, consumers collectively take hun- dreds of thousands of doses of MDMA weekly (Johnston et al., 2014). Altogether, 12 million Americans over the age of 11 have now tried the drug at least once in their lifetime (NSDUH, 2013, 2010).
What is Ecstasy’s allure? As a stimulant and hallucinogen, it helps to raise the mood of many partygoers and provides them with an energy boost that enables them to keep dancing and partying. It may also produce strong feelings of
attachment and connectedness in users. However, it can be a dangerous drug, particularly when taken repeatedly.
What are the Dangers of Using ecstasy? As MDMA has become more widely used, it has received more research scrutiny. As it turns out, the mood and energy lift pro- duced by MDMA comes at a high price (Downey et al., 2015; Koczor et al., 2015; Hart & Ksir, 2014; Parrott et al., 2014). The problems that the drug may cause include the following:
➤ Psychological problems such as confu- sion, depression, sleep difficulties, se- vere anxiety, and paranoid thinking.
➤ Impairment of memory and other cog- nitive skills.
➤ Physical symptoms such as muscle ten- sion, nausea, blurred vision, faintness, and chills or sweating.
➤ Increases in heart rate and blood pres-
sure, which place people with heart disease at special risk.
➤ Reduced sweat production. At a hot, crowded dance party, taking Ecstasy can even cause heat stroke, or hyper- thermia. Users generally try to remedy this problem by drinking lots of water, but since the body cannot sweat under the drug’s influence, the excess fluid intake can result in an equally perilous condition known as hyponatremia, or “water intoxication.”
➤ Potential liver damage.
How Does MDMa Operate in the brain? MDMA works by causing the neurotrans- mitters serotonin and (to a lesser extent) dopamine to be released all at once throughout the brain, at first increasing and then depleting a person’s overall sup- ply of the neurotransmitters. MDMA also interferes with the body’s ability to pro- duce new supplies of serotonin. With re- peated use, the brain eventually produces less and less serotonin (Lizarraga et al., 2014; McDowell, 2011, 2005). Ecstasy’s impact on these neurotransmitters ac- counts for its various psychological effects and associated problems (Lizarraga et al., 2014; Zakzanis et al., 2007).
end of the Honeymoon? Although it is no longer used as much as it was in the early 2000s, MDMA seems to have regained considerable popular- ity in recent years, finding its way back to raves, dance clubs, and various college settings (Johnston et al., 2014; Palamar & Kamboukos, 2014). Clearly, despite the alarming research results, the honeymoon for MDMA is not yet over.
Club Drugs: X Marks the (Wrong) Spot
Feeling the effects Shortly after taking MDMA, this couple manifests a shift in mood, energy, and behavior. Although MDMA can feel pleasurable and energizing, often it pro- duces undesired immediate effects, including confusion, depression, anxiety, sleep difficulties, and paranoid thinking.
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Cannabis Cannabis sativa, the hemp plant, grows in warm climates throughout the world. The drugs pro- duced from varieties of hemp are, as a group, called cannabis. The most powerful of them is hashish; the weaker ones include the best- known form of cannabis, marijuana, a mixture derived from the buds, crushed leaves, and flow- ering tops of hemp plants. More than 19 million people over the age of 11 (7.3 percent of the population) currently smoke marijuana at least monthly; more than 5 million smoke it daily (SAMHSA, 2014; NSDUH, 2013).
Each of the cannabis drugs is found in vari- ous strengths because the potency of a cannabis drug is greatly affected by the climate in which the plant is grown, the way it was prepared, and
the manner and duration of its storage. Of the several hundred active chemicals in cannabis, tetrahydrocannabinol (THC) appears to be the one most responsible for its effects. The higher the THC content, the more powerful the cannabis; hashish contains a large portion, while marijuana’s is small.
When smoked, cannabis produces a mixture of hallucinogenic, depressant, and stimulant effects. At low doses, the smoker typically has feelings of joy and relax- ation and may become either quiet or talkative. Some smokers, however, become anxious, suspicious, or irritated, especially if they have been in a bad mood or are smoking in an upsetting environment. Many smokers report sharpened perceptions and fascination with the intensified sounds and sights around them. Time seems to slow down, and distances and sizes seem greater than they actually are. This overall “high” is technically called cannabis intoxication. Physical changes include reddening
of the eyes, fast heartbeat, increases in blood pressure and appetite, dryness in the mouth, and dizziness. Some people become drowsy and may fall asleep.
In high doses, cannabis produces odd visual experi- ences, changes in body image, and hallucinations. Smok- ers may become confused or impulsive. Some worry that other people are trying to hurt them. Most of the effects of cannabis last two to six hours. The changes in mood, however, may continue longer.
Cannabis Use Disorder Until the early 1970s, the use of marijuana, the weak form of cannabis, rarely led to a pattern of cannabis use disorder. Today, however, many people, including large numbers of high school students, are developing the disorder, getting high on marijuana regularly and finding their social and occupational or aca- demic lives very much affected (see Figure 10-3). Many regular users also develop a tolerance for marijuana and may feel restless and irritable and have flulike symptoms when they stop smoking (Chen et al., 2005). Around 1.7 percent of all teenagers and adults in the United States have displayed cannabis use disorder within the past month (SAMHSA, 2014; NSDUH, 2013).
Why have more and more marijuana users developed cannabis use disorder over the past three decades? Mainly
The source of marijuana Marijuana is made from the leaves of the hemp plant, Cannabis sativa. The plant is an annual herb, reaches a height of between 3 and 15 feet, and is grown in a wide range of altitudes, climates, and soils.
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figure 10-3 How easy is it for teenagers to acquire substances? Most surveyed tenth graders say it is easy to get cigarettes, alcohol, and marijuana, and more than one-fifth say it is easy to get Ecstasy and amphetamines. (Information from: Johnston et al., 2014.)
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because marijuana has changed. The marijuana widely available in the United States today is at least four times more powerful than that used in the early 1970s. The average THC content of today’s marijuana is 8 percent, compared with 2 percent in the late 1960s. Marijuana is now grown in places with a hot, dry climate, which increases the THC content.
Is Marijuana Dangerous? As the strength and use of marijuana have in- creased, researchers have discovered that smoking it may pose certain dangers (NIDA, 2015; Price, 2011). It occasionally causes panic reactions similar to the ones caused by hallucinogens, and some smokers may fear they are losing their minds (APA, 2000). Typically such reactions end in two to six hours, along with mari- juana’s other effects.
Marijuana use can also adversely affect sensorimotor and cognitive functioning, especially among teenagers and children, whose brains are still developing (Barcott & Schererk, 2015). In turn, it has caused many automobile accidents (Brady & Li, 2014). Moreover, people on a marijuana high often fail to remember information, especially anything that has been recently learned, no matter how hard they try to concentrate; thus heavy marijuana smokers are at a serious disadvantage at school or work (Budney et al., 2011; Jaffe & Klein, 2010).
One study compared blood flow in the brain arteries of chronic marijuana users and nonusers (Herning et al., 2005). After one month of abstinence from smok- ing marijuana, chronic users continued to have higher blood flow than nonusers. Though still higher than normal, the blood flow of light marijuana users (fewer than 16 smokes per week) and of moderate users (fewer than 70 smokes per week) did improve somewhat over the course of the abstinence month. The blood flow of heavy users, however, showed no improvement. This lingering effect may help explain the memory and thinking problems of chronic heavy users of marijuana.
There are research indications that regular marijuana smoking may also lead to long-term health problems (NIDA, 2015; Budney et al., 2011; Whitten, 2010). It may, for example, contribute to lung disease, although there is considerable debate on this issue (Pletcher et al., 2012; Tashkin, 2001). Some studies suggest that marijuana smoking reduces the ability to expel air from the lungs, perhaps even more than tobacco smoking does. Another concern is the effect of regular marijuana smoking on human reproduction. Studies since the late 1970s have discovered lower sperm counts in men who are chronic smokers and abnormal ovulation in women who are chronic smokers (Hartney, 2014; Schuel et al., 2002).
Efforts to educate the public about the dangers of repeated marijuana use appeared to have paid off throughout the 1980s. The percentage of high school seniors who smoked marijuana on a daily basis decreased from 11 percent in 1978 to 2 percent in 1992. Today, however, 6.5 percent of high school seniors smoke it daily, and more than 50 percent of seniors do not believe that regular use poses a great risk ( Johnston et al., 2014; NSDUH, 2013).
Cannabis and Society: A Rocky Relationship For centuries, cannabis played a respected role in medicine. It was recommended as a surgi- cal anesthetic by Chinese physicians 2,000 years ago and was used in other lands to treat cholera, malaria, coughs, insomnia, and rheumatism. When can- nabis entered the United States in the early twentieth century, mainly in the form of marijuana, it was likewise used for various medical purposes. Soon, however, more effective medicines replaced it, and the favorable view of can- nabis began to change. Marijuana began to be used as a recreational drug, and its illegal distribution became a law enforcement problem. Authorities assumed it was highly dangerous and outlawed the “killer weed.”
“Medibles” ready for sale At his store “TH Candy” in Washington State, this confec- tioner displays a number of popular medical marijuana edibles (“medibles”), including can- dies, chocolates, teas, tinctures, and baked goods.
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▶▶ cannabis drugs Drugs produced from the varieties of the hemp plant Cannabis sativa. They cause a mixture of hallucino- genic, depressant, and stimulant effects.
▶▶ marijuana One of the cannabis drugs, derived from the buds, leaves, and flow- ering tops of the hemp plant Cannabis sativa.
▶▶ tetrahydrocannabinol (THC) The main active ingredient of cannabis substances.
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In the 1980s, researchers developed precise techniques for measuring THC and for extracting pure THC from cannabis; they also developed laboratory forms of THC. These inven- tions opened the door to new medical applications for cannabis (Mack & Joy, 2001), such as its use in treating glaucoma, a severe eye disease. Cannabis was also found to help patients with chronic pain or asthma, to reduce the nausea and vomiting of cancer patients in chemotherapy, and to improve the appetites of people with AIDS and so help them combat weight loss.
In light of these findings, several interest groups began campaigning during the late 1980s for the medical legalization of marijuana, which operates on the brain and body more quickly than the THC capsules developed in the laboratory. Government agencies initially resisted this movement, saying prescriptions for pure THC served all needed medical func- tions. However, medical marijuana advocates pressed on, and in 2009 the U.S. Attorney General directed federal prosecutors
to not pursue cases against medical marijuana users or their caregivers who are complying with state laws. Currently, 23 states have laws allowing marijuana to be used for medical purposes, and several more have such laws pending (Tilak, 2014).
Canada’s federal government has taken a more lenient position on the medi- cal marijuana issue than the U.S. federal government. Based on a series of studies and trial programs, Health Canada, the country’s health care regulator, now legally permits people who are suffering from severe and debilitating illnesses to use marijuana for medical purposes. It allows the sale of medical marijuana in select pharmacies, and it licenses numerous companies to produce medical marijuana (Tilak, 2014).
Heartened by such developments in the realm of medical marijuana, a move- ment to legalize the recreational use of marijuana has gained enormous momentum in recent years. In fact, since 2012 residents in the states of Colorado, Washington, Alaska, and Oregon have voted to legalize marijuana for use of any kind. Moreover, according to recent polls, more than half of Americans believe that marijuana should be made legal, up from 12 percent in 1969 and 41 percent in 2010 (Pew Research Center, 2013).
Combinations of Substances Because people often take more than one drug at a time, a pattern called poly- substance use, researchers have studied the ways in which drugs interact with one another (Murray et al., 2015; De La Garza & Kalechstein, 2012). When different drugs are in the body at the same time, they may multiply, or potentiate, each other’s effects. The combined impact, called a synergistic effect, is often greater than the sum of the effects of each drug taken alone: a small dose of one drug mixed with a small dose of another can produce an enormous change in body chemistry.
One kind of synergistic effect occurs when two or more drugs have similar actions (McCance-Katz, 2010). For instance, alcohol, benzodiazepines, barbiturates, and opioids—all depressants—may severely depress the central nervous system when mixed (Hart & Ksir, 2014). Combining them, even in small doses, can lead to extreme intoxication, coma, and even death. A young man may have just a few alcoholic drinks at a party, for example, and shortly afterward take a moderate dose of barbiturates to help him fall asleep. He believes he has acted with restraint and good judgment—yet he may never wake up.
A different kind of synergistic effect results when drugs have opposite, or antago- nistic, actions. Stimulant drugs, for example, interfere with the liver’s usual disposal of barbiturates and alcohol. Thus people who combine barbiturates or alcohol with
Sniffing for drugs An increasingly common scene in schools, airports, storage facilities, and similar settings is that of trained dogs sniffing for marijuana, cocaine, opioids, and other substances. Here one such animal sniffs lockers at a school in Texas to see whether students have hidden any illegal substances among their books or other belongings.
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cocaine or amphetamines may build up toxic, even lethal, levels of the depressant substances in their systems. Students who take amphetamines to help them study late into the night and then take barbiturates to help them fall asleep are unknow- ingly placing themselves in serious danger.
Each year tens of thousands of people are admitted to hospitals with a multiple- drug emergency, and several thousand of them die (SAMHSA, 2013). Sometimes the cause is carelessness or ignorance. Often, however, people use multiple drugs precisely because they enjoy the synergis- tic effects. In fact, as many as 90 percent of those who use one illegal drug are also using another to some extent (Rosenthal & Levounis, 2011, 2005).
Fans mourn the deaths of many celebrities who have died from polysubstance use. For example, in 2014 the New York City medical examiner ruled that actor Philip Seymour Hoffman died of “acute mixed drug intoxication,” citing the presence of heroin, cocaine, benzodiazepines, and amphetamines in his system (Coleman, 2014). In the more distant past, Elvis Presley’s delicate balancing act of stimulants and depressants, Janis Joplin’s mixtures of wine and heroin, and John Belushi’s and Chris Farley’s liking for the combined effect of cocaine and opioids (“speedballs”) each ended in tragedy.
➤ Summing Up HaLLUCinOgenS, CannabiS, anD COMbinaTiOnS OF SUbSTanCeS Hal- lucinogens, such as LSD, are substances that cause powerful changes primarily in sensory perception. People’s perceptions are intensified and they may have illusions and hallucinations. LSD apparently causes such effects by disturbing the release of the neurotransmitter serotonin.
The main ingredient of Cannabis sativa, a hemp plant, is tetrahydrocan- nabinol (THC). Marijuana, the most popular form of cannabis, is more powerful today than it was in years past. It can cause intoxication, and regular use can lead to cannabis use disorder.
Many people take more than one drug at a time, and the drugs interact. The use of two or more drugs at the same time—polysubstance use—has become increasingly common.
Real life versus acting Most fans of the television series Glee were shocked by the 2013 death of 31-year-old actor Cory Monteith (center), caused by a toxic combination of heroin and alcohol. One reason for their shock was that Finn Hudson, the Glee character played by Monteith, was so wholesome and happy. But Monteith himself had waged a long battle against substance use disorder, dating back to age 12. He had most recently pursued intense treatment for the disorder just four months before his death.
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What Causes Substance Use Disorders? Clinical theorists have developed sociocultural, psychological, and biological expla- nations for why people develop substance use disorders. No single explanation, how- ever, has gained broad support. Like so many other disorders, excessive and chronic drug use is increasingly viewed as the result of a combination of these factors.
Sociocultural Views A number of sociocultural theorists propose that people are most likely to develop substance use disorders when they live under stressful socioeconomic conditions (Fink et al., 2015; Marsiglia & Smith, 2010). Studies have found that poorer people tend to have higher rates of substance use disorder than wealthier people. In a related vein, 18 percent of unemployed adults currently use an illegal drug, compared with 9 percent of full-time employed workers and 12.5 percent of part-time employees (SAMHSA, 2014; NSDUH, 2013).
Sociocultural theorists hold that people confronted regularly by other kinds of stress also have a heightened risk of develop- ing substance use disorders. A range of studies conducted with Hispanic and African American people, for example, find higher rates of substance use disorders among those participants who live or work in environments of particularly intense discrimination (Clark, 2014; Hurd et al., 2014; Unger et al., 2014).
Still other sociocultural theorists propose that people are more likely to develop substance use disorders if they are part of a family or social envi- ronment in which substance use is valued or at least accepted (Chung et al., 2014; Washburn et al., 2014). Researchers have learned that problem drinking is more common among teenagers whose parents and peers drink, as well as among teenagers whose family environments are stressful and unsupportive (Wilens et al., 2014; Andrews & Hops, 2011). Moreover, lower rates of alcoholism are found among Jews and Protestants, groups in which drinking is typically acceptable only as long as it remains within clear limits, whereas alcoholism rates are higher among the Irish and Eastern Europeans, who do not, in general, draw as clear a line (Hart & Ksir, 2014; Ledoux et al., 2002).
Psychodynamic Views Psychodynamic theorists believe that people with substance use disorders have powerful dependency needs that can be traced to their early years (Iglesias et al., 2014; Dodes & Khantzian, 2011, 2005). They suggest that when parents fail to sat- isfy a young child’s need for nurturance, the child is likely to grow up depending excessively on others for help and comfort, trying to find the nurturance that was lacking during the early years. If this search for outside support includes experi- mentation with a drug, the person may well develop a dependent relationship with the substance.
Some psychodynamic theorists also believe that certain people respond to their early deprivations by developing a substance abuse personality that leaves them par- ticularly prone to drug abuse. Personality inventories, patient interviews, and even animal studies have in fact indicated that people who abuse drugs tend to be more
Common substance, uncommon danger A 13-year-old boy sniffs glue as he lies dazed near a garbage heap. In the United States, at least 6 percent of all people have tried to get high by inhaling the hydrocarbons found in common substances such as glue, gasoline, paint thinner, cleaners, and spray-can propel- lants (APA, 2013). Such behavior may lead to inhalant use disorder and poses a number of serious medical dangers.
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dependent, antisocial, impulsive, novelty-seeking, risk-taking, and depressive than other people (Hicks et al., 2014). However, these findings are correlational (at least, the findings from human studies are) and do not clarify whether such traits lead to chronic drug use or whether repeated drug use causes people to be dependent, impulsive, and the like.
In an effort to establish clearer causation, one pioneering longitudinal study measured the personality traits of a large group of nonalcoholic young men and then kept track of each man’s development ( Jones, 1971, 1968). Years later, the traits of the men who developed alcohol problems in middle age were compared with the traits of those who did not. The men who developed alcohol problems had been more impulsive as teenagers and continued to be so in middle age, a finding suggesting that impulsive men are indeed more prone to develop alcohol problems. Similarly, in some laboratory investigations, “impulsive” rats—those that generally have trouble delaying their rewards—have been found to drink more alcohol when offered it than other rats (Stein et al., 2013; Poulos et al., 1995).
A major weakness of this line of argument is the wide range of personality traits that have been tied to substance use disorders. Different studies point to different “key” traits (Wills & Ainette, 2010). Inasmuch as some people with these disorders appear to be dependent, others impulsive, and still others antisocial, researchers can- not presently conclude that any one personality trait or group of traits stands out in the development of the disorders (Chassin et al., 2001).
Cognitive-Behavioral Views According to behaviorists, operant conditioning may play a key role in substance use disorders. They argue that the temporary reduction of tension or raising of spirits produced by a drug has a rewarding effect, thus increasing the likelihood that the user will seek this reaction again (Urošević et al., 2015; Clark, 2014). Similarly, the rewarding effects may eventually lead users to try higher dosages or more powerful methods of ingestion. Cognitive theorists further argue that such rewards eventually produce an expectancy that substances will be rewarding, and this expectation helps motivate people to increase drug use at times of tension (Sussman, 2010).
In support of these behavioral and cognitive views, studies have found that many people do drink more alcohol or seek heroin when they feel tense (Kassel et al., 2010; McCarthy et al., 2010). In one study, as participants worked on a difficult ana- gram task, a confederate planted by the researchers unfairly criticized and belittled them (Marlatt et al., 1975). The participants were then asked to participate in an “alcohol taste task,” supposedly to compare and rate alcoholic beverages. Those who had been harassed drank more alcohol during the taste task than did the control participants who had not been criticized.
In a manner of speaking, the cognitive-behavioral theorists are arguing that many people take drugs to “medicate” themselves when they feel tense. If so, one would expect higher rates of substance use disorders among people who suffer from anxiety, depression, and other such problems. And, in fact, at least 19 percent of all adults who suffer from psychological disorders also display substance use disorders (Keyser-Marcus et al., 2015; NSDUH, 2013).
A number of behaviorists have proposed that classical conditioning may also play a role in these disorders (O’Brien, 2013; Cunningham et al., 2011). As you’ll remember from Chapters 2 and 4, classical conditioning occurs when two stimuli that appear close together in time become connected in a person’s mind, so that eventually, the person responds similarly to each stimulus. Cues or objects present in the environment at the time a person takes a drug may act as classically conditioned stimuli and come to produce some of the same pleasure brought on by the drugs themselves. Just the sight of a hypodermic needle, drug buddy, or regular supplier,
B e t W e e N t h e L I N e S
Celebrities Who Have Died of Substance Overdose in the Twenty-first Century Philip Seymour Hoffman, actor (polydrug, 2014)
Cory Monteith, actor (polydrug, 2013)
Whitney Houston, singer (cocaine and heart disease, 2012)
Amy Winehouse, singer (alcohol poisoning, 2011)
Michael Jackson, performer and song- writer (prescription polydrug, 2009)
Heath Ledger, actor (prescription polydrug, 2008)
Anna Nicole Smith, model (prescription polydrug, 2007)
Ol’ Dirty Bastard, rapper, Wu-Tang Clan (polydrug, 2004)
Rick James, singer (cocaine, 2004)
Dee Dee Ramone, musician, The Ramones (heroin, 2002)
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Bad Age By a strange coincidence, several of rock’s most famous stars and substance abusers have died at age 27. They include Jimi Hendrix, Jim Morrison, Janis Joplin, Kurt Cobain, Brian Jones, and Amy Winehouse. The phenom- enon has been called “The 27 Club” in some circles.
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for example, has been known to comfort people who are addicted to heroin or amphetamines and to relieve their withdrawal symptoms. In a similar manner, cues or objects that are present during withdrawal distress may produce withdrawal-like symptoms. One man who had formerly been dependent on heroin became nause- ated and had other withdrawal symptoms when he returned to the neighborhood where he had gone through withdrawal in the past—a reaction that led him to start taking heroin again (O’Brien et al., 1975). Although classical conditioning certainly appears to be at work in particular cases of substance use disorder, it has not received widespread research support as the key factor in such disorders (Grimm, 2011).
Biological Views In recent years, researchers have come to suspect that drug misuse may have biologi- cal causes. Studies on genetic predisposition and specific biochemical processes have provided some support for these suspicions.
Genetic Predisposition For years, breeding experiments have been conducted to see whether certain animals are genetically predisposed to become addicted to drugs (Saba et al., 2015; Carroll & Meisch, 2011; Weiss, 2011). In several studies, for example, investigators have first identified animals that prefer alcohol to other bever- ages and then mated them to one another. Generally, the offspring of these animals have been found also to display an unusual preference for alcohol.
Similarly, some research with human twins has suggested that people may inherit a predisposition to misuse substances (Ystrom et al., 2014). One classic study found an alcoholism concordance rate of 54 percent in a group of identical twins; that is, if one identical twin displayed alcoholism, the other twin also did in 54 percent of the
cases. In contrast, a group of fraternal twins had a concordance rate of only 28 percent (Kaij, 1960). Other studies have found similar twin patterns (Koskinen et al., 2011; Tsuang et al., 2001). As you have read, however, such findings do not rule out other interpreta- tions. For one thing, the parenting received by two identical twins may be more similar than that received by two fraternal twins.
A clearer indication that genetics may play a role in substance use disorders comes from studies of alcoholism rates in people adopted shortly after birth (Samek et al., 2014; Walters, 2002). These studies have compared adoptees whose biological parents abuse alcohol with adoptees whose biological parents do not. By adulthood, the individuals whose biological parents abuse alcohol typically show higher rates of alcoholism than those with nonalco- holic biological parents.
Genetic linkage strategies and molecular biology techniques pro- vide more direct evidence in support of a genetic explanation (Pieters et al., 2012; Gelernter & Kranzler, 2008). One line of investigation has found an abnormal form of the so-called dopamine-2 (D2) receptor gene in a majority of research participants with substance use disorders but in less than 20 percent of participants who do not have such disorders (Cosgrove, 2010; Blum et al., 1996, 1990). Other studies have tied still other genes to substance use disorders.
Biochemical Factors Over the past few decades, researchers have pieced together several biological explanations of drug tolerance and withdrawal symptoms (Chung et al., 2012; Kosten et al., 2011, 2005). According to one of the leading explanations, when a particular drug is ingested, it increases the activity of certain neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or increase alertness. When a person keeps on taking the drug, the brain apparently makes an adjustment and reduces its own production of the neurotransmitters.
▶▶ reward center A dopamine-rich path- way in the brain that produces feelings of pleasure when activated.
Crack cookies? Researchers at Connecticut College found that the lab-induced addic- tion of rats to Oreo cookies—particularly the creamy center—was as strong as their lab- induced addiction to cocaine and morphine in many ways. The study was conducted to test the growing theory that many high-fat, high- sugar foods stimulate the brain in the same ways and locations that addictive drugs do.
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Because the drug is increasing neurotrans- mitter activity or efficiency, the brain’s release of the neurotransmitter is less nec- essary. As drug intake increases, the body’s production of the neurotransmitters con- tinues to decrease, leaving the person in need of progressively more of the drug to achieve its effects. In this way, drug tak- ers build tolerance for a drug, becoming more and more reliant on it rather than on their own biological processes to feel comfortable, happy, or alert. If they sud- denly stop taking the drug, their natural supply of neurotransmitters will be low for a time, producing the symptoms of withdrawal. Withdrawal continues until the brain resumes its normal production of the neurotransmitters.
Which neurotransmitters are affected depends on the drug used. Repeated and excessive use of alcohol or benzodiazepines may lower the brain’s production of the neurotransmitter GABA, regular use of opioids may reduce the brain’s produc- tion of endorphins, and regular use of cocaine or amphetamines may lower the brain’s production of dopamine (Kosten et al., 2011, 2005). In addition, researchers have identified a neurotransmitter called anandamide that operates much like THC; excessive use of marijuana may reduce the production of anandamide ( Janis, 2015; Budney et al., 2011).
This theory helps explain why people who regularly take substances have toler- ance and withdrawal reactions. But why are drugs so rewarding, and why do certain people turn to them in the first place? A number of brain-imaging studies suggest that many, perhaps all, drugs eventually activate a reward center, or “pleasure pathway,” in the brain (Urošević et al., 2014) (see Figure 10-4). A key neurotrans- mitter in this pleasure pathway appears to be dopamine (Trifilieff & Martinez, 2014). When dopamine is activated along the pleasure pathway, a person feels pleasure. Music may activate dopamine in the reward center. So may a hug or a word of praise. And so do drugs. Some researchers believe that other neurotransmitters may also play important roles in the reward center (McClure et al., 2014).
Certain drugs apparently stimulate the reward center directly. Remember that cocaine and amphetamines directly increase dopamine activity. Other drugs seem to stimulate it in roundabout ways. The bio- chemical reactions triggered by alcohol, opioids, and marijuana probably set in motion a series of chemical events that eventually lead to increased dopamine activity in the reward center. A number of studies further suggest that when substances repeatedly stimulate this reward center, the center develops a hypersensitivity to the substances. That is, neurons in the center fire more readily when later stimulated by the substances, contributing to future desires for them. (Urošević et al., 2014).
Still other theorists suspect that people who chronically use drugs may suffer from a reward-deficiency syndrome: their reward center is not readily activated by the usual events in their lives, so they turn to drugs to stimulate this pleasure pathway, particularly in times of stress (Garfield et al., 2014; Blum et al., 2000). Abnormal genes, such as the abnormal D2 receptor gene, have been cited as a possible cause of this syndrome (Trifilieff & Martinez, 2014).
Nucleus accumbens
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figure 10-4 pleasure centers in the brain One of the reasons drugs produce feelings of pleasure is because they increase levels of the neu- rotransmitter dopamine along a “pleasure pathway” in the brain that extends from the ventral tegmental area to the nucleus accum- bens and then to the frontal cortex. This activation of pleasure centers plays a role in addiction.
Victims of a reward deficiency syndrome? The brain reward centers of people who develop substance use disorders may be inadequately activated by events in life—a problem called the reward deficiency syndrome. With the colors red and orange indicating more brain activity, these PET scans show that before abusers of cocaine, methamphetamine, and alcohol use drugs, their reward centers (right) are generally less active than the reward centers of nonabusers (left) (Volkow et al., 2004, 2002).
Reprinted from Neurobiology of Learning and Memory, N. D. Volkow et al. Role of Dopamine, the Frontal Cortex and Memory Circuits in Drug Addiction: Insight from Imaging Studies, 610–624, © 2002, with permission from Elsevier. http://www.sciencedirect.com/ science/article/pii/S1074742702940992
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➤ Summing Up WHaT CaUSeS SUbSTanCe USe DiSOrDerS? Several explanations for sub- stance use disorders have been put forward. Together they are beginning to shed light on the disorders.
According to sociocultural theorists, the people most likely to develop these disorders are those living in stressful socioeconomic conditions or people whose families value or accept drug use. In the psychodynamic view, people who develop substance use disorders have excessive dependency needs trace- able to the early stages of life. Some psychodynamic theorists also believe that certain people have a substance abuse personality that makes them prone to drug use. In the leading behavioral view, drug use is seen as being reinforced initially because it reduces tensions and lifts spirits. According to cognitive theo- rists, such effects may also lead to an expectancy that drugs will be comforting and helpful.
The biological explanations are supported by twin, adoptee, genetic linkage, and molecular biology studies, suggesting that people may inherit a predispo- sition to the disorders. Researchers have also learned that drug tolerance and withdrawal symptoms may be caused by cutbacks in the brain’s production of particular neurotransmitters during excessive and repeated drug use. Biological studies suggest that many, perhaps all, drugs may ultimately lead to increased dopamine activity in the brain’s reward center.
How Are Substance Use Disorders Treated? Many approaches have been used to treat substance use disorders (see MediaSpeak on page 336), including psychodynamic, behavioral, cognitive-behavioral, and biologi- cal approaches, along with several sociocultural therapies. Although these treatments sometimes meet with great success, more often they are only moderately helpful (Belendiuk & Riggs, 2014). Today the treatments are typically used on either an outpatient or inpatient basis or a combination of the two (see Figure 10-5).
figure 10-5 Where do people receive treatment? Most people receive treatment for substance use disorders in a self-help group, rehabilita- tion program, or mental health center. (Information from: NSDUH, 2013.)
Number of Patients
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Outpatient mental health center
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Inpatient rehabilitation
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Hospital inpatient 861,000
Private doctor’s office 735,000
Prison or jail 388,000
Emergency room 597,000
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Songs of Substance Substance use is a popular theme in music. Hit songs include Amy Winehouse’s “Rehab,” the Velvet Underground’s “Heroin,” the Rolling Stones’ “Sister Morphine,” Snoop Dogg’s “Gin and Juice,” Eric Clapton’s “Cocaine,” Eminem’s “Drug Ballad,” Lil’ Kim’s “Drugs,” Jay Z’s “I Know,” Miley Cyrus’ “We Can’t Stop,” and Rihanna’s “Diamonds.”
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Psychodynamic Therapies Psychodynamic therapists first guide clients to uncover and work through the underlying needs and conflicts that they believe have led to the substance use dis- order. Although this approach is often used, it has not been found to be particularly effective (McCrady, 2014). It may be that substance use disorders, regardless of their causes, eventually become stubborn independent problems that must be the direct target of treatment if people are to become drug-free. Psychodynamic therapy tends to be of more help when it is combined with other approaches in a multidimen- sional treatment program (Lightdale et al., 2011, 2008).
Behavioral Therapies A widely used behavioral treatment for substance use disorders is aversion therapy, an approach based on the principles of classical conditioning. Clients are repeatedly presented with an unpleasant stimulus (for example, an electric shock) at the very moment that they are taking a drug. After repeated pairings, they are expected to react negatively to the substance itself and to lose their craving for it.
Aversion therapy has been used to treat alcoholism more than it has to treat other substance use disorders. In one version of this therapy, drinking is paired with drug-induced nausea and vomiting (McCrady et al., 2014; Welsh & Liberto, 2001). The pairing of nausea with alcohol is expected to produce negative responses to alcohol itself. Another version of aversion therapy requires people with alcohol- ism to imagine extremely upsetting, repulsive, or frightening scenes while they are drinking. The pairing of the imagined scenes with alcohol is expected to produce negative responses to alcohol itself. Here is the kind of scene therapists may guide a client to imagine:
I’d like you to vividly imagine that you are tasting the (beer, whiskey, etc.). See your- self tasting it, capture the exact taste, color and consistency. Use all of your senses. After you’ve tasted the drink you notice that there is something small and white floating in the glass—it stands out. You bend closer to examine it more carefully, your nose is right over the glass now and the smell fills your nostrils as you remem- ber exactly what the drink tastes like. Now you can see what’s in the glass. There are several maggots floating on the surface. As you watch, revolted, one manages to get a grip on the glass and, undulating, creeps up the glass. There are even more of the repulsive creatures in the glass than you first thought. You realise that you have swallowed some of them and you’re very aware of the taste in your mouth. You feel very sick and wish you’d never reached for the glass and had the drink at all.
(Clarke & Saunders, 1988, pp. 143–144)
A behavioral approach that has been effective in the short-term treatment of people who are addicted to cocaine and several other drugs is contingency manage- ment, which makes incentives (such as cash, vouchers, prizes, or privileges) contin- gent on the submission of drug-free urine specimens (Godley et al., 2014). In one pioneering study, 68 percent of cocaine abusers who completed a six-month con- tingency training program achieved at least eight weeks of continuous abstinence (Higgins et al., 2011, 1993).
Behavioral interventions for substance use disorders have usually had only limited success when they are the sole form of treatment (Belendiuk & Riggs, 2014; Carroll, 2008). A major problem is that the approaches can be effective only when people are motivated to continue using them despite their unpleasantness or demands.
▶▶ aversion therapy A treatment in which clients are repeatedly presented with unpleasant stimuli while they are performing undesirable behaviors such as taking a drug.
Spreading the word In a particularly innova- tive effort to increase public awareness about the dangers of drug abuse, Harwinder Singh Gill, an artist in India, created a model of the human body made up of capsule shells. Gill did this on the eve of the 2012 International Day Against Drug Abuse and Illicit Trafficking.
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75%10:00 AM
MediaSpeak Enrolling at Sober High
by Jeff Forester
What advantages might
sober schools have over
other substance abuse
interventions?
J eff has been sober 22 months, he tells me. Without blinking or ducking, his clear blue eyes looking straight at me, he says that if it were not for Sobriety High, he’d be dead. I believe him. . . . Sobriety High started in Minneapolis in 1989 with just two students. It has 100 more today, and 33 sober high schools have sprung up in eight other states. . . . According to a National Institute on Drug Abuse study, 78% of the stu- dents in sober high schools attend after receiving formal rehab. . . .
While [Sobriety High] undoubtedly feels like a school, the wall banners feature phrases like “Turning It Over Is A Turning Point” rather than, say, a sign for the prom. The students are diverse, with hair of all differ- ent lengths and colors; some have the seemingly requi- site addict tattoos while others are decked out in Goth garb and still others project a distinctly Midwestern Wonder Bread aura. Their journeys are also diverse, with the lucky ones landing here after treatment but many coming from the courts, detox or the streets. . . .
. . . The classes are small so that teachers can check in with each student regularly and the curriculum flex- ible so as to help them with what they missed while they were using or in treatment. Some programs help students—many with hair-raising records—find work. Some also work with chemically dependent parents and older siblings as well. Students typically have “group” each day, and while it is not an AA meeting, the DNA of AA is evident. . . .
All teenagers have low impulse control but the stakes are higher for chemically dependent kids trying to stay sober. Says Joe Schrank, . . . a board member of the National Youth Recovery Foundation, . . . “When you put pot and booze on top of adolescent stupidity, kids are at risk.” . . .
Just try adding acne, constant temptation and regu- larly being heckled that you’re a “pussy” to a standard newcomer’s recovery and you’ll see just how high the deck is stacked against teenage sobriety; the notion of placing them in an environment that caters to clean liv- ing thus makes sense. . . .
Ninety percent of students at Sobriety High have other mental health issues besides chemical depen- dency [and] need the extra support of counselors, psychologists, and ongoing mental health support, and this is costly. . . . “It takes more money per student, and the schools must be on a segregated site if they are to have a drug and alcohol free campus.” . . .
For barely sober teens . . . closing recovery schools would be disastrous. “Many of them will go back to the streets, or prison, or they will be dead,” says . . . the Sobriety High social worker. . . . Supporters . . . point out that closing recovery schools
makes little fiscal sense. “Recovery school is a fraction of the cost of incarceration,” says Joe Schrank. . . . “Look at Drug Courts,” adds former Congressman Jim Ramstad. “The recidivism rate for those who complete the course is 24% while the rate for criminal court is 75%.” . . .
[Social worker Debbie Bolton] says plainly, “What we do is important. We save lives.”
“Most Sober High Schools Are Very Successful. So Why Are They Facing the Ax?” By Jeff Forester, TheFix.com (addiction website), 6/18/2011.
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Generally, behavioral treatments work best in combination with either biological or cognitive approaches (Belendiuk & Riggs, 2014; Carroll & Kiluk, 2012).
Cognitive-Behavioral Therapies Cognitive-behavioral treatments for substance use disorders help clients identify and change the behaviors and cognitions that keep contributing to their patterns of substance misuse (Gregg et al., 2014; Yoon et al., 2012). Practitioners of these approaches also help the clients develop more effective coping skills—skills that can be applied during times of stress, tempta- tion, and substance craving.
Perhaps the most prominent cognitive-behavioral approach to substance misuse is relapse-prevention training ( Jhanjee, 2014; Daley et al., 2011). The overall goal of this approach is for clients to gain control over their substance-related behaviors. To help reach this goal, clients are taught to identify high-risk situations, appreciate the range of decisions that confront them in such situations, change their dysfunctional lifestyles, and learn from mistakes and lapses.
Several strategies typically are included in relapse-prevention training for alcohol use disorder: (1) Therapists have clients keep track of their drinking by writing down the times, locations, emotions, bodily changes, and other circumstances of their drinking. (2) Therapists teach clients coping strategies to use when such situations arise, strategies such as employing relaxation techniques, spacing their drinks, or sipping drinks rather than gulping. (3) Therapists teach clients to plan ahead of time, determin- ing beforehand how many drinks are appropriate, what to drink, and under which circumstances to drink.
Relapse-prevention training has been found to lower some people’s frequency of intoxication and of binge drinking ( Jhanjee, 2014; Borden et al., 2011). People who are young and do not have the tolerance and withdrawal features of chronic alcohol use seem to do best with this approach (Hart & Ksir, 2014; Deas et al., 2008).
Another form of cognitive-behavioral treatment that has been used in cases of substance use disorder is acceptance and commitment therapy (ACT), the mindfulness- based approach that helps clients become aware of their streams of thoughts as they are occurring and to accept such thoughts as mere events of the mind (see Chap- ters 2 and 4). For people with substance use disorders, that means increasing their awareness and acceptance of their drug cravings, worries, and depressive thoughts. By accepting such thoughts rather than trying to eliminate them, the clients are expected to be less upset by them and less likely to act on them by seeking out drugs. Research indicates that ACT often is as effective as other cognitive-behavioral treatments for substance use disorders, and sometimes more effective (Lee et al., 2015; Bowen et al., 2014; Chiesa & Serretti, 2014).
Biological Treatments Biological treatments may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without increasing it further. As with the other forms of treatment, biological approaches alone rarely bring long- term improvement, but they can be helpful when combined with other approaches.
Detoxification Detoxification is systematic and medically supervised with- drawal from a drug. Some detoxification programs are offered on an outpatient basis. Others are located in hospitals and clinics and may also include individual
Better ways to cope Several treatments for substance use disorders, including relapse- prevention training, teach clients alternative— more functional—ways of coping with stress and negative emotions. In that spirit, this patient at a drug rehabilitation center in China developed the practice of kicking a punching dummy to help release his pent-up anger.
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▶▶ relapse-prevention training A cognitive-behavioral approach to treat- ing alcohol use disorder in which clients are taught to keep track of their drink- ing behavior, apply coping strategies in situations that typically trigger excessive drinking, and plan ahead for risky situa- tions and reactions.
▶▶ detoxification Systematic and medi- cally supervised withdrawal from a drug.
: chapter 10338
and group therapy, a “full-service” institutional approach that has become popular. One detoxification approach is to have clients withdraw gradually from the sub- stance, taking smaller and smaller doses until they are off the drug completely. A second—often medically preferred—detoxification strategy is to give clients other drugs that reduce the symptoms of withdrawal (Bisaga et al., 2015; Day & Strang, 2011). Antianxiety drugs, for example, are sometimes used to reduce severe alcohol withdrawal reactions such as delirium tremens and seizures. Detoxification programs seem to help motivated people withdraw from drugs (Müller et al., 2010). However, relapse rates tend to be high for those who do not receive a follow-up form of treatment—psychological, biological, or sociocultural—after successfully detoxify- ing (Blodgett et al., 2014).
Antagonist Drugs After successfully stopping a drug, people must avoid falling back into a pattern of misuse. As an aid to resisting temptation, some people with substance use disorders are given antagonist drugs, which block or change the effects of the addictive drug. Disulfiram (Antabuse), for example, is often given to people who are trying to stay away from alcohol. By itself, a low dose of disulfiram seems to have few negative effects, but a person who drinks alcohol while taking it will have intense nausea, vomiting, blushing, a faster heart rate, dizziness, and perhaps fainting. People taking disulfiram are less likely to drink alcohol because they know the terrible reaction that awaits them should they have even one drink. Disulfiram has proved helpful, but again only with people who are motivated to take it as pre- scribed (Diclemente et al., 2008).
For substance use disorders centered on opioids, several narcotic antagonists, such as naloxone, are used (Alter, 2014). These antagonists attach to endorphin receptor sites throughout the brain and make it impossible for the opioids to have their usual effect. Without the rush or high, continued drug use becomes pointless. Although narcotic antagonists have been helpful—particularly in emergencies, to rescue people from an overdose of opioids—they can in fact be dangerous for people who are addicted to opioids. The antagonists must be given very carefully because of their ability to throw such persons into severe withdrawal. Research indicates that narcotic antagonists may also be useful in the treatment of substance use disorders involving alcohol or cocaine (Crits-Christoph et al., 2015; Harrison & Petrakis, 2011).
Drug Maintenance Therapy A drug-related lifestyle may be a bigger prob- lem than the drug’s direct effects. Much of the damage caused by heroin addiction,
Forced detoxification Abstinence is not always medically supervised, nor is it neces- sarily planned or voluntary. This person, who is suffering from alcoholism, begins to have symptoms of withdrawal soon after being imprisoned for public intoxication. Pa
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▶▶ antagonist drugs Drugs that block or change the effects of an addictive drug.
▶▶ methadone maintenance program A treatment approach in which clients are given legally and medically super- vised doses of methadone—a heroin substitute—to treat heroin-centered sub- stance use disorder.
▶▶ alcoholics anonymous (aa) A self- help organization that provides support and guidance for people with alcohol use disorder.
Substance Use and Addictive Disorders : 339
for example, comes from overdoses, unsterilized needles, and an accompanying life of crime. Thus clinicians were very enthusiastic when methadone mainte- nance programs were developed in the 1960s to treat heroin addiction (Dole & Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory opioid methadone as a substitute for heroin. Although they then become
dependent on methadone, their new addiction is maintained under safe medical supervision. Unlike heroin, methadone produces a moderate high, can be taken by mouth (thus eliminating the dangers of needles), and needs to be taken only once a day.
At first, methadone programs seemed very effective, and many of them were set up through- out the United States, Canada, and England.
These programs became less popular during the 1980s, however, because of the dangers of methadone itself. Many clinicians came to believe that substituting one addiction for another is not an acceptable “solution” for a substance use disorder, and many people with an addiction complained that methadone addiction was creating an additional drug problem that simply complicated their original one (Winstock, Lintzeris, & Lea, 2011). Methadone is sometimes harder to withdraw from than heroin because the withdrawal symptoms can last longer (Hart & Ksir, 2014; Day & Strang, 2011). Moreover, pregnant women maintained on methadone have the added concern of the drug’s effect on their fetus.
Despite such concerns, maintenance treatment with methadone—or with other opioid substitute drugs—has again sparked interest among clinicians in recent years, partly because of new research support (Balhara, 2014; Fareed et al., 2011) and partly because of the rapid spread of the HIV and hepatitis C viruses among intravenous drug abusers and their sex partners and children (Lambdin et al., 2014; Galanter & Kleber, 2008). Not only is methadone treatment safer than street opioid use, but many methadone programs now include AIDS education and other health instruc- tions in their services. Research suggests that methadone maintenance programs are most effective when they are combined with education, psychotherapy, family therapy, and employment counseling ( Jhanjee, 2014). Today thousands of clinics provide methadone treatment across the United States.
Sociocultural Therapies As you have read, sociocultural theorists—both family-social and multicultural theorists— believe that psychological problems emerge in a social setting and are best treated in a social context. Three sociocultural approaches have been used to help people overcome substance use disorders: (1) self-help programs, (2) culture- and gender-sensitive programs, and (3) community prevention programs.
Self-Help and Residential Treatment Programs Many people with substance use disorders have organized among themselves to help one another recover without professional assistance. The drug self-help movement dates back to 1935, when two Ohio men suffering from alcoholism met and wound up discuss- ing alternative treatment possibilities. The first discussion led to others and to the eventual formation of a self-help group whose members discussed alcohol-related problems, traded ideas, and provided support. The organization became known as Alcoholics Anonymous (AA).
Today AA has more than 2 million members in 114,000 groups across the world (AA World Services, 2014). It offers peer support along with moral and spiritual guidelines to help people overcome alcoholism. Different members apparently find different aspects of AA helpful. For some it is the peer support; for others it is the
Pros and cons of methadone treatment Methadone is itself a narcotic that can be as dangerous as other opioids when not taken under safe medical supervision. Here a couple protests against a proposed methadone treatment facility in Maine. Their 19-year-old daughter, who was not an opioid addict, had died months earlier after taking methadone to get high.
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Why has the legal, medically
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States) sometimes failed to
combat drug problems?
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Staying Sober • 48% of current AA members have
been sober for more than five years.
• 37% of current AA members have been sober for less than one year.
(aa World Services, 2014)
: chapter 10340
spiritual dimension (Tusa & Burgholzer, 2013). Meetings take place regularly, and members are available to help each other 24 hours a day.
By offering guidelines for living, the organization helps members abstain “one day at a time,” urging them to accept as fact the ideas that they have a disease, are powerless over alcohol, and must stop drinking entirely and permanently if they are to live normal lives. Related self-help organizations, Al-Anon and Alateen, offer support for people who live with and care about people with alcoholism. Self-help programs such as Narcotics Anonymous and Cocaine Anonymous have been developed for other substance use disorders.
It is worth noting that the abstinence goal of AA directly opposes the controlled-drinking goal of relapse-prevention training and several other interventions for substance misuse (see page 337). In fact, this issue—abstinence versus controlled drinking—has been debated for years (Hart & Ksir, 2014; Rosenthal, 2011, 2005). Feelings about it have run so strongly that in the 1980s the people on one side challenged the motives and honesty of those on the other (Sobell & Sobell, 1984, 1973; Pendery et al., 1982).
Research indicates, however, that both controlled drinking and abstinence may be useful treatment goals, depending on the nature of the particular drinking problem. Studies suggest that abstinence may be a more appropriate goal for people who have a long-standing alcohol use disorder, whereas con- trolled drinking can be helpful to younger drinkers whose pattern does not include tolerance and withdrawal reactions. Many of those in the latter group may respond to treatments that teach a nonabusive form of drinking (Hart & Ksir, 2014; Witkiewitz & Marlatt, 2007, 2004).
Many self-help programs have expanded into residential treatment centers, or therapeutic communities—such as Daytop Village and Phoenix House—where people formerly addicted to drugs live, work, and socialize in a drug-free environ- ment while undergoing individual, group, and family therapies and making a transi- tion back to community life (Relf et al., 2014; Bonetta, 2010).
The evidence that keeps self-help and residential treatment programs going comes largely in the form of individual testimonials. Many tens of thousands of people have revealed that they are members of these programs and credit them with turning their lives around. Studies of the programs have also had favorable findings, but their numbers have been limited (Galanter, 2014).
Culture- and Gender-Sensitive Programs Many people with substance use disorders live in a poor and perhaps violent setting. A growing number of today’s treatment programs try to be sensitive to the special sociocultural pressures and problems faced by drug abusers who are poor, homeless, or members of minority groups (Hadland & Baer, 2014; Hurd et al., 2014). Therapists who are sensitive to their clients’ life challenges can do more to address the stresses that often lead to relapse.
Similarly, therapists have become more aware that women often require treatment methods different from those designed for men (Lund, Brendryen, & Ravndal, 2014; Greenfield et al., 2011). Women and men often have different physical and psychological reactions to drugs, for example. In addition, treatment of women with substance use disorders may be complicated by the impact of sexual abuse, the possibility that they may be or may
Fighting drug abuse while in prison Inmates at a county jail in Texas exercise and meditate as part of a drug and alcohol reha- bilitation program. The program also includes psychoeducation and other interventions to help inmates address their substance use disorders.
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▶▶ residential treatment center A place where people formerly addicted to drugs live, work, and socialize in a drug-free environment. Also called a therapeutic community.
Substance Use and Addictive Disorders : 341
become pregnant while taking drugs, the stresses of rais- ing children, and the fear of criminal prosecution for abusing drugs during pregnancy (Finnegan & Kandall, 2008). Thus many women with such disorders feel more comfortable seeking help at gender-sensitive clinics or residential programs; some such programs also allow chil- dren to live with their recovering mothers.
Community Prevention Programs Perhaps the most effective approach to substance use disorders is to prevent them (Sandler et al., 2014). The first drug- prevention programs were conducted in schools (Espada et al., 2015). Today such programs are also offered in workplaces, activity centers, and other community set- tings and even through the media (NSDUH, 2013). Around 75 percent of adolescents report that they have seen or heard a substance use–prevention message within the past year. And almost 60 percent have talked to their parents in the past year about the dangers of alcohol and other drugs.
Prevention programs may focus on the individual (for example, by providing education about unpleasant drug effects), the family (by teaching parenting skills), the
peer group (by teaching resistance to peer pres- sure), the school (by setting up firm enforce- ment of drug policies), or the community at large. The most effective prevention efforts focus on several of these areas to provide a consistent message about drug misuse in all areas of people’s lives (Wambeam et al., 2014).
Some prevention programs have even been developed for preschool children. Two of today’s leading community-based prevention programs are TheTruth.
com and Above the Influence. The Truth.com is an antismoking campaign, aimed at young people in particular, that has “edgy” ads on the Web (on YouTube, for instance), on television, and in magazines and newspapers. Above the Influence is a similar advertising campaign that focuses on a range of substances abused by teen- agers. One recent nationwide survey of 3,000 students has suggested that watching Above the Influence ads may help reduce marijuana use by teenagers (Slater et al., 2011). The survey found that 8 percent of eighth-graders familiar with the cam- paign have taken up marijuana use, in contrast to 12 percent of students who have never seen the ads.
➤ Summing Up HOW are SUbSTanCe USe DiSOrDerS TreaTeD? Treatments for substance use disorders vary widely. Usually several approaches are combined. Psychody- namic therapies are used to try to help clients become aware of and correct the underlying needs and conflicts that may have led to their use of drugs. A com- mon behavioral technique is aversion therapy, in which an unpleasant stimulus is paired with the drug that the person is abusing. Cognitive and behavioral techniques have been combined in such forms as relapse-prevention training. Biological treatments include detoxification, antagonist drugs, and drug main- tenance therapy. Sociocultural treatments approach substance use disorders in a social context by means of self-help groups (e.g., Alcoholics Anonymous), culture- and gender-sensitive treatments, and community prevention programs.
What impact might admissions
by celebrities about their past
drug use have on people’s
willingness to seek treatment?
Listen to my story A prisoner stands shackled before students at an Ohio high school and discusses his drunk-driving convic- tion (his intoxicated driving resulted in a fatal automobile crash). These visits by inmates are part of the school’s “Make the Right Choice” prevention program.
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Cocaine Alert Cocaine accounts for more drug treat- ment admissions than any other drug (Hart & Ksir, 2014; SAMHSA, 2014).
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Other Addictive Disorders As you read at the beginning of this chapter, DSM-5 lists gambling disorder as an addictive disorder alongside the substance use disorders. This represents a significant broadening of the concept of addiction, which in previous editions of the DSM referred only to the misuse of substances. In essence, DSM-5 is suggesting that people may become addicted to behaviors and activities beyond substance use.
Gambling Disorder It is estimated that as many as 4 percent of adults and 3 to 10 percent of teenagers and college students suffer from gambling disorder (Nowak & Aloe, 2013; Black et al., 2012). Clinicians are careful to distinguish between this disorder and social gambling (APA, 2013). Gambling disorder is defined less by the amount of time or money spent gambling than by the addictive nature of the behavior. People with gambling disorder are preoccupied with gambling and typically cannot walk away from a bet. When they lose money repeatedly, they often gamble more in an effort to win the money back and continue gambling even in the face of financial, social, occupational, educational, and health problems (see Table 10-3). They usually gamble more when feeling distressed and often lie to cover up the extent of their gambling. Many people with gambling disorder need to gamble with ever-larger amounts of money to reach the desired excitement, and they feel restless or irritable when they try to reduce or stop gambling—symptoms that are similar to the tolerance and withdrawal reactions displayed in cases of substance use disorder (APA, 2013).
The explanations proposed for gambling disorder often parallel those for sub- stance use disorders. Some studies suggest, for example, that people with gambling disorder may (1) inherit a genetic predisposition to develop the disorder (Vitaro et al., 2014); (2) experience heightened dopamine activity and operation of the brain’s reward center when they gamble ( Jabr, 2013); (3) have impulsive, novelty- seeking, and other personality styles that leave them prone to gambling disorder (Leeman et al., 2014); and (4) make repeated cognitive mistakes such as inaccurate
table: 10-3
Dx Checklist
gambling Disorder
1. Individual displays a maladaptive pattern of gambling, featuring at least four of the following symptoms over the course of a full year:
(a) Can achieve desired excitement only by gambling more and more money.
(b) Feels restless or irritable when tries to reduce gambling.
(c) Repeatedly tries and fails at efforts to control, reduce, or cease gambling.
(d) Consumed with gambling thoughts or plans.
(e) Gambling is often triggered by upset feelings.
(f ) Frequently returns to gambling to try to recoup previous losses.
(g) Covers up amount of gambling by lying.
(h) Gambling has put important relationships, job, or educational/career opportunities at risk.
( i ) Seeks money from others to address gambling-induced financial problems.
2. Individual experiences significant distress or impairment.
(Information from: APA, 2013)
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Smartphone Addiction? • Around 41 percent of Britons report
feeling anxious and not in control when separated from their smart- phone or tablet.
• Around 12 percent of Americans use their smartphones when in the shower.
• Around 75 percent of people report that their smartphone is less than five feet away from them at all times.
(archer, 2013)
Substance Use and Addictive Disorders : 343
expectations and misinterpretations of their emotions and bodily states (Spada et al., 2015; Williams et al., 2012). However, the research on these theories has been lim- ited thus far, leaving such explanations tentative for now.
Several of the leading treatments for substance use disorders have been adapted for use with gambling disorder. These treatments include cognitive-behavioral approaches like relapse-prevention training and biological approaches such as nar- cotic antagonists ( Jabr, 2013; Bosco et al., 2012). In addition, the self-help group program Gamblers Anonymous, a network modeled after Alcoholics Anonymous, is available to the many thousands of people with gambling disorder (Marceaux & Melville, 2011). People who attend such groups seem to have a better recovery rate.
Internet Gaming Disorder: Awaiting Official Status As people increasingly turn to the Internet for activities that used to take place in the “real world”—communicating, networking, shopping, playing games, and participat- ing in a community—a new psychological problem has emerged: an uncontrollable need to be online (Hsu et al., 2014; Young, 2011). This pattern has been called Internet use disorder, Internet addiction, and problematic Internet use, among other names.
For people who have this pattern—at least 1 percent of all people—the Internet has become a black hole. They spend all or most of their waking hours texting, tweeting, networking, gaming, Internet browsing, e-mailing, blogging, visiting vir- tual worlds, shopping online, or viewing online pornography (Yoo et al., 2014). Specific symptoms of this pattern parallel those found in substance use disorders and gambling disorder, extending from the loss of outside interests to possible with- drawal reactions when Internet use is not possible (APA, 2013).
Although clinicians, the media, and the public have shown enormous interest in this problem, it is not included as a disorder in DSM-5. Rather, the DSM work- group has recommended that one version of the pattern, which it calls Internet gaming disorder, receive further study for possible inclusion in future editions (APA, 2013). Time—and research—will tell whether this pattern reaches the status of a formal clinical disorder.
➤ Summing Up OTHer aDDiCTive DiSOrDerS DSM-5 groups gambling disorder alongside the substance use disorders as an addictive disorder. The explanations for this disorder, which are parallel to those for substance use disorders, include genetic factors, dopamine activity, personality styles, and cognitive factors. Treatments for gambling disorder include cognitive-behavioral approaches, narcotic antag- onists, and self-help groups. The DSM-5 task force recommended that another addictive pattern, Internet gaming disorder, receive further study for possible inclusion in future DSM revisions.
PUTTING IT...together New Wrinkles to a Familiar Story In some respects, the story of the misuse of drugs is the same today as in the past. Substance use is still rampant, often creating damaging psychological disorders. New drugs keep emerging, and the public goes through periods of believing, naïvely, that the new drugs are “safe.” Only gradually do people learn that these, too, pose dangers. And treatments for substance-use disorders continue to have only limited effect.
Increase in gambling venues This woman is playing a slot machine while vacationing on a cruise ship. Harmless fun for her, but not for everyone. Some theorists believe the recent increases in the prevalence of gam- bling disorder are related to the explosion of new gambling venues, in particular the many casinos that have been built in every part of the country, and the legalization and spread of online gambling.
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▶▶ gambling disorder A disorder marked by persistent and recurrent gam- bling behavior, leading to a range of life problems.
▶▶ internet gaming disorder A dis- order marked by persistent, recurrent, and excessive Internet gaming. Recom- mended for further study by the DSM-5 task force.
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Yet there are positive new wrinkles in this familiar story. Researchers have begun to develop a clearer understanding of how drugs act on the brain and body. In treat- ment, self-help groups and rehabilitation programs are flourishing. And preventive education to make people aware of the dangers of drug misuse is also expanding and seems to be having an effect. One reason for these improvements is that inves- tigators and clinicians have stopped working in isolation and are instead looking
for intersections between their own work and work from other models. Perhaps the most important insight to be gained from these inte-
grated efforts is that several of the models were already on the right track. Social pressures, personality characteristics, rewards, and genetic predispositions all seem to play roles in substance use disorders, and in fact to operate together. For example, some people may inherit a mal- function of the biological reward center and so may need special doses of external stimulation—which can be provided by, for example, gam- bling, intense relationships, an abundance of certain foods, or drugs—to stimulate their reward center. Their pursuit of external rewards may take on the character of an addictive personality. Such people may be especially prone to experimenting with drugs, particularly when their
social group makes the drugs available or when they are faced with intense stress. Just as each model has identified important factors in the development of sub-
stance use disorders, each has made important contributions to treatment. As you have seen, the various forms of treatment seem to work best when they are com- bined with approaches from the other models, making integrated treatment the most productive approach.
Yet another new wrinkle to the addiction story is that the clinical field has now formally proclaimed that substances are not the only things to which people may develop an addiction. By grouping gambling disorder with the substance use dis- orders and targeting Internet gaming disorder for possible inclusion in the future, DSM-5 has opened the door for a broader view and perhaps broader treatments of addictive patterns—whether they are induced by substances or by other kinds of experiences.
KEY TERMS substance intoxication, p. 310
hallucinosis, p. 310
substance use disorder, p. 310
tolerance, p. 310
withdrawal, p. 310
alcohol, p. 311
delirium tremens (DTs), p. 314
cirrhosis, p. 314
Korsakoff’s syndrome, p. 316
fetal alcohol syndrome, p. 316
sedative-hypnotic drug, p. 316
barbiturates, p. 316
benzodiazepines, p. 316
opioid, p. 316
opium, p. 316
morphine, p. 316
heroin, p. 317
endorphins, p. 317
cocaine, p. 319
free-basing, p. 321
crack, p. 321
amphetamines, p. 322
methamphetamine, p. 322
hallucinogen, p. 323
LSD (lysergic acid diethylamide), p. 323
cannabis, p. 326
marijuana, p. 326
tetrahydrocannabinol (THC), p. 326
polysubstance use, p. 328
synergistic effect, p. 328
dopamine-2 (D2) receptor gene, p. 332
reward center, p. 333
reward-deficiency syndrome, p. 333
substance-abuse personality, p. 334
aversion therapy, p. 335
contingency management, p. 335
relapse-prevention training, p. 337
detoxification, p. 337
antagonist drug, p. 338
disulfiram (Antabuse), p. 338
narcotic antagonist, p. 338
methadone maintenance program, p. 339
self-help program, p. 339
Alcoholics Anonymous (AA), p. 339
residential treatment center, p. 340
community prevention program, p. 341
gambling disorder, p. 342
Gamblers Anonymous, p. 343
Internet gaming disorder, p. 343
C li n i C al C h o i C e s Now that you’ve read about substance use and addictive disorders, try the interactive case study for this chapter. See if you are able to identify Jorge’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for Jorge? Go to LaunchPad to access Clinical Choices.
Substance Use and Addictive Disorders : 345
QuickQuiz
1. What are substance use disorders? pp. 310–311
2. How does alcohol act on the brain and body? What are the problems and dan- gers of alcohol misuse? pp. 311–316
3. Describe the features and problems of the misuse of barbiturates and benzodi- azepines. p. 316
4. Compare the various opioids (opium, heroin, morphine). What problems may result from their use? pp. 316–318
5. List and compare two kinds of stimulant drugs. Describe their biological actions and the problems caused by each of them. pp. 319–323
6. What are the effects of hallucinogens, particularly LSD? pp. 323–325
7. What are the effects of marijuana and other cannabis substances? Why is marijuana a greater danger today than it was decades ago? pp. 326–328
8. What special problems does polysub- stance use pose? pp. 328–329
9. Describe the leading explanations and treatments for substance use disorders. How well supported are these explana- tions and treatments? pp. 330–341
10. Name and describe two addictive pat- terns that are not triggered by sub- stance misuse. pp. 342–343
visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
Ed F
ai rb
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c h a p t e r
R obert, a 57-year-old man, came to sex therapy with his wife because of his inability to get erections. He had not had a problem with erections until six months earlier, when they attempted to have sex after an evening out, during which he had had several drinks. They attributed his failure to get an erection
to his being “a little drunk,” but he found himself worrying over the next few days that he was perhaps becoming impotent. When they next attempted intercourse, he found himself unable to get involved in what they were doing because he was so intent on watching himself to see if he would get an erection. Once again he did not, and they were both very upset. His failure to get an erection continued over the next few months. Robert’s wife was very upset and frustrated, accusing him of having an affair or of no longer finding her attractive. Robert wondered if he was getting too old or if his medication for high blood pressure, which he had been taking for about a year, might be interfering with erections. When they came for sex therapy, they had not attempted any sexual activity for over two months.
Sexual behavior is a major focus of both our private thoughts and public discussions. Sexual feelings are a crucial part of our development and daily functioning, sexual activity is tied to the satisfaction of our basic needs, and sexual performance is linked to our self-esteem. Most people are fascinated by the abnormal sexual behavior of others and worry about the normality of their own sexuality.
Experts recognize two general categories of sexual disorders: sexual dys- functions and paraphilic disorders. People with sexual dysfunctions have prob- lems with their sexual responses. Robert, for example, had a dysfunction known as erectile disorder, a repeated failure to attain or maintain an erec- tion during sexual activity. People with paraphilic disorders have repeated and intense sexual urges or fantasies in response to objects or situations that society deems inappropriate, and they may behave inappropriately as well. They may be aroused by the thought of sexual activity with a child, for example, or of exposing their genitals to strangers, and they may act on those urges. In addi- tion to the sexual disorders, DSM-5 includes a diagnosis called gender dysphoria, a pattern in which people persistently feel that they have been born to the wrong sex, identify with the other gender, and experience significant distress or impairment as a consequence of these feelings.
As you will see throughout this chapter, relatively little is known about racial and other cultural differences in sexuality. This is true for normal sexual patterns, sexual dysfunctions, and paraphilic disorders alike. Although differ- ent cultural groups have for years been labeled hypersexual, “hot blooded,” exotic, passionate, submissive, and the like, such incorrect stereotypes have grown strictly from ignorance or prejudice, not from objective observations or research (McGoldrick et al., 2007). In fact, sex therapists and sex research- ers have only recently begun to attend systematically to the importance of culture and race.
11
T O P I C O V E R V I E W
Sexual Dysfunctions Disorders of Desire Disorders of Excitement Disorders of Orgasm Disorders of Sexual Pain
Treatments for Sexual Dysfunctions What Are the General Features of Sex Therapy? What Techniques Are Used to Treat Particular Dysfunctions? What Are the Current Trends in Sex Therapy?
Paraphilic Disorders Fetishistic Disorder Transvestic Disorder Exhibitionistic Disorder Voyeuristic Disorder Frotteuristic Disorder Pedophilic Disorder Sexual Masochism Disorder Sexual Sadism Disorder
Gender Dysphoria Explanations of Gender Dysphoria Treatments for Gender Dysphoria
Putting It Together: A Private Topic Draws Public Attention
Disorders of Sex and Gender
: chapter 11348
Sexual Dysfunctions Sexual dysfunctions, disorders in which people cannot respond normally in key areas of sexual functioning, make it difficult or impossible to enjoy sexual intercourse. Studies suggest that as many as 30 percent of men and 45 percent of women around the world suffer from such a dys- function during their lives (Lewis et al., 2010). Sex- ual dysfunctions are typically very distressing, and they often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems (Faubion & Rullo, 2015; McCarthy & McCarthy, 2012). Often these dysfunctions are interrelated; many patients with one dysfunction have another as well. Sexual dysfunctioning is described here for heterosexual couples, the majority of couples seen in therapy. Gay and lesbian couples have the same dysfunctions, however, and therapists use the same basic techniques to treat them.
The human sexual response can be described as a cycle with four phases: desire, excitement, orgasm, and resolution (see Figure 11-1). Sexual dysfunctions affect one or more of the first three phases. Resolution consists simply of the relaxation and reduction in arousal that follow orgasm. Some people struggle with a sexual dys- function their whole lives; in other cases, normal sexual functioning preceded the dysfunction. In some cases the dysfunction is present during all sexual situations; in others it is tied to particular situations (APA, 2013).
Disorders of Desire The desire phase of the sexual response cycle consists of an interest in or urge to have sex, sexual attraction to others, and, for many people, sexual fantasies. Two dysfunctions affect the desire phase—male hypoactive sexual desire disorder and female sexual interest/arousal disorder. The latter disorder actually cuts across both the desire and excitement phases of the sexual response cycle. It is considered a single disorder in DSM-5 because, according to research, desire and arousal overlap particularly highly for women, and many women express difficulty distinguishing feelings of desire from those of arousal (APA, 2013).
A number of people have normal sexual interest but choose, as a matter of lifestyle rather than sexual desire, to avoid engaging in sexual relations (see InfoCentral on page 350). These people are not diagnosed as having one of the sexual desire disorders.
Orgasm
Excitement Resolution
Desire
Male
Le ve
l o f P
hy si
ol og
ic al
A ro
us al
High
Low
Time
Orgasm (Orgasm)
Excitement
Resolution without orgasm
Resolution with orgasm
Desire
Female
Le ve
l o f P
hy si
ol og
ic al
A ro
us al
High
Low
Time
figure 11-1 The normal sexual response cycle Researchers have found a similar sequence of phases in both males and females. Some- times, however, women do not experience orgasm; in that case, the resolution phase is less sudden. And sometimes women have two or more orgasms in succession before the resolution phase. (Information from: Kaplan, 1974; Masters & Johnson, 1970, 1966.)
rates for sexual behavior
are typically based on
population surveys. What
factors might affect the
accuracy of such surveys?
▶▶ sexual dysfunction A disorder marked by a persistent inability to func- tion normally in some area of the sexual response cycle.
▶▶ desire phase The phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction.
▶▶ male hypoactive sexual desire disorder A male dysfunction marked by a persistent reduction or lack of inter- est in sex and hence a low level of sexual activity.
▶▶ female sexual interest/arousal disorder A female dysfunction marked by a persistent reduction or lack of inter- est in sex, as well as, in some cases, limited excitement and few sexual sensa- tions during sexual activity.
Disorders of Sex and Gender : 349
Men with male hypoactive sexual desire disorder per- sistently lack or have reduced interest in sex and engage in little sexual activity (see Table 11-1). Nevertheless, when they do have sex, their physical responses may be normal and they may enjoy the experience. While most cultures portray men as wanting all the sex they can get, as many as 18 percent of men worldwide have this disorder, and the number seeking therapy has increased during the past decade (Martin et al., 2014; Lewis et al., 2010).
Women with female sexual interest/arousal disorder also lack normal interest in sex and rarely initiate sexual activ- ity (see Table 11-1 again). In addition, many such women feel little excitement during sexual activity, are unaroused by erotic cues, and have few genital or nongenital sensations during sexual activity (APA, 2013). As many as 38 percent of women world- wide have reduced sexual interest and arousal (Christensen et al., 2011; Laumann et al., 2005, 1999, 1994). It is important to note that many sex researchers and therapists believe it is inaccurate to combine desire and excitement symptoms into a single female disorder (Sungur & Gündüz, 2014).
A person’s sex drive is determined by a combination of bio- logical, psychological, and sociocultural factors, any of which may reduce sexual desire. Most cases of low sexual desire are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly.
Biological Causes of Low Sexual Desire A number of hormones inter- act to help produce sexual desire and behavior (see Figure 11-2), and abnormalities in their activity can lower a person’s sex drive (Randolph et al., 2015; Giraldi et al., 2013; Laan et al., 2013). In both men and women, a high level of the hormone prolactin, a low level of the male sex hormone testosterone, and either a high or low level of the female sex hormone estrogen can lead to low sex drive. Low sex drive has been linked to the high levels of estrogen contained in some birth control pills, for example. Conversely, it has also been tied to the low level of estrogen found in many postmenopausal women or women who have recently given birth. Long- term physical illness can also lower a person’s sex drive (Berry & Berry, 2013). The
table: 11-1
Dx Checklist
Male Hypoactive Sexual Desire Disorder
1. For at least 6 months, individual repeatedly experiences few or no sexual thoughts, fantasies, or desires.
2. Individual experiences significant distress about this.
Female Sexual Interest/Arousal Disorder
1. For at least 6 months, individual usually displays reduced or no sexual interest and arousal, characterized by the reduction or absence of at least three of the following: • Sexual interest • Sexual thoughts or fantasies • Sexual initiation or receptiveness • Excitement or pleasure during sex • Responsiveness to sexual cues • Genital or nongenital sensations during sex.
2. Individual experiences significant distress.
(Information from: APA, 2013.)
Orgasm
Contractions in uterus
Rhythmic contractions in orgasmic platform
Rectal sphincter contracts
Uterus
Bladder
Desire
Vaginal lubrication appears
Clitoris enlarges
Labia swell
figure 11-2 Normal female sexual anatomy Changes in the female anatomy take place during the different phases of the sexual response cycle. (Information from: Hyde, 1990, p. 200.)
InfoCentral
SEX THROUGHOUT THE LIFE CYCLE Sexual dysfunctions are different from the usual patterns of sexual functioning. But in the sexual realm, what is “the usual”? Studies conducted over the past two decades have provided a wealth of
enlightening information about sexual behavior in the “normal” populations of North America. As you might expect, sexual be- havior often differs by age and by gender.
ADOLESCENCE (AGES 11–19) 16 years old
30% 30% 54% 58%0 20 40 60
heterosexual intercourse oral sex
EARLY ADULTHOOD (AGES 20–34) 22 years old
63% 80% 69% 79% 10% 16% 25%
use condoms 0
20 40 60 80
heterosexual intercourse oral sex same-sex sexual activity
35 years old
85% 73% 83% 64% 8% 15% 0
20 40 60 80
100
heterosexual intercourse oral sex same-sex sexual activity
OLD AGE (AGE 60 AND OVER) 65 years old
54% 42% 40% 25% 7% 4%0 20 40 60
heterosexual intercourse oral sex same-sex sexual activity
MIDDLE ADULTHOOD (AGES 35–59) 45 years old
74% 70% 68% 55% 14% 11%0 20 40 60 80
heterosexual intercourse oral sex same-sex sexual activity
19 years old
53% 62% 62%60% 50%10% 8%
use condoms 0
20 40 60 80
heterosexual intercourse oral sex same-sex sexual activity
| 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 2 5
| 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 3 7
| 3 8 | 39 | 40 | 41 | 42 | 43 | 44 | 4
5 | 46 | 47 | 48 | 49 | 50 | 51 | 52 | 53 | 54 | 5
5 | 56 | 57 | 58 | 59 | 60 | 61 | 62 | 63 | 64 | 65 | 66 | 67 | 68
Masturbation by age 63% 75% 81% 82% 80%
14 16 19 22 35
43% 53% 63% 62% 63%
76% 62% 46% 40%
45 65 70 90
65% 46% 31% 25%
Age
Most sexually experienced teens engage in only one sexual relationship at a time.
The decline in men’s sexual activity usually comes gradually as they advance in age and their health fails.
The majority of very elderly people continue to have sexual fantasies.
males
females
Sexual activity is more likely to drop off sharply for elderly women, commonly because of the death or illness of a partner.
O’Sullivan et al., 2014; Herbenick et al., 2013, 2010; Chandra et al., 2011; Petersen & Hyde, 2011; Lindau et al., 2007; Laumann et al., 2005, 1999, 1994; Janus & Janus, 1993
One survey finds that 36% of people under age 35 go on FACEBOOK after having sex.
(Cayman, 2014)
From the ages of 25 to 59, sexual relationships last longer and are more monogamous.
Disorders of Sex and Gender : 351
reduced drive may be a direct result of the illness or an indirect result because of stress, pain, or depression brought on by the illness.
Clinical practice and research have further indicated that sex drive can be lowered by certain pain medications, psychotropic drugs, and illegal drugs such as cocaine, marijuana, amphetamines, and heroin (Glina et al., 2013). Low levels of alcohol may enhance the sex drive by lowering a person’s inhibitions, but high levels may reduce it (George et al., 2011).
Psychological Causes of Low Sexual Desire A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women (Rajkumar & Kumaran, 2015; Štulhofer et al., 2013). Frequently, as cognitive theo- rists have noted, people with low sexual desire have particular attitudes, fears, or memories that contribute to their dysfunction, such as a belief that sex is immoral or dangerous (Giraldi et al., 2013). Other people are so afraid of losing control over their sexual urges that they try to resist them completely. And still others fear pregnancy.
Certain psychological disorders may also contribute to low sexual desire. Even a mild level of depression can interfere with sexual desire, and some people with obsessive-compulsive symptoms find contact with another person’s body fluids and odors to be highly unpleasant (Rubio-Aurioles & Bivalacqua, 2013).
Sociocultural Causes of Low Sexual Desire The attitudes, fears, and psychological disorders that contribute to low sexual desire occur within a social context, and thus certain sociocultural factors have also been linked to disorders of sexual desire. Many people who have low sexual desire are feeling situational pressures—for example, divorce, a death in the family, job stress, infertility difficul- ties, or having a baby (Hamilton & Meston, 2013). Other people may be having problems in their relationships (Witherow et al., 2015; Brenot, 2011). People who are in an unhappy relationship, have lost affection for their partner, or feel power- less and dominated by their partner can lose interest in sex. Even in basically happy relationships, if one partner is a very unskilled, unenthusiastic lover, the other can begin to lose interest in sex ( Jiann, Su, & Tsai, 2013). And sometimes partners differ in their needs for closeness. The one who needs more personal space may develop low sexual desire as a way of keeping distance.
Cultural standards can also set the stage for low sexual desire. Some men adopt our culture’s double standard and thus cannot feel sexual desire for a woman they love and respect (Maurice, 2007). More generally, because our society equates sexual attractiveness with youthfulness, many middle-aged and older men and women lose interest in sex as their self-image or their attraction to their partner diminishes with age (Leiblum, 2010).
The trauma of sexual molestation or assault is especially likely to produce the fears, attitudes, and memories found in disorders of sexual desire. Some survivors of sexual abuse may feel repelled by sex, sometimes for years, even decades (Turchik & Hassija, 2014; Giraldi et al., 2013). In some cases, survivors may have vivid flashbacks of the assault during adult consensual sexual activity.
Disorders of Excitement The excitement phase of the sexual response cycle is marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing. In men, blood pools in the pelvis and leads to erection of the penis; in women, this phase produces swelling of the clitoris and labia, as well as lubrication of the vagina. As you read earlier, female sexual interest/arousal disorder may include dysfunction during the excitement phase. In addition, a male disorder—erectile disorder—involves dysfunction during the excitement phase only.
▶▶ excitement phase The phase of the sexual response cycle marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing.
Grand Theft Auto: The sexual controversy With 15 different titles, Grand Theft Auto is one of today’s most popular video game series. But it was almost derailed in 2004 with the release of one of the titles, Grand Theft Auto: San Andreas. Fearing that the sexual material in this game was too graphic for children and an unhealthy devel- opmental influence, parents and politicians pressured the producer to develop enhanced security measures and, eventually, to remove the sexual material.
Pa ul
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: chapter 11352
Erectile Disorder Men with erectile disorder persistently fail to attain or maintain an erection during sexual activity (see Table 11-2). This problem occurs in as much as 25 percent of the male population, including Robert, the man whose difficulties opened this chapter (Martin et al., 2014; Christensen et al., 2011). Carlos Domera also has erectile disorder:
Carlos Domera is a 30-year-old dress manufacturer who came to the United States from Argentina at age 22. He is married to . . . Phyllis, also age 30. They have no children. Mr. Domera’s problem was that he had been unable to have sexual inter- course for over a year due to his inability to achieve or maintain an erection. He had avoided all sexual contact with his wife for the prior five months, except for two brief attempts at lovemaking which ended when he failed to maintain his erection.
The couple separated a month ago by mutual agreement due to the tension that surrounded their sexual problem and their inability to feel comfortable with each other. Both professed love and concern for the other, but had serious doubts re- garding their ability to resolve the sexual problem. . . .
[Carlos] conformed to the stereotype of the “macho Latin lover,” believing that he “should always have erections easily and be able to make love at any time.” Since he couldn’t “perform” sexually, he felt humiliated and inadequate, and he dealt with this by avoiding not only sex, but any expression of affection for his wife.
[Phyllis] felt “he is not trying; perhaps he doesn’t love me, and I can’t live with no sex, no affection, and his bad moods.” She had requested the separation temporar- ily, and he readily agreed. However, they had recently been seeing each other twice a week. . . .
During the evaluation he reported that the onset of his erectile difficulties was concurrent with a tense period in his business. After several “failures” to complete intercourse, he concluded he was “useless as a husband” and therefore a “total fail- ure.” The anxiety of attempting lovemaking was too much for him to deal with.
He reluctantly admitted that he was occasionally able to masturbate alone to a full, firm erection and reach a satisfying orgasm. However, he felt ashamed and guilty about this, from both childhood masturbatory guilt and a feeling that he was “cheat- ing” his wife. It was also noted that he had occasional firm erections upon awakening in the morning. Other than the antidepressant, the patient was taking no drugs, and he was not using much alcohol. There was no evidence of physical illness.
(Spitzer et al., 1983, pp. 105–106)
Unlike Carlos, most men with an erectile disorder are over the age of 50, largely because so many cases are associated with ailments or diseases of older adults (Regal, 2015). Around 7 percent of men who are under 40 years old also have the disorder; that number increases to as many as 40 percent of men in their sixties and 75 percent of those in their seventies and eighties (Lewis et al., 2010; Rosen, 2007). Moreover, according to surveys, half of all adult men experience erectile difficulty during inter- course at least some of the time. Most cases of erectile disorder result from an interaction of biological, psychological, and socio- cultural processes.
Biological causes The same hormonal imbalances that can cause male hypoactive sexual desire disorder can also produce erectile disorder (Glina et al., 2013; Hyde, 2005). More commonly, however, vascular problems—problems with the body’s blood vessels—are involved (Lewis et al., 2010; Rosen, 2007). An erection occurs
table: 11-2
Dx Checklist
Erectile Disorder
1. For at least 6 months, individual usually finds it very difficult to obtain an erection, maintain an erection, and/or achieve past levels of erectile rigidity during sex.
2. Individual experiences significant distress.
(Information from: APA, 2013.)
Why do you think the clini-
cal field has been slow to
investigate possible cultural
and racial differences in
sexual behaviors?
▶▶ erectile disorder A dysfunction in which a man repeatedly fails to attain or maintain an erection during sexual activity.
▶▶ nocturnal penile tumescence (NPT) Erection during sleep.
▶▶ performance anxiety The fear of performing inadequately and a related tension experienced during sex.
▶▶ spectator role A state of mind that some people experience during sex, focusing on their sexual performance to such an extent that their performance and their enjoyment are reduced.
Disorders of Sex and Gender : 353
when the chambers in the penis fill with blood, so any condition that reduces blood flow into the penis, such as heart disease or clogging of the arteries, may lead to erectile disorder (Glina et al., 2013). It can also be caused by damage to the nervous system as a result of diabetes, spinal cord injuries, multiple sclerosis, kidney failure, or treatment by dialysis (da Silva et al., 2015; Berry & Berry, 2013). In addition, as is the case with male hypoactive sexual desire disorder, the use of certain medications and various forms of substance abuse, from alcohol abuse to cigarette smoking, may interfere with erections (Glina et al., 2013; Herrick et al., 2011).
Medical procedures, including ultrasound recordings and blood tests, have been developed for diagnosing biological causes of erectile disorder. Measuring nocturnal penile tumescence (NPT), or erections during sleep, is particularly useful in assessing whether physical factors are responsible. Men typically have erec- tions during rapid eye movement (REM) sleep, the phase of sleep in which dreaming takes place. A healthy man is likely to have two to five REM periods each night, and several penile erections as well. Abnormal or absent nightly erections usually (but not always) indicate some physical basis for erectile failure. As a rough screen- ing device, a patient may be instructed to fasten a simple “snap gauge” band around his penis before going to sleep and then check it the next morning. A broken band indicates that he has had an erection during the night. An unbroken band indicates that he did not have nighttime erections and suggests that his general erectile prob- lem may have a physical basis. A newer version of this device further attaches the band to a computer, which provides precise measurements of erections throughout the night (Wincze et al., 2008). Such assessment devices are less likely to be used in clinical practice today than in past years. As you’ll see later in the chapter, Viagra and other drugs for erectile disorder are typically given to patients without much formal evaluation of their problem (Rosen, 2007).
Psychological causes Any of the psychological causes of male hypoactive sexual desire disorder can also interfere with arousal and lead to erectile disorder. As many as 90 percent of all men with severe depression, for example, experience some degree of erectile dysfunction (Montejo et al., 2011; Stevenson & Elliott, 2007).
One well-supported psychological explanation for erectile disorder is the cognitive-behavioral theory developed by William Masters and Virginia Johnson (1970). The explanation emphasizes performance anxiety and the spectator role. Once a man begins to have erectile problems, for whatever reason, he becomes fearful about failing to have an erection and worries during each sexual encounter. Instead of relaxing and enjoying the sensations of sexual pleasure, he remains distanced from the activity, watching himself and focusing on the goal of reaching erection. Instead of being an aroused participant, he becomes a judge and spectator. Whatever the initial reason for the erectile dysfunction, the resulting spectator role becomes the reason for the ongo- ing problem. In this vicious cycle, the original cause of the erectile failure becomes less important than fear of failure.
sociocultural causes Each of the sociocultural factors that contribute to male hypoactive sexual desire disorder has also been tied to erectile disorder. Men who have lost their jobs and are under financial stress, for example, are more likely to develop erectile difficulties than other men (Štulhofer et al., 2013). Marital stress, too, has been tied to this dysfunction (Brenot, 2011; Rosen, 2007; LoPiccolo, 2004, 1991). Two relationship patterns in particular may contribute to it. In one, a wife provides too little physical
“Well, how convenient.”
Jo e
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T he
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C o
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T he
C ar
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B e t W e e N t h e L I N e S
In Their Words “Erection is chiefly caused by scuraum, eringoes, cresses, crymon, parsnips, artichokes, turnips, asparagus, candied ginger, acorns bruised to powder and drank in muscadel, scallion, sea shell fish, etc.”
aristotle, The Masterpiece, fourth century b.c.
: chapter 11354
stimulation for her aging husband, who, because of normal aging changes, now requires more intense, direct, and lengthy physical stimulation of the penis in order to have an erection. In the second relationship pattern, a couple believes that only intercourse can give the wife an orgasm. This idea increases the pressure on the man to have an erection and makes him more vulnerable to erectile dysfunction. If the wife reaches orgasm manually or orally during their sexual encounter, his pressure to perform is reduced.
Disorders of Orgasm During the orgasm phase of the sexual response cycle, a person’s sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract, or draw together, rhythmically (see Figure 11-3). The man’s semen is ejaculated, and the outer third of the woman’s vaginal wall contracts. Dysfunctions of this phase of the sexual response cycle are premature ejaculation and delayed ejaculation in men and female orgasmic disorder in women.
Premature Ejaculation Eduardo is typical of many men in his experience of premature ejaculation:
Eduardo, a 20-year-old student, sought treatment after his girlfriend ended their relationship because his premature ejaculation left her sexually frustrated. Eduardo had had only one previous sexual relationship, during his senior year in high school. With two friends he would drive to a neighboring town and find a certain prostitute. After picking her up, they would drive to a deserted area and take turns having sex with her, while the others waited outside the car. Both the prostitute and his friends urged him to hurry up because they feared discovery by the police, and besides, in the winter it was cold. When Eduardo began his sexual relationship with his girl- friend, his entire sexual history consisted of this rapid intercourse, with virtually no foreplay. He found caressing his girlfriend’s breasts and genitals and her touching of his penis to be so arousing that he sometimes ejaculated before complete entry of the penis, or after at most only a minute or so of intercourse.
Full erection
Partially stimulated state
Unstimulated state
Partial elevation of testes
Desire
Penile contractions
Urethral contractions
Contractions force the seminal fluid through the urethra
Internal sphincter of bladder closes
Rectal sphincter contracts
Seminal vesicles contract
Orgasm
Prostate gland contracts
figure 11-3 Normal male sexual anatomy Changes in the male anatomy occur during the different phases of the sexual response cycle. (Informa- tion from: Hyde, 1990, p. 199.)
▶▶ orgasm phase The phase of the sexual response cycle during which a per- son’s sexual pleasure peaks and sexual tension is released as muscles in the pel- vic region contract rhythmically.
▶▶ premature ejaculation A dysfunc- tion in which a man persistently reaches orgasm and ejaculates within one minute of beginning sexual activity with a part- ner and before he wishes to. Also called early or rapid ejaculation.
▶▶ delayed ejaculation A male dysfunc- tion characterized by persistent inability to ejaculate or very delayed ejaculations during sexual activity with a partner.
Disorders of Sex and Gender : 355
A man suffering from premature ejaculation (also called early, or rapid, ejacu- lation) persistently reaches orgasm and ejaculates within one minute of beginning sexual activity with a partner and before he wishes to (see Table 11-3). As many as 30 percent of men worldwide ejaculate early at some time (Lewis et al., 2010; Laumann et al., 2005, 1999, 1994). The typical duration of intercourse in our society has increased over the past several decades, which has caused more distress among men who ejaculate prematurely. Although many young men certainly con- tend with the dysfunction, research suggests that men of any age may suffer from it (Sansone et al., 2015; Rowland, 2012).
Psychological, particularly behavioral, explanations of premature ejaculation have received more research support than other kinds of explanations. The dysfunction is common, for example, among young, sexually inexperienced men such as Eduardo, who simply have not learned to slow down, control their arousal, and extend the pleasurable process of making love (Althof, 2007). In fact, young men often ejaculate prematurely during their first sexual encounter. With continued sexual experience, most men acquire more control over their sexual responses. Men of any age who have sex only occasionally are also prone to ejaculate early.
Clinicians have also suggested that premature ejaculation may be related to anxiety, hurried masturbation experiences during adoles- cence (in fear of being “caught” by parents), or poor recognition of one’s own sexual arousal (Althof, 2007). However, these theories have only sometimes received clear research support.
There is a growing belief among many clinical theorists that bio- logical factors may also play a key role in many cases of premature ejaculation. Three biological theories have emerged from the limited investigations done so far (Althof, 2007; Mirone et al., 2001). One theory states that some men are born with a genetic predisposition to develop this dysfunction. Indeed, one study found that 91 per- cent of a small sample of men suffering from early ejaculation had first-degree relatives who also had the dysfunction. A second theory, based on animal studies, argues that the brains of men who ejaculate prematurely contain certain serotonin receptors that are overactive and others that are underactive. A third explanation holds that men with this dysfunction have greater sensitivity or nerve conduction in the area of their penis, a notion that has received inconsistent research support thus far.
Delayed Ejaculation A man with delayed ejaculation (previously called male orgasmic disorder or inhibited male orgasm) persistently is unable to ejaculate or has very delayed ejaculations during sexual activity with a partner (see Table 11-3 again). Around 10 percent of men worldwide have this disorder (Lewis et al., 2010; Laumann et al., 2005, 1999). It is typically a source of great frustration and upset, as in the case of John:
John, a 38-year-old sales representative, had been married for 9 years. At the insistence of his 32-year-old wife, the couple sought counseling for their sexual problem—his inability to ejaculate during intercourse. During the early years of the marriage, his wife had experienced difficulty reaching orgasm until he learned to delay his ejaculation for a long period of time. To do this, he used mental distraction techniques and regularly smoked marijuana before making love. Initially, John felt very satisfied that he could make love for longer and longer periods of time without ejaculation and regarded his ability as a sign of masculinity.
table: 11-3
Dx Checklist Premature Ejaculation
1. For at least 6 months, individual usually ejaculates within 1 minute of beginning sex with a partner and earlier than he wants to.
2. Individual experiences significant distress.
Delayed Ejaculation
1. For at least 6 months, individual usually displays a significant delay, infrequency, or absence of ejaculation during sexual activity with a partner.
2. Individual experiences significant distress.
Female Orgasmic Disorder
1. For at least 6 months, individual usually displays a significant delay, infrequency, or absence of orgasm, and/or is unable to achieve past orgasmic intensity.
2. Individual experiences significant distress.
(Information from: APA, 2013.)
(continues on the next page)
: chapter 11356
About 3 years prior to seeking counseling, after the birth of their only child, John found that he was losing his erection before he was able to ejaculate. His wife sug- gested different intercourse positions, but the harder he tried, the more difficulty he had in reaching orgasm. Because of his frustration, the couple began to avoid sex altogether. John experienced increasing performance anxiety with each successive failure, and an increasing sense of helplessness in the face of his problem.
Rosen & Rosen, 1981, pp. 317–318)
A low testosterone level, certain neurological diseases, and some head or spinal cord injuries can interfere with ejaculation (Lewis et al., 2010; Stevenson & Elliott, 2007). Substances that slow down the sympathetic nervous system (such as alcohol, some medications for high blood pressure, and certain psychotropic medications) can also affect ejaculation (Herrick et al., 2011). For example, certain serotonin- enhancing antidepressant drugs appear to interfere with ejaculation in at least 30
percent of men who take them (Glina et al., 2013; Montejo et al., 2011). A leading psychological cause of delayed ejaculation appears to be
performance anxiety and the spectator role, the cognitive-behavioral factors also involved in erectile disorder (Kashdan et al., 2011). Once a man begins to focus on reaching orgasm, he may stop being an aroused participant in his sexual activity and instead become an unaroused, self-critical, and fearful observer (Rowland, 2012; Wiederman, 2001). Another psychological cause of delayed ejaculation may be past mastur-
bation habits. If, for example, a man has masturbated all his life by rubbing his penis against sheets, pillows, or other such objects, he may have difficulty reaching orgasm in the absence of the sensations tied to those objects (Wincze et al., 2008). Finally, delayed ejaculation may develop out of male hypoactive sexual desire disorder (Apfelbaum, 2000). A man who engages in sex largely because of pressure from his partner, without any real desire for it, simply may not get aroused enough to ejaculate.
Female Orgasmic Disorder Janel and Isaac, married for three years, went for sex therapy because of her lack of orgasm.
Janel had never had an orgasm in any way, but because of Isaac’s concern, she had been faking orgasm during intercourse until recently. Finally she told him the truth, and they sought therapy together. Janel had been raised by a strictly religious fam- ily. She could not recall ever seeing her parents kiss or show physical affection for each other. She was severely punished on one occasion when her mother found her looking at her own genitals, at about age 7. Janel received no sex education from her parents, and when she began to menstruate, her mother told her only that this meant that she could become pregnant, so she mustn’t ever kiss a boy or let a boy touch her. Her mother restricted her dating severely, with repeated warnings that “boys only want one thing.” While her parents were rather critical and demanding of her (asking her why she got one B among otherwise straight As on her report card, for example), they were loving parents and their approval was very important to her.
Women with female orgasmic disorder persistently fail to reach orgasm, have very low intensity orgasms, or have a very delayed orgasm (see Table 11-3 again). As many as 25 percent of women apparently have this problem to some degree— including more than a third of postmenopausal women (Lewis et al., 2010; Heiman, 2007, 2002). Studies indicate that 10 percent or more of women have never had
are there other problem
areas in life that might
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▶▶ female orgasmic disorder A dys- function in which a woman persistently fails to reach orgasm, has very low intensity orgasms, or has very delayed orgasms.
B e t W e e N t h e L I N e S
Nightly Visits People can sometimes have an orgasm during sleep. Ancient Babylonians said that such nocturnal orgasms were caused by a “maid of the night” who visited men in their sleep and a “little night man” who visited women (Kahn & Fawcett, 1993).
Disorders of Sex and Gender : 357
an orgasm, either alone or during intercourse, and at least another 9 percent rarely have orgasms (Bancroft et al., 2003). At the same time, half of all women experience orgasm in intercourse at least fairly regularly (de Sutter et al., 2014; SOGC, 2014). Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly (Carrobles et al., 2011; Hurlbert, 1991). Female orgasmic disorder appears to be more common among single women than among women who are married or living with someone (Lewis et al., 2010; Laumann et al., 2005, 1999, 1994). In one study, when participants with female orgasmic disorder were asked to pick a word that best describes their feelings about it, two- thirds of them chose “frustration” (Kingsberg et al., 2013).
Most clinicians agree that orgasm during intercourse is not mandatory for nor- mal sexual functioning (Meana, 2012). Many women instead reach orgasm with their partners by direct stimulation of the clitoris. Although early psychoanalytic theory considered a lack of orgasm during intercourse to be pathological, evidence suggests that women who rely on stimulation of the clitoris for orgasm are entirely normal and healthy (Laan, Rellini, & Barnes, 2013; Heiman, 2007).
Biological, psychological, and sociocultural factors may combine to produce female orgasmic disorder (Berry & Berry, 2013; Jiann, Su, & Tsai, 2013). Because arousal plays a key role in orgasms, arousal difficulties often are featured prominently in explanations of female orgasmic disorder.
Biological causes A variety of physiological conditions can affect a woman’s orgasm. Diabetes can damage the nervous system in ways that interfere with arousal, lubrication of the vagina, and orgasm. Lack of orgasm has sometimes been linked to multiple sclerosis and other neurological diseases, to the same drugs and medications that may interfere with ejaculation in men, and to changes, often postmenopausal, in skin sensitivity and structure of the clitoris, vaginal walls, or the labia—the folds of skin on each side of the vagina (Cordeau & Courtois, 2014; Blackmore et al., 2011; Lombardi et al., 2011).
Psychological causes The psychological causes of female sexual interest/arousal disorder, including depression, may also lead to female orgasmic disorder (Kalmbach et al., 2014; Laan et al., 2013). In addi- tion, as both psychodynamic and cognitive theorists might predict, memories of childhood traumas or problematic childhood relation- ships have sometimes been associated with orgasm problems. In one large study, memories of an unhappy childhood or loss of a parent dur- ing childhood were tied to lack of orgasm in adulthood (Raboch & Raboch, 1992). In other studies, childhood memories of a dependable father, a positive relationship with one’s mother, affection between the parents, the mother’s positive personality, and the mother’s expression of positive emotions were all predictors of positive orgasm outcomes (Heiman, 2007; Heiman et al., 1986).
sociocultural causes For years many clinicians have believed that female orgasmic problems may result from society’s recurrent message to women that they should repress and deny their sexuality, a message that has often led to “less permissive” sexual attitudes and behavior among women than among men. In fact, many women with both arousal and orgasmic difficulties report that they had an overly strict religious upbringing, were punished for childhood masturbation, received no preparation for the onset of menstruation, were restricted in their dating as teenagers, and were told that “nice girls don’t” (Laan et al., 2013; LoPiccolo & Van Male, 2000).
“The region of insanity” Medical authori- ties described “excessive passion” in Victorian women as dangerous and as a possible cause of insanity (Gamwell & Tomes, 1995). This illustration from a nineteenth-century medical textbook even labels a woman’s reproductive organs as her “region of insanity.”
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: chapter 11358
A sexually restrictive history, however, is just as common among women who function well during sexual activity (LoPiccolo, 2002, 1997). In addition, cultural messages about female sexuality have been more positive in recent years, while the rate of arousal and orgasmic problems remains the same for women. Why, then, do some women and not others develop such problems? Researchers suggest that unusually stressful events, traumas, or relationships may help produce the fears, memories, and attitudes that often characterize these sexual problems (Meana, 2012; Westheimer & Lopater, 2005). For example, many women molested as children or raped as adults have female orgasmic disorder (Hall, 2007; Heiman, 2007).
Research has also related orgasmic behavior to certain qualities in a woman’s intimate relationships (Laan et al., 2013; Brenot, 2011). Studies have found, for example, that the likelihood of reaching orgasm may be tied to how much emo- tional involvement a woman had during her first experience of intercourse and how long that relationship lasted, the pleasure the woman felt during the experience, her current attraction to her partner’s body, and her marital happiness. Interestingly, the same studies have found that orgasmic women more often have erotic fantasies during sex with their current partner than do nonorgasmic women.
Disorders of Sexual Pain Certain sexual dysfunctions are characterized by enormous physical discomfort dur- ing intercourse, a difficulty that does not fit neatly into a specific part of the sexual response cycle. Women have such dysfunctions, collectively called genito-pelvic pain/penetration disorder, much more often than men do (APA, 2013).
For some women with genito-pelvic pain/penetration disorder, the muscles around the outer third of the vagina involuntarily contract, preventing entry of the penis (see Table 11-4). This problem, known in medical circles as vaginismus, can pre- vent a couple from ever having intercourse. The problem has received relatively little research, but estimates are that fewer than 1 percent of all women have vaginismus (Christensen et al., 2011). A number of women with vaginismus enjoy sex greatly, have a strong sex drive, and reach orgasm with stimulation of the clitoris (Cherner & Reissing, 2013). They just fear the discomfort of penetration of the vagina.
Most clinicians agree with the cognitive-behavioral position that this form of genito-pelvic pain/penetration disorder is usually a learned fear response, set off by a woman’s expectation that intercourse will be painful and damaging (Simonelli et al., 2014; Cherner & Reissing, 2013). A variety of factors apparently can set the stage for this fear, including anxiety and ignorance about intercourse, exaggerated stories about how painful and bloody the first occasion of intercourse is for women, trauma caused by an unskilled lover who forces his penis into the vagina before the woman is aroused and lubricated, and the trauma of childhood sexual abuse or adult rape ( Jiann et al., 2013; Fugl-Meyer et al., 2013).
Alternatively, women may have this form of genito-pelvic pain/penetration disorder because of an infection of the vagina or urinary tract, a gynecological disease such as herpes simplex, or the physical effects of menopause. In such cases, the dysfunction can be overcome only if the women receive medical treatment for these conditions.
Other women with genito-pelvic pain/penetration disorder do not have invol- untary contractions of their vaginal muscles, but they do experience severe vaginal or pelvic pain during sexual intercourse, a pattern known medically as dyspareunia (from Greek words meaning “painful mating”). Surveys suggest that more than 14 percent of women suffer from this problem to some degree (Antony & Barlow, 2010, 2004; Laumann et al., 2005, 1999). Women with dyspareunia typically enjoy sex and get aroused but find their sex lives very limited by the pain that accompanies what used to be a positive event (Huijding et al., 2011).
table: 11-4
Dx Checklist
Genito-Pelvic Pain/ Penetration Disorder
1. For at least 6 months, individual repeatedly experiences at least one of the following problems: • Difficulty having vaginal penetration during intercourse • Significant vaginal or pelvic pain when trying to have intercourse or penetration • Significant fear that vaginal penetration will cause vaginal or pelvic pain • Significant tensing of the pelvic muscles during vaginal penetration.
2. Individual experiences significant distress from this.
(Information from: APA, 2013.)
▶▶ genito-pelvic pain/penetration disorder A sexual dysfunction charac- terized by significant physical discomfort during intercourse.
Disorders of Sex and Gender : 359
This form of genito-pelvic pain/penetration disorder usually has a physical cause (Fugl-Meyer et al., 2013). Among the most common is an injury (for example, to the vagina or pelvic ligaments) during childbirth. The scar left by an episiotomy (a cut often made to enlarge the vaginal entrance and ease delivery) also can cause pain. Around 16 percent of women have severe vaginal or pelvic pain during intercourse for up to a year after giving birth (Bertozzi et al., 2010). More generally, such pain has also been tied to the penis colliding with remaining parts of the hymen, vagi- nal infections, wiry pubic hair rubbing against the labia during intercourse, pelvic diseases, tumors, cysts, allergic reactions to the chemicals in vaginal douches and contraceptive creams, the rubber in condoms and diaphragms, and the protein in semen (Tripoli et al., 2011).
Although psychological factors (for instance, heightened anxiety or overatten- tiveness to one’s body) or relationship problems may contribute to dyspareunia (Granot et al., 2011), psychosocial factors alone are rarely responsible for it (Dewitte, Van Lankveld, & Crombez, 2011). In cases that are truly psychogenic, the woman may in fact be suffering from female sexual interest/arousal disorder. That is, pen- etration into an unaroused, unlubricated vagina is painful (Fugl-Meyer et al., 2013). It also is the case that at least 3 percent of men suffer from pain in the genitals dur- ing intercourse, and many of these men also qualify for a diagnosis of genito-pelvic pain/ penetration disorder.
➤ Summing Up SExuAl DySFuNCTIONS Sexual dysfunctions make it difficult or impossible for a person to have or enjoy sexual activity.
DSM-5 lists two disorders of the desire phase of the sexual response cycle: male hypoactive sexual desire disorder and female sexual interest/arousal dis- order. Biological causes for these disorders include abnormal hormone levels, certain drugs, and some medical illnesses. Psychological and sociocultural causes include specific fears, situational pressures, relationship problems, and the trauma of having been sexually molested or assaulted.
Disorders of the excitement phase include erectile disorder. Biological causes of the disorder include abnormal hormone levels, vascular problems, medical conditions, and certain medications. Psychological and sociocultural causes include the combination of performance anxiety and the spectator role, situ- ational pressures such as job loss, and relationship problems.
Premature ejaculation, a disorder of the orgasm phase, has been attributed most often to behavioral causes, such as inappropriate early learning and inex- perience. In recent years, possible biological factors have been identified as well. Delayed ejaculation, another orgasm disorder, can have biological causes, such as low testosterone levels, neurological diseases, and certain drugs, and psychological causes, such as performance anxiety and the spectator role. The dysfunction may also develop from male hypoactive sexual desire disorder. Female orgasmic disorder, which is often accompanied by arousal difficulties, has been tied to biological causes such as medical diseases and changes that occur after menopause, psychological causes such as memories of childhood traumas, and sociocultural causes such as relationship problems.
Genito-pelvic pain/penetration disorder involves significant pain during intercourse. In one form of this disorder, vaginismus, involuntary contractions of the muscles around the outer third of the vagina prevent entry of the penis. In another form, dyspareunia, the person has severe vaginal or pelvic pain during intercourse. This form of the disorder usually occurs in women and typically has a physical cause, such as injury resulting from childbirth.
B e t W e e N t h e L I N e S
Favorite Part of the Sexual Cycle In some studies, the majority of female participants from sexually healthy and generally positive marriages reported that foreplay is the most satisfying component of sexual activity with their partner (Basson, 2007; Hurlbert et al., 1993).
B e t W e e N t h e L I N e S
Eye of the Beholder In the movie Annie Hall, Annie’s psycho therapist asks her how often she and her boyfriend, Alvy Singer, sleep together. Simultaneously, across town, Alvy’s therapist asks him the same question. Alvy answers, “Hardly ever. Maybe three times a week,” while Annie re sponds, “Constantly. I’d say three times a week.”
: chapter 11360
Treatments for Sexual Dysfunctions The last 40 years have brought major changes in the treatment of sexual dysfunc- tions. For the first half of the twentieth century, the leading approach was long-term psychodynamic therapy. Clinicians assumed that sexual dysfunctioning was caused by failure to progress properly through the psychosexual stages of development, and they used techniques of free association and therapist interpretations to help clients gain insight about themselves and their problems. Although it was expected that broad personality changes would lead to improvement in sexual functioning, psychodynamic therapy was typically unsuccessful (Bergler, 1951).
In the 1950s and 1960s, behavioral therapists offered new treatments for sexual dysfunctions. Usually they tried to reduce the fears that they believed were causing the dysfunctions. They did so through such procedures as relaxation training and systematic desensitization (Lazarus, 1965; Wolpe, 1958). These approaches had some
success, but they failed to work in cases where the key problems included misinformation, negative attitudes, and lack of effective sexual techniques (LoPiccolo, 2002, 1995).
A revolution in the treatment of sexual dysfunctions took place with the publication of William Masters and Virginia Johnson’s landmark book Human Sexual Inadequacy in 1970. The sex therapy program they introduced has evolved into a complex approach,
which now includes interventions from the various models, particularly cognitive- behavioral, couple, and family systems therapies (McCarthy & McCarthy, 2012; Leiblum, 2010, 2007). In recent years, biological interventions, particularly drug therapies, have been added to the treatment arsenal (Berry & Berry, 2013).
What Are the General Features of Sex Therapy? Modern sex therapy is short-term and instructive, typically lasting 15 to 20 ses- sions. It centers on specific sexual problems rather than on broad personality issues (Recordon & Köhl, 2014). Carlos Domera, the Argentine man with erectile disorder whom you met earlier, responded successfully to the multiple techniques of modern sex therapy:
At the end of the evaluation session the psychiatrist reassured the couple that Mr. Domera had a “reversible psychological” sexual problem that was due to several factors, including his depression, but also more currently his anxiety and embarrass- ment, his high standards, and some cultural and relationship difficulties that made communication awkward and relaxation nearly impossible. The couple was advised that a brief trial of therapy, focused directly on the sexual problem, would very likely produce significant improvement within ten to fourteen sessions. They were assured that the problem was almost certainly not physical in origin, but rather psychogenic, and that therefore the prognosis was excellent.
Mr. Domera was shocked and skeptical, but the couple agreed to commence the therapy on a weekly basis, and they were given a typical first “assignment” to do at home: a caressing massage exercise to try together with specific instructions not to attempt genital stimulation or intercourse at all, even if an erection might occur.
Not surprisingly, during the second session Mr. Domera reported with a cautious smile that they had “cheated” and had had intercourse “against the rules.” This was their first successful intercourse in more than a year. Their success and happiness were acknowledged by the therapist, but they were cautioned strongly that rapid initial improvement often occurs, only to be followed by increased performance anx- iety in subsequent weeks and a return of the initial problem. They were humorously chastised and encouraged to try again to have sexual contact involving caressing
Sex is one of the topics most
commonly searched on the
Internet. Why might it be such
a popular search topic?
B e t W e e N t h e L I N e S
In Their Words “Some nights he said that he was tired, and some nights she said that she wanted to read, and other nights no one said anything.”
Joan Didion, Play It as It Lays
Disorders of Sex and Gender : 361
and non-demand light genital stimulation, without an expectation of erection or orgasm, and to avoid intercourse.
During the second and fourth weeks [Carlos] did not achieve erections during the love play, and the therapy sessions dealt with helping him to accept himself with or without erections and to learn to enjoy sensual contact without intercourse. His wife helped him to believe genuinely that he could please her with manual or oral stimu- lation and that, although she enjoyed intercourse, she enjoyed these other stimula- tions as much, as long as he was relaxed.
[Carlos] struggled with his cultural image of what a “man” does, but he had to admit that his wife seemed pleased and that he, too, was enjoying the nonintercourse caressing techniques. He was encouraged to view his new lovemaking skills as a “success” and to recognize that in many ways he was becoming a better lover than many husbands, because he was listening to his wife and responding to her requests.
By the fifth week the patient was attempting intercourse successfully with relaxed confidence, and by the ninth session he was responding regularly with erections. If they both agreed, they would either have intercourse or choose another sexual technique to achieve orgasm. Treatment was terminated after ten sessions.
(Spitzer et al., 1983, pp. 106–107)
As Carlos Domera’s treatment indicates, modern sex therapy includes a variety of principles and techniques. The following ones are used in almost all cases, regardless of the dysfunction:
1. Assessing and conceptualizing the problem. Patients are initially given a medi- cal examination and are interviewed concerning their “sex history.” The therapist’s focus during the interview is on gathering information about past life events and, in particular, current factors that are contributing to the dys- function (Althof et al., 2013; Berry & Berry, 2013). Sometimes proper assess- ment requires a team of specialists, perhaps including a psychologist, urologist, and neurologist.
2. Mutual responsibility. Therapists stress the principle of mutual responsibility. Both partners in the relationship share the sexual problem, regardless of who has the actual dysfunction, so treatment is likely to be more successful when both are in therapy (Laan et al., 2013; McCarthy & McCarthy, 2012).
3. Education about sexuality. Many patients who suffer from sexual dysfunc- tions know very little about the physiology and techniques of sexual activity (Hucker & McCabe, 2015; Rowland, 2012). Thus sex therapists may discuss these topics and offer educational materials, including instructional books, videos, and Internet sites.
4. Emotion identification. Sex therapists help patients identify and express upsetting emotions tied to past events that may keep in- terfering with sexual arousal and enjoyment (Kleinplatz, 2010).
5. Attitude change. Following a cardinal principle of cognitive therapy, sex therapists help patients examine and change any be- liefs about sexuality that are preventing sexual arousal and plea- sure (McCarthy & McCarthy, 2012; Hall, 2010). Some of these mistaken beliefs are widely shared in our society and can result from past traumatic events, family attitudes, or cultural ideas.
6. Elimination of performance anxiety and the spectator role. Therapists often teach couples sensate focus, or nondemand plea- suring, a series of sensual tasks, sometimes called “petting” exercises, in which the partners focus on the sexual pleasure Ca
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B e t W e e N t h e L I N e S
Drugs That Sometimes Interfere with Sexual Functioning Alcohol, opioids, sedativehypnotics
Cocaine, amphetamines
Hallucinogens, marijuana
Antidepressants, antipsychotics, diuretics, amyl nitrate, hypertension medications
: chapter 11362
that can be achieved by exploring and caressing each other’s body at home, without demands to have intercourse or reach orgasm—demands that may be interfering with arousal (Hucker & McCabe, 2015). Couples are told at first to refrain from intercourse at home and to restrict their sexual activity to kissing, hugging, and sensual massage of various parts of the body, but not of the breasts or genitals. Over time, they learn how to give and receive greater sexual pleasure and they build back up to the activity of sexual intercourse.
7. Increasing sexual and general communication skills. Couples are taught to use their sensate-focus skills and apply new sexual techniques and positions at home. They may, for example, try sexual positions in which the person being caressed can guide the other’s hands and control the speed, pressure, and loca- tion of sexual contact (Heiman, 2007). Couples are also taught to give instruc- tions to each other in a nonthreatening, informative manner (“It feels better over here, with a little less pressure”), rather than a threatening uninformative manner (“The way you’re touching me doesn’t turn me on”). Moreover, couples are often given broader training in how best to communicate with each other (Brenot, 2011).
8. Changing destructive lifestyles and marital interactions. A therapist may en- courage a couple to change their lifestyle or take other steps to improve a situation that is having a destructive effect on their relationship—to distance themselves from interfering in-laws, for example, or to change a job that is too demanding. Similarly, if the couple’s general relationship is marked by conflict, the therapist will try to help them improve it, often before work on the sexual problems per se begins (Brenot, 2011).
9. Addressing physical and medical factors. Systematic increases in physical ac- tivity have proved helpful for persons with various kinds of sexual dysfunc- tions (Lewis et al., 2010). In addition, when sexual dysfunctions are caused by a medical problem, such as disease, injury, medication, or substance abuse, therapists try to address that problem (Korda et al., 2010). If antidepressant medications are causing erectile disorder, for example, the clinician may sug- gest lowering the dosage of the medication, changing the time of day when the drug is taken, or turning to a different antidepressant.
Sexual pioneers William Masters and Virginia Johnson work with a couple in their office. The two researchers, the field’s most important figures in the study of the human sexual response and the treatment of sexual dysfunctions, conducted their work from 1967 until the 1990s, writing two classic books, Human Sexual Response and Human Sexual Inadequacy. Their work and personal lives are currently portrayed—in largely fictional form— in the Showtime series Masters of Sex. Ge
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“Just a Second” According to recent surveys, 1 in 10 respondents admit to using their cell phone during sex (Archer, 2013).
Disorders of Sex and Gender : 363
What Techniques Are Used to Treat Particular Dysfunctions? In addition to the general components of sex therapy, specific tech- niques can help in each of the sexual dysfunctions.
Disorders of Desire Male hypoactive sexual desire disorder and female sexual interest/arousal disorder are among the most difficult dysfunctions to treat because of the many issues that may feed into them (Leiblum, 2010). Thus therapists typically use a combination of techniques. In a technique called affectual awareness, patients visualize sexual scenes in order to discover any feelings of anxiety, vulner- ability, and other negative emotions they may have concerning sex (McCarthy & McCarthy, 2012; Kleinplatz, 2010). In another tech- nique, patients receive cognitive self-instruction training to help them change their negative reactions to sex. That is, they learn to replace negative statements during sex with “coping statements,” such as “I can allow myself to enjoy sex; it doesn’t mean I’ll lose control.”
Therapists may also use behavioral approaches to help heighten a patient’s sex drive. They may instruct clients to keep a “desire diary” in which they record sexual thoughts and feelings, to read books and view films with erotic content, and to fantasize about sex. They also may encourage pleasurable shared activities such as dancing and walking together (Rubio-Aurioles & Bivalacqua, 2013). If the reduced sexual desire has resulted from sexual assault or childhood molestation, additional techniques may be needed (Hall, 2010, 2007). A patient may, for example, be encouraged to remember, talk about, and think about the assault until the memo- ries no longer arouse fear or tension. These and related psychological approaches apparently help many women and men with low sexual desire eventually to have intercourse more than once a week (Meana, 2012; Rowland, 2012). However, only a few controlled studies have been conducted.
Finally, biological interventions can have a role in the treatment for desire problems. Hormone treatments have been used and received some research support (Wright & O’Connor, 2015; Rubio-Aurioles & Bivalacqua, 2013). In addition, in 2015 the FDA approved the drug flibanserin (brand name Addyi), as a treatment for women distressed by low sexual desire.
Erectile Disorder Treatments for erectile disorder focus on reducing a man’s performance anxiety, increasing his stimulation, or both, using a range of behav- ioral, cognitive, and relationship interventions (Mola, 2015; Rowland, 2012; Carroll, 2011). In one treatment, the couple may be instructed to try the tease technique dur- ing sensate-focus exercises: the partner keeps caressing the man, but if the man gets an erection, the partner stops caressing him until he loses it. This exercise reduces pressure on the man to perform and at the same time teaches the couple that erec- tions occur naturally in response to stimulation, as long as the partners do not keep focusing on performance. In another technique, the couple may be instructed to use manual or oral sex to try to achieve the woman’s orgasm, again reducing pressure on the man to perform (LoPiccolo, 2004, 2002, 1995).
Biological approaches gained great momentum with the development in 1998 of sildenafil (trade name Viagra). This drug increases blood flow to the penis within one hour of ingestion; the increased blood flow enables the user to attain an erection during sexual activity (see PsychWatch on page 365). In general, sildenafil appears to be safe; however, it may not be so for men with certain coronary heart diseases and cardiovascular diseases, particularly those who are taking nitroglycerin and other heart medications (Stevenson & Elliott, 2007). Soon after Viagra emerged, two other erectile dysfunction drugs were also approved—tadalafil (Cialis) and vardenafil
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Despite Popular Belief . . . The newlyapproved drug flibanserin (trade name Addyi) is often referred to as “female Viagra.” However, that is a misnomer. Whereas Addyi induces or enhances sexual desire, Viagra does not. Rather, Viagra induces or enhances erections among men who already have sexual desire.
: chapter 11364
(Levitra)—that are now actively competing with Viagra for a share of the lucrative marketplace. Collectively, the three drugs are the most common form of treatment for erectile disorder. They effectively restore erections in 75 percent of men who use them. Some research, though, suggests that a combination of one of these erectile dysfunc- tion drugs and a psychological intervention such as those mentioned above may be more helpful than either kind of treatment alone (Schmidt et al., 2014).
Prior to the development of Viagra, Cialis, and Levitra, a range of other medical procedures were developed for erectile disorder. These procedures are now viewed as “second line”—often costly— treatments that are used primarily when the medications are unsuc- cessful or too risky for individuals (Martin et al., 2013). Such treatments include gel suppositories, injections of drugs into the penis, and a vacuum erection device (VED), a hollow cylinder that is placed over the penis. Here a man uses a hand pump to pump air out of the cylinder, drawing blood into his penis and producing an erection.
Premature Ejaculation Early ejaculation has been treated successfully for years by behavioral procedures (McMahon et al., 2013; Masters & Johnson, 1970). In one such approach, the stop-start, or pause, procedure, the penis is manually stimulated until the man is highly aroused. The couple then pauses until his arousal subsides, after which the stimulation is resumed. This sequence is repeated several times before stimulation is carried through to ejaculation, so the man ultimately experi- ences much more total time of stimulation than he has ever experienced before (LoPiccolo, 2004, 1995). Eventually the couple progresses to putting the penis in the vagina, making sure to withdraw it and to pause whenever the man becomes too highly aroused. According to clinical reports, after two or three months, many couples can enjoy prolonged intercourse without any need for pauses (Althof, 2007).
Some clinicians treat premature ejaculation with SSRIs, the serotonin- enhancing antidepressant drugs. Because these drugs often reduce sexual arousal or orgasm, the reasoning goes, they may be helpful to men who ejaculate prematurely. Many studies report positive results with this approach (McMahon et al., 2013). The effect of this approach is consistent with the biological theory, mentioned earlier, that serotonin receptors in the brains of men with early ejaculation may function abnormally.
Delayed Ejaculation Therapies for delayed ejaculation include techniques to reduce performance anxiety and increase stimulation (Rowland, 2012; LoPiccolo, 2004). In one of many such techniques, a man may be instructed to masturbate to orgasm in the presence of his partner or to masturbate just short of orgasm before inserting his penis for intercourse (Marshall, 1997). This increases the likelihood that he will ejaculate during intercourse. He then is instructed to insert his penis at ever earlier stages of masturbation.
When delayed ejaculation is caused by physical factors such as neurological dam- age or injury, treatment may include a drug to increase arousal of the sympathetic nervous system (Stevenson & Elliott, 2007). However, few studies have systemati- cally tested the effectiveness of such treatments (Hartmann & Waldinger, 2007).
Female Orgasmic Disorder Specific treatments for female orgasmic dis- order include cognitive-behavioral techniques, self-exploration, enhancement of body awareness, and directed masturbation training (Laan et al., 2013; McCarthy & McCarthy, 2012). These procedures are especially useful for women who have never had an orgasm under any circumstances. Biological treatments, including hormone therapy or the use of sildenafil (Viagra), have also been tried, but research has not consistently found these to be helpful (Wright & O’Connor, 2015; Laan et al., 2013).
Viagra around the world Few drugs have had the worldwide impact of Viagra (and its cousins Cialis and Levitra). Here technicians at a pharmaceutical factory in Cairo sort thou- sands of Viagra pills for distribution and marketing in Egypt’s pharmacies.
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Sexual Self-Satisfaction • A Finnish study of almost 10,000
adults found that half of all male and female participants were satisfied with the appearance of their genitals.
• Half of all women were satisfied with the appearance of their breasts.
• Higher genital selfsatisfaction was related to better sexual functioning for both genders.
(algars et al., 2011)
Disorders of Sex and Gender : 365
In directed masturbation training, a woman is taught step by step how to masturbate effectively and eventually to reach orgasm during sexual interactions. The training includes the use of diagrams and reading material, private self- stimulation, erotic material and fantasies, “orgasm triggers” such as holding her breath or thrust- ing her pelvis, sensate focus with her partner, and sexual positioning that produces stimulation of the clitoris during intercourse. This training program appears to be highly effective: over 90 percent of female clients learn to have an orgasm during masturbation, about 80 percent during caressing by their partners, and about 30 percent during intercourse (Laan et al., 2013; Heiman, 2007).
As you read earlier, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and can reach orgasm through caressing, either by her partner or by herself. For this reason some therapists believe that the wisest course is simply to educate women whose only concern is lack of orgasm during intercourse, informing them that they are quite normal.
Genito-Pelvic Pain/Penetration Disorder Specific treatment for involuntary contractions of the muscles around the vagina typically involves two approaches (Ter Kuile et al., 2015, 2013; Rosenbaum, 2011). First, a woman may practice tightening and relaxing her vaginal muscles until she gains more voluntary control over them. Second, she may receive gradual behavioral exposure treatment to help her overcome her fear of penetration, beginning, for example, by inserting increasingly large dilators in her vagina at home and at her own pace and eventually
PsychWatch
Many of us believe that we live in an enlightened world, where sexism is declining and where health care and benefits are available to men and women in equal measure. However, the responses of government agencies and insurance companies to the discovery and marketing of Viagra in 1998 called this belief into question (Goldstein, 2014).
Consider, first, the nation of Japan. In early 1999, just six months after it was introduced in the United States, Viagra
was approved for use among men in Japan (Goldstein, 2014; Martin, 2000). In contrast, low-dose contraceptives—“the pill”—were not approved for use among women in Japan until June 1999—a full 40 years after their introduction else- where! Many observers believe that birth control pills would still be unavailable to women in Japan had Viagra not received its quick approval.
Has the United States been able to avoid such an apparent double standard
in its health care system? Not really. Before Viagra was intro- duced, insurance companies were not required to reimburse women for the cost of prescrip- tion contraceptives. As a result, women had to pay 68 percent more out-of-pocket expenses for health care than did men, largely because of uncovered reproductive health care costs (Hayden, 1998). In contrast, when Viagra was introduced in 1998, many insurance com-
panies readily agreed to cover the new drug. As the public outcry grew over the contrast between coverage of Viagra for men and lack of coverage of oral contra- ceptives for women, laws across the country finally began to change. Today 28 states require female contraceptive coverage by private insurance companies (Guttmacher, 2011). The Affordable Care Act—the federal health care law passed in 2010 and enacted in 2013—includes provisions that require all insurance com- panies to cover contraceptives. However, in the so-called “Hobby Lobby” decision, the Supreme Court ruled in 2014 that corporation owners can refuse to provide such insurance coverage for their employ- ees based on religious grounds.
Sexism, Viagra, and the Pill
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▶▶ directed masturbation training A sex therapy approach that teaches women with female arousal or orgasmic problems how to masturbate effectively and eventually to reach orgasm during sexual interactions.
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ending with the insertion of her partner’s penis. Most clients treated with such pro- cedures eventually have pain-free intercourse. Some medical interventions have also been used. For example, several clinical investigators have injected the problematic vaginal muscles with Botox to help reduce spasms in those muscles (Pacik, 2014; Fugl-Meyer et al., 2013). However, studies of this approach have been unsystematic.
Different approaches are used to treat the other form of genito-pelvic pain/ penetration disorder—severe vaginal or pelvic pain during intercourse. As you saw earlier, the most common cause of this problem is physical, such as pain-causing scars, lesions, or infection aftereffects. When the cause is known, pain management proce- dures (see pages 273–275) and sex therapy techniques may be tried, including helping a couple to learn intercourse positions that avoid putting pressure on the injured area (Fugl-Meyer et al., 2013; Dewitte et al., 2011). Medical interventions—from topical creams to surgery—may also be tried, but typically they must be combined with other sex therapy techniques to overcome the years of sexual anxiety and lack of arousal (Archer et al., 2015; Goodman, 2013). Many experts believe that, in most cases, both forms of genito-pelvic pain/penetration disorder are best assessed and treated by a team of professionals, including a gynecologist, physical therapist, and sex therapist or other mental health professional (Berry & Berry, 2013; Rosenbaum, 2011, 2007).
What Are the Current Trends in Sex Therapy? Sex therapists have now moved well beyond the approach first developed by Masters and Johnson. For example, today’s sex therapists regularly treat partners who are living together but not married. They also treat sexual dysfunctions that arise from psychological disorders such as depression, mania, schizophrenia, and certain per- sonality disorders (Leiblum, 2010, 2007). In addition, sex therapists no longer screen out clients with severe marital discord, the elderly, the medically ill, the physically handicapped, gay clients, or individuals who have no long-term sex partner (Rowen, 2013; Stevenson & Elliott, 2007). Sex therapists are also paying more attention to excessive sexuality, sometimes called persistent sexuality disorder, hypersexuality, or sexual addiction (Carvalho et al., 2013; Lee, 2011), although this condition is not listed as a disorder in DSM-5.
Many sex therapists have expressed concern about the sharp increase in the use of drugs and other medical interventions for sexual dysfunctions, particularly for the disorders characterized by low sexual desire and erectile disorder. Their con- cern is that therapists will increasingly choose the biological interventions rather than integrating biological, psychological, and sociocultural interventions. In fact, a narrow approach of any kind probably cannot fully address the complex factors that cause most sexual problems (Berry & Berry, 2013; Meana, 2012). It took sex therapists years to recognize the considerable advantages of an integrated approach to sexual dysfunctions. The development of new medical interventions should not lead to its abandonment.
➤ Summing Up TREATMENTS FOR SExuAl DySFuNCTIONS In the 1970s, the work of William Masters and Virginia Johnson led to the development of sex therapy. Today sex therapy combines a variety of cognitive, behavioral, couple, and family systems therapies. It generally includes features such as careful assessment, education, acceptance of mutual responsibility, attitude changes, sensate-focus exercises, improvements in communication, and couple therapy. In addition, specific tech- niques have been developed for each of the sexual dysfunctions. The use of biological treatments for sexual dysfunctions is also increasing.
B e t W e e N t h e L I N e S
Tattoos and Sexuality 31% Percentage of people with
tattoos who say that their tattoos make them feel sexier
39% Percentage of people without tattoos who say that people with tattoos are less sexy
(harris poll, 2008)
Disorders of Sex and Gender : 367
Paraphilic Disorders Paraphilias are patterns in which people repeatedly have intense sexual urges or fantasies or display sexual behaviors that involve objects or situations outside the usual sexual norms. The sexual focus may, for example, involve nonhuman objects or the experience of suffering or humiliation. Many people with a paraphilia can become aroused only when a paraphilic stimulus is present, fantasized about, or
acted out. Others need the stimulus only during times of stress or under other spe- cial circumstances. Some people with one kind of paraphilia have others as well (Seto, Kingston, & Bourget, 2014). The large con- sumer market in paraphilic pornography and growing trends such as sexting and cybersex
lead clinicians to suspect that paraphilias are, in fact, quite common (Ahlers et al., 2011; Pipe, 2010) (see MindTech on the next page).
According to DSM-5, a diagnosis of paraphilic disorder should be applied when paraphilias cause a person significant distress or impairment or when the sat- isfaction of the paraphilias places the person or other people at risk of harm—either currently or in the past (APA, 2013) (see Table 11-5 on page 369). People who initiate sexual contact with children, for example, warrant a diagnosis of pedophilic disorder regardless of how troubled the individuals may or may not be over their behavior. People whose paraphilic disorder involves children or nonconsenting adults often come to the attention of clinicians as a result of legal issues generated by their inappropriate actions.
Although theorists have proposed various explanations for paraphilic disorders, there is little formal evidence to support such explanations (Becker et al., 2012). Moreover, none of the many treatments applied to these disorders have received much research or proved clearly effective. Psychological and sociocultural treatments have been available the longest, but today’s professionals are also using biological interventions.
Some practitioners administer drugs called antiandrogens that lower the produc- tion of testosterone, the male sex hormone, and reduce the sex drive (Assumpção et al., 2014). Although antiandrogens may indeed reduce paraphilic patterns, sev- eral of them disrupt normal sexual feelings and behavior as well. Thus the drugs tend to be used primarily when the paraphilic disorders are of particular danger either to the individuals themselves or to other people. Clinicians are also increasingly prescribing SSRIs, the serotonin-enhancing antidepressant medications, to treat people with paraphilic disorders, hoping that the SSRIs will reduce these compulsion-like sexual behaviors just as they help reduce other kinds of compulsions (Assumpção et al., 2014). In addition, of course, a common effect of the SSRIs is to lower sexual arousal.
A word of caution is in order before examining the vari- ous paraphilic disorders. The definitions of these disorders, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur (McManus et al., 2013). Some clinicians argue that except when other people are hurt by them, at least some paraphilic behaviors should not be considered disorders at all (De Block & Adriaens, 2013; Wright, 2010). Especially in light of the stigma associated with sexual disorders and the self-revulsion that many people feel when they believe they have such a disorder, we need to be very careful about applying these
Is the availability of sex chat
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healthy or damaging?
Playful context Dressing in clothes of the opposite sex does not necessarily convey a paraphilia. Here two members—both male—of Harvard University’s Hasty Pudding Theatricals Club, known for staging musicals in which male undergraduates dress like women, plant a kiss on actress Anne Hathaway. Hathaway was receiving the club’s 2010 Woman of the Year award.
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▶▶ paraphilias Patterns in which a person has recurrent and intense sexual urges, fantasies, or behaviors involving nonhu- man objects, children, nonconsenting adults, or experiences of suffering or humiliation.
▶▶ paraphilic disorder A disorder in which a person’s paraphilia causes great distress, interferes with social or occupa- tional activities, or places the person or others at risk of harm—either currently or in the past.
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labels to others or to ourselves. Keep in mind that for years clinicians considered homosexuality a paraphilic disorder, and their judgment was used to justify laws and even police actions against gay people (Drescher, 2015; Dickinson et al., 2012). Only when the gay rights movement helped change society’s understanding of and attitudes toward homosexuality did clinicians officially stop considering it a disorder and remove it from the DSM—partly in 1973 and then fully in 1986. Even then,
MindTech
“Sexting”: Healthy or Pathological? “Sexting” is the sending of sexually explicit material—particularly, photos or text messages—between cell phones or other digital devices. The term “sexting” did not make its debut until 2005.
Surveys suggest that 20 percent of cell phone users have texted a sexually explicit photo of themselves and 40 percent have received a sexually explicit photo (McAfee, 2014; Strassberg et al., 2013). Half of all people save the sexual images and text mes- sages they receive and more than 25 percent of recipients forward the sexual photos that they receive to others.
Naïve behavior? Not always. More than one-third of all sexters say they recog- nize that the act could lead to legal or personal problems. Young adults (18 to 24
years old) are the largest group of sexters. And males sext more often than females by a 3-to-2 margin.
Is sexting a symptom of abnormal func- tioning? It depends. Certainly, some sexters fit the criteria for exhibitionistic disorder, the paraphilic pattern in which people act on urges to expose their genitals to others. Six- teen percent of sexters send sexual photos of themselves to complete strangers (McAfee, 2014). And like other forms of exhibition- ism, sexting can cause psychological prob- lems for nonconsenting recipients (Smith et al., 2014).
There are yet other ways in which sexting may reflect psychological or rela- tionship problems. According to one study, people who sext to strangers or other nonconsenting recipients are more likely to have general problems with attachment or intimacy than other people (Drouin & Landgraff, 2012). In addition, research indicates that sexting (when done outside of one’s marriage or monogamous rela- tionship) is often a step toward infidelity. Some psychologists believe that sexting is itself a form of infidelity even though it does not involve physical contact. It has even been the grounds for divorce in some cases (Centeno, 2011; Cable, 2008).
On the other side of the coin, sexting can be a constructive activity, according to some psychologists. Many couples engage in it as an added dimension to their marriage or relationship. According to surveys, more than half of all couples have texted sexual photos or messages to their partners at least once, one-third more than once (Drouin & Landgraff, 2012). Research suggests that this often enhances the in-person romantic relationship, creates more bonding, and heightens sexual satisfaction in the relationship (Parker et al., 2012).
Putting sexting on the map In 2011 New York congressman Anthony Weiner resigned his congressional seat and gave up his mayoral bid when his multiple episodes of sexting were revealed and widely reported in the media.
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as you observed in Chapter 1, many clinicians continued for years to recommend conversion, or reparative, therapy to “fix” the sexual orientation of gay people. In the meantime, the clinical field had unintentionally contributed to the persecution, anxiety, and humiliation of millions of people because of personal sexual behavior that differed from the conventional norms.
Fetishistic Disorder One relatively common paraphilic disorder is fetishistic disorder. Key features of this disorder are recurrent intense sexual urges, sexually arousing fantasies, or behav- iors that involve the use of a nonliving object or nongenital body part, often to the exclusion of all other stimuli (APA, 2013). Usually the disorder, which is far more common in men than in women, begins in adolescence. Almost anything can be a fetish; women’s underwear, shoes, and boots are particularly common. Some people with this disorder steal in order to collect as many of the desired objects as possible. The objects may be touched, smelled, worn, or used in some other way while the person masturbates, or the person may ask a partner to wear the object when they have sex (Marshall et al., 2008). Several of these features are seen in the following case:
A 32-year-old, single male . . . related that although he was somewhat sexually at- tracted by women, he was far more attracted by “their panties.”
To the best of the patient’s memory, sexual excitement began at about age 7, when he came upon a pornographic magazine and felt stimulated by pictures of partially nude women wearing “panties.” His first ejaculation occurred at 13 via masturbation to fantasies of women wearing panties. He masturbated into his older sister’s panties, which he had stolen without her knowledge. Subsequently he stole panties from her friends and from other women he met socially. He found pretexts to “wander” into the bedrooms of women during social occasions, and would quickly rummage through their possessions until he found a pair of panties to his satisfaction. He later used these to masturbate into, and then “saved them” in a “private cache.” The pattern of masturbating into women’s underwear had been his preferred method of achieving sexual excitement and orgasm from adolescence until the present consultation.
(Spitzer et al., 1994, p. 247)
Researchers have not been able to pinpoint the causes of fetishistic disorder. Behaviorists propose that fetishes are acquired through classical conditioning (Dozier, Iwata, & Worsdell, 2011; Roche & Quayle, 2007). In a pioneering behavioral study, male participants were shown a series of slides of nude women along with slides of boots (Rachman, 1966). After many trials, the participants became aroused by the boot photos alone. If early sexual experiences similarly occur in the presence of par- ticular objects, perhaps the stage is set for the development of fetishes.
Behaviorists have sometimes treated fetishistic disorder with aversion therapy (Plaud, 2007; Krueger & Kaplan, 2002). In one study, an electric shock was admin- istered to the arms or legs of participants with this disorder while they imagined their objects of desire (Marks & Gelder, 1967). After two weeks of therapy all men in the study showed at least some improvement. In another aversion technique, covert sensitization, people with fetishistic disorder are guided to imagine the pleasurable object and repeatedly to pair this image with an imagined aversive stimulus until the object of sexual pleasure is no longer desired.
Another behavioral treatment for fetishistic disorder is masturbatory satiation (Plaud, 2007). In this method, the client masturbates to orgasm while fantasizing
table: 11-5
Dx Checklist
Paraphilic Disorder
1. For at least 6 months, individual experiences recurrent and intense sexually arousing fantasies, urges, or behaviors involving objects or situations outside the usual sexual norms (nonhuman objects; nongenital body parts; the suffering or humiliation of oneself or one’s partner; or children or other nonconsenting persons).
2. Individual experiences significant distress or impairment over the fantasies, urges, or behaviors. (In some paraphilic disorders— pedophilic disorder, exhibitionistic disorder, voyeuristic disorder, frotteuristic disorder, and sexual sadism disorder—the performance of the paraphilic behaviors indicates a disorder, even in the absence of distress or impairment.)
(Information from: APA, 2013.)
▶▶ fetishistic disorder A paraphilic dis- order consisting of recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clini- cally significant distress or impairment.
▶▶ masturbatory satiation A behavioral treatment in which a client masturbates for a long period of time while fantasizing in detail about a paraphilic object. The procedure is expected to produce a feel- ing of boredom that becomes linked to the object.
: chapter 11370
about a sexually appropriate object, then switches to fantasizing in detail about fetishistic objects while masturbating again and continues the fetishistic fantasy for an hour. The procedure is meant to produce a feeling of boredom, which in turn becomes linked to the fetishistic object.
Yet another behavioral approach to fetishistic disorder, also used for other para- philias, is orgasmic reorientation, which teaches individuals to respond to more appropriate sources of sexual stimulation (Wright & Hatcher, 2006). People are shown conventional stimuli while they are responding to unconventional objects. A person with a shoe fetish, for example, may be instructed to obtain an erection from pictures of shoes and then to begin masturbating to a picture of a nude woman. If he starts to lose the erection, he must return to the pictures of shoes until he is masturbating effectively, then change back to the picture of the nude woman. When orgasm approaches, he must direct all attention to the conventional stimulus.
Transvestic Disorder A person with transvestic disorder, also known as transvestism or cross- dressing, feels recurrent and intense sexual arousal from dressing in clothes of the opposite sex—arousal expressed through fantasies, urges, or behaviors (APA, 2013). In the following passage, a 42-year-old married father describes his pattern:
I have been told that when I dress in drag, at times I look like Whistler’s Mother [laughs], especially when I haven’t shaved closely. I usually am good at detail, and I make sure when I dress as a woman that I have my nails done just so, and that my colors match. Honestly, it’s hard to pin a date on when I began cross dressing. . . . If pressed, I would have to say it began when I was about 10 years of age, fooling around with and putting on my mom’s clothes. . . . I was always careful to put every- thing back in its exact place, and in 18 years of doing this in her home, my mother never, I mean never, suspected, or questioned me about putting on her clothes. I belong to a transvestite support group . . . a group for men who cross dress. Some of the group are homosexuals, but most are not. A true transvestite—and I am one, so I know—is not homosexual. We don’t discriminate against them in the group at all; hey,
Mrs. Robinson’s stockings The 1967 film The Graduate helped define a generation by focusing on the personal confusion, apathy, and sexual adventures of a young man in search of meaning. Marketers promoted this film by using a fetishistic-like photo of Mrs. Robinson putting on her stockings under Benjamin’s watchful eye, a scene forever identified with the movie. Em
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we have enough trouble getting acceptance as normal people and not just a bunch of weirdos ourselves. They are a bunch of nice guys . . . really. Most of them are like me.
Most of [the men in the group] have told their families about their dressing incli na- tions, but those that are married are a mixed lot; some wives know and some don’t, they just suspect. I believe in honesty, and told my wife about this before we were married. We’re separated now, but I don’t think it’s because of my cross dressing. . . . Some of my friends, when I was growing up, suggested psychotherapy, but I don’t regard this as a problem. If it bothers someone else, then they have the problem. . . . I function perfectly well sexually with my wife, though it took her some time to be comfortable with me wearing feminine underwear; yes, sometimes I wear it while making love, it just makes it more exciting.
( Janus & Janus, 1993, p. 121)
Like this man, the typical person with transvestic disorder, almost always a het- erosexual male, begins cross-dressing in childhood or adolescence (Marshall et al., 2008; Långström & Zucker, 2005). He is the picture of characteristic masculinity in everyday life and is usually alone when he cross-dresses. A small percentage of such men cross-dress to visit bars or social clubs. Some wear a single item of women’s clothing, such as underwear or hosiery, under their masculine clothes. Others wear makeup and dress fully as women. Some married men with transvestic disorder involve their wives in their cross-dressing. Transvestic disorder is often confused with gender dysphoria, but, as you will see, they are two separate patterns that overlap only in some individuals (Zucker et al., 2012).
The development of transvestic disorder sometimes seems to follow the behav- ioral principles of operant conditioning. In such cases, parents or other adults may openly encourage the child to cross-dress or even reward them for doing so. In one case, a woman was delighted to discover that her young nephew enjoyed dressing in girls’ clothes. She had always wanted a niece, and she proceeded to buy him dresses and jewelry and sometimes dressed him as a girl and took him out shopping.
Exhibitionistic Disorder A person with exhibitionistic disorder experiences recurrent and intense sexual arousal from exposing his genitals to an unsuspecting individual—arousal reflected by fantasies, urges, or behaviors (APA, 2013). Most often, the person wants to pro- voke shock or surprise rather than initiate sexual activity with the victim. Some- times an exhibitionist will expose himself in a particular neighborhood at particular hours. In a survey of 2,800 men, 4.3 percent of them reported that they perform exhibitionistic behavior (Långström & Seto, 2006). Yet between one-third and half of all women report having seen or had direct contact with an exhibitionist, or so- called flasher (Marshall et al., 2008). The urge to exhibit typically becomes stronger when the person has free time or is under significant stress.
Generally, exhibitionistic disorder begins before age 18 and usually, but not always, is found among men (APA, 2013). Some studies suggest that those with the disorder are typically immature in their dealings with the opposite sex and have difficulty in interpersonal relationships (Marshall et al., 2008; Murphy & Page, 2006). Around 30 percent of them are married and another 30 percent divorced or separated; their sexual relations with their wives are not usually satisfactory (Doctor & Neff, 2001). Many have doubts or fears about their masculinity, and some seem to have a strong bond to a possessive mother. As with other paraphilic disorders, treatment generally includes aversion therapy and masturbatory satiation, possibly combined with orgas- mic reorientation, social skills training, or cognitive-behavioral therapy (Assumpção et al., 2014; Federoff & Marshall, 2010).
▶▶ orgasmic reorientation A proce- dure for treating certain paraphilias by teaching clients to respond to new, more appropriate sources of sexual stimulation.
▶▶ transvestic disorder A paraphilic disorder consisting of repeated and intense sexual urges, fantasies, or behav- iors that involve dressing in clothes of the opposite sex, accompanied by clinically significant distress or impairment. Also known as transvestism or cross-dressing.
▶▶ exhibitionistic disorder A para- philic disorder in which persons have repeated sexually arousing urges or fantasies about exposing their genitals to others, and either act on these urges with nonconsenting individuals or expe- rience clinically significant distress or impairment.
B e t W e e N t h e L I N e S
Sexual Census The World Health Organization esti mates that around 115 million acts of sexual intercourse occur each day.
: chapter 11372
Voyeuristic Disorder A person with voyeuristic disorder experiences recurrent and intense sexual arousal from observing an unsuspecting individual who is naked, disrobing, or engaging in sexual activity. As with other paraphilic disorders, this arousal takes the form of fantasies, urges, or behaviors (APA, 2013). The disorder usually begins before the age of 15 and tends to persist.
A person with voyeuristic disorder may masturbate during the act of observing or when thinking about it afterward but does not gener- ally seek to have sex with the person being spied on. The vulnerability of the people being observed and the probability that they would feel humiliated if they knew they were under observation are often part of the enjoyment. In addition, the risk of being discovered adds to the excitement.
Voyeurism, like exhibitionism, is often a source of sexual excite- ment in fantasy; it can also play a role in normal sexual interactions, but in such cases it is engaged in with the partner’s consent or under- standing. The clinical disorder of voyeuristic disorder is marked by the repeated invasion of other people’s privacy. Some people with the dis- order are unable to have normal sexual relations; others have a normal sex life apart from their disorder.
Many psychodynamic clinicians propose that people with voy- euristic disorder are seeking by their actions to gain power over others, possibly because they feel inadequate or are sexually or socially shy
(Metzl, 2004). Behaviorists explain the disorder as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene (Lavin, 2008). If the onlookers observe such scenes on several occasions while masturbating, they may develop a voyeuristic pattern.
Frotteuristic Disorder A person with frotteuristic disorder experiences repeated and intense sexual arousal from touching or rubbing against a nonconsenting person. The arousal may, like with the other paraphilic disorders, take the form of fantasies, urges, or behaviors. Frottage (from French frotter, “to rub”) is usually committed in a crowded place, such as a subway or a busy sidewalk (Guterman, Martin, & Rudes, 2010). The person, almost always a male, may rub his genitals against the victim’s thighs or buttocks or fondle her genital area or breasts with his hands. Typically he fantasizes during the act that he is having a caring relationship with the victim. This paraphilia usually begins in the teenage years or earlier, often after the person observes others committing an act of frottage. After the age of about 25, people gradually decrease and often cease their acts of frottage (APA, 2000).
Pedophilic Disorder A person with pedophilic disorder experiences equal or greater sexual arousal from children than from physically mature people. This arousal is expressed through fantasies, urges, or behaviors (APA, 2013). Those with the disorder may be attracted to prepubescent children (classic type), early pubescent children (hebephilic type), or both (pedohebephilic type). Some people with pedophilic disorder are satisfied by child pornography or seemingly innocent material such as children’s underwear ads; others are driven to actually watch, touch, fondle, or engage in sexual intercourse with children (Babchishin, Hanson, & VanZuylen, 2014; Schmidt et al., 2014). Some people with the disorder are attracted only to children; others are attracted to adults
Lady Godiva and “Peeping Tom” According to legend, Lady Godiva (shown in this 1890 illustration) rode naked through the streets of Coventry, England, in order to per- suade her husband, the earl of Mercia, to stop taxing the city’s poor. Although all townspeople were ordered to stay inside their homes with shutters drawn during her eleventh-century ride, a tailor named Tom “could not contain his sexual curiosity and drilled a hole in his shutter in order to watch Lady Godiva pass by” (Mann et al., 2008). Since then, the term “Peeping Tom” has been used to refer to people with voyeuristic disorder.
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as well. Both boys and girls can be pedophilic victims, but there is evidence suggest- ing that two-thirds are girls (Seto, 2008; Koss & Heslet, 1992).
People with pedophilic disorder usually develop their pattern of sexual need dur- ing adolescence (Farkas, 2013). Some were themselves sexually abused as children (Nunes et al., 2013), and many were neglected, excessively punished, or deprived of genuinely close relationships during their childhood. It is not unusual for them to be married and to have sexual difficulties or other frustrations in life that lead them to seek an area in which they can be masters. Often these individuals are immature: their social and sexual skills may be underdeveloped, and thoughts of normal sexual relationships fill them with anxiety (Marshall & Marshall, 2015; Seto, 2008).
Some people with pedophilic disorder also have distorted thinking, such as, “It’s all right to have sex with children as long as they agree” (Roche & Quayle, 2007; Abel et al., 2001, 1984). It is not uncommon for pedophiles to blame the children for adult–child sexual contacts or to assert that the children benefited from the experience (Durkin & Hundersmarck, 2008; Lanning, 2001).
While many people with this disorder believe that their feelings are indeed wrong and abnormal, others consider adult sexual activity with children to be acceptable and normal. Some even have joined pedophile organizations that advo- cate abolishing the age-of-consent laws. The Internet has opened the channels of communication among such people, and there is now a wide range of Web sites, newsgroups, chat rooms, forums, and message boards centered on pedophilia and adult–child sex (Durkin & Hundersmarck, 2008).
Studies have found that most men with pedophilic disorder also display at least one additional psychological disorder (Farkas, 2013; McAnulty, 2006). Some theorists have proposed that pedophilic disorder may be related to biochemical or brain structure abnormalities, but such abnormalities have yet to receive consistent research support (Lucka & Dziemian, 2014; Wiebking & Northoff, 2013).
Most pedophilic offenders are imprisoned or forced into treatment if they are caught (Staller & Faller, 2010). After all, they are committing child sexual abuse when they take any steps toward sexual contact with a child (Farkas, 2013). There are now many residential registration and community notification laws across the United States that help law enforcement agencies and the public account for and control where convicted child sex offenders live and work (OJJDP, 2010).
Pedophilia, abuse, and justice People enter the courthouse in Angers, France, in 2005, to witness the largest child abuse trial ever held in France. The court found 65 defendants (39 men and 26 women) guilty of raping, molesting, and prostituting children. The victims ranged in age from 6 months to 14 years, and the defen- dants ranged from 27 to 73 years.Fr
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▶▶ voyeuristic disorder A paraphilic disorder in which a person has repeated and intense sexual desires to observe unsuspecting people in secret as they undress or to spy on couples having intercourse, and either acts on these urges with nonconsenting people or experiences clinically significant distress or impairment.
▶▶ frotteuristic disorder A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies that involve touching and rubbing against a nonconsenting person, and either acts on these urges with the nonconsenting per- son or experiences clinically significant distress or impairment.
▶▶ pedophilic disorder A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children, and either acts on these urges or experiences clinically significant distress or impairment.
: chapter 11374
Treatments for pedophilic disorder include those already mentioned for other paraphilic disorders, such as aversion therapy, masturbatory satiation, orgasmic reorientation, cognitive-behavioral therapy, and antiandrogen drugs (Assumpção et al., 2014; Fromberger, Jordan, & Müller, 2013). One widely applied cognitive- behavioral treatment for this disorder, relapse-prevention training, is modeled after the relapse-prevention training programs used in the treatment of substance use disorders (see page 337). In this approach, clients identify the kinds of situations that typically trigger their pedophilic fantasies and actions (such as depressed mood or distorted thinking). They then learn strategies for avoiding those situations or coping with them more appropriately and effectively. Relapse-prevention training has sometimes, but not consistently, been of help in this and certain other paraphilic disorders (Marshall & Marshall, 2015; Federoff & Marshall, 2010).
Sexual Masochism Disorder A person with sexual masochism disorder is repeatedly and intensely sexually aroused by the act of being humiliated, beaten, bound, or otherwise made to suffer (APA, 2013). Again, this arousal may take such forms as fantasies, urges, or behaviors. Many people have fantasies of being forced into sexual acts against their will, but only those who are very distressed or impaired by the fantasies receive this diagnosis. Some people with the disorder act on the masochistic urges by themselves, perhaps tying, sticking pins into, or even cutting themselves. Others have their sexual part- ners restrain, tie up, blindfold, spank, paddle, whip, beat, electrically shock, “pin and pierce,” or humiliate them (APA, 2013).
An industry of products and services has arisen to meet the desires of people with the paraphilia or the paraphilic disorder of sexual masochism. Here a 34-year- old woman describes her work as the operator of a sadomasochism (S/M) facility:
I get people here who have been all over looking for the right kind of pain they feel they deserve. Don’t ask me why they want pain, I’m not a psychologist; but when they have found us, they usually don’t go elsewhere. It may take some of the other girls an hour or even two hours to make these guys feel like they’ve had their treatment— I can achieve that in about 20 minutes. . . .
Among the things I do, that work really quickly and well, are: I put clothespins on their nipples, or pins in their [testicles]. Some of them need to see their own blood to be able to get off. . . .
All the time that a torture scene is going on, there is constant dialogue. . . . I scream at the guy, and tell him what a no-good rotten bastard he is, how this is even too good for him, that he knows he deserves worse, and I begin to list his sins. It works every time. Hey, I’m not nuts, I know what I’m doing. I act very tough and hard, but I’m really a very sensitive woman. But you have to watch out for a guy’s health . . . you must not kill him, or have him get a heart attack. . . . I know of other places that have had guys die there. I’ve never lost a customer to death, though they may have wished for it during my “treatment.” Remember, these are repeat customers. I have a clientele and a reputation that I value.
( Janus & Janus, 1993, p. 115)
In one form of sexual masochism disorder, hypoxyphilia, people strangle or smother themselves (or ask their partner to strangle them) in order to enhance their sexual pleasure. There have, in fact, been a disturbing number of clinical reports of autoerotic asphyxia, in which people, usually males and as young as 10 years old, may accidentally induce a fatal lack of oxygen by hanging, suffocating, or strangling themselves while masturbating (Sauvageau, 2014; Hucker, 2011, 2008). There is
A celebration of S/M Sexual sadism and sexual masochism have been viewed by the public with either bemusement or horror, depending on the circumstances and events that surround particular acts of these paraphil- ias. On the light side, the annual Folsom Street Fair in San Francisco is a very large event that celebrates S/M and invites people (like this participant) to go on stage, display their trade- mark outfits, and, in some cases, participate in whippings or spankings.
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some debate as to whether the practice should be characterized as sexual masochism disorder, but it is at least sometimes accompanied by other acts of bondage.
Most masochistic sexual fantasies begin in childhood. However, the person does not act out the urges until later, usually by early adulthood. The pattern typically continues for many years. Some people practice more and more dangerous acts over time or during times of particular stress (Krueger, 2010).
In many cases, sexual masochism disorder seems to have developed through the behavioral process of classical conditioning (Stekel, 2010; Akins, 2004). A classic case study tells of a teenage boy with a broken arm who was caressed and held close by an attractive nurse as the physician set his fracture, a procedure done in the past without anesthesia (Gebhard, 1965). The powerful combination of pain and sexual arousal the boy felt then may have been the cause of his later masochistic urges and acts.
Sexual Sadism Disorder A person with sexual sadism disorder, usually male, is repeatedly and intensely sexually aroused by the physical or psychological suffering of another individual (APA, 2013). This arousal may be expressed through fantasies, urges, or behaviors, including acts such as dominating, restraining, blindfolding, cutting, strangling, mutilating, or even killing the victim (Nitschke et al., 2013). The label is derived from the name of the famous Marquis de Sade (1740–1814), who tortured others in order to satisfy his sexual desires.
People who fantasize about sexual sadism typically imagine that they have total control over a sexual victim who is terrified by the sadistic act. Many carry out sadistic acts with a consenting partner, often a person with sexual masochism dis- order. Some, however, act out their urges on nonconsenting victims (Mokros et al., 2014). A number of rapists and sexual murderers, for example, exhibit sexual sadism disorder (Knecht, 2014; Healey et al., 2013). In all cases, the real or fantasized vic- tim’s suffering is the key to arousal (Marshall & Marshall, 2015; Seto et al., 2012).
Fantasies of sexual sadism, like those of sexual masochism, may first appear in childhood or adolescence (Stone, 2010). People who engage in sadistic acts begin to do so by early adulthood (APA, 2013). The pattern is long-term. Some people with the disorder engage in the same level of cruelty in their sadistic acts over time, but often their sadism becomes more and more severe over the years (Robertson & Knight, 2014; Mokros et al., 2011). Obviously, people with severe forms of the disorder may be highly dangerous to others.
Some behaviorists believe that classical conditioning is at work in sexual sadism disorder (Akins, 2004). While inflicting pain, perhaps uninten- tionally, on an animal or person, a teenager may feel intense emotions and sexual arousal. The association between inflict- ing pain and being aroused sexually sets the stage for a pattern of sexual sadism. Behaviorists also propose that the disorder may result from modeling, when adolescents observe others achieving sexual satisfaction by inflicting pain. Many Internet sex sites and sexual videos, magazines, and books in our soci- ety make such models readily available (Brophy, 2010).
Both psychodynamic and cognitive theorists suggest that people with sexual sadism disorder inflict pain in order to achieve a sense of power or control, necessitated perhaps by underlying feelings of sexual inadequacy (Marshall & Marshall, 2015). The sense of power in turn increases their sexual arousal (Stekel, 2010; Rathbone, 2001). Alternatively, certain biological studies have found signs of possible brain and hormonal abnormalities in people with sexual sadism
Cinematic introduction In one of film- dom’s most famous scenes, Alex, the sexually sadistic character in A Clockwork Orange, is forced to observe violent images while he experiences painful stomach spasms.
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▶▶ sexual masochism disorder A paraphilic disorder in which a person has repeated and intense sexual urges, fantasies, or behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer, accompanied by clinically significant distress or impairment.
▶▶ sexual sadism disorder A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies that involve inflicting suffering on oth- ers, and either acts on these urges with nonconsenting individuals or experi- ences clinically significant distress or impairment.
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(Harenski et al., 2012; Jacobs, 2011). None of these explanations, however, has been thoroughly investigated.
The disorder has been treated by aversion therapy. The public’s view of and distaste for this procedure have been influenced by the novel and 1971 movie A Clockwork Orange, which depicts simultaneous presentations of violent images and drug-induced stomach spasms to a sadistic young man until he is conditioned to feel nausea at the sight of such images. It is not clear that aversion therapy is helpful in cases of sexual sadism disorder. However, relapse-prevention training, used in some criminal cases, may be of value (Federoff & Marshall, 2010; Bradford et al., 2008).
➤ Summing Up PARAPHIlIC DISORDERS Paraphilias are patterns characterized by recurrent and intense sexual urges, fantasies, or behaviors involving objects or situations outside the usual sexual norms—for example, nonhuman objects, children, nonconsenting adults, or experiences of suffering or humiliation. When an indi- vidual’s paraphilia causes great distress, interferes with social or occupational functioning, or places the individual or others at risk of harm, a diagnosis of paraphilic disorder is applied. Paraphilic disorders are found primarily in men. The paraphilic disorders include fetishistic disorder, transvestic disorder, exhibi- tionistic disorder, voyeuristic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, and sexual sadism disorder. Although various expla- nations have been proposed for these disorders, research has revealed little about their causes. A range of treatments have been tried, including aversion therapy, masturbatory satiation, orgasmic reorientation, and relapse-prevention training.
Gender Dysphoria As children and adults, most people feel like and identify themselves as males or females—a feeling and identity that is consistent with their assigned gender, the gen- der to which they are born. But society has come to appreciate that many people do not experience such gender clarity. Instead, they have transgender experiences—a sense that their actual gender identity is different from their assigned gender or a sense that it lies outside the usual male versus female categories. It is estimated that 1.5 million people in the United States are transgender—0.5% of the population (Steinmetz, 2014). The prevalence in other countries is about the same (Kuyper & Wijsen, 2014). Many transgender people come to terms with their gender inconsis- tencies, but others experience extreme unhappiness with their assigned gender and may seek treatment for their problem. DSM-5 categorizes these people as having gender dysphoria, a disorder in which people persistently feel that a vast mistake has been made—they have been born to the wrong sex—and have clinically signifi- cant distress or impairment with this gender mismatch (see Table 11-6).
The DSM-5 categorization of gender dysphoria is controversial (Sennott, 2011). Many argue that since transgender experiences reflect alternative—not pathological—ways of experiencing one’s gender identity, they should never be considered a psychological disorder, even when they bring significant unhappiness. At the other end of the spectrum, many argue that transgender experiences are in fact a medical problem that may produce personal unhappiness for some of the people with these experiences. According to this position, gender dysphoria should not be categorized as a psychological disorder, just as kidney disease and cancer,
▶▶ gender dysphoria A disorder in which a person persistently feels clinically significant distress or impairment due to his or her assigned gender and strongly wishes to be a member of another gender.
B e t W e e N t h e L I N e S
Sex and the Law In 1996 the California state legislature passed the first law in the United States allowing state judges to order antian- drogen drug treatments, often referred to as “chemical castration,” for repeat sex crime offenders, such as men who repeatedly commit pedophilic acts or rape. Since then, at least seven other states also have passed laws permitting some form of coerced antiandrogen drug treatment.
Disorders of Sex and Gender : 377
medical conditions that may also produce unhappiness, are not categorized as psy- chological disorders. Although one of these views may eventually prove to be an appropriate perspective, this chapter largely will follow DSM-5’s position that (1) a transgender orientation is more than a variant lifestyle if it is accompanied by sig- nificant distress or impairment, and (2) a transgender orientation is far from a clearly defined medical problem. We will also examine what clinical theorists believe they know about gender dysphoria.
People with gender dysphoria typically would like to get rid of their primary and secondary sex characteristics—many of them find their own genitals repugnant—and acquire the characteristics of another sex (APA, 2013). Men with this disorder (i.e., “male-assigned people”) outnumber women (“female-assigned people”) by around 2 to 1. The individuals feel anxiety or depression and may have thoughts of suicide ( Judge et al., 2014; Steinmetz, 2014). Such reactions may be related to the confusion and pain brought on by the disorder itself, or they may be tied to the prejudice typically faced by people who are transgender. According to an extensive survey across the United States, for example, 80 to 90 percent of transgender people have been harassed at school or work; 50 percent have been fired from a job, not hired, or not promoted; and 20 percent have been denied a place to live (Steinmetz, 2014). Studies also suggest that some people with gender dysphoria manifest a personality disorder (Singh et al., 2011). Today the term gender dysphoria has replaced the old term transsexualism, although the word “transsexual” is still sometimes used to describe those who desire and seek full gender change, often by surgery (APA, 2013).
Sometimes gender dysphoria emerges in children (Milrod, 2014; Nicholson & McGuinness, 2014). Like adults with this disorder, the children feel uncomfortable about their assigned gender and yearn to be members of another gender. This childhood pattern usually disap- pears by adolescence or adulthood, but in some cases it develops into adolescent and adult forms of gender dysphoria (Cohen-Kettenis, 2001). Thus adults with this disorder may have had a childhood form of gender dysphoria, but most children with the childhood form do not become adults with the disorder. Surveys of mothers indicate that about 1.5 percent of young boys wish to be a girl, and 3.5 percent of young girls wish to be a boy (Carroll, 2007; Zucker & Bradley, 1995), yet considerably less than 1 percent of adults manifest gender dysphoria (Zucker, 2010). This age shift in the prevalence of gender dysphoria is, in part, why leading experts on the disorder strongly recommend against any form of irreversible
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Dx Checklist
Gender Dysphoria in Adolescents and Adults
1. For 6 months or more, individual’s gender-related feelings and/or behaviors is at odds with those of his or her assigned gender, as indicated by two or more of the following symptoms: • Gender-related feelings and/or behaviors clearly contradict the individual’s primary or secondary sex characteristics • Powerful wish to eliminate one’s sex characteristics • Yearning for the sex characteristics of another gender • Powerful wish to be a member of another gender • Yearning to be treated as a member of another gender • Firm belief that one’s feelings and reactions are those that characterize another gender.
2. Individual experiences significant distress or impairment.
(Information from: APA, 2013.)
A delicate matter A 5-year-old boy (left), who identifies and dresses as a girl and asks to be called “she,” plays with a female friend. Sensitive to the gender identity rights move- ment and to the special needs of children with gender dysphoria, a growing number of parents, educators, and clinicians are now sup- portive of children like this boy.
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physical treatment for this pattern until people reach adulthood, a recommendation upheld in the World Professional Association for Transgender Health Standards of Care (Milrod, 2014; HBIGDA, 2001). Nevertheless, some surgeons continue to perform such procedures for younger patients.
Explanations of Gender Dysphoria Many clinicians suspect that biological factors—perhaps genetic or prenatal—play a key role in gender dysphoria (Rametti et al., 2011; Nawata et al., 2010). Consistent with a genetic explanation, the disorder does sometimes run in families. Research indicates, for example, that people whose siblings have gender dysphoria are more likely to have the same disorder than are people without such siblings (Gómez-Gil et al., 2010). Indeed, one study of 23 pairs of identical twins found that when one of the twins had gender dysphoria, the other twin had it as well in 9 of the pairs (Heylens et al., 2012).
Biological investigators have recently detected differences between the brains of control participants and participants with gender dysphoria. One study found, for example, that those with the disorder had heightened blood flow in the insula and reduced blood flow in the anterior cingulate cortex (Nawata et al., 2010). These brain areas are known to play roles in human sexuality and consciousness.
A biological study that was conducted around 20 years ago continues to receive considerable attention (Zhou et al., 1997, 1995). Dutch investigators autopsied the brains of six people who had changed their sex from male to female. They found that a cluster of cells in the hypothalamus called the bed nucleus of stria terminalis (BST ) was only half as large in these people as it was in a control group of non- transgender men. Usually, a woman’s BST is much smaller than a man’s, so in effect the male-assigned people with gender dysphoria were found to have a female-sized BST. Scientists do not know for certain what the BST does in humans, but they know that it helps regulate sexual behavior in male rats. Thus it may be that male- assigned people who develop gender dysphoria have a key biological difference that leaves them very uncomfortable with their assigned sex characteristics.
Treatments for Gender Dysphoria In order to more effectively assess and treat those with gender dysphoria, clinical theorists have tried to distinguish the most common patterns of the disorder encoun- tered in clinical practice.
Client Patterns of Gender Dysphoria Richard Carroll (2007), a leading theorist on gender dysphoria, has described the three patterns of gender dysphoria for which people most commonly seek treatment: (1) female-to-male gender dysphoria, (2) male-to-female gender dysphoria: androphilic type, and (3) male-to-female gender dys- phoria: autogynephilic type.
Female-to-male gender dysPhoria People with a female-to-male gender dys- phoria pattern are born female but appear or behave in a stereotypically masculine manner from early on—often as young as 3 years of age or younger. As children, they always play rough games or sports, prefer the company of boys, hate “girlish” clothes, and state their wish to be male. As adolescents, they become disgusted by the physical changes of puberty and are sexually attracted to females. However, lesbian relationships do not feel like a satisfactory solution to them because they want other women to be attracted to them as males, not as females.
male-to-Female gender dysPhoria: androPhilic tyPe People with an andro- philic type of male-to-female gender dysphoria are born male but appear or behave in a stereotypically female manner from birth. As children, they are viewed as
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Growing Awareness 9% Percentage of Americans who say
they have a close friend or family member who is transgender.
65% Percentage of Americans who say they have a close friend or family member who is gay.
(Steinmetz, 2014)
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effeminate, pretty, and gentle; avoid rough games; and hate to dress in boys’ cloth- ing. As adolescents, they become sexually attracted to males, and they often come out as gay and develop gay relationships (the term “androphilic” means attracted to males). But by adulthood, it often becomes clear to them that such gay relationships do not truly address their gender dysphoric feelings because they want to be with heterosexual men who are attracted to them as women.
male-to-Female gender dysPhoria: autogynePhilic tyPe People with an autogynephilic type of male-to-female gender dysphoria are not sexually attracted to males; rather, they are attracted to the idea of themselves being female (the term “autogynephilic” means attracted to oneself as a female). Like males with the paraphilic disorder transvestic disorder (see pages 370–371), persons with this form of gender dysphoria behave in a stereotypically masculine manner as children, start to enjoy dressing in female clothing during childhood, and after puberty become sexually aroused when they cross-dress. Also, like males with transvestic disorder, they are attracted to females during and beyond adolescence. However, unlike people with transvestic disorder, these persons have desires of becoming female that become increasingly intense and overwhelming during adulthood.
In short, cross-dressing is characteristic of both men with transvestic disorder (the paraphilic disorder) and people with this type of male-to-female gender dys- phoria (Zucker et al., 2012). But the former cross-dress strictly to become sexually aroused, whereas the latter develop much deeper reasons for cross-dressing, reasons of gender identity.
Types of Treatment for Gender Dysphoria Many adults with gen- der dysphoria receive psychotherapy (Affatati et al., 2004), but a large number of them further seek to address their concerns through biological interventions (see MediaSpeak on the next page). For example, many transgender adults change their sexual characteristics by means of hormone treatments (Wierckx et al., 2014). Physi- cians prescribe the female sex hormone estrogen for male-assigned patients, causing breast development, loss of body and facial hair, and changes in body fat distribu- tion. Some such patients also go to speech therapy, raising their tenor voice to alto
Hero to a new audience When he won the gold medal for the decathlon at the 1976 Olympics, Bruce Jenner became a national hero and was widely viewed as the personifi- cation of masculinity—the world’s best male athlete—leading to lucrative contracts as the spokesperson for the popular cereal Wheaties (left), among other products. When in 2015 Jenner appeared in Vanity Fair magazine (right) as a transgender woman, Caitlyn, she became a hero to thousands of transgender persons who hoped that this high-profile revelation would reduce the public’s misunderstanding of and prejudice against transgender individuals. Fr
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Key Decision On September 19, 2008, the Federal District Court for Washington, DC, ruled for the first time ever that discrimina tion against a transgender person constitutes illegal sex discrimination. Specifically, it held that the Library of Congress had discriminated against a woman (the plaintiff) by rescinding a job offer to her after she disclosed that she was changing from male to female.
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MediaSpeak A Different Kind of Judgment
By Angela Woodall, Oakland Tribune
Few county judges command standing ovations before they say a word, nor do they compel hate mail from strangers halfway around the world.
Alameda County Superior Court Judge Victoria Kolakowski receives both. She is the first transgender person elected as a trial judge and one of the very few elected to any office. “No, I am not going to be able to get you out of things,” she said jokingly to an audi- ence of transgender advocates . . . two weeks after her upset victory. . . . “I had a chance to serve. If my being visible helps a community that is often ignored and looked down upon, then I am happy. If not me, then who?”
But it took years of rejection and perseverance to get from Michael Kolakowski to 49-year-old Judge Victoria Kolakowski, even though as a child she hoped and prayed to wake up in a female body. “I guess the prayer was answered,” she said. “But not for a long time afterward.” . . .
Kolakowski, a New York native, is a carefully groomed, mildly spoken brunette of average build who usually appears wearing glasses, modest makeup, dark pantsuits and pumps. In other words, she looks a lot like a conservatively dressed judge. . . .
[Back when she was a teenager], the Internet did not exist, and information about transsexuals was un- available to minors, Kolakowski said. At Louisiana State University, she finally found some books in the college library about transsexuality and realized that she was not alone. But when she told her parents, they took her to the emergency room of the hospital. This started an on-again, off-again series of counseling and therapy that lasted for a decade.
Kolakowski eventually married, came out with her wife during law school and began her transition to be- coming a woman on April 1, 1989. It was her last semes- ter at LSU. She was 27. Three years later, she underwent surgery to complete her transition to a woman.
She was a 30-year-old lawyer with five degrees on her resume. So she had no problem attracting job offers—only to be rejected when she walked into the interview.
Rejection is one of the commonalities for transgen- der women and men, and the pain can run deep. Some
of the transgender lawyers Kolakowski knew killed themselves.
Kolakowski attributes her resilience to her faith—she also holds a master’s degree in divinity—and the sup- port of “some very loving people.” That includes her parents and her second wife. . . . They wed in 2006.
By then, Kolakowski had become an administrative law judge. . . . Her chance to run for the Superior Court bench came in 2008. . . . Kolakowski didn’t win, but she tried again in 2010. “This time, things were differ- ent, and in June, I came in first,” she said.
The spotlight turned in her direction because she became a symbol of success for the transgender com- munity. But she also has become a target. The more successful you are, the more backlash you are likely to get, she said, “and that backlash can be violent.”. . . [T]wo transgender women were killed in Houston last year, even though voters there elected a transgender municipal judge in November. . . . “We’re dealing with people who don’t know us and don’t really understand who we are,” she said.
Kolakowski is also mindful that she must be sensi- tive to the dignity of the office voters elected her to. Some people, she predicted, will accuse her of “acting inappropriately.” But she said: “This is what it is. I was elected based on my qualifications. It just happens to be historic.”
“Vicky Kolakowski Overcame Discrimination to Become Nation’s First Transgender Trial Judge.” Angela Woodall, Oakland Tribune, 12/30/2010. Used with permission of The Oakland Tribune © 2014. All rights reserved.
A new kind of role model Judge Victoria Kolakowski (left) waves during the 41st annual Gay Pride parade in San Francisco, June 26, 2011.
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through training, and some have facial feminization surgery (Capitán et al., 2014; Steinmetz, 2014). In contrast, treatments with the male sex hormone tes- tosterone are given to female-assigned patients with gender dysphoria, resulting in a deeper voice, increased muscle mass, and changes in facial and body hair.
These approaches enable many persons with the disorder to lead a fulfill- ing life in the gender that fits them. For others, however, this is not enough, and they seek out one of the most controversial practices in medicine: sexual reassignment, or sex-change surgery ( Judge et al., 2014). This surgery, which is usually preceded by one to two years of hormone therapy, involves, for male-assigned persons, partial removal of the penis and restructuring of its remaining parts into a clitoris and vagina, a procedure called vaginoplasty. In addition, some individuals undergo face-changing plastic surgery. For female- assigned persons, surgery may include bilateral mastectomy and hysterectomy (Ott et al., 2010). The procedure for creating a functioning penis, called phallo- plasty, is performed in some cases, but it is not perfected. Alternatively, doctors have developed a silicone prosthesis that can give patients the appearance of having male genitals. One review calculates that 1 of every 3,100 persons in the United States has had or will have sex-change surgery during their life- time (Horton, 2008). For female-assigned persons, the incidence is 1 of every 4,200, and for male-assigned individuals, it is 1 of every 2,500. Many insurance companies refuse to cover these or even less invasive biological treatments for people with gender dysphoria, but a growing number of states now prohibit such insurance exclusions (Steinmetz, 2014).
Clinicians have debated heatedly whether sexual reassignment surgery is an appropriate treatment for gender dysphoria (Gozlan, 2011). Some consider it a humane solution, perhaps the most satisfying one to many people with the pattern. Others argue that sexual reassignment is a “drastic nonsolution” for a complex disorder. Either way, such surgery appears to be on the increase (Allison, 2010; Horton, 2008).
Research into the outcomes of sexual reassignment surgery has yielded mixed findings. On the one hand, in a number of studies, the majority of patients—both female-assigned and male-assigned—report satisfaction with the outcome of the sur- gery, improvements in self-satisfaction and interpersonal interactions, and improve- ments in sexual functioning ( Judge et al., 2014; Johansson et al., 2010). On the other hand, several studies have yielded less favorable findings. A long-term follow-up study in Sweden, for example, found that although sexually reassigned participants did show a reduction in gender dysphoria, they also had a higher rate of psychological disorders and of suicide attempts than the general population (Dhejne et al., 2011). People with significant pretreatment psychological disturbances seem most likely to later regret the surgery (Carroll, 2007). All of this argues for careful screening prior to surgical interventions, continued research to better understand the impact of such procedures, and, more generally, better clinical care for transgender people.
➤ Summing Up GENDER DySPHORIA People with gender dysphoria persistently feel that they have been born the wrong gender and, along with this, experience significant distress or impairment. The causes of this disorder are not well understood. Hormone treatments, facial surgery, speech therapy, and psychotherapy have been used to help some people adopt the gender role they believe to be right for them. Sex-change operations have also been performed, but the appropri- ateness of surgery as a form of treatment has been debated heatedly.
Lea T. Transgender model Lea T. emerged in 2010 as the face of Givenchy, the famous French fashion brand. Born male, the Brazilian model has become a leading female figure in runway fashion shows and magazines, includ- ing Vogue Paris, Cover magazine, and Love magazine. In 2012 she underwent sexual reas- signment surgery.
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▶▶ sex-change surgery A surgical procedure that changes a person’s sex organs, features, and, in turn, sexual iden- tity. Also known as sexual reassignment surgery.
: chapter 11382
PUTTING IT...together A Private Topic Draws Public Attention For all the public interest in sexual and gender disorders, clinical theorists and practitioners have only recently begun to understand their nature and how to treat them. As a result of research done over the past few decades, people with sexual dysfunctions are no longer doomed to a lifetime of sexual frustration. At the same time, however, insights into the causes and treatment of paraphilic disorders and gender dysphoria remain limited.
Studies of sexual dysfunctions have pointed to many psychological, sociocultural, and biological causes. Often, as you have seen with so many disorders, the various
causes may interact to produce a particular dysfunction, as in erectile disorder and female orgasmic disorder. For some dysfunctions, however, one cause alone is dominant, and integrated explanations may be inac- curate and unproductive. Some sexual pain dysfunctions, for example, have a physical cause exclusively.
Recent work has also yielded important progress in the treatment of sexual dysfunctions, and people with such problems are now often helped greatly by therapy. Sex therapy is usually a complex program tai- lored to the particular problems of an individual or couple. Techniques from the various models may be combined, although in some instances the particular problem calls primarily for one approach.
One of the most important insights to emerge from all of this work is that educa- tion about sexual dysfunctions can be as important as therapy. Sexual myths are still taken so seriously that they often lead to feelings of shame, self-hatred, isolation, and hopelessness—feelings that themselves contribute to sexual difficulty. Even a modest amount of education can help people who are in treatment.
In fact, most people can benefit from a more accurate understanding of sexual functioning. Public education about sexual functioning—through the Internet, books, television and radio, school programs, group presentations, and the like—has become a major clinical focus. It is important that these efforts continue and even increase in the coming years.
KEY TERMS sexual dysfunction, p. 348
desire phase, p. 348
male hypoactive sexual desire disorder, p. 349
female sexual interest/arousal disorder, p. 349
excitement phase, p. 351
erectile disorder, p. 352
nocturnal penile tumescence (NPT), p. 353
performance anxiety, p. 353
spectator role, p. 353
orgasm phase, p. 354
premature ejaculation, p. 355
delayed ejaculation, p. 355
female orgasmic disorder, p. 356
genito-pelvic pain/penetration disorder, p. 358
vaginismus, p. 358
dyspareunia, p. 358
sex therapy, p. 360
sensate focus, p. 361
flibanserin, p. 363
sildenafil (Viagra), p. 363
directed masturbation training, p. 365
paraphilia, p. 367
paraphilic disorder, p. 367
fetishistic disorder, p. 369
masturbatory satiation, p. 369
orgasmic reorientation, p. 370
transvestic disorder, p. 370
exhibitionistic disorder, p. 371
voyeuristic disorder, p. 372
frotteuristic disorder, p. 372
pedophilic disorder, p. 372
sexual masochism disorder, p. 374
sexual sadism disorder, p. 375
transgender experiences, p. 376
gender dysphoria, p. 376
hormone treatments, p. 379
sex-change surgery, p. 381
C li n i C al C h o i C e s Now that you’ve read about disorders of sex and gender, try the interactive case study for this chapter. See if you are able to identify Charles’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for Charles? Go to LaunchPad to access Clinical Choices.
Disorders of Sex and Gender : 383
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the ebook, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
QuickQuiz
1. What sexual dysfunctions are associ- ated with the desire phase of the sexual response cycle? How com- mon are they, and what causes them? pp. 348–351
2. What are the symptoms and prevalence of erectile disorder? To which phase of the sexual response cycle is it related? p. 352
3. What are the possible causes of erec- tile disorder? pp. 352–354
4. Which sexual dysfunctions seem to involve performance anxiety and the spectator role? pp. 353, 356
5. What are the symptoms, rates, and leading causes of premature ejacula- tion, delayed ejaculation, and female orgasmic disorder? To which phase of the sexual response cycle are they related? pp. 354–358
6. Identify, describe, and explain disorders of sexual pain. pp. 358–359
7. What are the general features of mod- ern sex therapy? What particular tech- niques are further used to treat specific sexual dysfunctions? pp. 360–366
8. List, describe, and explain the various paraphilic disorders. pp. 367–375
9. Describe the treatment techniques of aversion therapy, masturbatory sa- tiation, orgasmic reorientation, and relapse-prevention training. Which paraphilic disorders have they been used to treat, and how successful are they? pp. 369–376
10. Distinguish transvestic disorder from gender dysphoria. What are the various types of gender dysphoria, and what are today’s treatments for this disor- der? pp. 370–371, 376–381
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L aura, 40 years old: Laura’s desire was to become independent and leave home . . . as soon as possible. . . . She became a professional dancer at the age of 20 . . . and was booked for . . . theaters in many European countries. . . .
It was during one of her tours in Germany that Laura met her husband. . . . They were married and went to live in a small . . . town in France where the husband’s business was. . . . She spent a year in that town and was very unhappy. . . . [Finally] Laura and her husband decided to emigrate to the United States. . . .
They had no children, and Laura . . . showed interest in pets. She had a dog to whom she was very devoted. The dog became sick and partially paralyzed, and veterinar- ians felt that there was no hope of recovery. . . . Finally [her husband] broached the problem to his wife, asking her “Should the dog be destroyed or not?” From that time on Laura became restless, agitated, and depressed. . . .
Later Laura started to complain about the neighbors. A woman who lived on the floor beneath them was knocking on the wall to irritate her. According to the hus- band, this woman had really knocked on the wall a few times; he had heard the noises. However, Laura became more and more concerned about it. She would wake up in the middle of the night under the impression that she was hearing noises from the apartment downstairs. She would become upset and angry at the neighbors. . . . Later she became more disturbed. She started to feel that the neighbors were now recording everything she said; maybe they had hidden wires in the apartment. She started to feel “funny” sensations. There were many strange things happening, which she did not know how to explain; people were looking at her in a funny way in the street. . . . She felt that people were planning to harm either her or her hus- band. . . . In the evening when she looked at television, it became obvious to her that the programs referred to her life. Often the people on the programs were just repeating what she had thought. They were stealing her ideas. She wanted to go to the police and report them.
(Arieti, 1974, pp. 165–168)
Richard, 23 years old: In high school, Richard was an average student. After gradua- tion from high school, he [entered] the army. . . . Richard remembered [the] period . . . after his discharge from the army . . . as one of the worst in his life. . . . Any, even remote, anticipation of disappointment was able to provoke attacks of anxiety in him. . . .
Approximately two years after his return to civilian life, Richard left his job because he became overwhelmed by these feelings of lack of confidence in himself, and he refused to go look for another one. He stayed home most of the day. His mother would nag him that he was too lazy and unwilling to do anything. He became slower and slower in dressing and undressing and taking care of himself. When he went out of the house, he felt compelled “to give interpretations” to everything he looked at. He did not know what to do outside the house, where to go, where to turn. If he saw a red light at a crossing, he would interpret it as a message that he should not go in that direction. If he saw an arrow, he would follow the arrow interpreting it as a sign sent by God that he should go in that direction. Feeling lost and horrified, he would go home and stay there, afraid to go out because going out meant making decisions or choices that he felt unable to make. He reached the point where he stayed home most of the time. But even at home, he was tortured by his symptoms. He could not act; any motion that he felt like making seemed to him an insurmountable obstacle, because he did not know whether he should make it or not. He was increasingly afraid of doing the wrong thing. Such fears prevented him from dressing, undress- ing, eating, and so forth. He felt paralyzed and lay motionless in bed. He gradually became worse, was completely motionless, and had to be hospitalized. . . .
Being undecided, he felt blocked, and often would remain mute and motionless, like a statue, even for days.
(Arieti, 1974, pp. 153–155)
12
T O P I C O V E R V I E W
The Clinical Picture of Schizophrenia What Are the Symptoms of Schizophrenia? What Is the Course of Schizophrenia?
How Do Theorists Explain Schizophrenia? Biological Views Psychological Views Sociocultural Views
How Are Schizophrenia and Other Severe Mental Disorders Treated? Institutional Care in the Past Institutional Care Takes a Turn for the Better Antipsychotic Drugs Psychotherapy The Community Approach
Putting It Together: An Important Lesson
Schizophrenia
: chapter 12386
Eventually, Laura and Richard each received a diagnosis of schizo- phrenia (APA, 2013). People with schizophrenia, though they pre- viously functioned well or at least acceptably, deteriorate into an isolated wilderness of unusual perceptions, odd thoughts, disturbed emotions, and motor abnormalities. Like Laura and Richard, people with schizophrenia experience psychosis, a loss of contact with reality. Their ability to perceive and respond to the environment becomes so disturbed that they may not be able to function at home, with friends, in school, or at work (Harvey, 2014). They may have hallucinations (false sensory perceptions) or delusions (false beliefs), or they may withdraw into a private world. DSM-5 calls for a diag- nosis of schizophrenia only after the symptoms of psychosis continue for six months or more (see Table 12-1).
As you saw in Chapter 10, taking LSD or abusing amphetamines or cocaine may produce psychosis. So may injuries or diseases of the brain. And so may other severe psychological disorders, such as major depressive disorder or bipolar disorder (Pearlson & Ford, 2014). Most commonly, however, psychosis appears in the form of schizophrenia.
Actually, there are a number of schizophrenia-like disorders listed in DSM-5, each distinguished by particular durations and sets of symptoms (see Table 12-2). Because these psychotic disorders all bear a similarity to schizophrenia, they—along with schizophrenia itself—
are collectively called schizophrenia spectrum disorders (APA, 2013). Schizophrenia is the most prevalent of these disorders. Most of the explanations and treatments offered for schizophrenia are applicable to the other disorders as well (Potkin et al., 2014).
Approximately 1 of every 100 people in the world suffers from schizophrenia during his or her lifetime (Long et al., 2014). An estimated 26 million people world- wide are afflicted with it, including 3 million in the United States (MHF, 2015; NIMH, 2010). Its financial cost is enormous, and the emotional cost is even greater
table: 12-1
Dx Checklist
Schizophrenia
1. For 1 month, individual displays two or more of the following symptoms much of the time:
(a) Delusions (b) Hallucinations (c) Disorganized speech (d) Very abnormal motor activity, including catatonia (e) Negative symptoms
2. At least one of the individual’s symptoms must be delusions, hallucinations, or disorganized speech.
3. Individual functions much more poorly in various life spheres than was the case prior to the symptoms.
4. Beyond this 1 month of intense symptomology, individual continues to display some degree of impaired functioning for at least 5 additional months.
(Information from: APA, 2013.)
table: 12-2
Schizophrenia Spectrum Disorders: An Array of Psychosis
Disorder Key Features Duration Lifetime Prevalence
Schizophrenia Various psychotic symptoms, such as delusions, hallucinations, disorganized speech, restricted or inappropriate affect, and catatonia
6 months or more
1.0%
Brief psychotic disorder Various psychotic symptoms, such as delusions, hallucinations, disorganized speech, restricted or inappropriate affect, and catatonia
Less than 1 month
Unknown
Schizophreniform disorder Various psychotic symptoms, such as delusions, hallucinations, disorganized speech, restricted or inappropriate affect, and catatonia
1 to 6 months
0.2%
Schizoaffective disorder Marked symptoms of both schizophrenia and a major depressive episode or a manic episode
6 months or more
Unknown
Delusional disorder Persistent delusions that are not bizarre and not due to schizophrenia; persecutory, jealous, grandiose, and somatic delusions are common
1 month or more
0.1%
Psychotic disorder due to another medical condition
Hallucinations, delusions, or disorganized speech caused by a medical illness or brain damage
No minimum length
Unknown
Substance/medication- induced psychotic disorder
Hallucinations, delusions, or disorganized speech caused directly by a substance, such as an abused drug
No minimum length
Unknown
(Information from: APA, 2013.)
Schizophrenia : 387
(Kennedy et al., 2014). In addition, people with schizophre- nia have an increased risk of suicide and of physical—often fatal—illness (Dickerson et al., 2014). On average, they live 20 fewer years than other people (Laursen et al., 2014).
Although schizophrenia appears in all socioeconomic groups, it is found more frequently at the lower economic levels (Burns, Tomita, & Kapadia, 2014; Sareen et al., 2011) (see Figure 12-1). This has led some theorists to believe that the stress of poverty is itself a cause of the disorder. How- ever, it could be that schizophrenia causes its sufferers to fall from a higher to a lower socioeconomic level or to remain poor because they are unable to function effectively. This is sometimes called the downward drift theory.
Equal numbers of men and women are diagnosed with schizophrenia. The average age of onset for men is 23 years, compared with 28 years for women (Lindenmayer & Khan, 2012). Almost 3 percent of all those who are divorced or separated suffer from schizophrenia sometime during their lives, compared with 1 percent of married people and 2 percent of people who remain single. Again, however, it is not clear whether marital problems are a cause or a result (Solter et al., 2004).
People have long shown great interest in schizophrenia, flocking to plays and movies that explore or exploit our fascination with the disorder. Yet, as you will read, all too many people with schizophrenia are neglected in our country, their needs almost entirely ignored. Although effective interventions have been devel- oped, those sufferers live without adequate treatment and may never fully fulfill their potential as human beings.
The Clinical Picture of Schizophrenia The symptoms of schizophrenia vary greatly from sufferer to sufferer, and so do its triggers, course, and responsiveness to treatment (APA, 2013). In fact, a number of clinicians believe that schizophrenia is actually a group of distinct disorders that happen to have some features in common (Boutros et al., 2014). Regardless of whether schizophrenia is a single disorder or several disorders, the lives of people who struggle with its symptoms are filled with pain and turmoil.
What Are the Symptoms of Schizophrenia? Think back to Laura and Richard, the two people described at the beginning of the chapter. Both of them deteriorated from a normal level of functioning to become ineffective in dealing with the world. Each had some of the symptoms found in schizophrenia. The symptoms can be grouped into three categories: positive symptoms (excesses of thought, emotion, and behavior), negative symptoms (deficits of thought, emotion, and behavior), and psychomotor symptoms (unusual movements or gestures). Some people with schizophrenia are more dominated by positive symptoms and others by negative symptoms, although most tend to have both kinds of symptoms to some degree. In addition, around half of those with schizophrenia have significant difficulties with memory and other kinds of cognitive functioning (Ragland et al., 2015; Eich et al., 2014).
Positive Symptoms Positive symptoms are “pathological excesses,” or bizarre additions, to a person’s behavior. Delusions, disorganized thinking and speech, heightened perceptions and hallucinations, and inappropriate affect are the ones most often found in schizophrenia.
Below $20,000
Above $70,000
$20,000– $40,000
$40,000– $70,000
Annual Prevalence of Schizophrenia
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figure 12-1 Socioeconomic class and schizophrenia Poor people in the United States are more likely than wealthy people to experience schizophrenia. (Information from: Sareen et al., 2011.)
▶▶ schizophrenia A psychotic dis- order in which personal, social, and occupational functioning deteriorate as a result of unusual perceptions, odd thoughts, disturbed emotions, and motor abnormalities.
▶▶ psychosis A state in which a person loses contact with reality in key ways.
▶▶ positive symptoms Symptoms of schizophrenia that seem to be excesses of or bizarre additions to normal thoughts, emotions, or behaviors.
: chapter 12388
Delusions Many people with schizophrenia develop delusions, ideas that they believe wholeheartedly but that have no basis in fact. Some people hold a single delusion that dominates their lives and behavior; others have many delusions. Delusions of persecution are the most common in schizophrenia (APA, 2013). People with such delusions believe they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized. Laura believed that her neighbors were trying to irritate her and that other people were trying to harm her and her husband.
People with schizophrenia may also have delusions of reference: they attach special and personal meaning to the actions of others or to various objects or events. Richard, for example, interpreted arrows on street signs as indicators of the direction he should take. People with delusions of grandeur believe themselves to be great inventors, religious saviors, or other specially empowered persons. And those with delusions of control believe their feelings, thoughts, and actions are being controlled by other people.
DisorganizeD Thinking anD speech People with schizophrenia may not be able to think logically (Briki et al., 2014) and may speak in peculiar ways (Millier et al., 2014). These formal thought disorders can cause the sufferer great confusion and make communication extremely difficult. Often such thought disorders take the form of positive symptoms (pathological excesses), as in loose associations, neolo- gisms, perseveration, and clang.
People who have loose associations, or derailment, the most common formal thought disorder, rapidly shift from one topic to another, believing that their inco- herent statements make sense. A single, perhaps unimportant word in one sentence becomes the focus of the next. One man with schizophrenia, asked about his itchy arms, responded:
The problem is insects. My brother used to collect insects. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number. I also like to dance, draw, and watch television.
Some people with schizophrenia use neologisms, made-up words that typically have meaning only to the person using them. One person said, for example, “I am here from a foreign university . . . and you have to have a ‘plausity’ of all acts of amendment to go through for the children’s code . . . it is an ‘amorition’ law . . . the children have to have this ‘accentuative’ law so they don’t go into the ‘mortite’ law of the church” (Vetter, 1969, p. 189). Others may have the formal thought disorder of perseveration, in which they repeat their words and statements again and again. Finally, some use clang, or rhyme, to think or express themselves. When asked how he was feeling, one man replied, “Well, hell, it’s well to tell.” Another described the weather as “So hot, you know it runs on a cot.” Research suggests that some people may have disorganized speech or thinking long before their full pattern of schizo- phrenia unfolds (Remington et al., 2014; Covington et al., 2005).
heighTeneD percepTions anD hallucinaTions The perceptions and attention of some people with schizophrenia seem to intensify (Rossi-Arnaud et al., 2014). The persons may feel that their senses are being flooded by all the sights and sounds that surround them (Galderisi et al., 2014). This makes it almost impossible for them to attend to anything important. Such problems may develop years before the onset of
philosopher Friedrich Nietzsche
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is the rule." What did he mean?
Delusions of grandeur In 1892, an artist who was a patient at a mental hospital claimed credit for this painting, Self-Portrait as Christ. Although few people with schizophrenia have his artistic skill, a number have similar delusions of grandeur.
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Famous, but rare, delusion In the MTV show Teen Wolf, a possessed man cries out in terror as his body changes into that of a wolf. Lycanthropy, the delusion of being an animal, is a rare psychological syndrome, but it has been the subject of many profitable books, movies, and TV shows over the years.
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Schizophrenia : 389
the actual disorder (Remington et al., 2014). It is possible that these prob- lems further contribute to the memory impairments that are common to many people with schizophrenia (Ordemann et al., 2014).
Another kind of perceptual problem in schizophrenia consists of hallucinations, perceptions that a person has in the absence of external stimuli (see InfoCentral on the next page). People who have auditory hal- lucinations, by far the most common kind in schizophrenia, hear sounds and voices that seem to come from outside their heads. The voices may talk directly to the hallucinator, perhaps giving commands or warning of dangers, or they may be experienced as overheard.
Research suggests that people with auditory hallucinations actually produce the nerve signals of sound in their brains, “hear” them, and then believe that external sources are responsible (Chun et al., 2014; Sarin & Wallin, 2014). One study instructed six men with schizophrenia to press a button whenever they had an auditory hallucination (Silbersweig et al., 1995). PET scans revealed increased activity near the surfaces of their brains, in the tissues of the auditory cortex, the brain’s hearing center, when they pressed the button.
Hallucinations can also involve any of the other senses. Tactile hallucinations may take the form of tingling, burning, or electric-shock sensations. Somatic hal- lucinations feel as if something is happening inside the body, such as a snake crawl- ing inside one’s stomach. Visual hallucinations may produce vague perceptions of colors or clouds or distinct visions of people or objects. People with gustatory hallucinations regularly find that their food or drink tastes strange, and people with olfactory hallucinations smell odors that no one else does, such as the smell of poison or smoke.
Hallucinations and delusional ideas often occur together (Cutting, 2015; Shiraishi et al., 2014). A woman who hears voices issuing commands, for example, may have the delusion that the commands are being placed in her head by someone else. Whatever the cause and whichever comes first, the hallucination and delusion eventually feed into each other.
I thought the voices I heard were being transmitted through the walls of my apart- ment and through the washer and dryer and that these machines were talking and telling me things. I felt that the government agencies had planted transmitters and receivers in my apartment so that I could hear what they were saying and they could hear what I was saying.
(Anonymous, 1996, p. 183)
inappropriaTe affecT Many people with schizophrenia display inappropriate affect, emotions that are unsuited to the situation (Taylor et al., 2014; Gard et al., 2011). They may smile when making a somber statement or upon being told ter- rible news, or they may become upset in situations that should make them happy. They may also undergo inappropriate shifts in mood. During a tender conversa- tion with his wife, for example, a man with schizophrenia suddenly started yelling obscenities at her and complaining about her inadequacies.
In at least some cases, these emotions may be merely a response to other features of the disorder. Consider a woman with schizophrenia who smiles when told of her husband’s serious illness. She may not actually be happy about the news; in fact, she may not be understanding or even hearing it. She could, for example, be responding instead to another of the many stimuli flooding her senses, perhaps a joke coming from an auditory hallucination.
▶▶ delusion A strange false belief firmly held despite evidence to the contrary.
▶▶ formal thought disorder A distur- bance in the production and organization of thought.
▶▶ hallucination The experiencing of sights, sounds, or other perceptions in the absence of external stimuli.
▶▶ inappropriate affect Displays of emotions that are unsuited to the situa- tion; a symptom of schizophrenia.
The human brain during hallucinations This PET scan, taken at the moment a patient was having auditory hallucinations, shows heightened activity (yellow-orange) in Broca’s area, a brain region that helps people pro- duce speech, and in the auditory cortex, the brain area that helps people hear sounds (Silbersweig et al., 1995). Conversely, the front of the brain, which is responsible for determin- ing the source of sounds, was quiet during the hallucinations. Thus people who are hallucinat- ing seem to hear sounds produced by their own brains, but their brains cannot recognize that the sounds are actually coming from within (Juckel, 2014).
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Motor cortex Auditory areas Visual areas Cerebellum
HALLUCINATIONS Hallucinations are the experiencing of sights, sounds, smells, and other perceptions that occur in the absence of external stimuli.
TYPES OF HALLUCINATIONS AUDITORY HALLUCINATIONS: Sounds and voices that seem to come from outside of the head.
TACTILE HALLUCINATIONS: Perceptions of tingling, burning, or electric-shock sensations.
OLFACTORY HALLUCINATIONS: Odors that no one else smells, such as the smell of poison or smoke.
SOMATIC HALLUCINATIONS: Feelings that something is happening inside the body, such as a snake crawling inside one’s stomach.
VISUAL HALLUCINATIONS: Vague perceptions of colors or clouds, or distinct visions of people or objects.
GUSTATORY HALLUCINATIONS: Food or drink tastes strange on a regular basis.
27% delirium (visual type)
25% Alzheimer’s (visual and auditory types)
20% vision impairment (visual type)
20% hearing impairment (auditory type)
20% loss of smell (olfactory type)
10% migraines (visual and olfactory types)
Hallucinations are also experienced by people with:
BRAIN EXPLANATIONS FOR AUDITORY HALLUCINATIONS ABNORMAL ACTIVATION of the primary auditory cortex.
FAILURE to recognize internally generated speech as one’s own. Cross- activation with the auditory areas, so what most people experience as thoughts become “voiced.”
ABNORMAL ATTENTION to the subvocal stream that accompanies verbal˜thinking.
MUSICAL HALLUCINATIONS result from activation of the brain network involving auditory areas, the motor cortex, visual areas, basal ganglia, cerebellum, hippocampus, and amygdala.
HALLUCINATIONS OVER THE AGES
Ancient times: Attributed to gifts from the gods or the Muses.
Prior to 18th century: Caused by supernatural forces, such as gods or demons, angels or djinns.
Middle of 18th century: Caused by the overactivity of certain centers in the brain.
1990s: Resulting from a network of cortical and subcortical areas.
(Sachs, 2012; Shergill et al., 2000)
(AFA, 2014; Mandal, 2014; Sacks, 2012; Knott, 2011; Norton, 2011; Frey, 2005)
ILLUSIONS – Distorted or misinterpreted real perceptions
IMAGERY – Under voluntary control and does not mimic real perception
DREAMING – Occurs when person is asleep
PSEUDOHALLUCINATIONS – Internally triggered, vivid perceptions that are recognized by individual as unreal, and partly under voluntary control
HALLUCINATIONS CAN BE “NORMAL” Many people experience hallucinations that are unrelated to disorders or substance ingestion. These hallucinations...
—affect as many as 10–15% of the population
—occur every 3 days, on average
—last for 2–3 minutes
—can be controlled around 60% of the time
—cause little distress or disruption, unless misinterpreted (de Leede-Smith and Barkus, 2013; Dallman & Hellhammer, 2011)
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Negative Symptoms Negative symptoms are those that seem to be “pathological deficits,” characteristics that are lacking in a person. Poverty of speech, restricted affect, loss of volition, and social withdrawal are commonly found in schizophrenia (Azorin et al., 2014; Rocca et al., 2014). Such deficits greatly affect one’s life and activities.
poverTy of speech People with schizophrenia often have alogia, or poverty of speech, a reduction in speech or speech content. Some people with this negative kind of formal thought disorder think and say very little. Others say quite a bit but still manage to convey little meaning (Haas et al., 2014).
resTricTeD affecT Many people with schizophrenia have a blunted affect—they show less anger, sadness, joy, and other feelings than most people (Rocca et al., 2014). And some show almost no emotions at all, a condition known as flat affect. Their faces are still, their eye contact is poor, and their voices are monotonous. In some cases, people with these problems may have anhedonia, a general lack of pleasure or enjoyment. In other cases, however, the restricted affect may reflect an inability to express emotions as others do. One study had participants view very emotional film clips. The participants with schizophrenia showed less facial expression than the others; however, they reported feeling just as much positive and negative emotion and in fact displayed more skin arousal (Kring & Neale, 1996).
loss of voliTion Many people with schizophrenia experience avolition, or apathy, feeling drained of energy and of interest in normal goals and unable to start or follow through on a course of action (Gard et al., 2014; Gold et al., 2014). This problem is particularly common in people who have had schizophrenia for many years, as if they have been worn down by it. Similarly, people with schizophrenia may feel ambivalence, or conflicting feelings, about most things. The avolition and ambivalence of Richard, the young man you read about earlier, made eating, dress- ing, and undressing impossible ordeals for him.
social WiThDraWal People with schizophrenia may withdraw from their social envi- ronment and attend only to their own ideas and fantasies (Gard et al., 2014; Pinkham, 2014). Because their ideas are illogical and confused, the withdrawal has the effect of distancing them still further from reality. The social withdrawal seems also to lead to a breakdown of social skills, including the ability to recognize other people’s needs and emotions accurately (Fogley et al., 2014; Lysaker et al., 2014).
Psychomotor Symptoms People with schizophrenia sometimes experience psychomotor symptoms, for example, awkward movements or repeated grimaces and odd gestures that seem to have a private purpose—perhaps ritualistic or magical (Grover et al., 2015; Stegmayer et al., 2014). The psychomotor symptoms of schizo- phrenia may take certain extreme forms, collectively called catatonia.
People in a catatonic stupor stop responding to their environment, remaining motionless and silent for long stretches of time. Recall how Richard would lie motionless and mute in bed for days. People with catatonic rigidity maintain a rigid, upright posture for hours and resist efforts to be moved. Still others exhibit catatonic posturing, assuming awkward, bizarre positions for long periods of time. Finally, people with catatonic excitement, a different form of catatonia, move excitedly, some- times wildly waving their arms and legs.
What Is the Course of Schizophrenia? Schizophrenia usually first appears between the person’s late teens and mid-thirties (Häfner, 2015; Lindenmayer & Khan, 2012). Although its course varies widely from case to case, many sufferers seem to go through three phases—prodromal, active, and residual (Fukumoto et al., 2014). During the prodromal phase, symptoms are
▶▶ negative symptoms Symptoms of schizophrenia that seem to be deficits in normal thought, emotions, or behaviors.
▶▶ alogia A decrease in speech or speech content; a symptom of schizophrenia. Also known as poverty of speech.
▶▶ catatonia A pattern of extreme psycho motor symptoms, found in some forms of schizophrenia, which may include catatonic stupor, rigidity, or posturing.
“Is there anybody out there?” Schizo- phrenia is often depicted in positive terms in the arts. Pink Floyd’s hugely popular album and movie The Wall, for example, portrays the dis- order as a social withdrawal and inward search undertaken by some people to cure them- selves of confusion and unhappiness caused by society. Here former Pink Floyd band member Roger Waters tries to break down the societal wall during a recent concert.
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not yet obvious, but the person is beginning to deteriorate. He or she may withdraw socially, speak in vague or odd ways, develop strange ideas, or express little emotion. During the active phase, symptoms become apparent. Sometimes this phase is triggered by stress or trauma in the person’s life. For Laura, the middle-aged woman described earlier, the immediate trigger was the loss of her cherished dog. Finally, many people with schizophrenia eventually enter a residual phase in which they return to a prodromal-like level of functioning. They may retain some negative symptoms, such as blunted emotion, but have a lessening of the striking symptoms of the active phase. Although 25 percent or more of patients recover completely from schizophrenia, the majority continue to have at least some residual problems for the rest of their lives (an der Heiden & Häfner, 2011).
A fuller recovery from schizophrenia is more likely in people who functioned quite well before the disorder; whose disorder is triggered by stress, comes on abruptly, or develops during middle
age; and who receive early treatment (Remberk et al., 2015). Relapses are apparently more likely during times of life stress (Bebbington & Kuipers, 2011).
Many researchers believe that in order to help predict the course of schizophre- nia, there should be a distinction between so-called Type I and Type II schizophrenia. People with Type I schizophrenia are thought to be dominated by positive symptoms, such as delusions, hallucinations, and certain formal thought disorders (Crow, 2008, 1995, 1985, 1980). Those with Type II schizophrenia have more negative symptoms, such as restricted affect, poverty of speech, and loss of volition. Type I patients gen- erally seem to have been better adjusted prior to the disorder, to have later onset of symptoms, and to be more likely to show improvement, especially when treated with medications (Corves et al., 2014; Blanchard et al., 2011). In addition, as you will soon see, the positive symptoms of Type I schizophrenia may be linked more closely to biochemical abnormalities in the brain, while the negative symptoms of Type II schizophrenia may be tied largely to structural abnormalities in the brain.
➤ Summing Up The CliniCAl PiCTure of SChizoPhreniA Schizophrenia is a disorder in which functioning deteriorates as a result of disturbed thought processes, dis- torted perceptions, unusual emotions, and motor abnormalities. Approximately 1 percent of the world’s population suffers from this disorder. The symptoms of schizophrenia fall into three groupings. Positive symptoms include delusions, certain formal thought disorders, hallucinations and other disturbances in per- ception and attention, and inappropriate affect. Negative symptoms include poverty of speech, restricted affect, loss of volition, and social withdrawal. Schizophrenia may also include psychomotor symptoms, collectively called catatonia in their extreme form. Schizophrenia usually emerges during late adolescence or early adulthood and tends to progress through three phases: prodromal, active, and residual.
How Do Theorists Explain Schizophrenia? As with many other kinds of disorders, biological, psychological, and sociocultural theorists have each proposed explanations for schizophrenia. So far, the biologi- cal explanations have received by far the most research support. This is not to say that psychological and sociocultural factors play no role in the disorder. Rather, a
A catatonic pose These patients, photo- graphed in the early 1900s, show features of catatonia, including catatonic posturing, in which they assume bizarre positions for long periods of time.
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In Their Words “What’s so great about reality?”
person with schizophrenia, 1988
Schizophrenia : 393
diathesis-stress relationship may be at work: people with a biological predisposition will develop schizophrenia only if certain kinds of events or stressors are also present. Similarly, a diathesis-stress relationship often seems to be operating in the develop- ment of other kinds of psychotic disorders (see PsychWatch on the next page).
Biological Views Perhaps the most enlightening research on schizophrenia during the past several decades has come from genetic and biological investigations. These studies have revealed the key roles of inheri- tance and brain activity in the development of schizophrenia and have opened the door to important treatment changes.
Genetic Factors Following the principles of the diathesis- stress perspective, genetic researchers believe that some people inherit a biological predisposition to schizophrenia and develop the disorder later when they face extreme stress, usually during late adolescence or early adulthood (Pocklington et al., 2014). The genetic view has been supported by studies of (1) relatives of people with schizophrenia, (2) twins with schizophrenia, (3) people with schizophrenia who are adopted, and (4) genetic linkage and molecular biology.
are relaTives vulnerable? Family pedigree studies have found repeatedly that schizophrenia and schizophrenia-like brain abnormalities are more common among relatives of people with the disorder (Scognamiglio et al., 2014). And the more closely related the relatives are to the person with schizophrenia, the more likely they are to develop the disorder (see Figure 12-2).
is an iDenTical TWin More vulnerable Than a fraTernal TWin? Twins, who are among the closest of relatives, have in particular been studied by schizophrenia researchers. If both members of a pair of twins have a particular trait, they are said to be concordant for that trait. If genetic factors are at work
in schizophrenia, identical twins (who share all their genes) should have a higher concordance rate for schizophrenia than fraternal twins (who share only some genes). This expectation has been supported consis- tently by research (Higgins & George, 2007; Gottesman, 1991). Studies have found that if one identical twin develops schizophrenia,
there is a 48 percent chance that the other twin will do so as well. If the twins are fraternal, on the other hand, the second twin has approximately a 17 percent chance of developing the disorder.
are The biological relaTives of an aDopTee vulnerable? Adoption studies look at adults with schizophrenia who were adopted as infants and compare them with both their biological and their adoptive relatives. Because they were reared apart from their biological relatives, similar symptoms in those relatives would indicate genetic influences. Conversely, similarities to their adoptive relatives would suggest environmental influences. Researchers have repeatedly found that the bio- logical relatives of adoptees with schizophrenia are more likely than their adoptive relatives to develop schizophrenia or another schizophrenia spectrum disorder (Andreasen & Black, 2006; Kety, 1988, 1968).
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figure 12-2 family links People who are biologically related to someone with schizophrenia have a heightened risk of developing the disorder during their lifetimes. The closer the biologi- cal relationship (that is, the more similar the genetic makeup), the greater the risk of devel- oping the disorder. (Information from: Coon & Mitterer, 2007; Gottesman, 1991, p. 96.)
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WhaT Do geneTic linkage anD Molecular biology sTuDies suggesT? As with bipolar disorders (see Chapter 6), researchers have run studies of genetic linkage and molecular biology to pinpoint the possible genetic factors in schizophrenia (Singh et al., 2014). In one approach, they select large families in which schizophrenia is very common, take blood and DNA samples from all members of the families, and then compare gene fragments from members with and without schizophrenia. Applying this procedure to families from around the world, various studies have identified possible gene defects on chromosomes 1, 2, 6, 8, 10, 13, 15, 18, 20, and 22 and on the X chromosome, each of which may help predispose a person to develop schizophrenia (Huang et al., 2014; Müller, 2014).
PsychWatch
On the morning of June 20, 2001, the nation’s televi-sion viewers watched in horror as officials escorted 36-year-old Andrea Yates to a police car. Just minutes before, she had called police and ex- plained that she had drowned her five children in the bathtub because “they weren’t devel- oping correctly” and because she “realized [that she had not been] a good mother to them.” Homicide sergeant Eric Mehl described how she looked him in the eye, nodded, an- swered with a polite “Yes, sir” to many of his questions, and twice recounted the order in which the children had died: first 3-year-old Paul, then 2-year-old Luke, followed by 5-year- old John and 6-month-old Mary. She then described how she had had to drag 7-year-old Noah to the bathroom and how he had come up twice as he fought for air. Later she told doctors she wanted her hair shaved so she could see the num- ber 666—the mark of the Antichrist—on her scalp (Roche, 2002).
In Chapter 6 you read that as many as 80 percent of mothers experience “baby blues” soon after giving birth, while be- tween 10 and 30 percent display the clini- cal syndrome of postpartum depression. Yet another postpartum disorder that has become all too familiar to the public in recent times, by way of cases such as that of Andrea Yates, is postpartum psychosis (Engqvist et al., 2014).
Postpartum psychosis affects about 1 to 2 of every 1,000 mothers who have
recently given birth (Posmontier, 2010). The symptoms apparently are triggered by the enormous shift in hormone levels that takes place after delivery (Meinhard et al., 2014). Within days or at most a few months of childbirth, the woman develops signs of losing touch with reality, such as delusions (for example, she may become convinced that her baby is the devil); hallucinations (perhaps hearing voices); extreme anxiety, confusion, and disorien- tation; disturbed sleep; and illogical or chaotic thoughts (for example, thoughts about killing herself or her child).
Women with a history of bipolar dis- order, schizophrenia, or depression are particularly vulnerable to the disorder (Di Florio et al., 2014). Women who have previously experienced postpartum de- pression or postpartum psychosis have an increased likelihood of developing post- partum psychosis after subsequent births (Bergink et al., 2012; Nonacs, 2007).
Andrea Yates had developed signs of postpartum depres- sion (and perhaps postpartum psychosis) and had attempted suicide after the birth of her fourth child. At that time, however, she appeared to respond well to a combina- tion of medications, including antipsychotic drugs, and so she and her husband later de- cided to conceive a fifth child. Although they were warned that she was at risk for serious postpartum symptoms once again, they believed that the same combination of medica- tions would help if the symp-
toms were to recur (King, 2002). After the birth of her fifth child, the
symptoms did in fact recur, along with features of psychosis. Yates again at- tempted suicide. Although she was hospitalized twice and treated with vari- ous medications, her condition failed to improve. Six months after giving birth to Mary, her fifth child, she drowned all five of her children. Although only a fraction of women with postpartum psychosis ac- tually harm their children (estimates run as high as 4 percent), the Yates case re- minds us that such an outcome is possible (Posmontier, 2010) and that early detec- tion and treatment are critical (O’Hara & Wisner, 2014).
On July 26, 2006, after an initial con- viction for murder was overturned by an appeals court, Yates was found not guilty by reason of insanity and assigned to a state mental hospital, where she contin- ues to receive treatment today.
Postpartum Psychosis: The Case of Andrea Yates
Family tragedy In this undated photograph, Andrea Yates poses with her husband and four of the five children she later drowned.
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These varied findings may indicate that some of the suspected gene sites are cases of mistaken identity and do not actually contribute to schizophrenia. Alternatively, it may be that different kinds of schizophrenia are linked to different genes. It is most likely, however, that schizophrenia, like a number of other disorders, is a polygenic disorder, caused by a combination of gene defects (Purcell et al., 2014).
How might genetic factors lead to the development of schizophrenia? Research has pointed to two kinds of biological abnormalities that could conceivably be inherited—biochemical abnormalities and abnormal brain structure.
Biochemical Abnormalities As you have read, the brain is made up of neu- rons whose electrical impulses (or “messages”) are transmitted from one to another by neurotransmitters. After an impulse arrives at a receiving neuron, it travels down the axon of that neuron until it reaches the nerve ending. The nerve ending then releases neurotransmitters that travel across the synaptic space and bind to receptors on yet another neuron, thus relaying the message to the next “station.” This neuron activity is known as “firing.”
Over the past four decades, researchers have developed a dopamine hypothesis to explain their findings on schizophrenia: certain neurons that use the neurotrans- mitter dopamine fire too often and transmit too many messages, thus producing the symptoms of schizophrenia (Brisch et al., 2014; Düring et al., 2014). This hypothesis has undergone challenges and adjustments in recent years, but it is still the foundation for current biochemical explanations of schizophrenia (Rao & Remington, 2014). As you will see later in this chapter, the chain of events leading to this hypothesis began with the accidental discovery of antipsychotic drugs, medications that help remove the symptoms of schizophrenia. The first group of antipsychotic medications, the phenothiazines, was discovered in the 1950s by researchers who were looking for better antihistamine drugs to combat allergies. Although phenothiazines failed as antihistamines, it soon became obvious that they were effective in reducing schizophrenic symptoms, and clinicians began to pre- scribe them widely (Adams et al., 2014).
Researchers later learned that these early antipsychotic drugs often produce troublesome muscular tremors, symptoms that are identical to the central symptom of Parkinson’s disease, a disabling neurological illness. This undesired reaction to antipsychotic drugs offered the first important clue to the biology of schizophre- nia. Scientists already knew that people who suffer from Parkinson’s disease have abnormally low levels of the neurotransmitter dopamine in some areas of the brain and that lack of dopamine is the reason for their uncontrollable shaking. If antipsy- chotic drugs produce Parkinsonian symptoms in people with schizophrenia while removing their psychotic symptoms, perhaps the drugs reduce dopamine activity. And, scientists reasoned further, if lowering dopamine activity helps remove the symptoms of schizophrenia, perhaps schizophrenia is related to excessive dopamine activity in the first place.
Since the 1960s, research has supported and helped clarify the dopamine hypoth- esis. It has been found, for example, that some people with Parkinson’s disease develop schizophrenia-like symptoms if they take too much L-dopa, a medication that raises Parkinson’s patients’ dopamine levels (Brunelin et al., 2013). The L-dopa apparently raises the dopamine activity so much that it produces psychosis. Support has also come from research on amphetamines, drugs that, as you saw in Chapter 10, stimulate the central nervous system by increasing dopamine in the brain. Clinical investigators have observed that people who take high doses of amphetamines may develop amphetamine psychosis—a syndrome very similar to schizophrenia (Hawken & Beninger, 2014; Li et al., 2014).
Researchers have located areas of the brain that are rich in dopamine receptors and have found that phenothiazines and other antipsychotic drugs bind to many of these receptors (Yoshida et al., 2014). Apparently the drugs are dopamine antagonists— drugs
▶▶ dopamine hypothesis The theory that schizophrenia results from exces- sive activity of the neurotransmitter dopamine.
▶▶ antipsychotic drugs Drugs that help correct grossly confused or distorted thinking.
▶▶ phenothiazines A group of antihista- mine drugs that became the first group of effective antipsychotic medications.
B e t W e e N t h e L I N e S
Whose Brain Has the Most Neurons? Human 100,000,000,000 neurons
Octopus 300,000,000 neurons
Rat 21,000,000 neurons
Frog 16,000,000 neurons
Cockroach 1,000,000 neurons
Honey bee 850,000 neurons
Fruit fly 100,000 neurons
Ant 10,000 neurons
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that bind to dopamine receptors, prevent dopamine from binding there, and so prevent the neurons from firing. Researchers have identified five kinds of dopamine receptors in the brain—called the D-1, D-2, D-3, D-4, and D-5 receptors—and have found that phenothiazines bind most strongly to the D-2 receptors (Chun et al., 2014).
These and related findings suggest that in schizophrenia, messages traveling from dopamine-sending neurons to dopamine receptors on other neurons, particularly to the D-2 receptors, may be transmitted too easily or too often. This theory is appealing because certain dopamine neurons are known to play a key role in guid- ing attention (Brisch et al., 2014). People whose attention is severely disturbed by excessive dopamine activity might well be expected to suffer from the problems of attention, perception, and thought found in schizophrenia (see MindTech).
MindTech
Can Computers Develop Schizophrenia? One of the leading explanations for schizophrenia holds that people with this disorder are overwhelmed by the stimuli around them. According to this theory, excessive dopamine floods the brains of people with schizophre-
nia, leading them to process stimulus information at too high a rate. They are unable to disregard extraneous sensory information, which leads to a process dubbed
“hyperlearning.” As a result of hyperlearning, people with schizo- phrenia cannot distinguish between reality and illusion or recognize the barriers between unrelated pieces of information or unrelated experiences (Boyle, 2011).
Researchers in the computer science department at the University of Texas at Austin created a study to test the hyperlearning theory (Hoffman et al., 2011). They built a computer neural network they called DISCEN and programmed it to store information in ways that parallel the ways the human brain organizes words, sentences, and other bits of information into knowledge and memories. The researchers then simulated the effects of a dopamine flood by pro- gramming the computer system to process information at a faster
and faster rate, while at the same time programming it to ignore less and less data. The researchers reported that after DISCEN had finished being reprogrammed,
it began to display patterns of functioning that were similar to those found in people with schizophrenia. For example, while retelling stories that it had been programmed to recall, DISCEN began to place itself at the center of the retell- ing, often telling fantastical, delusional stories. In one instance, for example, the computer claimed that it had been responsible for a terrorist bombing. The researchers further found that the computer’s delusional stories were similar to those produced by human participants with schizophrenia after they had been given similar pieces of information.
This study may bring to mind the famous film 2001: A Space Odyssey, in which a computer named “HAL,” with the capacity for artificial intelligence, develops a mental disorder when presented with orders that it could not logically reconcile. Of course, HAL’s actions in that film still remain the stuff of science fiction, and the University of Texas study provides, at most, limited support for the hyperlearning model of schizophrenia.
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“Dave, my mind is going.” These are the words spoken by the brilliant computer HAL (shown at right) to his colleague Dave Bowman, one of the astronauts aboard the Discovery One spacecraft in Stanley Kubrick’s movie 2001: A Space Odyssey.
MGM/Photofest
▶▶ second-generation antipsychotic drugs A relatively new group of antipsy- chotic drugs whose biological action is different from that of the traditional anti- psychotic drugs. Also known as atypical antipsychotic drugs.
Schizophrenia : 397
Though enlightening, the dopamine hypothesis has certain prob- lems. The biggest challenge to it has come with the relatively recent discovery of a new group of antipsychotic drugs, initially referred to as atypical antipsychotic drugs and now called second-generation antipsychotic drugs, which are often more effective than the tradi- tional ones. The new drugs bind not only to D-2 dopamine receptors, like the traditional antipsychotic drugs, but also to many D-1 and D-4 receptors and to receptors for other neurotransmitters such as serotonin (Waddington et al., 2011). Thus, it may be that schizophrenia is related to abnormal activity or interactions of both dopamine and other neurotransmitters, rather than to abnormal dopamine activity alone (Hashimoto, 2014; Juckel, 2014).
Abnormal Brain Structure During the past decade, researchers have also linked schizophrenia, particularly cases dominated by nega- tive symptoms, to abnormalities in brain structure (Millan et al., 2014; Shinto et al., 2014). Using brain scans, they have found, for example, that many people with schizophrenia have enlarged ventricles—the brain cavities that contain cerebrospinal fluid (Hartberg et al., 2011).
It may be that enlarged ventricles are actually a sign that nearby parts of the brain have not developed properly or have been damaged, and perhaps these problems are the ones that help produce schizophrenia. In fact, studies suggest that some patients with schizophrenia also have smaller temporal and frontal lobes than other people, smaller amounts of cortical white and gray matter, and, perhaps most importantly, abnormal blood flow—either reduced or heightened—in certain areas of the brain (Lener et al., 2015; Kochunov & Hong, 2014). Still other studies have linked schizo- phrenia to abnormalities of the hippocampus, amygdala, and thalamus, among other brain structures (Arnold et al., 2014; Markota et al., 2014) (see Figure 12-3).
Viral Problems What might cause the biochemical and structural abnormalities found in many cases of schizophrenia? Various studies have pointed to genetic fac- tors, poor nutrition, fetal development, birth complications, immune reactions, and toxins (Avramopoulos et al., 2015; Clarke et al., 2012). In addition, some investiga- tors suggest that the brain abnormalities may result from exposure to viruses before birth. Perhaps the viruses enter the fetus’ brain and interrupt proper brain develop- ment, or perhaps the viruses remain quiet until puberty or young adulthood, when, activated by changes in hormones or by another viral infection, they help to bring about schizophrenic symptoms (Brown, 2012; Fox, 2010; Torrey, 2001, 1991).
Some of the evidence for the viral theory comes from animal model investigations, and other evidence is circumstantial, such as the finding that an unusually large number of people with schizophrenia are born during the winter (Patterson, 2012). The winter birth rate among people with schizophrenia is 5 to 8 per- cent higher than among other people (Harper & Brown, 2012; Tamminga et al., 2008). This could be because of an increase in fetal or infant exposure to viruses at that time of year. More direct evidence comes from studies showing that mothers of people with schizophrenia were more likely to have been exposed to the influ- enza virus during pregnancy than were mothers of people without schizophrenia (Canetta et al., 2014). And, finally, studies have found antibodies to certain viruses in the blood of 40 percent of research participants with schizophrenia (Leweke et al., 2004; Torrey et al., 1994). The presence of such antibodies suggests that these people had at some time been exposed to those particular viruses.
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figure 12-3 Biology of schizophrenia Some studies show that people with schizophrenia have relatively small temporal and frontal lobes, as well as abnormalities in brain structures such as the hippocampus, amygdala, and thalamus.
Not-so-identical twins The man on the left does not have schizophrenia, while his identical twin, on the right, does. Magnetic resonance imaging (MRI), shown in the background, clarifies that the brain of the twin with schizo- phrenia is smaller overall than his brother’s and has larger ventricles, indicated by the dark, butterfly-shaped spaces.
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Together, the biochemical, brain structure, and viral findings are shedding much light on the mysteries of schizophrenia. At the same time, it is important to rec- ognize that many people who have these biological abnormalities never develop schizophrenia. Why not? Possibly, as you read earlier, because biological factors merely set the stage for schizophrenia, while key psychological and sociocultural factors must be present for the disorder to appear.
Psychological Views When schizophrenia investigators began to identify genetic and biological factors during the 1950s and 1960s, many clinicians abandoned the psychological theories of the disorder. During recent decades, however, the tables have been turned and psychological factors are once again being considered as important pieces of the schizophrenia puzzle (Green et al., 2014). The most prominent psychological theo- ries come from the psychodynamic and cognitive perspectives.
The Psychodynamic Explanation In the middle of the twentieth century, noted psychodynamic clinician Frieda Fromm-Reichmann (1948) elaborated on an earlier notion by Sigmund Freud (1924, 1915, 1914) that cold or unnurturing parents may set schizophrenia in motion. Fromm-Reichmann described the mothers of people who develop the disorder as cold, domi- neering, and uninterested in their children’s needs. She claimed that these mothers may appear to be self-sacrificing but are actually using their children to meet their own needs. At once overprotective and rejecting, they confuse their children and set the stage for schizophrenic functioning. She called them schizophrenogenic (schizophrenia-causing) mothers. Fromm-Reichmann’s theory has received little research support (Harrington, 2012; Willick, 2001). In fact, the majority of people with schizophrenia do not appear to have mothers who fit the schizophrenogenic description.
The Cognitive Explanation A leading cognitive explanation of schizo- phrenia is congruent with the biological view that during hallucinations and related perceptual difficulties, the brains of people with schizophrenia are actually producing strange and unreal sensations—sensations triggered by biological factors. According to the cognitive explanation, when people attempt to understand these unusual experiences, more features of their disorder emerge (Howes & Murray, 2014). When first confronted by voices or other troubling sensations, the individuals turn to friends and relatives. Naturally, the friends and relatives deny the reality of
the sensations, and eventually the sufferers conclude that the others are trying to hide the truth. They begin to reject all feedback, and some develop beliefs (delusions) that they are being persecuted (Howes & Murray, 2014). In short, according to this theory, people with schizophrenia take a “rational path to madness” (Zimbardo, 1976). This process of drawing incorrect and bizarre conclusions (delusions) may be helped along by a cognitive bias that many people with schizophrenia have—a tendency to jump to conclu- sions (Sarin & Wallin, 2014).
Researchers have established that people with schizophrenia do indeed experience sensory and perceptual problems. As you saw ear- lier, many have hallucinations and most have trouble keeping their attention focused. But researchers have yet to provide clear, direct support for the cognitive notion that misinterpretations of such sensory problems actually produce a syndrome of schizophrenia.
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Paternal Impact People whose fathers were over 50 years of age when they were born are more likely to develop schizophre- nia than people who are born to fathers under 50 years old (Crystal et al., 2012; Petersen et al., 2011). Various explana- tions, both biological and psychological, have been offered for this relation- ship, but researchers have yet to make sense of it.
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Sociocultural Views Sociocultural theorists, recognizing that people with men- tal disorders are subject to a wide range of social and cul- tural forces, believe that multicultural factors, social labeling, and family dysfunctioning all contribute to schizophrenia. Research has yet to clarify what the precise causal relation- ships might be.
Multicultural Factors Rates of schizophrenia appear to differ between racial and ethnic groups, particularly between African Americans and white Americans (Singh & Kunar, 2010). As many as 2.1 percent of African Ameri- cans receive a diagnosis of schizophrenia, compared with around 1.4 percent of white Americans (Lawson, 2008; Folsom et al., 2006). Similarly, studies suggest that African Americans with schizophrenia are overrepresented in state hospitals (Durbin et al., 2014; Barnes, 2004). For example, in Tennessee’s state hospitals, 48 percent of those with a diagnosis of schizophrenia are African American, although only 16 percent of the state population is African American.
It is not clear why African Americans are more likely than white Americans to receive this diagnosis. One possibility is that African Americans are more prone to develop schizophrenia. Another is that clinicians from majority groups are unin- tentionally biased in their diagnoses of African Americans or misread cultural dif- ferences as symptoms of schizophrenia.
Yet another explanation for the difference between African Americans and white Americans may lie in the economic sphere. On average, African Americans are more likely than white Americans to be poor; when economic differences are controlled
for, the prevalence rates of schizophrenia become closer for the two racial groups. Consistent with the economic explanation is the finding that Hispanic Americans, who also tend to be economically disad- vantaged, appear to be much more likely to be diagnosed with schizophrenia than
white Americans, although their diagnostic rate is not as high as that of African Americans (Blow et al., 2004).
It also appears that schizophrenia differs from country to country in key ways ( Johnson et al., 2014; McLean et al., 2014). Although the overall prevalence of this disorder is stable—around 1 percent—in countries across the world, the course and outcome of the disorder may vary considerably. According to a 10-country study conducted by the World Health Organization (WHO), the 25 million schizo- phrenic patients who live in developing countries have better recovery rates than schizophrenic patients in Western and other developed countries (Vahia & Vahia, 2008; Jablensky, 2000). During the course of the two-year study, the schizophrenic patients from developing countries (Columbia, India, and Nigeria) were more likely than those in developed countries (the Czech Republic, Denmark, Ireland, Japan, Russia, the United Kingdom, and the United States) to recover from their disorder and less likely to have continuous symptoms, impaired social functioning, or require heavy antipsychotic drugs or hospitalization.
Some theorists believe that the psychosocial environments of developing coun- tries tend to be more supportive and therapeutic than those of developed countries, leading to more favorable outcomes for people with schizophrenia (Vahia & Vahia, 2008; Jablensky, 2000). In developing countries, for example, there may be more
▶▶ schizophrenogenic mother A type of mother—supposedly cold, domineer- ing, and uninterested in the needs of her children—who was once thought to cause schizophrenia in her child.
Coming together Different countries and cultures each have their own way of viewing and interacting with schizophrenic people and those with other mental disturbances. Here patients and members of the community come together and dance during the annual Carnival parade in front of the Psychiatric Institute in Rio de Janeiro, Brazil.
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family and social support for people with schizophrenia; more relatives and friends available to help care for such people; and less judgmental, critical, and hostile attitudes toward people with schizophrenia. The Nigerian culture, for example, is gen- erally more tolerant of the presence of voices than are Western cultures (Matsumoto & Juang, 2008).
Social Labeling Many sociocultural theorists believe that the features of schizophrenia are influenced by the diag- nosis itself. In their opinion, society assigns the label “schizo- phrenic” to people who fail to conform to certain norms of behavior. Once the label is assigned, justified or not, it becomes a self-fulfilling prophecy that promotes the devel- opment of many schizophrenic symptoms (Omori, Mori, & White, 2014).
We have already seen the very real dangers of diagnostic labeling. In the famous Rosenhan (1973) study, discussed in
Chapter 2, eight normal people presented themselves at various mental hospitals, complaining that they had been hearing voices utter the words “empty,” “hollow,” and “thud.” They were quickly diagnosed as schizophrenic, and all eight were hos- pitalized. Although the pseudopatients then dropped all symptoms and behaved normally, they had great difficulty getting rid of the label and gaining release from the hospital.
The pseudopatients reported that staff members were authoritarian in their behaviors toward patients and also treated them as though they were invisible. “A nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn’t notice us.” In addition, the pseudopatients described feeling powerless, bored, tired, and uninterested. The deceptive design and possible implications of this study have aroused the emotions of clinicians and researchers, pro and con. The investigation does demonstrate, however, that the label “schizo- phrenic” can itself have a negative effect not just on how people are viewed but also on how they themselves feel and behave.
Family Dysfunctioning Many studies suggest that schizo- phrenia, like a number of other mental disorders, is often linked to family stress (Cullen et al., 2014; Quah, 2014). Parents of people with schizophrenia often (1) display more conflict, (2) have more diffi- culty communicating with one another, and (3) are more critical of and overinvolved with their children than other parents.
Family theorists have long recognized that some families are high in expressed emotion—that is, members frequently express criticism, disapproval, and hostility toward each other and intrude on one another’s privacy. People who are trying to recover from schizo- phrenia are almost four times more likely to relapse if they live with such a family than if they live with one low in expressed emotion (Koutra et al., 2015; Okpokoro et al., 2014). Do such findings mean that family dysfunctioning helps cause and maintain schizophrenia? Not necessarily. It is also the case that people with schizophrenia greatly disrupt family life (Friedrich et al., 2015). In so doing, they themselves may help produce the family problems that clinicians and researchers continue to observe (Hsiao et al., 2014).
What’s in a name? The British band Mad- ness entertains an audience in Italy in 2012, just as they have entertained millions of fans during their four decades of performing. Some social critics worry that band names like Mad- ness, Bad Brains, the Insane Clown Posse, the Schizos, and Bark Psychosis serve to trivialize or romanticize the plight of people with schizo- phrenia and other psychotic disorders.
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Although the sociocultural causes of schizophrenia, like the psychological causes, have yet to be fully understood, many clinicians currently believe that such factors play an important role in the disorder. As you have seen, most hold a diathesis-stress view of schizophrenia, believing that biological factors set up a predisposition to the disorder, but that certain kinds of personal, family, or social stress are further needed for the syndrome to spring to life.
➤ Summing Up how Do TheoriSTS exPlAin SChizoPhreniA? The biological explanations of schizophrenia point to genetic, biochemical, structural, and viral causes. The genetic view is supported by studies of relatives, twins, adoptees, genetic link- age, and molecular biology. The leading biochemical explanation holds that the brains of people with schizophrenia experience excessive dopamine activity. Brain-imaging techniques have also detected abnormal brain structures in many people with schizophrenia. Finally, some researchers believe that schizophrenia is related to a virus that settles in the fetus.
The most prominent psychological explanations for schizophrenia come from the psychodynamic and cognitive models. In a once-influential psychody- namic explanation, Fromm-Reichmann proposed that schizophrenogenic moth- ers help produce schizophrenia. Cognitive theorists hold that when people with schizophrenia try to understand their strange biological sensations, they develop delusional thinking.
One sociocultural explanation holds that multicultural differences may influ- ence the rate and character of schizophrenia, as well as recovery from this disor- der, both within the United States and around the world. Another sociocultural explanation says that society expects people who are labeled as having schizo- phrenia to behave in certain ways and that these expectations actually lead to further symptoms. Still other sociocultural theorists point to family dysfunction- ing as a cause of schizophrenia.
Most clinical theorists now agree that schizophrenia can be traced to a com- bination of biological, psychological, and sociocultural factors, operating in a diathesis-stress relationship.
How Are Schizophrenia and Other Severe Mental Disorders Treated? Today’s treatment picture for schizophrenia and other severe mental disorders is marked by miraculous triumphs for some, modest success for others, and heartbreaking failure for still others. It is typically characterized by medications, medication-linked health problems, compromised lifestyles, and a mixture of hope and frustration. Despite this, today’s treatment outlook is vastly superior to that of past years. In fact, for much of human history, people with such disorders were considered beyond help. Few returned to any semblance of normal or functional living. Indeed, few returned home from the institutions to which they were sent.
Let us look at the case of Cathy, whose journey is typical of that of hundreds of thousands of people with schizophrenia and other severe mental disorders. To be sure, there are other patients whose efforts to overcome schizophrenia go more smoothly. And at the other end of the spectrum, there are many whose struggles against severe mental dysfunctioning never come close to Cathy’s level of success. In between, there are the Cathys.
▶▶ expressed emotion The general level of criticism, disapproval, and hostility expressed in a family. People recovering from schizophrenia are considered more likely to relapse if their families rate high in expressed emotion.
B e t W e e N t h e L I N e S
Treatment Delay The average length of time between the first appearance of psychotic symp- toms and the initiation of treatment is more than one year (Addington et al., 2015).
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During [her] second year in college . . . her emotional troubles worsened. . . . and [Cathy was] put on Haldol and lithium.
For the next sixteen years, Cathy cycled in and out of hospitals. She “hated the meds”—Haldol stiffened her muscles and caused her to drool, while the lithium made her depressed—and often she would abruptly stop taking them. . . . The problem was that off the drugs, she would “start to decompensate and become disorganized.”
In early 1994, she was hospitalized for the fifteenth time. She was seen as chroni- cally mentally ill, occasionally heard voices now . . . and was on a cocktail of drugs: Haldol, Ativan, Tegretol, Halcion, and Cogentin, the last drug an antidote to Haldol’s nasty side effects. But after she was released that spring, a psychiatrist told her to try Risperdal, a new antipsychotic that had just been approved by the FDA. “Three weeks later, my mind was much clearer,” she says. “The voices were going away. I got off the other meds and took only this one drug. I got better. I could start to plan. I wasn’t talking to the devil anymore. Jesus and God weren’t battling it out in my head.” Her father put it this way: “Cathy is back.” . . .
She went back to school and earned a degree in radio, film, and television. . . . In 1998, she began dating the man she lives with today. . . . In 2005, she took a part-time job. . . . Still, she remains on SSDI (Social Security Disability Insurance)— “I am a kept woman,” she jokes—and although there are many reasons for that, she believes that Risperdal, the very drug that has helped her so much, nevertheless has proven to be a barrier to full-time work. Although she is usually energetic by the early afternoon, Risperdal makes her so sleepy that she has trouble getting up in the morning. . . .
Risperdal has also taken a physical toll. . . . She has . . . developed some of the metabolic problems, such as high cholesterol, that the atypical antipsychotics regularly cause. “I can go toe-to-toe with an old lady with a recital of my physical problems,” she says. “My feet, my bladder, my heart, my sinuses, the weight gain— I have it all.” . . . But she can’t do well without Risperdal. . . .
Such has been her life’s course on medications. Sixteen terrible years, followed by fourteen pretty good years on Risperdal. She believes that this drug is essential to her mental health today, and indeed, she could be seen as a local poster child for promoting the wonders of that drug. Still, if you look at the long-term course of her illness . . . you have to ask: Is hers a story of a life made better by our drug-based . . . care for mental disorders, or a story of a life made worse? . . .
Cathy believes that this is a question that psychiatrists never contemplate. “They don’t have any sense about how these drugs affect you over the long
term. They just try to stabilize you for the moment, and look to manage you from week to week, month to month. That’s all they ever think about.”
(Whitaker, 2010)
As Cathy’s journey illustrates, schizophrenia is extremely difficult to treat, but clinicians are much more successful at doing so today than they were in the past. Much of the credit goes to antipsychotic drugs—imperfect, troubling, and even dangerous though they may be. These medications help many people with schizo- phrenia and other psychotic disorders to think clearly and to profit from psycho- therapies that previously would have had little effect for them (Skelton et al., 2015; Miller et al., 2012).
To best convey the plight of people with schizophrenia, this chapter will depart from the usual format and discuss the treatments from a historical perspective. A look at how treatment has changed over the years will help us understand the nature, problems, and promise of today’s approaches. As we consider past treatments for schizophrenia, it is important to keep in mind that throughout much of the twen- tieth century the label “schizophrenia” was assigned to most people with psychosis. Clinical theorists now realize that many people with psychotic symptoms are instead
▶▶ state hospitals Public mental hos- pitals in the United States, run by the individual states.
B e t W e e N t h e L I N e S
In Their Words “I shouldn’t precisely have chosen mad- ness if there had been any choice, but once such a thing has taken hold of you, you can’t very well get out of it.”
Vincent van Gogh, 1889
Schizophrenia : 403
experiencing a severe form of bipolar disorder or major depressive disor- der and that such people were in past times inaccurately diagnosed with schizophrenia (Tondo et al., 2015; Lake, 2012). Thus, our discussions of past treatments for schizophrenia, particularly the failures of institutional care, are as applicable to those other severe mental disorders as they are to schizophrenia. Similarly, our discussions about current approaches to schizophrenia, such as the community mental health movement, often apply to other severe mental disorders as well.
Institutional Care in the Past For more than half of the twentieth century, most people diagnosed with schizophrenia were institutionalized in a public mental hospital. Because patients with schizophrenia did not respond to traditional therapies, the primary goals of these hospitals were to restrain them and give them food, shelter, and clothing. Patients rarely saw therapists and generally were neglected. Many were abused. Oddly enough, this state of affairs unfolded in an atmosphere of good intentions.
As you read in Chapter 1, the move toward institutionalization in hospitals began in 1793 when French physician Philippe Pinel “unchained the insane” at La Bicêtre asylum and began the practice of “moral treatment.” For the first time in centuries, patients with severe disturbances were viewed as human beings who should be cared for with sympathy and kindness. As Pinel’s ideas spread throughout Europe and the United States, they led to the creation of large mental hospitals rather than asylums to care for those with severe mental disorders (Goshen, 1967).
These new mental hospitals, typically located in isolated areas where land and labor were cheap, were meant to protect patients from the stresses of daily life and offer them a healthful psychological environment in which they could work closely with therapists (Grob, 1966). States throughout the United States were even required by law to establish public mental institutions, state hospitals, for patients who could not afford private ones.
Eventually, however, the state hospital system encountered serious problems. Between 1845 and 1955, nearly 300 state hospitals opened in the United States, and the number of hospitalized patients on any given day rose from 2,000 in 1845 to nearly 600,000 in 1955. During this expansion, wards became overcrowded, admis- sions kept rising, and state funding was unable to keep up.
Institutional life In a scene reminiscent of public mental hospitals in the United States dur- ing the first half of the twentieth century, these patients spend their days crowded together on a hospital ward in central Shanghai. Because of a shortage of therapists, only a small fraction of Chinese people with psychological disorders receive proper professional care today.
A graphic reminder During the 1800s and 1900s, tens of thousands of patients with severe mental disorders were abandoned by their families and spent the rest of their lives in the back wards of the public mental institutions. We are reminded of their tragic situation by the numerous brass urns filled with unclaimed ashes currently stored in a building at Oregon State Hospital.
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The priorities of the public mental hospitals, and the quality of care they pro- vided, changed over those 110 years. In the face of overcrowding and understaffing, the emphasis shifted from giving humanitarian care to keeping order. In a throw- back to the asylum period, difficult patients were restrained, isolated, and punished; indi- vidual attention disappeared. Patients were transferred to back wards, or chronic wards, if they failed to improve quickly (Bloom, 1984). Most of the patients on these wards suffered from schizophrenia (Häfner & an der Heiden, 1988). The back wards were human warehouses filled with hopelessness. Staff members relied on straitjackets and handcuffs to deal with difficult patients. More “advanced” forms of treatment included medical approaches such as lobotomy (see PsychWatch on the next page). Many patients not only failed to improve under these conditions but also developed additional symptoms, apparently as a result of institutionalization itself.
Institutional Care Takes a Turn for the Better In the 1950s, clinicians developed two institutional approaches that finally brought some hope to patients who had lived in institutions for years: milieu therapy, based on humanistic principles, and the token economy program, based on behavioral prin- ciples. These approaches particularly helped improve the personal care and self- image of patients, problem areas that had been worsened by institutionalization. The approaches were soon adapted by many institutions and are now standard features of institutional care.
Milieu Therapy In 1953, Maxwell Jones, a London psychiatrist, converted a ward of patients with various psychological disorders into a therapeutic commu- nity—the first application of milieu therapy in a hospital setting. The premise of milieu therapy is that institutions can help patients by creating a social climate, or milieu, that promotes productive activity, self-respect, and individual responsibility. In such settings, patients are often given the right to run their own lives and make their own decisions. They may participate in community government, working with staff members to set up rules and decide penalties. Patients may also take on
special projects, jobs, and recreational activities. In short, their daily schedule is designed to resemble life outside the hospital.
Since Jones’ pioneering effort, milieu-style programs have since been set up in institutions throughout the West- ern world. The programs vary from setting to setting, but at a minimum, staff members try to encourage interactions (especially group interactions) between patients and staff, to keep patients active, and to raise their expectations about what they can accomplish.
Research over the years has shown that people with schizophrenia and other severe mental disorders in milieu hospital programs often improve and that they leave the hospital at higher rates than patients in programs offering primarily custodial care (Paul, 2000; Paul & Lentz, 1977). Many remain impaired, however, and must live in sheltered settings after their release. Despite its limitations, milieu therapy continues to be practiced in many institutions, often combined with other hospital approaches (Borge et al., 2013). Moreover, you will see later in this chapter that
Art that heals Art and other creative activi- ties can be therapeutic for people with severe mental disorders. Here, artist William Scott paints a San Francisco cityscape at the Creative Growth Art Center in California. Scott, who has been diagnosed with schizophrenia and autism, sells paintings and sculptures around the world.
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▶▶ milieu therapy A humanistic approach to institutional treatment based on the premise that institutions can help patients recover by creating a climate that promotes self-respect, responsible behavior, and meaningful activity.
▶▶ token economy program A behavioral program in which a person’s desirable behaviors are reinforced systematically throughout the day by the awarding of tokens that can be exchanged for goods or privileges.
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many of today’s halfway houses and other community programs for people with severe mental disorders apply the principles of milieu therapy.
The Token Economy In the 1950s, behaviorists discovered that the system- atic use of operant conditioning techniques on hospital wards could help change the behaviors of patients (Ayllon, 1963; Ayllon & Michael, 1959). Programs that apply these techniques are called token economy programs.
PsychWatch
In 1935, a Portuguese neurologist named Egas Moniz performed a revo-lutionary new surgical procedure, which he called a prefrontal leucotomy, on a patient with severe mental dysfunction- ing (Raz, 2013). The procedure, the first form of lobotomy, consisted of drilling two holes in either side of the skull and inserting an instrument resembling an ice- pick into the brain tissue to cut or destroy nerve fibers. Moniz believed that severe abnormal thinking—such as that on dis- play in schizophrenia, depression, and obsessive-compulsive disorder—was the result of nerve pathways that carried such thoughts from one part of the brain to another. By cutting these pathways, Moniz believed, he could stop the abnormal thinking in its tracks and restore normal mental functioning.
After Moniz published a monograph describing 20 leucotomies that he had performed, an American neurologist, Walter Freeman, called the procedure to the attention of the medical community in the United States and performed it on many patients (Raz, 2013). In 1947 Freeman further developed a second kind of lobotomy called the transorbital lobotomy, in which the surgeon inserted a needle into the brain through the eye socket and rotated it in order to destroy the brain tissue.
From the early 1940s through the mid- 1950s, the lobotomy was viewed as a miracle cure by most doctors and became a mainstream part of psychiatry (Levinson, 2011). An estimated 50,000 people in the United States alone eventually received lobotomies (Johnson, 2005).
We now know that the lobotomy was hardly a miracle treatment. Far from
“curing” people with mental disorders, the procedure left thousands upon thou- sands extremely withdrawn, subdued, and even stuporous. Why then was the procedure so enthusiastically accepted by the medical community in the 1940s and 1950s? Neuroscientist Elliot Valenstein (1986) points first to the extreme over- crowding in mental hospitals at the time. This crowding was making it difficult to maintain decent standards in the hospi- tals. Valenstein also points to the person- alities of the inventors of the procedure as important factors. Although they were highly regarded, gifted, and dedicated physicians—in 1949 Moniz was awarded the Nobel Prize for his work—Valenstein believes that their professional ambitions led them to move too quickly in applying the procedure.
For years, physicians throughout the world were apparently misled by the seem- ingly positive findings of early studies of the lobotomy, which, as it turned out, were
not based on sound methodology (Cooper, 2014). By the 1950s, however, better stud- ies revealed that in addition to having a fatality rate of 1.5 to 6 percent, lobotomies could cause serious problems such as brain seizures, huge weight gain, loss of motor coordination, partial paralysis, inconti- nence, endocrine malfunctions, and very poor intellectual and emotional respon- siveness (Lapidus et al., 2013). The discov- ery of effective antipsychotic drugs helped put an end to this inhumane treatment for mental disorders (Krack et al., 2010).
Today’s psychosurgical procedures are greatly refined, used only as a last resort for various severe disorders, and hardly resemble the lobotomies of 60 years back (Nair et al., 2014; Lapidus et al., 2013). Even so, many professionals believe that any kind of surgery that destroys brain tissue is inappropriate and perhaps unethical and that it keeps alive one of the clinical field’s most shameful and ill- advised efforts at cure.
Lobotomy: How Could It Happen?
Lessons in psychosur- gery Neuropsychiatrist Walter Freeman performs a lobotomy in 1949 before a group of interested onlook- ers by inserting a needle through a patient’s eye socket into the brain.
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In token economies, patients are rewarded when they behave acceptably and are not rewarded when they behave unacceptably. The immediate rewards for accept- able behavior are often tokens that can later be exchanged for food, cigarettes, hos- pital privileges, and other desirable items, all of which compose a “token economy.” Acceptable behaviors likely to be included are caring for oneself and for one’s possessions (making the bed, getting dressed), going to a work program, speaking normally, following ward rules, and showing self-control. Researchers have found that token economies do help reduce psychotic and related behaviors (Swartz et al., 2012; Dickerson et al., 2005).
Some clinicians have questioned the quality of the improvements made under token economy programs. Are behaviorists changing a patient’s psychotic thoughts and perceptions or simply improving the patient’s ability to imitate normal behav- ior? This issue is illustrated by the case of a middle-aged man named John, who had the delusion that he was the U.S. government. Whenever he spoke, he spoke as the government. “We are happy to see you. . . . We need people like you in our service. . . . We are carrying out our activities in John’s body.” When John’s hospital ward converted to using a token economy, the staff members targeted his delusional statements and required him to identify himself properly to earn tokens. After a few months on the token economy program, John stopped referring to himself as the government. When asked his name, he would say, “John.” Although staff members were understandably pleased with his improvement, John himself had a different view of the situation. In a private discussion he said:
We’re tired of it. Every damn time we want a cigarette, we have to go through their bullshit. “What’s your name? Who wants the cigarette? Where is the government?” Today, we were desperate for a smoke and went to Simpson, the damn nurse, and she made us do her bidding. “Tell me your name if you want a cigarette. What’s your name?” Of course, we said, “John.” We needed the cigarettes. If we told her the truth, no cigarettes. But we don’t have time for this nonsense. We’ve got busi- ness to do, international business, laws to change, people to recruit. And these people keep playing their games.
(Comer, 1973)
Critics of the behavioral approach would argue that John was still delusional and therefore as psychotic as before. Behaviorists, however, would argue that at the very least, John’s judgment about the consequences of his behavior had improved.
Token economy programs are no longer as popular as they once were, but they are still used in many mental hospitals, usually along with medication, and in many community residences as well (Kopelowicz et al., 2008). The approach has also been applied to other clinical problems, including intellectual disability, delinquency, and hyperactivity, as well as in other fields, such as education and business (Spiegler & Guevremont, 2015).
Antipsychotic Drugs Milieu therapy and token economy programs helped improve the gloomy outlook for patients diagnosed with schizophrenia, but it was the discovery of antipsychotic drugs in the 1950s that truly revolutionized treatment for schizophrenia. These drugs eliminate many of its symptoms and today are almost always a part of treatment.
As you read earlier, the discovery of antipsychotic medications dates back to the 1940s, when researchers developed the first antihistamine drugs to combat allergies. The French surgeon Henri Laborit soon discovered that one group of antihista- mines, phenothiazines, could also be used to help calm patients about to undergo
B e t W e e N t h e L I N e S
In Their Words “I believe that if you grabbed the near- est normal person off the street and put them in a psychiatric hospital, they’d be diagnosable as mad within weeks.”
clare allan, novelist, Poppy Shakespeare
B e t W e e N t h e L I N e S
In Their Words “Men will always be mad and those who think they can cure them are the maddest of all.”
Voltaire (1694–1778)
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surgery. Laborit suspected that the drugs might also have a calming effect on people with severe psychological disorders. One of the drugs, chlorpromazine, was eventually tested on six patients with psychotic symptoms and found to reduce their symptoms sharply. In 1954, chlorpromazine was approved for sale in the United States as an antipsychotic drug under the trade name Thorazine (Adams et al., 2014).
Since the discovery of the phenothiazines, other kinds of antipsychotic drugs have been developed. The ones developed throughout the 1960s, 1970s, and 1980s are now referred to as “conventional” antipsychotic drugs in order to distinguish them from the “second-generation” antipsychotics (also called “atypical” antipsychotic drugs) that have been developed in more recent decades. The conventional drugs are also known as neuroleptic drugs because they often produce undesired movement effects similar to the symptoms of neurological diseases. As you saw earlier, the conventional drugs reduce psychotic symptoms at least in part by blocking excessive activity of the neurotransmitter dopamine, particularly at the brain’s dopamine D-2 receptors (Chun et al., 2014; Düring et al., 2014).
How Effective Are Antipsychotic Drugs? Research has shown that antipsychotic drugs reduce symptoms in at least 65 percent of patients diagnosed with schizophrenia (Advokat et al., 2014; Geddes et al., 2011). Moreover, in direct comparisons the drugs appear to be a more effective treatment for schizophrenia than any of the other approaches used alone, such as psychotherapy, milieu therapy, or electroconvulsive therapy. In most cases, the drugs produce at least some improve- ment within weeks (Rabinowitz et al., 2014); however, symptoms may return if the patients stop taking the drugs too soon (Razali & Yusoff, 2014). The antipsychotic drugs, particularly the conventional ones, reduce the positive symptoms of schizo- phrenia (such as hallucinations and delusions) more completely, or at least more quickly, than the negative symptoms (such as restricted affect, poverty of speech, and loss of volition) (Millan et al., 2014; Stroup et al., 2012).
The Unwanted Effects of Conventional Antipsychotic Drugs In addition to reducing psychotic symptoms, the conventional antipsychotic drugs sometimes produce disturbing movement problems (Kinon et al., 2014; Stroup et al., 2012). These effects are called extrapyramidal effects because they appear
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to be caused by the drugs’ impact on the extrapyramidal areas of the brain, areas that help control motor activity.
The most common extrapyramidal effects are Parkinsonian symptoms, reactions that closely resemble the features of the neurological disorder Parkinson’s disease. At least half of patients on conventional antipsychotic drugs have muscle tremors and muscle rigidity at some point in their treatment; they may shake, move slowly, shuffle their feet, and show little facial expression (Geddes et al., 2011; Haddad & Mattay, 2011). Some also have related symptoms such as movements of the face, neck, tongue, and back; and a number experience significant restlessness and discom- fort in their limbs.
Whereas most undesired drug effects appear within days or weeks, a reaction called tardive dyskinesia (meaning “late-appearing move- ment disorder”) does not usually unfold until after a person has taken conventional antipsychotic drugs for more than a year (Tenback et al., 2015; Advokat et al., 2014). This reaction may include involuntary writhing or ticlike movements of the tongue, mouth, face, or whole
body; involuntary chewing, sucking, and lip smacking; and jerky movements of the arms, legs, or entire body. It is believed that more than 10 percent of the people who take conventional antipsychotic drugs for an extended time develop tardive dyskinesia to some degree, and the longer the drugs are taken, the higher the risk becomes (Achalia, 2014). Patients over 50 years of age seem to be at greater risk. Tardive dyskinesia can be difficult, sometimes impossible, to eliminate (Combs et al., 2008).
Today clinicians are more knowledgeable and more cautious about prescribing conventional antipsychotic drugs than they were in the past (see Table 12-3). Previ- ously, when patients did not improve with such a drug, their clinician would keep increasing the dose; today a clinician will typically add an additional drug to achieve a synergistic effect, stop the drug and try an alternative one, or stop all medications
(Li et al., 2014; Roh et al., 2014). Today’s clinicians also try to prescribe the low- est effective doses for each patient and to gradually reduce medications weeks or months after the patient begins functioning normally (Takeuchi et al., 2014).
Newer Antipsychotic Drugs As you read earlier, second- generation (“atypical”) antipsychotic drugs have been developed in recent decades. These include clozapine (trade name Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). As noted earlier, these drugs are received at fewer dopamine D-2 receptors and more D-1, D-4, and serotonin receptors than the conventional antipsychotic drugs (Advokat et al., 2014; Nord & Farde, 2011).
Second-generation antipsychotic drugs appear to be more effective than the conventional drugs (Advokat et al., 2014; Bianchini et al., 2014). Recall, for example, Cathy, the woman whom we met earlier, and how well she responded to risperidone after years of doing poorly on conventional antipsychotic drugs. Unlike the conventional drugs, the new drugs reduce not only the positive symptoms of schizophrenia, but also the negative ones (Millan et al., 2014). Another major benefit of the second-generation antipsychotic drugs is that they cause fewer extrapyramidal symptoms and seem less likely to produce tardive dyskinesia, although some of them produce significant undesired effects of their own (Young et al., 2015; Waddington et al., 2011).
Given such advantages, more than half of all medicated patients with schizo- phrenia now take the second-generation drugs, which are considered the first line of treatment for the disorder (Barnes & Marder, 2011). Many patients with bipolar or other severe mental disorders also seem to be helped by several of these antipsychotic drugs (Advokat et al., 2014).
Unwanted effects This man has a severe case of Parkinson’s disease, a disorder caused by low dopamine activity, and his muscle tremors prevent him from shaving himself. The conventional antipsychotic drugs often produce similar Parkinsonian symptoms.
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Some Antipsychotic Drugs Generic name Trade name
Conventional antipsychotics
Chlorpromazine Thorazine Trifluoperazine Stelazine Fluphenazine Prolixin, Permitil Perphenazine Trilafon Acetophenazine Tindal Chlorprothixene Taractan Thiothixene Navane Haloperidol Haldol Loxapine Loxitane Molindone hydrochloride Moban, Lidone Pimozide Orap
Second-generation antipsychotics
Risperidone Risperdal Clozapine Clozaril Olanzapine Zyprexa Quetiapine Seroquel Ziprasidone Geodon Aripiprazole Abilify Iloperidone Fanapt Lurasidone Latuda Paliperidone Invega
Schizophrenia : 409
Psychotherapy Before the discovery of antipsychotic drugs, psychotherapy was not really an option for people with schizophrenia. Most were too far removed from reality to profit from it. Today, however, psychotherapy is helpful to many such patients (Miller et al., 2012). By helping to relieve thought and perceptual disturbances, antipsychotic drugs allow many people with schizophrenia to learn about their disorder, partici- pate actively in therapy (see MindTech on the next page), think more clearly, make changes in their behavior, and cope with stressors in their lives. The most helpful forms of psychotherapy include cognitive-behavioral therapy and two sociocultural interventions—family therapy and social therapy. Often the various approaches are combined.
Cognitive-Behavioral Therapy As you read earlier, the cognitive expla- nation for schizophrenia starts with the premise that people with the disorder do indeed actually hear voices (or experience other kinds of hallucinations) as a result of biologically triggered sensations. According to this theory, the journey into schizophrenia takes shape when people try to make sense of these strange sensa- tions and conclude incorrectly that the voices are coming from external sources, that they are being persecuted, or another such notion. These misinterpretations are essentially delusions.
With this explanation in mind, an increasing number of clinicians now employ a cognitive-behavioral treatment for schizophrenia that seeks to help change how people view and react to their hallucinations (Howes & Murray, 2014; Naeem et al., 2014). The therapists believe that if people can be guided to interpret such experi- ences in a more accurate way, they will not suffer the fear and confusion produced by their delusional misinterpretations. Thus, the therapists use a combination of behavioral and cognitive techniques:
1. They provide clients with education and evidence about the biological causes of hallucinations.
2. They help clients learn more about the “comings and goings” of their own hallucinations and delusions. The clients learn, for example, to iden- tify which kinds of events and situations trigger the voices in their heads.
3. The therapists challenge their clients’ inaccurate ideas about the power of their hallucinations, such as the idea that the voices are all-powerful and uncontrollable and must be obeyed. The therapists also have the clients conduct behavioral experiments to put such notions to the test. What happens, for example, if the clients occasionally resist following the orders from their hallucinatory voices?
4. The therapists teach clients to more accurately interpret their hallucina- tions. Clients may, for example, adopt alternative conclusions such as, “It’s not a real voice, it’s my illness.”
5. The therapists teach clients techniques for coping with their unpleasant sensations (hallucinations). The clients may, for example, learn ways to re- duce the physical arousal that accompanies hallucinations—using special breathing and relaxation techniques and the like. Similarly, they may learn to distract themselves whenever the hallucinations occur (Veiga-Martínez et al., 2008).
These behavioral and cognitive techniques often help schizophrenic people feel more control over their hallucinations and reduce their delusional ideas. Can any- thing be done further to lessen the hallucinations’ unpleasant impact on the person? Yes, say new-wave cognitive-behavioral therapists, including practitioners of acceptance and commitment therapy.
▶▶ tardive dyskinesia Extrapyramidal effects involving involuntary movements that some patients have after they have taken conventional antipsychotic drugs for an extended time.
B e t W e e N t h e L I N e S
Private Notions • Surveys suggest that 22 to 37 percent
of people in the United States and Britain believe Earth has been visited by aliens from outer space.
• Twenty percent of people worldwide believe that aliens walk on Earth dis- guised as humans.
(reuters, 2010; Spanton, 2008; andrews, 1998)
: chapter 12410
As you read in Chapters 2 and 4, new-wave cognitive-behavioral therapists believe that the most useful goal of treatment is often to help clients accept their streams of problematic thoughts rather than to judge them, act on them, or try fruitlessly to change them. The therapists, for example, help individuals with anxiety disorders to become mindful of the worries that engulf their thinking and to accept such negative thoughts as but harmless events of the mind (see pages 114–115). Similarly, in cases of schizophrenia, new-wave cognitive-behavioral therapists try to help clients become detached and comfortable observers of their hallucinations—merely mindful of the unusual sensations and accepting of them—while otherwise moving forward with the tasks and events of their lives (Bacon et al., 2015; Chien et al., 2014).
Studies indicate that the various cognitive-behavioral treatments are often very helpful to clients with schizophrenia (A-Tjak et al., 2015; Briki et al., 2014; Morrison et al., 2014). Many clients who receive such treatments report that they feel less distressed by their hallucinations and that they have fewer delusions. Indeed, they are often able to shed the diagnosis of schizophrenia. Rehospitalizations decrease by 50 percent among clients treated with cognitive-behavioral therapy.
MindTech
Putting a Face on Auditory Hallucinations In Chapter 2, you read that a growing number of therapists are using avatar therapy to help clients overcome their psychological problems. In this form of cybertherapy, therapists have the clients interact with computer- generated
on-screen virtual human figures. Perhaps the boldest application of avatar therapy is its use with schizophrenic patients. Clinical researcher Julian Leff and several col- leagues have developed an approach that seems to offer particular promise for such people (Leff et al., 2014, 2013).
For a pilot study, the researchers selected 16 participants who were being tormented by imaginary voices (auditory hal- lucinations). In each case, the therapist presented the patient with a mean-sounding and mean-looking avatar. The avatar’s voice pitch and appearance were designed based on the patient’s description of what he was hearing and what he believed would be a corresponding face.
The patient was placed alone in a room with the computer simulation while the therapist generated the on-screen avatar from another room. Initially, the avatar spewed all sorts of fright- ening and upsetting statements at the patient. Then, the therapist encouraged the patient to fight back—to tell the avatar things
such as, “I will not put up with this, what you are saying is nonsense, I don’t believe these things, you must go away and leave me alone, and I do not need this kind of torment” (Leff et al., 2014, 2013; Kedmey, 2013).
After seven 30-minute sessions, most of the participants in the pilot study had less frequent and less intense auditory hallucinations and reported being less upset by the voices they did continue to hear. The participants also reported improve- ments in their feelings of depression and suicidal thinking. Three of the 16 actually reported a total cessation of their auditory hallucinations after the sessions. These promising results are now being followed up in a larger study with more participants. The results of that study should clarify whether confronting one’s hallucinations in a virtual world can truly help people with schizophrenia.
Voices spring to virtual life This is one of the sinister-looking avatars developed by clinical researcher Julian Leff and his colleagues in their new treatment for people with schizophrenia. Un
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In Their Words “If you talk to God, you are praying. If God talks to you, you have schizophrenia.”
thomas Szasz, psychiatric theorist
Schizophrenia : 411
Family Therapy More than 50 percent of those who are recovering from schizophrenia and other severe mental disorders live with their families: parents, siblings, spouses, or children (Tsai et al., 2011; Barrowclough & Lobban, 2008). Generally speaking, people with schizophrenia who feel positive toward their rela- tives do better in treatment (Okpokoro et al., 2014). As you saw earlier, recovered patients living with relatives who display high levels of expressed emotion—that is, relatives who are very critical, emotionally overinvolved, and hostile—often have a much higher relapse rate than those living with more positive and supportive relatives. Moreover, for their part, family members may be very upset by the social withdrawal and unusual behaviors of a relative with schizophrenia (Friedrich et al., 2014; Quah, 2014).
To address such issues, clinicians now commonly include family therapy in their treatment of schizophrenia, providing family members with guidance, train- ing, practical advice, psychoeducation about the disorder, and emotional support and empathy. In family therapy, relatives develop more realistic expectations and become more tolerant, less guilt-ridden, and more willing to try new patterns of communication. Family therapy also helps the person with schizophrenia cope with the pressures of family life, make better use of family members, and avoid trouble- some interactions. Research has found that family therapy—particularly when it is combined with drug therapy—helps reduce tensions within the family and so helps relapse rates go down (Girón et al., 2015; Okpokoro et al., 2014).
The families of people with schizophrenia and other severe mental disorders may also turn to family support groups and family psychoeducational programs for encourage- ment and advice (Duckworth & Halpern, 2014). In such programs, family members meet with others in the same situation to share their thoughts and emotions, provide mutual support, and learn about schizophrenia.
Social Therapy Many clinicians believe that the treatment of people with schizophrenia should include techniques that address social and personal difficul- ties in the clients’ lives. These clinicians offer practical advice; work with clients on problem solving, decision making, and social skills; make sure that the clients are taking their medications properly; and may even help them find work, finan- cial assistance, appropriate health care, and proper housing (Granholm et al., 2014; Ordemann et al., 2014). Research finds that this practical, active, and broad approach, called social therapy or personal therapy, does indeed help keep people out of the hos- pital (Haddock & Spaulding, 2011; Hogarty, 2002).
The Community Approach The broadest approach for the treatment of schizophrenia and other severe mental disorders is the community approach. In 1963, partly in response to the terrible condi- tions in public mental institutions and partly because of the emergence of antipsy- chotic drugs, the U.S. government ordered that patients be released and treated in the community. Congress passed the Community Mental Health Act, which provided that patients with psychological disorders were to receive a range of mental health services—outpatient therapy, inpatient treatment, emergency care, preventive care, and aftercare—in their communities rather than being transported to institutions far from home. The act was aimed at a variety of psychological disorders, but patients diagnosed with schizophrenia and other severe disorders, especially those who had been institutionalized for years, were affected most. Other countries around the world put similar sociocultural treatment programs into action shortly thereafter (Wiley-Exley, 2007).
Thus began several decades of deinstitutionalization, an exodus of hundreds of thousands of patients with schizophrenia and other long-term mental disorders
Spontaneous improvement? For reasons unknown, the symptoms of some people with schizophrenia lessen during old age, even with- out treatment. An example was the remarkable late-life improvement of John Nash, the subject of the book and movie A Beautiful Mind. Nash, seen here giving a presentation, received the 1994 Nobel Prize in Economic Science after struggling with schizophrenia for 35 years. He died in an automobile accident in 2015.
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▶▶ deinstitutionalization The discharge of large numbers of patients from long- term institutional care so that they might be treated in community programs.
: chapter 12412
from state institutions into the community. On a given day in 1955, close to 600,000 patients were living in state institutions; today fewer than 40,000 patients live in such facilities (Althouse, 2010). Clini- cians have learned that patients recovering from schizophrenia and other severe disorders can profit greatly from community programs. As you will see, however, the actual qual- ity of community care for these people has often been inadequate throughout the United States. The result is a “revolving door” pattern for many patients. They are released to the community, readmitted to an institution within months, released a second time, admitted yet again, and so on, over and over (Duhig et al., 2015; Burns & Drake, 2011).
What Are the Features of Effective Community Care? People recovering from schizophrenia and other severe disorders need medication, psy- chotherapy, help in handling daily pressures and responsibilities, guidance in making decisions, social skills training, residential supervision, and vocational counseling—a combination of services sometimes called assertive community treatment (Keller et al., 2014). Those whose communities help them meet these needs make more progress than those living in other communities (Malm, Ivarsson, & Allebeck, 2014; Swartz et al., 2012). Some of the key features of effective community care programs are (1) coordination of patient services, (2) short-term hospitalization, (3) partial hospi- talization, (4) supervised residencies, and (5) occupational training.
coorDinaTeD services When the Community Mental Health Act was first passed, it was expected that community care would be provided by community mental health centers, treatment facilities that would supply medication, psycho- therapy, and inpatient emergency care to people with severe disturbances, as well as coordinate the services offered by other community agencies. When community mental health centers are available and do provide these services, patients with schizophrenia and other severe disorders often make significant progress (Burns & Drake, 2011). Coordination of services is particularly important for so-called
Mental health on the streets In Indonesia, a police officer cuts the hair of a homeless per- son who he believes to have a severe mental disorder. The officer is a member of a special police unit that is trained to care for the home- less mentally ill and then take them to proper treatment facilities.
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Healthy competition As part of the com- munity mental health philosophy, people with schizophrenia and other severe mental dis- orders are also encouraged to participate in normal activities, athletic endeavors, and artis- tic undertakings. Here, for example, coached by former Napoli goalkeeper Enrico Zazzaro, patients from the Iflhan Rehabilitation Centre in Italy compete in a soccer league for people with psychological and intellectual disabilities. ©
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Schizophrenia : 413
mentally ill chemical abusers (MICAs), or dual diagnosis patients, individuals with psychotic disorders as well as substance use disorders (Drake et al., 2015; De Witte et al., 2014).
shorT-TerM hospiTalizaTion When people develop severe psychotic symptoms, today’s clinicians first try to treat them on an outpatient basis, usually with a combination of anti- psychotic medication and psychotherapy. If this approach fails, they may try short-term hospitalization—in a mental hospital or a general hospital’s psychiatric unit—that lasts a few weeks (rather than months or years) (Craig & Power, 2010). Soon after the patients improve, they are released for aftercare, a general term for follow-up care and treatment in the community.
parTial hospiTalizaTion People’s needs may fall between full hospitalization and outpatient therapy, and so some com- munities offer day centers, or day hospitals, all-day pro- grams in which patients return to their homes for the night. Such programs provide patients with daily supervised activities, therapy, and programs to improve social skills. People recovering from severe disorders in day centers often do better than those who spend extended periods in a hospital or in traditional outpatient therapy (Bales et al., 2014). Another kind of institution that has become popular is the semihospital, or residential crisis center. Semihospitals are houses or other structures in the community that provide 24-hour nursing care for people with severe mental disorders (Soliman et al., 2008).
superviseD resiDences Many people do not require hospitalization but are unable to live alone or with their families. Halfway houses, also known as crisis houses or group homes, often serve individuals well (Lindenmayer & Khan, 2012). Such resi- dences may shelter between one and two dozen people. Live-in staff members usu- ally are paraprofessionals—lay people who receive training and ongoing supervision from outside mental health professionals. The houses are usually run with a milieu therapy philosophy that emphasizes mutual support, resident responsibility, and self- government. Research indicates that halfway houses help many people recovering from schizophrenia and other severe disorders adjust to community life and avoid rehospitalization (Hansson et al., 2002; McGuire, 2000).
occupaTional Training anD supporT Paid employment provides income, inde- pendence, self-respect, and the stimulation of working with others. It also brings companionship and order to one’s daily life. For these reasons, occupational train- ing and placement are important services for people with schizophrenia and other severe mental disorders ( Johnsonn et al., 2014; Bell et al., 2011).
Many people recovering from such disorders receive occupational training in a sheltered workshop—a supervised workplace for employees who are not ready for competitive or complicated jobs. For some, the sheltered workshop becomes a permanent workplace. For others, it is an important step toward better-paying and more demanding employment or a return to a previous job. In the United States, however, occupational training is not consistently available to people with severe mental disorders.
An alternative work opportunity for people with severe psychological disorders is supported employment, in which vocational agencies and counselors help clients find competitive jobs in the community and provide psychological support while the clients are employed (Solar, 2014: Bell et al., 2011). Like sheltered workshops, supported employment opportunities are often in short supply.
▶▶ community mental health center A treatment facility that provides medica- tion, psychotherapy, and emergency care for psychological problems and coordi- nates treatment in the community.
▶▶ aftercare A program of posthos- pitalization care and treatment in the community.
▶▶ day center A program that offers hospital-like treatment during the day only. Also known as a day hospital.
▶▶ halfway house A residence for peo- ple with schizophrenia or other severe problems, often staffed by paraprofes- sionals. Also known as a group home or crisis house.
▶▶ sheltered workshop A supervised workplace for people who are not yet ready for competitive jobs.
Cause célèbre During the 1990s, Larry Hogue, nicknamed the “Wild Man of West 96th Street” by neighbors, roamed the streets of New York City’s Upper West Side, scream- ing at, threatening, and frightening passers-by. Displaying the combined effects of schizophre- nia and substance abuse, Hogue became the best known mentally ill chemical abuser (MICA) in the United States. His repeated cycles of imprisonment, hospitalization, and community placements exemplified the plight of thousands of people with severe mental disorders.
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: chapter 12414
How Has Community Treatment Failed? There is no doubt that effec- tive community programs can help people with schizophrenia and other severe mental disorders recover. However, fewer than half of all the people who need them receive appropriate community mental health services (Addington et al., 2015; Burns & Drake, 2011). In fact, in any given year, 40 to 60 percent of all people with schizophrenia and other severe mental disorders receive no treatment at all (NIH, 2014; Torrey, 2001). Two factors are primarily responsible: poor coordination of ser- vices and a shortage of services.
poor coorDinaTion of services The various mental health agencies in a com- munity often fail to communicate with one another. There may be an opening at a nearby halfway house, for example, and the therapist at the community mental health center may not know about it. In addition, even within a community agency a patient may not have continuing contacts with the same staff members and may fail to receive consistent services. Still another problem is poor communication between state hospitals and community mental health centers, particularly at times of discharge (Torrey, 2001).
To help deal with such problems in communication and coordination, a grow- ing number of community therapists have become case managers for people with schizophrenia and other severe mental disorders (Mas-Expósito et al., 2014; Burns, 2010). They try to coordinate available community services, guide clients through the community system, and help protect clients’ legal rights. Like the social thera- pists described earlier, they also offer therapy and advice, teach problem-solving and social skills, ensure that clients are taking their medications properly, and keep an eye on possible health care needs. Many professionals now believe that effective case management is the key to success for a community program.
shorTage of services The number of community programs—community men- tal health centers, halfway houses, sheltered workshops—available to people with
severe mental disorders falls woefully short (Zipursky, 2014; Burns & Drake, 2011). Moreover, the community mental health centers that do exist generally fail to provide adequate services for people with severe disorders. They tend to devote their efforts and money to people with less disabling problems, such as anxiety disorders or problems in social adjustment. Only a fraction of the patients treated by community mental health centers suffer from schizophrenia or other disorders marked by psychosis (Torrey, 2001).
There are various reasons for this shortage of services. The primary one is economic (Feldman et al., 2014; Covell et al., 2011). On the one hand, more public funds are available for people with psychological disorders now than in the past. In 1963 a total of $1 billion was spent in this area, whereas today approximately $171 billion in public funding is devoted each year to people with mental disorders (Rampell, 2013; Gill, 2010; Redick et al., 1992). This represents a significant increase even when inflation and so-called real dollars are factored in. On the other hand, rather little of the additional money is going to community treat- ment programs for people with severe disorders. Much of it goes instead to prescription drugs, monthly income payments such as social security disability income, services for people with mental disorders in nursing homes and general hospitals, and community services for people who are less disturbed. Today, the financial burden of providing community treatment for people with long-term severe disorders often falls on local governments and nonprofit organizations rather than the federal or state government, and local resources cannot always meet this challenge.
Changing the unacceptable A resident of a group home holds a sign during a rally in New York to protest the shortage of appropri- ate community residences for people with severe mental disorders. This shortage is one of the reasons that many such people have become homeless and/or imprisoned.
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▶▶ case manager A community therapist who offers a full range of services for people with schizophrenia or other severe disorders, including therapy, advice, medication, guidance, and protection of patients’ rights.
Schizophrenia : 415
What Are the Consequences of Inadequate Community Treat- ment? What happens to people with schizophrenia and other severe disorders whose communities do not provide the services they need and whose families can- not afford private treatment (see Figure 12-4)? As you have read, a large number receive no treatment at all; many others spend a short time in a state hospital or semihospital and are then discharged prematurely, often without adequate follow-up treatment (Burns & Drake, 2011; Gill, 2010).
Many of the people with severe mental disorders return to their families and receive medication and perhaps emotional and financial support, but little else in the way of treatment (Barrowclough & Lobban, 2008). Around 8 percent enter an alternative institution such as a nursing home or rest home, where they receive only custodial care and medication (Torrey, 2001). As many as 18 percent are placed in privately run residences where supervision often is provided by untrained staff—foster homes (small or large), boardinghouses, care homes, and similar facilities (Lindenmayer & Khan, 2012). Another 34 percent of people with severe disorders live in totally unsupervised settings. Some are equal to the challenge of living alone, but many cannot really func- tion independently and wind up in rundown single-room occupancy hotels (SROs) or rooming houses, often located in poor neighborhoods. They may live in conditions that are substandard and unsafe, which may exacerbate their disorder (Bowen et al., 2015; Bhavsar et al., 2014).
Finally, a great number of people with schizophrenia and other severe disorders have become homeless (Ogden, 2014; Kooyman & Walsh, 2011). There are between 400,000 and 800,000 homeless people in the United States, and approximately one-third have a severe mental disorder, commonly schizophrenia. Many have been released from hospitals; others are young adults who were never hospi- talized in the first place. Another 135,000 or more people with severe mental disorders end up in prisons because their disorders have led them to break the law (Morrissey & Cuddeback, 2008; Peters et al., 2008) (see MediaSpeak on the next page). Certainly deinstitutionalization and the community mental health movement have failed these individuals, and many report actually feeling relieved if they are able to return to hospital life.
A long way to go A man with schizophrenia lies on the floor of the emergency room wait- ing area at Delafontaine Hospital near Paris, France. The plight of this patient is a reminder that, despite the development of various effec- tive interventions, the overall treatment picture for many people with severe mental disorders leaves much to be desired.©
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figure 12-4 where do people with schizophrenia live? More than one-third live in unsuper- vised residences, 6 percent in jails, and 5 percent on the streets or in homeless shelters. (Information from Kooyman & Walsh, 2011; Torrey, 2001.)
Unsupervised living (34%)
Living with family member (25%)
Supervised living (e.g., halfway house) (18%)
Nursing homes (8%)
Jails and prisons (6%)
Hospitals (5%) Homeless (5%)
: chapter 12416
75%10:00 AM
MediaSpeak "Alternative" Mental Health Care
By Merrill Balassone, Washington Post, December 6, 2010
A n 18-year-old schizophrenic pounds on the thick security glass of his single-man cell. A woman lets out a long guttural scream to nobody
in particular to turn off the lights. A 24-year-old man drags his mattress under his
bunk, fearful of the voices telling him to hurt himself. This is not the inside of a psychiatric hospital. It’s
the B-Mental Health Unit [at a prison in California’s] Stanislaus County. . . . Sheriff’s deputy David Frost, who oversees the unit, says most of the inmates aren’t difficult, just needy. “They do want help,” Frost said.
Stanislaus County is not unique. Experts say U.S. prisons and jails have become the country’s largest mental health institutions, its new asylums. Nearly four times more Californians with serious mental illnesses are housed in jails and prisons than in hospitals. . . . Nationally, 16 to 20 percent of prisoners are mentally ill, said Harry K. Wexler, a psychologist specializing in crime and substance abuse.
“I think it’s a national tragedy,” Wexler said. “Prisons are the institutions of last resort. The mentally ill are generally socially undesirable, less employable, more likely to be homeless and get on that slippery slope of repeated involvement in the criminal justice system.”
Those who staff prisons and jails are understand- ably ill-equipped to be psychiatric caretakers. . . . Frost agrees. . . . “I’m not a mental health technician,” he says, although he does hold a psychology degree. “I’m a sworn law enforcement officer.” He walked the halls on a recent day, asking inmates if they were taking their medications and how they were feeling. . . .
Mentally ill offenders have higher recidivism rates than other inmates (they’re called “frequent fliers” in the criminal justice world) because they receive little psychiatric care after their release. . . . Wexler said these inmates also are more likely to commit suicide. Because they’re less capable of conforming to the rigid rules of a jailhouse, they can end up in isolation as pun- ishment, Wexler said.
At 4:30 a.m. in the . . . jail—and again 12 hours later—it’s “pill pass time,” when the medical staff hands out about a dozen types of medications. . . . “You’re making jailers our mental health treatment
personnel,” said a forensic psychologist. “They’re not trained to do that. . . . This population is not getting what they need.” Because of the lack of hospital space, police are often forced to take the mentally ill who commit minor misdemeanors—from petty thefts to uri- nating in public—to jail instead. . . .
One nationally recognized solution is called a men- tal health treatment court, which gives offenders the choice between going to jail or following a treatment plan—including taking prescribed medications. [Such programs have had] success in decreasing the recidi- vism rate among mentally ill offenders and helping smooth their transition back into society. But at the same time, [the mental health treatment courts have been] forced to stop taking new offenders [because of budget cuts]. . . .
“We deal every day with this crisis of the mentally ill—in jail or out on the street,” Frost said. “We do need the funding for these types of programs.”
December 6, 2010, “Jails, Prisons Increasingly Taking Care of Mentally Ill” by Merrill Balassone. From The Modesto Bee, 12/6/2010, © 2010 McClatchy. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmis- sion of this content without express written permission is prohibited.
Trying to help Sheriff’s deputy David Frost talks with an inmate in the B-Mental Health Unit of the Public Safety Center, a prison in Stanislaus County, California.
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The Promise of Community Treatment Despite these very serious problems, proper community care has shown great potential for assisting people in recovering from schizophrenia and other severe disorders, and clinicians and many government officials continue to press to make it more available. In addition, a number of national interest groups have formed in countries around the world that push for better community treatment. In the United States, for example, the National Alliance on Mental Illness (NAMI ) began in 1979 with 300 members and has expanded to 200,000 members in more than 1,000 chapters (NAMI, 2014). Made up largely of families and people affected by severe mental disorders, NAMI has become not only a source of information, support, and guidance for its members but also a powerful lob- bying force in state and national legislatures, and it has pressured community mental health centers to treat more people with schizophrenia and other severe disorders.
Today, community care is a major feature of treatment for people recovering from severe mental disorders in countries around the world. Both in the United States and abroad, well-coordinated community treatment is seen as an important part of the solution to the problem of severe mental dysfunctioning (Wise, 2014; Burns & Drake, 2011).
➤ Summing Up how Are SChizoPhreniA AnD oTher Severe menTAl DiSorDerS TreATeD? For more than half of the twentieth century, the main treatment for schizophrenia and other severe mental disorders was institutionalization and custodial care. In the 1950s, two in-hospital approaches were developed, milieu therapy and token economy programs. They often brought improvement.
The discovery of antipsychotic drugs in the 1950s revolutionized the treat- ment of schizophrenia and other disorders marked by psychosis. Today they are almost always a part of treatment. Theorists believe that conventional anti- psychotic drugs operate by reducing excessive dopamine activity in the brain. These drugs reduce the positive symptoms of schizophrenia more completely, or more quickly, than the negative symptoms.
The conventional antipsychotic drugs can also produce dramatic unwanted effects, particularly movement abnormalities. One such effect, tardive dys- kinesia, apparently occurs in more than 10 percent of the people who take conventional antipsychotic drugs for an extended time and can be difficult or impossible to eliminate. In recent decades, atypical antipsychotic drugs have been developed; these seem to be more effective than the conventional drugs and to cause fewer or no extrapyramidal effects.
Today psychotherapy is often employed successfully in combination with antipsychotic drugs. Helpful forms include cognitive-behavioral therapy, family therapy, and social therapy.
A community approach to the treatment of schizophrenia and other severe mental disorders began in the 1960s, when a policy of deinstitutionalization in the United States brought about a mass exodus of hundreds of thousands of patients from state institutions into the community. Among the key elements of effective community care programs are coordination of patient services by a community mental health center, short-term hospitalization (followed by after- care), day centers, halfway houses, occupational training and support, and case
(continues on the next page)
A place to call home This man, recovering from schizophrenia and bipolar disorder, joy- fully assumes a yoga pose in the living room of his new Chicago apartment. He found the resi- dence with the help of a community program called Direct Connect.
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Schizophrenia and Jail There are more people with schizophre- nia and other severe mental disorders in jails and prisons than there are in all hospitals and other treatment facilities.
Chicago’s Cook County Jail, where several thousand of the inmates require daily mental health services, is now in effect the largest mental institution in the United States.
(pruchno, 2014; Balassone, 2011; Steadman et al., 2009; Morrissey & cuddeback,
2008; peters et al., 2008)
: chapter 12418
management. However, the quality and funding of community care for people with schizophrenia and other severe disorders have been inadequate through- out the United States, often resulting in a “revolving door” pattern. One result is that many people with such disorders are now homeless or in prison. Despite these problems, the potential of proper community care continues to capture the interest of clinicians and policy makers.
PUTTING IT...together An Important Lesson Schizophrenia—a bizarre and frightening disorder—was studied intensively through- out the twentieth century. Only since the discovery of antipsychotic drugs, however, have clinicians acquired any practical insight into its causes. As they do with most other psychological disorders, clinical theorists now believe that schizophrenia is probably caused by a combination of factors, though researchers have been far more successful in identifying the biological influences than the psychological and sociocultural ones. While biological investigations have closed in on specific genes, abnormalities in brain biochemistry and structure, and even viral infections, most of the psychological and sociocultural research has been able to cite only general fac- tors, such as the roles of family conflict and diagnostic labeling. Clearly, researchers must identify psychological and sociocultural factors with greater precision if we are to gain a full understanding of schizophrenia.
The treatment picture for schizophrenia and other severe mental disorders has greatly improved in recent decades. After years of frustration and failure, clinicians now have an arsenal of weapons to use against these disorders—medication, insti- tutional programs, psychotherapy, and community programs. It has become clear that antipsychotic medications open the door for recovery, but in most cases other kinds of treatment are also needed to help the recovery process along. The various approaches must be combined in a way that meets each individual’s specific needs.
Working with schizophrenia and other severe disorders has taught therapists an important lesson: no matter how compelling the evidence for biological causation may be, a strictly biological approach to the treatment of psychological disorders is a mistake more often than not. Largely on the basis of pharmacological advances, hundreds of thousands of patients with schizophrenia and other severe mental dis-
orders were released to their communities beginning in the 1960s. Little attention was paid to their psychological and sociocultural needs, and many have been trapped in their pathology ever since. Clinicians must remember this lesson, especially in today’s climate, when managed care and government priorities often promote medication as the sole treat- ment for psychological problems.
When pioneering clinical researcher Emil Kraepelin described schizophrenia at the end of the nineteenth century, he estimated that only 13 percent of its victims ever improved. Today, even with short- ages in community care, many more such people—at least three times as many—show improvement (Pinna et al., 2014). Certainly the clinical
field has advanced considerably since Kraepelin’s day, but it still has far to go. Studies suggest that the recovery rates—both partial and full—could be considerably higher (Zipursky, 2014). It is unacceptable that so many people with this and other severe mental disorders receive few or none of the effective community interventions that have been developed, worse still that tens of thousands have become homeless or prison inmates. It is now up to clinicians, along with public officials, to address the needs of all people with schizophrenia and other severe disorders.
C li n i C al C h o i C e s Now that you’ve read about schizophrenia, try the interactive case study for this chapter. See if you are able to identify Randy’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for Randy? Go to LaunchPad to access Clinical Choices.
B e t W e e N t h e L I N e S
In Their Words “No great genius was ever without some tincture of madness.”
aristotle
Schizophrenia : 419
KEY TERMS schizophrenia, p. 386
psychosis, p. 386
schizophrenia spectrum disorders, p. 386
positive symptom, p. 387
delusion, p. 388
formal thought disorder, p. 388
loose associations, p. 388
hallucination, p. 389
inappropriate affect, p. 389
negative symptoms, p. 391
alogia, p. 391
restricted affect, p. 391
avolition, p. 391
catatonia, p. 391
dopamine hypothesis, p. 395
antipsychotic drug, p. 395
phenothiazines, p. 395
atypical antipsychotic drugs, p. 397
schizophrenogenic mother, p. 398
expressed emotion, p. 400
state hospital, p. 403
milieu therapy, p. 404
token economy program, p. 405
neuroleptic drugs, p. 407
extrapyramidal effects, p. 407
tardive dyskinesia, p. 408
social therapy, p. 409
deinstitutionalization, p. 410
assertive community treatment, p. 412
community mental health center, p. 412
mentally ill chemical abuser (MICA), p. 413
aftercare, p. 413
day center, p. 413
halfway house, p. 413
sheltered workshop, p. 413
case manager, p. 414
QuickQuiz
1. What is schizophrenia, and how prevalent is it? What is its relation to socioeconomic class and gender? pp. 386–387
2. What are the positive, negative, and psychomotor symptoms of schizophre- nia? pp. 387–391
3. Describe the genetic, biochemical, brain structure, and viral explanations of schizophrenia, and discuss how they have been supported in research. pp. 393–398
4. What are the key features of the psy- chodynamic, cognitive, multicultural, social labeling, and family explanations of schizophrenia? pp. 398–401
5. Describe institutional care for people with schizophrenia and other severe mental disorders over the course of the twentieth century. How effective are the milieu and token economy treat- ment programs? pp. 403–406
6. How do antipsychotic drugs operate on the brain? How do conventional antipsychotic and atypical antipsychotic drugs differ? pp. 406–408
7. How effective are antipsychotic drugs in the treatment of schizophrenia? What are the unwanted effects of conven- tional antipsychotic drugs? pp. 407–408
8. What kinds of psychotherapy seem to help people with schizophrenia and other disorders marked by psychosis? pp. 409–411
9. What is deinstitutionalization? What features of community care seem criti- cal for helping people with schizophre- nia and other severe mental disorders? pp. 411–414
10. How and why has the community men- tal health approach been inadequate for many people with severe mental disorders? pp. 414–416
visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T O P I C O V E R V I E W
“Odd” Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder
“Dramatic” Personality Disorders Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder
“Anxious” Personality Disorders Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder
Multicultural Factors: Research Neglect
Are There Better Ways to Classify Personality Disorders? The “Big Five” Theory of Personality and Personality Disorders “Personality Disorder—Trait Specified”: Another Dimensional Approach
Putting It Together: Disorders of Personality—Rediscovered and Reconsidered
Personality Disorders
W hile interviewing for the job of editor of a start-up news Web site, Frederick said, “This may sound self-serving, but I am extraordinarily gifted. I am cer- tain that I will do great things in this position. I and the Osterman Post will soon set the standard for journalism and blogging in the country. Within a
year, we’ll be looking at the Huffington Post in the rearview mirror.” The committee was impressed. Certainly, Frederick’s credentials were strong, but even more impor- tant, his self-confidence and boldness had wowed them.
A year later, many of the same individuals were describing Frederick differently— arrogant, self-serving, cold, ego-maniacal, draining. He had performed well as edi- tor (though not as spectacularly as he seemed to think), but that performance could not outweigh his impossible personality. Colleagues below and above him had grown weary of his manipulations, his emotional outbursts, his refusal ever to take the blame, his nonstop boasting, and his grandiose plans. Once again Frederick had outworn his welcome.
To be sure, Frederick had great charm, and he knew how to make others feel impor- tant, when it served his purpose. Thus he always had his share of friends and admir- ers. But in reality they were just passing through, until Frederick would tire of them or feel betrayed by their lack of enthusiasm for one of his self-serving interpretations or grand plans. Or until they simply could take Frederick no longer.
Bright and successful though he was, Frederick always felt entitled to more than he was receiving—to higher grades at school, greater compensation at work, more at- tention from girlfriends. If criticized even slightly, he reacted with fury and was certain that the critic was jealous of his superior intelligence, skill, or looks. At first glance, Frederick seemed to have a lot going for him socially. Typically, he could be found in the midst of a deep, meaningful romantic relationship—in which he might be tender, attentive, and seemingly devoted to his partner. But Frederick would always tire of his partner within a few weeks or months and would turn cold or even mean. Often he started affairs with other women while still involved with the current partner. The breakups—usually unpleasant and sometimes ugly—rarely brought sadness or re- morse to him, and he would almost never think about his former partner again. He always had himself.
Each of us has a personality—a set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and interactions. Our particular characteristics, often called personality traits, lead us to react in fairly predict- able ways as we move through life. Yet our personalities are also flexible. We learn from experience. As we interact with our surroundings, we try out various responses to see which feel better and which are more effective. This is a flexibility that people who suffer from a personality disorder usually do not have.
People with a personality disorder display an enduring, rigid pattern of inner experience and outward behavior that impairs their sense of self, emo- tional experiences, goals, capacity for empathy, and/or capacity for intimacy (APA, 2013). Put another way, they have personality traits that are much more extreme and dysfunctional than those of most other people in their culture, leading to significant problems and psychological pain for themselves or others.
Frederick appears to display a personality disorder. For most of his life, his extreme narcissism, grandiosity, and insensitivity have led to poor functioning in both the personal and social realms. They have caused him to repeatedly feel angry and unappreciated, deprived him of close personal relationships,
: chapter 13422
and brought considerable pain to others. Witness the upset and turmoil felt by Frederick’s coworkers and girlfriends.
The symptoms of personality disorders last for years and typically become rec- ognizable in adolescence or early adulthood, although some start during childhood (APA, 2013). These disorders are among the most difficult psychological disorders to treat. Many people with the disorders are not even aware of their personality
problems and fail to trace their difficulties to their maladaptive style of thinking and behaving. Surveys indicate that between 10 and 15 percent of all adults in the United States have a personality disorder (APA, 2013; Sansone & Sansone, 2011).
It is common for a person with a personality disorder to also suffer from another disorder, a relationship called comorbidity. As you will see later in this chapter, for example, many people with avoidant personality disorder, who fear- fully shy away from all relationships, also display social anxiety disorder. Perhaps avoidant personality disorder predisposes people to develop social anxiety disorder. Or perhaps social anxiety disorder sets the stage for the personality disorder. Then again, some biological factor may create a predisposition to both the personality disorder and the anxiety disorder. Whatever the reason
for the relationship, research indicates that the presence of a personality disorder complicates a person’s chances for a successful recovery from other psychological
problems (Fok et al., 2014). DSM-5, like its predecessor, DSM-IV-TR, identifies 10 personality disorders
(APA, 2013). Often these disorders are separated into three groups, or clusters. One cluster, marked by odd or eccentric behavior, consists of the paranoid, schizoid, and schizotypal personality disorders. A second cluster features dramatic behavior and consists of the antisocial, borderline, histrionic, and narcissistic personality disorders. The final cluster features a high degree of anxiety and includes the avoidant, dependent, and obsessive-compulsive personality disorders.
These 10 personality disorders are each characterized by a group of very prob- lematic personality symptoms. For example, as you will soon see, paranoid personality disorder is diagnosed when a person has unjustified suspicions that others are harm- ing him or her, has persistent unfounded doubts about the loyalty of friends, reads threatening meanings into benign events, persistently bears grudges, and has recur- rent unjustified suspicions about the faithfulness of a life partner.
The DSM’s listing of 10 distinct personality disorders is called a categorical approach. Like a light switch that is either on or off, this kind of approach assumes that (1) problematic personality traits are either present or absent in people, (2) a personality disorder is either displayed or not displayed by a person, and (3) a person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder.
It turns out, however, that these assumptions are frequently contradicted in clinical practice. In fact, the symptoms of the personality disorders listed in DSM-5 overlap so much that clinicians often find it difficult to distinguish one disorder from another (see Figure 13-1), resulting in frequent disagreements about which diagno- sis is correct for a person with a personality disorder. Diagnosticians sometimes even determine that particular people have more than one personality disorder (APA, 2013). This lack of agreement has raised serious questions about the validity (accu- racy) and reliability (consistency) of the 10 DSM-5 personality disorder categories.
Given this state of affairs, many theorists have challenged the use of a categori- cal approach to personality disorders. They believe that personality disorders dif- fer more in degree than in type of dysfunction and should instead be classified by the severity of personality traits rather than by the presence or absence of specific traits—a procedure called a dimensional approach (Morey, Skodol, & Oldham, 2014). In a dimensional approach, each trait is seen as varying along a continuum extending from nonproblematic to extremely problematic. People with a personality disorder
Early notions of personality In the popu- lar nineteenth-century theory of phrenology, Franz Joseph Gall (1758–1828) suggested that the brain consists of distinct portions, each responsible for some aspect of personality. Phrenologists tried to assess personality by feeling bumps and indentations on a person’s head.
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are those who display extreme degrees of problematic traits—degrees not com- monly found in the general population (see Table 13-1 on the next page).
Given the inadequacies of a categorical approach and the growing enthusiasm for a dimensional one, the framers of DSM-5 initially proposed significant changes in how personality disorders should be classified. They proposed a largely dimen- sional system that would allow many additional kinds of personality problems to be classified as personality disorders and would require clinicians to assess the severity
Relationship problems
Suspicious/ distrustful
Hostile
Blames others
Deceitful
Controlling/ manipulative
Jealous
Sensitive
Aloof/isolated
Self-absorbed
Self-critical
Central Feature Prominent Feature
Impulsive/reckless
Grandiose/egocentric
Emotionally unstable
Overly emotional
Depressed/helpless
Anxious/tense
Cognitive/perceptual eccentricities
Attention deficiencies
Psychotic-like episodes
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ES figure 13-1 Prominent and central features of the personality disorders in DSM-5 The symptoms of the various personality disorders often have significant overlap, leading to fre- quent misdiagnoses or to multiple diagnoses for a given client.
▶▶ personality disorder An enduring, rigid pattern of inner experience and out- ward behavior that repeatedly impairs a person’s sense of self, emotional experi- ences, goals, capacity for empathy, and/ or capacity for intimacy.
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of each problematic trait exhibited by a person who receives a diagnosis of per- sonality disorder. However, this proposal itself produced enormous concern and criticism in the clinical field, leading the framers of DSM-5 to change their mind and to retain, for now, a classic 10-disorder categorical approach in the new DSM. At the same time, the framers acknowledged the likely future direction of person- ality disorder classifications by also describing an alternative dimensional approach (Anderson et al., 2014).
Most of the discussions in this chapter are organized around the 10-disorder categorical approach currently used in DSM-5. Later in the chapter, however, we will examine possible alternative—dimensional—approaches of the future, includ- ing the one presented in DSM-5.
As you read about the various personality disorders, you should be clear that diagnoses of such disorders can be assigned too often. We may catch glimpses of ourselves or of people we know in the descriptions of these disorders and be tempted to conclude that we or they have a personality disorder. In the vast major- ity of instances, such interpretations are incorrect. We all display personality traits. Only occasionally are they so maladaptive, distressful, and inflexible that they can be considered disorders.
➤ Summing Up PerSonality DiSorDerS anD DSM-5 People with a personality disorder display an enduring, rigid pattern of inner experience and outward behavior. Their personality traits are much more extreme and dysfunctional than those of most other people in their culture, resulting in significant problems for them or those around them. It has been estimated that as many as 10 to 15 percent of adults have such a disorder. DSM-5 uses a categorical approach that lists 10 dis- tinct personality disorders. In addition, the framers of DSM-5 have proposed a dimensional approach to the classification of personality disorders, an approach that they assigned for further study and possible inclusion in a future revision of the DSM.
“Odd” Personality Disorders The cluster of “odd” personality disorders consists of the paranoid, schizoid, and schizo- typal personality disorders. People with these disorders typically have odd or eccen- tric behaviors that are similar to but not as extensive as those seen in schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things. Such behaviors often leave the person isolated. Some clinicians believe that these personality disorders are related to schizophrenia (Rosell et al., 2014). In fact, schizotypal personality disorder is listed twice in DSM-5—as one of the schizophrenia spectrum disorders (see page 386) and as one of the personality disorders (APA, 2013). Directly related or not, people with an odd cluster personal- ity disorder often qualify for an additional diagnosis of schizophrenia or have close relatives with schizophrenia (Chemerinski & Siever, 2011).
Clinicians have learned much about the symptoms of the odd cluster personality disorders but have not been so successful in determining their causes or how to treat them. In fact, as you’ll soon see, people with these disorders rarely seek treatment.
Why do you think personality
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table: 13-1
Dx Checklist
Personality Disorder
1. Individual displays a long-term, rigid, and wide-ranging pattern of inner experience and behavior that leads to dysfunction in at least two of the following realms: • Cognition • Emotion • Social interactions • Impulsivity.
2. The individual’s pattern is significantly different from ones usually found in his or her culture.
3. Individual experiences significant distress or impairment.
(Information from: APA, 2013)
B e t W e e N t h e L I N e S
In Their Words “I am a kind of paranoid in reverse. I suspect people of plotting to make me happy.”
J. D. Salinger, novelist
Personality Disorders : 425
Paranoid Personality Disorder As you read earlier, people with paranoid personality disorder deeply distrust other people and are suspicious of their motives (APA, 2013). Because they believe that everyone intends them harm, they shun close relationships. Their trust in their own ideas and abilities can be excessive, though, as you can see in the case of Eduardo:
For Eduardo, a researcher at a genetic engineering company, this was the last straw. He had been severely chastised by his supervisor for deviating from the research procedure on a major study. He knew where this was coming from. He had been “ratted out” by his jealous, conniving lab colleagues. This time, Eduardo would not sit back quietly. He demanded a meeting with his supervisor and the three other researchers in the lab.
At the outset of the meeting, Eduardo insisted that he would not leave the room until he was told the name of the person who had ratted him out. He acknowledged that he had, in fact, changed the study’s design in key ways, maintaining that these changes would open the door to enormous medical gains. Eduardo quickly shifted the focus onto his lab colleagues. He stated that the other scientists were intimi- dated by his visionary ideas, and he accused them of trying to get him out of the way so they could continue to work in an unproductive, low-pressure atmosphere. He said that their desire to get rid of him was always apparent to him, revealed by their coldness toward him each and every day and their outright nastiness whenever he tried to correct them or offer constructive criticism. Nor did it escape his atten- tion that they were always laughing at him, talking about him behind his back, and, on more than one occasion, trying to copy or destroy his notes.
The other researchers were aghast as Eduardo laid out his suspicions. They pointed out that it was Eduardo, not they, who was always behaving in an unfriendly manner. He had stopped speaking to all of them two months ago and he regularly tried to antagonize them—giving them dirty looks and slamming doors.
Next, Eduardo’s supervisor, Lisa, spoke up. She said that in her objective opinion, none of Eduardo’s accusations were true. First, none of his colleagues had informed on him. She herself had reviewed videos from the lab cameras as a matter of routine and had noticed him feeding rats that were supposed to be left hungry. Second, she said that it was his coworkers’ account, not Eduardo’s, that rang true. In fact, she had received many complaints from people outside the lab about Eduardo’s cold and aloof manner.
Later, in the privacy of her office, Lisa told Eduardo that she had no choice but to let him go. Eduardo was furious, but not completely surprised. His past two jobs had ended badly as well.
Ever on guard and cautious and seeing threats everywhere, people like Eduardo continually expect to be the targets of some trickery (see Figure 13-2 on the next page). They find “hidden” meanings, which are usually belittling or threatening, in everything. In a study that required people to role-play, participants with paranoia were more likely than control participants to read hostile intentions into the actions of others (Turkat et al., 1990). In addition, they more often chose anger as the appropriate role-play response.
Quick to challenge the loyalty or trustworthiness of acquaintances, people with paranoid personality disorder remain cold and distant. A woman might avoid confid- ing in anyone, for example, for fear of being hurt, or a husband might, without any justification, persist in questioning his wife’s faithfulness. Although inaccurate and inappropriate, their suspicions are not usually delusional; the ideas are not so bizarre or so firmly held as to clearly remove the individuals from reality (Millon, 2011).
“Zero Degrees of Empathy” With the term “Skinhead” tattooed on the back of his head, this man awaits trial in Germany for com- mitting neo-Nazi crimes against foreigners and liberals. Clinicians sometimes confront extreme racism and intolerance in their practices, partic- ularly among clients with paranoid, antisocial, and certain other personality disorders. Famous developmental psychologist Simon Baron- Cohen proposes in his book Zero Degrees of Empathy that the common element in all such behaviors is a total lack of empathy.
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▶▶ paranoid personality disorder A personality disorder marked by a pattern of distrust and suspiciousness of others.
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People with this disorder are critical of weakness and fault in others, particularly at work (McGurk et al., 2013). They are unable to recognize their own mistakes, though, and are extremely sensitive to criticism. They often blame others for the things that go wrong in their lives, and they repeatedly bear grudges (Rotter, 2011). As many as 4.4 percent of adults in the United States experience this disorder, which is apparently more common in men than in women (APA, 2013; Sansone & Sansone, 2011).
How Do Theorists Explain Paranoid Personality Disorder? The theories that have been proposed to explain paranoid personality disorder, like those about most other personal- ity disorders, have received little systematic research (Triebwasser et al., 2013). Psychodynamic theories, the oldest of these explana- tions, trace the pattern to early interactions with demanding parents, particularly distant, rigid fathers and overcontrolling, rejecting moth- ers (Caligor & Clarkin, 2010; Williams, 2010). (You will see that psychodynamic explanations for almost all the personality disorders begin the same way—with repeated mistreatment during childhood and lack of love.) According to one psychodynamic view, some people come to view their environment as hostile as a result of their parents’ persistently unreasonable demands. They must always be on the alert because they cannot trust others, and they are likely to develop feelings of extreme anger. They also project these feelings onto others and, as a result, feel increasingly persecuted (Koenigsberg et al., 2001). Similarly, some cognitive theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as “People are evil” and “People will attack you if given the chance” (Beck & Weishaar, 2014; Weishaar & Beck, 2006).
Biological theorists propose that paranoid personality disorder has genetic causes (APA, 2013; Bernstein & Useda, 2007). An early study that looked at self-reports of suspiciousness in 3,810 Austra- lian twin pairs found that if one twin was excessively suspicious, the
other had an increased likelihood of also being suspicious (Kendler et al., 1987). Once again, however, it is important to note that such similarities between twins might also be the result of common environmental experiences.
Treatments for Paranoid Personality Disorder People with paranoid personality disorder do not typically see themselves as needing help, and few come to treatment willingly (Millon, 2011). Furthermore, many who are in treatment view the role of patient as inferior and distrust and rebel against their therapists (Kellett & Hardy, 2014). Thus it is not surprising that therapy for this disorder, as for most other personality disorders, has limited effect and moves very slowly (Piper & Joyce, 2001).
Object relations therapists—the psychodynamic therapists who give center stage to relationships—try to see past the patient’s anger and work on what they view as his or her deep wish for a satisfying relationship (Caligor & Clarkin, 2010). Cogni- tive and behavioral techniques have also been used to treat people with paranoid personality disorder and are often combined into an integrated cognitive-behavioral approach. On the behavioral side, therapists help clients to master anxiety-reduction techniques and to improve their skills at solving interpersonal problems. On the cognitive side, therapists guide the clients to develop more realistic interpretations of other people’s words and actions and to become more aware of other people’s points of view (Kellett & Hardy, 2014). Antipsychotic drug therapy seems to be of limited help (Birkeland, 2013).
Percentage Who Distrust Them
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51%
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Lawyers 68%
Congressional members 85%
Doctors 12%
Social network ads
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Internet information
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figure 13-2 Whom do you distrust? Although distrust and suspiciousness are the hallmarks of para- noid personality disorder, even people with- out this disorder are surprisingly untrusting. In various surveys, the majority of respondents said they distrust Internet information, mem- bers of Congress, lawyers, journalists, social network ads, and television newscasters. (Information from: YouGov, 2014; Harris Inter- active, 2013, 2006; Press TV, 2013; Mancx, 2012).
Personality Disorders : 427
Schizoid Personality Disorder People with schizoid personality disorder persistently avoid and are removed from social relationships and demonstrate little in the way of emotion (APA, 2013). Like people with paranoid personality disorder, they do not have close ties with other people. The reason they avoid social contact, however, has nothing to do with paranoid feelings of distrust or suspicion; it is because they genuinely prefer to be alone. Take Eli:
Eli, a student at the local technical institute, had been engaged in several different Internet certificate programs over the past few years, and was about to engage in yet another, when his mother, confused as to why he would not apply for a tradi- tional degree at a “real” college, insisted he seek therapy. A loner by nature, Eli preferred not to socialize in any traditional sense, having little to no desire to get to know much about the people in his immediate social context. The way Eli saw it, . . . “at least at my school you just go to class and go home.”
Routinely, he slept through much of his day and then spent his evenings, nights, and weekends at the school’s computer lab, “chatting” with others over the Internet while not in class. Notably, people that he chatted with often sought to meet Eli, but he always declined these invitations, stating that he didn’t really have any desire to learn more about them than what they shared over the computer in the chat rooms. He described a family life that was similar to that of his social surroundings; he was mostly oblivious of his younger brother and sister, two outgoing teens, despite the fact that they seemed to hold him in the highest regard, and he had recently alien- ated himself entirely from his father, who had left the family several years earlier. . . .
A marked deficit in social interest was notable in Eli, as were frequent behavioral eccentricities. . . . At best, he had acquired a peripheral . . . role in social and fam- ily relationships. . . . Rather than venturing outward, he had increasingly removed himself from others and from sources of potential growth and gratification. Life was uneventful, with extended periods of solitude interspersed.
(Millon, 2011)
People like Eli, often described as “loners,” make no effort to start or keep friend- ships, take little interest in having sexual relationships, and even seem indifferent to their families. They seek out jobs that require little or no contact with others. When necessary, they can form work relations to a degree, but they prefer to keep to themselves. Many live by themselves as well. Not surprisingly, their social skills tend to be weak. If they marry, their lack of interest in intimacy may create marital or family problems.
People with schizoid personality disorder focus mainly on themselves and are generally unaffected by praise or criticism. They rarely show any feelings, expressing neither joy nor anger. They seem to have no need for attention or acceptance; are typically viewed as cold, humorless, or dull; and generally succeed in being ignored. This disorder is present in 3.1 per- cent of the adult population (APA, 2013; Sansone & Sansone, 2011). Men are slightly more likely to experience it than are women, and men may also be more impaired by it.
How Do Theorists Explain Schizoid Personal- ity Disorder? Many psychodynamic theorists, particularly object relations theorists, propose that schizoid personality disorder has its roots in an unsatisfied need for human contact
A darker knight In this scene from the popular 2008 movie The Dark Knight, Bruce Wayne confronts Batman, Wayne’s alter ego and only real friend. True to the vision of comic book artist and writer Frank Miller, this film and its sequel, The Dark Knight Rises, present the crime-fighter as a singularly driven loner incapa- ble of forming or sustaining relationships. Some clinical observers have argued that the current Dark Knight version of Batman often displays the features of schizoid personality disorder.
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▶▶ schizoid personality disorder A personality disorder characterized by persistent avoidance of social relation- ships and little expression of emotion.
: chapter 13428
(Caligor & Clarkin, 2010). The parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been unaccepting or even abusive of their children. Whereas people with paranoid symptoms react to such parenting chiefly with distrust, those with schizoid personality disorder are left unable to give or receive love. They cope by avoiding all relationships.
Cognitive theorists propose, not surprisingly, that people with schizoid per- sonality disorder suffer from deficiencies in their thinking. Their thoughts tend to be vague, empty, and without much meaning, and they have trouble scanning the environment to arrive at accurate perceptions (Kramer & Meystre, 2010). Unable to pick up emotional cues from others, they simply cannot respond to emotions. As this theory might predict, children with schizoid personality disorder develop language and motor skills very slowly, whatever their level of intelligence (APA, 2013; Wolff, 2000, 1991).
Treatments for Schizoid Personality Disorder Their social with- drawal prevents most people with schizoid personality disorder from entering therapy unless some other disorder, such as alcoholism, makes treatment necessary (Mittal et al., 2007). These clients are likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best (Colli et al., 2014).
Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interac- tions (Beck & Weishaar, 2011; Beck et al., 2004). On the cognitive end, their tech- niques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences. On the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role-playing, exposure techniques, and homework assignments as tools. Group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part (Piper & Joyce, 2001). As with paranoid personality disorder, drug therapy seems to offer limited help (Silk & Jibson, 2010).
Schizotypal Personality Disorder People with schizotypal personality disorder display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities (APA, 2013). Anxious around others, they seek isolation and have few close friends. Some feel intensely lonely. The disorder is more severe than the paranoid and schizoid personality disorders, as we see in the case of 41-year-old Kevin:
Kevin was a night security guard at a warehouse, where he had worked since his high school graduation more than 20 years ago. His parents, both successful profes- sionals, had been worried for many years, as Kevin seemed entirely disconnected from himself and his surroundings and had never taken initiative to make any changes, even toward a shift supervisory position. They therefore made the referral for therapy, and Kevin simply acquiesced. He explained that he liked his work, as it was a place where he could be by himself in a quiet atmosphere, away from anyone else. He described where he worked as “an empty warehouse; they don’t use it no more but they don’t want no one in there. It’s nice; ‘homey.’”
Throughout the . . . interview, Kevin remained aloof, never once looking at the counselor, usually answering questions with either one-word responses or short phrases, and usually waiting to respond until a second question was asked or the
▶▶ schizotypal personality disorder A personality disorder characterized by extreme discomfort in close relationships, very odd patterns of thinking and per- ceiving, and behavioral eccentricities.
B e t W e e N t h e L I N e S
In Their Words “I’m not anti-social. I’m just not social.”
Woody allen
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first question was repeated. He described, in . . . short, bizarre answers, a life de- void of almost any human interconnectedness, almost his only tangible contact being his brother, whom he saw only during major holidays. Living alone, he could only remember one significant relationship, and that was with a girl in high school. Very simply, he stated, “We graduated, and then I didn’t see her anymore.” He ex- pressed no apparent loneliness, however, and appeared entirely emotionless regard- ing any aspect of his life. . . .
Kevin . . . often seemed to experience a separation between his mind and his physical body. There was a strange sense of nonbeing or nonexistence, as if his floating conscious awareness carried with it a depersonalized or identityless human form. Behaviorally, his tendency was to be drab, sluggish, and inexpressive. He . . . appeared bland, indifferent, unmotivated, and insensitive to the external world. . . . Most people considered him to be [a] strange person . . . who faded into the back- ground, self-absorbed . . . and lost to the outside world. . . . Bizarre “telepathic” powers enabled him to communicate with mythical or distant others. . . . Kevin also occasionally decompensated when faced with too much, rather than too little, stimu- lation. . . . He would simply fade out, becoming blank, losing conscious awareness, and turning off the pressures of the outer world.
(Millon, 2011)
As with Kevin, the thoughts and behaviors of people with schizotypal person- ality disorder can be noticeably disturbed. These symptoms may include ideas of reference—beliefs that unrelated events pertain to them in some important way—and bodily illusions, such as sensing an external “force” or presence. A number of people with this disorder see themselves as having spe- cial extrasensory abilities, and some believe that they have magical control over others. Examples of schizotypal eccentricities include repeatedly arranging cans to align their labels, organizing closets extensively, or wearing an odd assortment of clothing. The emo- tions of these individuals may be inappropriate, flat, or humorless.
People with schizotypal personality disorder often have great difficulty keeping their attention focused. Correspondingly, their conversation is typically vague, even sprinkled with loose associa- tions (Millon, 2011). Like Kevin, they tend to drift aimlessly and lead an idle, unproductive life (Hengartner et al., 2014). They are likely to choose undemanding jobs in which they can work below their capacity and are not required to interact with other people. Surveys suggest that 3.9 percent of adults—slightly more males than females— display schizotypal personality disorder (Rosell et al., 2014; Sansone & Sansone, 2011).
How Do Theorists Explain Schizotypal Personality Disorder? Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors may be at work in both disorders. A wide range of studies have supported such expectations (Hazlett et al., 2015; Rosell et al., 2015). Investigators have found that schizotypal symptoms, like schizophrenic patterns, are often linked to family conflicts and to psychological disorders in parents. They have also learned that defects in attention and short-term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia. For example, research participants with either disorder perform poorly on backward masking, a laboratory test of attention that requires a person to identify a visual stimulus immediately after a previous stimulus has flashed on and off the screen. People with these disorders have a hard time shutting out the first
When personality disorders explode In this video, Seung-Hui Cho, a student at Virginia Tech, described the slights he experi- enced throughout his life. After mailing the video to NBC News, he proceeded, on April 16, 2007, to kill 32 people, including himself, and to wound 25 others in a massive campus shooting. Most clinical observers agree that he displayed a combination of features from the antisocial, borderline, paranoid, schizoid, schizo- typal, and narcissistic personality disorders, including boundless fury and hatred, extreme social withdrawal, persistent distrust, strange thinking, intimidating behavior and arrogance, and disregard for others.
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stimulus in order to focus on the second. Finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter (Lener et al., 2015; Ettinger et al., 2014). As you read in Chapter 12, there are indications that these biological factors may have a genetic base.
Although these findings do suggest a close relationship between schizotypal personality disorder and schizophrenia, the personality disorder also has been linked to disorders of mood (Lentz et al., 2010). More than half of people with schizotypal personality disorder also suffer from major depressive disorder at some point in their lives (APA, 2013). Moreover, relatives of people with depression have a higher than usual rate of schizotypal personality disorder, and vice versa. Thus, at the very least, this personality disorder is not tied exclusively to schizophrenia.
Treatments for Schizotypal Personality Disorder Therapy is as difficult in cases of schizotypal personality disorder as it is in cases of paranoid and schizoid personality disorders. Most therapists agree on the need to help these cli- ents “reconnect” with the world and recognize the limits of their thinking and their powers. The therapists may thus try to set clear limits—for example, by requiring punctuality—and work on helping the clients recognize where their views end and those of the therapist begin. Other therapy goals are to increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings (Colli et al., 2014; Sperry, 2003).
Cognitive-behavioral therapists further combine cognitive and behavioral tech- niques to help people with schizotypal personality disorder function more effec- tively. Using cognitive interventions, they try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones (Beck & Weishaar, 2011; Weishaar & Beck, 2006). Therapists may keep track of cli- ents’ odd or magical predictions, for example, and later point out their inaccuracy. When clients are speaking and begin to digress, the therapists might ask them to sum up what they are trying to say. In addition, specific behavioral methods, such as speech lessons, social skills training, and tips on appropriate dress and manners, have sometimes helped clients learn to blend in better with and be more comfortable around others (Farmer & Nelson-Gray, 2005).
Antipsychotic drugs have been given to people with schizotypal personality disorder, again because of the disorder’s similarity to schizophrenia. In low doses the drugs appear to have helped some people, usually by reducing certain of their thought problems (Rosenbluth & Sinyor, 2012).
➤ Summing Up “oDD” PerSonality DiSorDerS Three of the personality disorders in DSM-5 are marked by the kinds of odd or eccentric behaviors often seen in schizophre- nia, although they are not as extensive as those found in schizophrenia. Some clinicians believe that these personality disorders are related to schizophrenia.
People with paranoid personality disorder display a broad pattern of distrust and suspiciousness. Those with schizoid personality disorder persistently avoid social relationships and show little emotional expression. People with schizo- typal personality disorder display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd forms of thinking and behavior, and various behavioral eccentricities. People with these three kinds of disorders usually are resistant to treatment, and treatment gains tend to be modest at best.
B e t W e e N t h e L I N e S
A Common Belief People who think that they have extrasensory abilities are not necessarily suffering from schizotypal personality disorder. In fact, 73 percent of Americans believe in some form of the paranormal or occult—ESP, astrology, ghosts, communicating with the dead, or psychics.
(Gallup poll, 2005).
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In Their Words “What loneliness is more lonely than distrust?”
George eliot, novelist
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“Dramatic” Personality Disorders The cluster of “dramatic” personality disorders includes the antisocial, borderline, histrionic, and narcissistic personality disorders. The behaviors of people with these problems are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying.
These personality disorders are more commonly diagnosed than the others. However, only the antisocial and borderline personality disorders have received much study, partly because they create so many problems for other people. The causes of the disorders, like those of the odd personality disorders, are not well understood. Treatments range from ineffective to moderately effective.
Antisocial Personality Disorder Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights (APA, 2013). Aside from substance use disorders, this is the disorder most closely linked to adult criminal behavior. DSM-5 stipulates that a person must be at least 18 years of age to receive this diagnosis; however, most people with antisocial personality disorder displayed some patterns of misbehavior before they were 15, including truancy, run- ning away, cruelty to animals or people, and destroying property.
Robert Hare, a leading researcher of antisocial personality disorder, recalls an early professional encounter with a prison inmate named Ray:
In the early 1960s, I found myself employed as the sole psychologist at the British Columbia Penitentiary. . . . I wasn’t in my office for more than an hour when my first “client” arrived. He was a tall, slim, dark-haired man in his thirties. The air around him seemed to buzz, and the eye contact he made with me was so direct and in- tense that I wondered if I had ever really looked anybody in the eye before. That stare was unrelenting—he didn’t indulge in the brief glances away that most people use to soften the force of their gaze.
Without waiting for an introduction, the inmate—I’ll call him Ray—opened the conversation: “Hey, Doc, how’s it going? Look, I’ve got a problem. I need your help. I’d really like to talk to you about this.”
Eager to begin work as a genuine psychotherapist, I asked him to tell me about it. In response, he pulled out a knife and waved it in front of my nose, all the while smiling and maintaining that intense eye contact.
Once he determined that I wasn’t going to push the button, he explained that he intended to use the knife not on me but on another inmate who had been making overtures to his “protégé,” a prison term for the more passive member of a homo- sexual pairing. Just why he was telling me this was not immediately clear, but I soon suspected that he was checking me out, trying to determine what sort of a prison employee I was. . . .
From that first meeting on, Ray managed to make my eight-month stint at the prison miserable. His constant demands on my time and his attempts to manipulate me into doing things for him were unending. On one occasion, he convinced me that he would make a good cook . . . and I supported his request for a transfer from the machine shop (where he had apparently made the knife). What I didn’t consider was that the kitchen was a source of sugar, potatoes, fruit, and other ingredients that could be turned into alcohol. Several months after I had recommended the transfer, there was a mighty eruption below the floorboards directly under the warden’s table. When the commotion died down, we found an elaborate system for distilling alcohol below the floor. Something had gone wrong and one of the pots had exploded. There was nothing unusual about the presence of a still in a
Notorious disregard In 2009, financier Bernard Madoff was sentenced to 150 years in prison after defrauding thousands of investors, including many charities, of billions of dollars. Given his overwhelming disregard for others and other such qualities, some clinicians sug- gest that Madoff displays antisocial personality disorder.
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▶▶ antisocial personality disorder A personality disorder marked by a general pattern of disregard for and violation of other people’s rights.
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maximum-security prison, but the audacity of placing one under the warden’s seat shook up a lot of people. When it was discovered that Ray was the brains behind the bootleg operation, he spent some time in solitary confinement.
Once out of “the hole,” Ray appeared in my office as if nothing had happened and asked for a transfer from the kitchen to the auto shop—he really felt he had a knack, he saw the need to prepare himself for the outside world, if he only had the time to practice he could have his own body shop on the outside. . . . I was still feel- ing the sting of having arranged the first transfer, but eventually he wore me down.
Soon afterward I decided to leave the prison to pursue a Ph.D. in psychology, and about a month before I left Ray almost persuaded me to ask my father, a roof- ing contractor, to offer him a job as part of an application for parole.
Ray had an incredible ability to con not just me but everybody. He could talk, and lie, with a smoothness and a directness that sometimes momentarily disarmed even the most experienced and cynical of the prison staff. When I met him he had a long criminal record behind him (and, as it turned out, ahead of him); about half his adult life had been spent in prison, and many of his crimes had been violent. . . . He lied endlessly, lazily, about everything, and it disturbed him not a whit whenever I pointed out something in his file that contradicted one of his lies. He would simply change the subject and spin off in a different direction. Finally convinced that he might not make the perfect job candidate in my father’s firm, I turned down Ray’s request—and was shaken by his nastiness at my refusal.
Before I left the prison for the university, I took advantage of the prison policy of letting staff have their cars repaired in the institution’s auto shop—where Ray still worked, thanks (he would have said no thanks) to me. The car received a beautiful paint job and the motor and drivetrain were reconditioned.
With all our possessions on top of the car and our baby in a plywood bed in the backseat, my wife and I headed for Ontario. The first problems appeared soon after we left Vancouver, when the motor seemed a bit rough. Later, when we encountered some moderate inclines, the radiator boiled over. A garage mechanic discovered ball bearings in the carburetor’s float chamber; he also pointed out where one of the hoses to the radiator had clearly been tampered with. These problems were repaired easily enough, but the next one, which arose while we were going down a long hill, was more serious. The brake pedal became very spongy and then simply dropped to the floor—no brakes, and it was a long hill. Fortunately, we made it to a service station, where we found that the brake line had been cut so that a slow leak would occur. Perhaps it was a coincidence that Ray was working in the auto shop when the car was being tuned up, but I had no doubt that the prison “telegraph” had informed him of the owner of the car.
(Hare, 1993)
Like Ray, people with antisocial personality disorder lie repeatedly (APA, 2013). Many cannot work consistently at a job; they are absent frequently and are likely to quit their jobs altogether (Hengartner et al., 2014). Usually they are also careless with money and frequently fail to pay their debts. They are often impulsive, taking action without thinking of the consequences (Lang et al., 2015). Correspondingly, they may be irritable, aggres- sive, and quick to start fights. Many travel from place to place.
Recklessness is another common trait: people with antisocial personality disor- der have little regard for their own safety or for that of others, even their children. They are self-centered as well, and are likely to have trouble maintaining close rela- tionships. Usually they develop a knack for gaining personal profit at the expense of other people. Because the pain or damage they cause seldom concerns them, clinicians commonly say that they lack a moral conscience. They think of their
how do various institutions in our
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how might such views affect lying
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Previous Identity Antisocial personality disorder was referred to as “moral insanity” during the nineteenth century.
Personality Disorders : 433
victims as weak and deserving of being conned, robbed, or even physically harmed (see PsychWatch on the next page).
Surveys indicate that 3.6 percent of adults in the United States meet the criteria for antisocial personality disorder (Sansone & Sansone, 2011). The disorder is as much as four times more common among men than women.
Because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations (Pondé et al., 2014). It is estimated that at least 40 percent of people in prison meet the diagnostic criteria for this disorder (Naidoo & Mkize, 2012). Among men in urban jails, the antisocial personality pattern has been linked strongly to past arrests for crimes of violence (De Matteo et al., 2005). The criminal behavior of many people with this disor- der declines after the age of 40; some, however, continue their criminal activities throughout their lives (APA, 2013).
Studies and clinical observations also indicate that people with antisocial per- sonality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population (Brook et al., 2014; Reese et al., 2010). Perhaps intoxication and substance misuse help trigger the development of antisocial per- sonality disorder by loosening a person’s inhibitions. Perhaps this personality disor- der somehow makes a person more prone to abuse substances. Or perhaps antisocial personality disorder and substance use disorders both have the same cause, such as a deep-seated need to take risks. Interestingly, drug users with the personality dis- order often cite the recreational aspects of drug use as their reason for starting and continuing it.
How Do Theorists Explain Antisocial Personality Disorder? Expla- nations of antisocial personality disorder come from the psychodynamic, behav- ioral, cognitive, and biological models. As with many other personality disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust (Meloy & Yakeley, 2010; Sperry, 2003). In this view, some children—the ones who develop antisocial personality disorder—respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. In support of
Popular sociopaths Television audiences seem to love characters with the symptoms of antisocial personality disorder. Legendary char- acter Tony Soprano of The Sopranos (left) had hardly left our screens when he was replaced in the hearts of television viewers everywhere by the equally legendary Walter White of Breaking Bad (right).
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Character Ingestion As late as the Victorian era, many Eng- lish parents believed babies absorbed personality and moral uprightness as they took in milk. Thus, if a mother could not nurse, it was important to find a wet nurse of good character.
(asimov, 1997).
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PsychWatch
In 2012, a young man entered the Sandy Hook Elementary School in Newtown, Connecticut, and killed 26 people—20 of them young children—in a shooting rampage. In the months prior to this massacre, gunmen killed 12 moviegoers at a Batman movie in Colorado and 6 churchgoers at a Sikh temple in Wiscon- sin. And in 2015 a young man shot and killed 9 people who were participating in a Bible study group at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina. The clinical field has offered various theories about why individuals commit mass murders, but enlightening research and effective in- terventions have been elusive (Montaldo, 2014; Friedman, 2013).
What do we know about mass killings? We know they involve, by definition, the murder of four or more people in the same location and at around the same time. FBI records also indicate that, on average, mass killings occur in the United States every two weeks, 75 percent of them feature a lone killer, 67 percent in- volve the use of guns, and most are com- mitted by males (Hoyer & Heath, 2012).
We also know that despite appear- ances, the number of mass killings is not on the rise overall (O’Neill, 2012). What is increasing, however, are certain set- tings for mass killings (e.g., schools) and certain patterns of mass murder. Although specific issues vary from mass murder to mass murder— racial or religious hatred, for example—two general patterns are on the rise. In one pattern, so-called pseudo- commando mass murders, the murderer “kills in public, often during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. He has no escape planned and expects to be killed during the inci- dent” (Knoll, 2010). In another pattern, “autogenetic” (self- generated) massacres, individuals kill people indiscriminately to fulfill a personal agenda (Bowers et al., 2010; Mullen, 2004).
Theorists have suggested a number of factors to help explain pseudocommando,
autogenetic, and other mass killings, in- cluding the availability of guns, bullying behavior, substance abuse, the prolifera- tion of violent media and video games, dysfunctional homes, and contagion effects (Towers et al., 2015). Moreover, regardless of one’s position on gun con- trol, media violence, or the like, almost everyone, including most clinicians, be- lieve that mass killers typically suffer from a mental disorder (Auxemery, 2015; Fox & Levin, 2014). Which mental disorder? On this, there is little agreement. Each of the following has been suggested:
➤ Antisocial, borderline, paranoid, or schizotypal personality disorder
➤ Schizophrenia or severe bipolar disorder
➤ Intermittent explosive disorder—an impulse-control disorder featuring repeated, unprovoked verbal and/or behavioral outbursts
➤ Severe depression, stress, or anxiety
Although these and yet other disorders have been proposed, none has received clear support in the limited research con- ducted on mass killings. On the other
hand, several psychological variables have emerged as a common denominator across the various studies: severe feel- ings of anger and resentment, feelings of being persecuted or grossly mistreated, and desires for revenge (Fox & Levin, 2014; Knoll, 2010). That is, regardless of which mental disorder a mass killer may display, he usually is driven by this set of feelings. For a growing number of clinical researchers, this repeated finding suggests that research should focus less on diagnosis and much more on identify- ing and understanding these particular feelings.
Clearly, clinical research must expand its focus on this area of enormous social concern. It is a difficult problem to inves- tigate, partly because so few mass killers survive their crimes, but the clinical field has managed to gather useful insights about other elusive areas. And, indeed, in the aftermath of the horrific murders mentioned at the beginning of this box, a wave of heightened determination and commitment seems to have seized the clinical community.
Mass Murders: Where Does Such Violence Come From?
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A nation grieves . . . again During a 2015 prayer vigil at a Washington, D. C. church, con- gregants hold up photographs of nine Bible study participants who had been shot and killed two days earlier at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina.
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the psychodynamic explanation, researchers have found that people with this dis- order are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce (Kumari et al., 2014; Martens, 2005).
Many behavioral theorists have suggested that antisocial symptoms may be learned through modeling, or imitation (Gaynor & Baird, 2007). As evidence, they point to the higher rate of antisocial personality disorder found among the parents of people with this disorder (APA, 2013). Other behaviorists have suggested that some parents unintentionally teach antisocial behavior by regularly rewarding a child’s aggressive behavior (Kazdin, 2005). When the child misbehaves or becomes violent in reaction to the parents’ requests or orders, for example, the parents may give in to restore peace. Without meaning to, they may be teaching the child to be stubborn and perhaps even violent.
The cognitive view says that people with antisocial personality disorder hold attitudes that trivialize the importance of other people’s needs (Elwood et al., 2004). Such a philosophy of life, some theorists suggest, may be far more common in our society than people rec- ognize (see Table 13-2). Cognitive theorists further propose that people with this disorder have genuine difficulty recognizing points of view or feelings other than their own (Herpertz & Bertsch, 2014).
Finally, studies suggest that biological factors may play an important role in antisocial personality disorder. Researchers have found that antisocial people, par- ticularly those who are highly impulsive and aggressive, have lower serotonin activity than other people (Thompson et al., 2014). As you’ll recall, both impulsivity and aggression also have been linked to low serotonin activity in other kinds of studies (see page 235), so the presence of this biological factor in people with antisocial personality disorder is not surprising.
Other studies indicate that individuals with this disorder display deficient func- tioning in their frontal lobes, particularly in the prefrontal cortex (Liu et al., 2014). Among other duties, this brain region helps people to plan and execute realistic strategies and to have personal characteristics such as sympathy, judgment, and empathy. These are, of course, all qualities found wanting in people with antisocial personality disorder.
In yet another line of research, investigators have found that people with anti- social personality disorder often feel less anxiety than other people, and so lack a key ingredient for learning (Blair et al., 2005). This would help explain why they have so much trouble learning from negative life experiences or tuning in to the emotional cues of others. Why should people with antisocial personality disorder experience less anxiety than other people? The answer may lie once again in the biological realm. Research participants with the disorder often respond to warn- ings or expectations of stress with low brain and bodily arousal (Thompson et al., 2014; Perdeci et al., 2010). Perhaps because of the low arousal, they easily tune out threatening or emotional situations, and so are unaffected by them.
It could also be argued that because of their physical underarousal, people with antisocial personality disorder would be more likely than other people to take risks and seek thrills. That is, they may be drawn to antisocial activity precisely because it meets an underlying biological need for more excitement and arousal. In support of this idea, as you read earlier, antisocial personality disorder often goes hand in hand with sensation-seeking behavior.
Treatments for Antisocial Personality Disorder Treatments for people with antisocial personality disorder are typically ineffective (Black, 2015). Major obstacles to treatment include the individuals’ lack of conscience, desire to change, or respect for therapy (Colli et al., 2014; Kantor, 2006). Most of those in therapy have been forced to participate by an employer, their school, or the law,
can you point to attitudes
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annual Hate Crimes in the United States
Group attacked
number of reported incidents
Racial/ethnic groups 4,119
LGBT* groups 1,318
Religious groups 1,166
Groups with disability 102
*Widely accepted acronym for Lesbian, Gay, Bisexual, and Transgender people
Information from: U.S. Department of Justice, Federal Bureau of Investigation, 2013, 2012
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or they come to the attention of therapists when they also develop another psychological disorder (Agronin, 2006).
Some cognitive therapists try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people (Beck & Weishaar, 2011; Weishaar & Beck, 2006). In a similar vein, a number of hospitals and prisons have tried to create a therapeutic community for people with this disorder, a structured environment that teaches responsibility toward others (Harris & Rice, 2006). Some patients seem to profit from such approaches, but it appears that most do not. In recent years, clinicians have also used psychotro- pic medications, particularly atypical antipsychotic drugs, to treat people with antisocial personality disorder. Some report that these drugs help reduce certain features of the disorder, but systematic stud-
ies of this claim are still needed (Brown et al., 2014; Thompson et al., 2014).
Borderline Personality Disorder People with borderline personality disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity (APA, 2013). These characteristics combine to make their relationships very unstable as well (Paris, 2010, 2005). Some of Ellen Farber’s difficulties are typical:
Ellen Farber, a 35-year-old, single insurance company executive, came to a psychi- atric emergency room . . . with complaints of depression and the thought of driving her car off a cliff. An articulate, moderately overweight, sophisticated woman, Ms. Farber appeared to be in considerable distress. She reported a 6-month period of increasingly persistent dysphoria and lack of energy and pleasure. Feeling as if she were “made of lead,” Ms. Farber had recently been spending 15–20 hours a day in her bed. She also reported daily episodes of binge eating, when she would con- sume “anything I can find.”. . . She reported problems with intermittent binge eat- ing since adolescence, but these had recently increased in frequency, resulting in a 20-pound weight gain. . . .
She attributed her increasing symptoms to financial difficulties. Ms. Farber had been fired from her job two weeks before. . . . She claimed it was because she “owed a small amount of money.” When asked to be more specific, she reported owing $150,000 to her former employers and another $100,000 to various local banks. . . . From age 30 to age 33, she had used her employer’s credit cards to fi- nance weekly “buying binges,” accumulating the $150,000 debt. She . . . reported that spending money alleviated her chronic feelings of loneliness, isolation, and sad- ness. Experiencing only temporary relief, every few days she would impulsively buy expensive jewelry, watches, or multiple pairs of the same shoes. . . .
In addition to lifelong feelings of emptiness, Ms. Farber described chronic uncer- tainty about what she wanted to do in life and with whom she wanted to be friends. She had many brief, intense relationships with both men and women, but her quick temper led to frequent arguments and even physical fights. Although she had al- ways thought of her childhood as happy and carefree, when she became depressed, she began to recall [being abused verbally and physically by her mother].
(Spitzer et al., 1994, pp. 395–397)
Hardly a new disorder A worker attaches a tag that translates as “Killer of a Wife” to a wax-covered head at the Lombroso Museum in Turin, Italy. Hundreds of such heads, taken from prisons throughout Europe, line the museum’s shelves, each with the tags like “Ladro” (“Thief”) or “Omicida” (“Murderer”). The display comes from nineteenth-century psychia- trist Cesare Lombroso’s crude but pioneering research into the nature of criminal and related antisocial behavior.
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▶▶ borderline personality disorder A personality disorder characterized by repeated instability in interpersonal rela- tionships, self-image, and mood and by impulsive behavior.
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Like Ellen Farber, people with borderline personality disorder swing in and out of very depressive, anxious, and irritable states that last anywhere from a few hours to a few days or more (see Table 13-3). Their emotions seem to be always in conflict with the world around them. They are prone to bouts of anger, which sometimes result in physical aggression and violence (Martino et al., 2015; Scott et al., 2014). Just as often, however, they direct their impulsive anger inward and inflict bodily harm on themselves. Many seem troubled by deep feelings of emptiness.
Borderline personality disorder is a complex disorder, and it is fast becoming one of the more common conditions seen in clinical practice. Many of the patients who come to mental health emergency rooms are people with this disorder who have intentionally hurt themselves. Their impulsive, self-destructive activities may range from alcohol and substance abuse to delinquency, unsafe sex, and reckless driving (Kienast et al., 2014; Coffey et al., 2011). Many engage in self-injurious or self-mutilation behaviors, such as cutting or burning themselves or banging their heads (Turner et al., 2015). As you saw in Chapter 7, such behaviors typically cause immense physical suffering, but those with borderline personality disorder often feel as if the physical discomfort offers relief from their emotional suffering. It may serve as a distraction from their emotional or interpersonal upsets, “snapping” them out of an “emotional overload” (Sadeh et al., 2014). Many try to hurt themselves as a way of dealing with their chronic feelings of emptiness, boredom, and identity confusion. Scars and bruises also may provide them with a kind of concrete evidence of their emotional distress (Paris, 2010, 2005).
Suicidal threats and actions are also common (Amore et al., 2014; Zimmerman et al., 2014). Studies suggest that around 75 percent of people with borderline per- sonality disorder attempt suicide at least once in their lives; as many as 10 percent actually commit suicide. It is common for people with this disorder to enter clinical treatment by way of the emergency room after a suicide attempt.
People with borderline personality disorder frequently form intense, conflict- ridden relationships in which their feelings are not necessarily shared by the other person. They may come to idealize another person’s qualities and abilities after
table: 13-3
Comparison of Personality Disorders
Cluster Similar Disorders responsiveness to treatment
Paranoid Odd Schizophrenia; delusional disorder Modest
Schizoid Odd Schizophrenia; delusional disorder Modest
Schizotypal Odd Schizophrenia; delusional disorder Modest
Antisocial Dramatic Conduct disorder Poor
Borderline Dramatic Depressive disorder; bipolar disorder Moderate
Histrionic Dramatic Somatic symptom disorder; depressive disorder
Modest
Narcissistic Dramatic Cyclothymic disorder (mild bipolar disorder)
Poor
Avoidant Anxious Social anxiety disorder Moderate
Dependent Anxious Separation anxiety disorder; depressive disorder
Moderate
Obsessive- compulsive
Anxious Obsessive-compulsive disorder Moderate
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Letting It Out expression of anger Only 23 percent of adults report openly expressing their anger (Kanner, 2005, 1995). Around 39 percent say that they hide or contain their anger, and 23 percent walk away to try to collect themselves.
the Myth of Venting Contrary to the notion that “letting off steam” reduces anger, angry participants in one study acted much more aggressively after hitting a punching bag than did angry participants who first sat quietly for a while (Bushman et al., 1999).
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just a brief first encounter. They also may violate the boundaries of relationships (Lazarus et al., 2014). They quickly feel rejected and may become furious when their expectations are not met, yet they remain very attached to the relationships (Berenson et al., 2011). In fact, they have recurrent fears of impending abandonment and frequently engage in frantic efforts to avoid real or imagined separations from important people in their lives (Gunderson, 2011). Sometimes they cut themselves or carry out other self-destructive acts to prevent partners from leaving.
People with borderline personality disorder typically have dramatic identity shifts. Because of this unstable sense of self, their goals, aspirations, friends, and even sexual orientation may shift rapidly (Westen et al., 2011; Skodol, 2005).They may at times have no sense of themselves at all, leading to the feelings of emptiness described earlier.
According to surveys, 5.9 percent of the adult population display borderline personality disorder (Zanarini et al., 2014; Sansone & Sansone, 2011). Close to 75 percent of the patients who receive the diagnosis are women (Gunderson, 2011). The course of the disorder varies from person to person. In the most common pattern, the person’s instability and risk of suicide peak during young adulthood and then gradually wane with advancing age (APA, 2013). Given the chaotic and unstable relationships characteristic of borderline personality disorder, it is not sur- prising that the disorder tends to interfere with job performance even more than most other personality disorders do (Hengartner et al., 2014).
How Do Theorists Explain Borderline Personality Disorder? Because a fear of abandonment tortures so many people with borderline personality disorder, psychodynamic theorists have looked once again to early parental relation- ships to explain the disorder (Gabbard, 2010). Object relations theorists, for example,
propose that an early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation (Caligor & Clarkin, 2010).
Research has found that this is consistent with the early childhoods of people with borderline personality disorder. In many cases, when they were children, their parents neglected or rejected them, verbally abused them, or otherwise behaved inappropriately (Martín-Blanco et al., 2014). Their childhoods were often marked by multiple parent substitutes, divorce, death, or traumas such as physical or sexual abuse (Newnham & Janca, 2014; Huang et al., 2010). At the same time, it is important to recognize that the vast majority of people with histories of physical, sexual, or psychological abuse do not go on to develop borderline personality disorder (Skodol, 2005).
Borderline personality disorder also has been linked to cer- tain biological abnormalities, such as an overly reactive amyg-
dala, the brain structure that is closely tied to fear and other negative emotions, and an underactive prefrontal cortex, the brain region linked to planning, self-control, and decision making (Mitchell et al., 2014; Stone, 2014). Moreover, people with borderline personality disorder who are particularly impulsive—those who attempt suicide or are very aggressive toward others— apparently have lower brain serotonin activity (Soloff et al., 2014). In accord with these various biological findings, close relatives of those with borderline personality disorder are five times more likely than the general population to have the same personality disorder (Amad et al., 2014; Torgersen, 2000, 1984).
A number of theorists currently use a biosocial theory to explain borderline per- sonality disorder (Neacsiu & Linehan, 2014). According to this view, the disorder results from a combination of internal forces (for example, difficulty identifying and
Personality disorders—at the movies In the 1999 film Girl, Interrupted, based on a best-selling memoir, Susanna Kaysen (left, played by actress Winona Ryder) is befriended by Lisa Rowe (played by Angelina Jolie) at a mental hospital. Kaysen received a diagnosis of borderline personality disorder at the hospital, while Rowe’s diagnosis was antisocial personal- ity disorder.
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Dealing with Anger • Women are 2.5 times more likely than
men to turn to food as a way to calm down when angry.
• According to surveys, men are 3 times more likely than women to use sex as a way to calm down when angry.
• Women are 56 percent more likely than men to “yell a lot” when angry.
• Men are 35 percent more likely than women to “seethe quietly” when angry.
(Zoellner, 2000)
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controlling one’s emotions, social skill deficits, abnor- mal neurotransmitter reactions) and external forces (for example, an environment in which a child’s emotions are punished, ignored, trivialized, or disregarded). Par- ents may, for instance, misinterpret their child’s intense emotions as exaggerations or attempts at manipulation rather than as serious expressions of unsettled internal states. According to the biosocial theory, if children have intrinsic difficulty identifying and controlling their emotions and if their parents teach them to ignore their intense feelings, they may never learn how properly to recognize and control their emotional arousal or how to handle emotional distress (Herpertz & Bertsch, 2014; Lazarus et al., 2014). Such children will be at risk for the development of borderline personality disorder (Gill & Warburton, 2014).
Note that the biosocial theory is similar to one of the leading explanations for eating disorders. As you saw in Chapter 9, theorist Hilde Bruch proposed that children whose parents do not respond accurately to the children’s internal cues may never learn to identify cues of hunger, thus increasing their risk of developing an eating disorder (see pages 289–290). Small wonder that a large number of people with borderline personality disorder also have an eating disorder (Gabriel & Waller, 2014). Recall, for example, Ellen Farber’s dysfunctional eating pattern.
Finally, some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment. Family units may come apart, leaving people with little sense of belonging. Changes of this kind in society today may explain growing reports of the disorder (Millon, 2011).
Treatments for Borderline Personality Disorder It appears that psychotherapy can eventually lead to some degree of improvement for people with borderline personality disorder (McMain, 2015; Neville, 2014). It is, however, extraordinarily difficult for a therapist to strike a balance between empathizing with the borderline client’s dependency and anger and challenging his or her way of thinking (Goodman et al., 2014). The wildly fluctuating interpersonal attitudes of clients with the disorder can also make it difficult for therapists to establish collaborative working relationships with them. Moreover, clients with borderline personality disorder may violate the boundaries of the client–therapist relationship (for example, calling the therapist’s emergency contact number to discuss matters of a less urgent nature) (Colli et al., 2014).
Over the past two decades, an integrative treatment for borderline personality disorder, called dialectical behavior therapy (DBT), has been receiving considerable research support and is now considered the treatment of choice in many clinical circles (Linehan et al., 2015, 2006, 2002, 2001). DBT, developed by psychologist Marsha Linehan, grows largely from the cognitive-behavioral treatment model (see MediaSpeak on the next page). It includes a number of the same cognitive and behavioral techniques that are applied to other disorders: homework assignments, psychoeducation, the teaching of social and other skills, modeling by the therapist, clear goal setting, reinforcements for appropriate behaviors, and collaborative exami- nations by the client and therapist of the client’s ways of thinking.
DBT also borrows heavily from the humanistic and contemporary psycho- dynamic approaches, placing the client–therapist relationship itself at the center
Troubled princess Admired by millions dur- ing her short life, particularly for her numerous charitable efforts and humane acts, Princess Diana also had a range of psychological prob- lems that she herself disclosed in books and interviews. Diagnosing and explaining her problems has become a common practice— both inside and outside the clinical field—since her death in 1997. Her self-cutting, possible borderline personality functioning, and disor- dered eating behaviors have received the most attention.
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Whither “Borderline”? In 1938 the term “borderline” was intro- duced by psychoanalyst Adolph Stern. He used it to describe patients who were more disturbed than “neurotic” patients, yet not psychotic (Bateman, 2011; Stern, 1938). The term has since evolved to its present usage.
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MediaSpeak The Patient as Therapist
By Benedict Carey, New York Times, June 23, 2011
Marsha M. Linehan, 68 . . . told her story in public for the first time last week. . . .
Dr. Linehan . . . was driven by a mission to rescue people who are chronically suicidal, often as a result of borderline personality dis- order, an enigmatic condition char- acterized in part by self-destructive urges. “I honestly didn’t realize at the time that I was dealing with myself,” she said. “But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got.”
She learned the central tragedy of severe mental illness the hard way, banging her head against the wall of a locked room.
Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself ha- bitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.
The seclusion room . . . had no such weapon. Yet her urge to die only deepened. . . .
“I was in hell,” she said. “And I made a vow: when I get out, I’m going to come back and get others out of here.”. . .
radical acceptance . . . It was 1967, several years after she left the insti-
tute as a desperate 20-year-old whom doctors gave little chance of surviving outside the hospital. . . . “One night I was kneeling in [church], looking up at the cross, and the whole place became gold—and suddenly I felt something coming toward me,” she said. “It was this shimmering experience, and I just ran back to my room and said, ‘I love myself.’ . . . I felt transformed.”. . .
What had changed? It took years of study in psychology—she earned a
Ph.D. at Loyola in 1971—before she found an answer. On the surface, it seemed obvious: She had accepted herself as she was. . . . That basic idea—radical accep- tance, she now calls it—became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher. . . .
No therapist could promise a quick transformation or even sudden “insight,” much less a shimmering religious vision. But now Dr. Linehan was closing in on two seemingly op- posed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it. . . .
She chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder. . . .
Yet even as she climbed the academic ladder, moving from the
Catholic University of America to the University of Washington in 1977, she understood from her own experience that acceptance and change were hardly enough. . . . She relied on therapists herself, off and on over the years, for support and guidance. . . .
Dr. Linehan’s own emerging approach to treatment— now called dialectical behavior therapy, or D.B.T.— would also have to include day-to-day skills. . . . She borrowed some of these from other behavioral thera- pies and added elements, like opposite action, in which patients act opposite to the way they feel when an emo- tion is inappropriate; and mindfulness meditation. . . .
In studies in the 1980s and ’90s, researchers at the University of Washington and elsewhere tracked the progress of hundreds of borderline patients at high risk of suicide who attended weekly dialectical therapy sessions. Compared with similar patients who got other experts’ treatments, those who learned Dr. Linehan’s approach made far fewer suicide attempts, landed in the hospital less often and were much more likely to stay in treatment. D.B.T. is now widely used for a vari- ety of clients, including juvenile offenders. . . .
Most remarkably, perhaps, Dr. Linehan has reached a place where she can stand up and tell her story, come what will. “I’m a very happy person now.”. . . “I still have ups and downs, of course, but I think no more than anyone else.”
June 23, 2011, “Lives Restored: Expert on Mental Illness Reveals Her Own Fight” by Benedict Carey, From New York Times, 6/23/2011, © 2011 The New York Times. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmission of this content without express written permission is prohibited.
Psychologist Marsha Linehan
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of treatment interactions, making sure that appropriate treatment boundaries are adhered to and providing an environment of acceptance and validation of the client. Indeed, DBT therapists regularly empathize with their borderline clients and with the emotional turmoil they are experiencing, locate kernels of truth in the clients’ complaints or demands, and examine alternative ways for them to address valid needs.
DBT is often supplemented by the clients’ participation in social skill-building groups (Roney & Cannon, 2014). In these groups, clients practice new ways of relating to other people in a safe environment and receive validation and support from other group members.
DBT has received more research support than any other treatment for border- line personality disorder (Neacsiu & Linehan, 2014; Roepke et al., 2011). Many clients who receive DBT become more able to tolerate stress; develop new, more appropriate, social skills; respond more effectively to life situations; and develop a more stable identity. They also have significantly fewer suicidal behaviors and require fewer hospitalizations than those who receive other forms of treatment (Linehan et al., 2015). In addition, they are more likely to remain in treatment and to report less anger, more social gratification, improved work performance, and reductions in substance abuse (Rizvi et al., 2011).
Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder (Bridler et al., 2015; Knappich et al., 2014). However, given the numerous suicide attempts by people with this disorder, the use of drugs on an outpatient basis is controversial (Gunder- son, 2011). Many professionals believe that psychotropic drug treatment for borderline personality disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy (Omar et al., 2014).
Histrionic Personality Disorder People with histrionic personality disorder, once called hysterical personality disorder, are extremely emotional—they are typically described as “emotionally charged”—and continually seek to be the center of attention (APA, 2013). Their exaggerated moods and neediness can complicate life considerably, as we see in the case of Lucinda:
Unhappy over her impending divorce, Lucinda decided to seek counseling. She arrived at her first session wearing a very provocative outfit, including a revealing blouse and extremely short skirt. Her hair had been labored over, and she had on an excessive amount of makeup—very carefully applied.
When asked to discuss her separation, Lucinda first insisted that the therapist call her Cindy, saying, “All my close friends call me that, and I like to think that you and I will become very good friends here.” She said that her husband Morgan had suddenly abandoned her—“probably brainwashed by some young trollop.” She proceeded to describe their break-up in a theatrical manner. Over a span of five minutes, her voice ranged from whispers to cries of agony and back again to whis- pers; she waved her arms dramatically while making some points and sat totally still while making others. She seemed to be on center stage.
Lucinda said that when Morgan first told her that he wanted a divorce, she did not know whether she could go on. The pain was palpable. After all, they had been so “incredibly and irrevocably” close, and he had been so devoted to her. She said that initially she even had thoughts of doing away with herself. But, of course,
“You’ll have to excuse me—I’m myself today.”
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▶▶ histrionic personality disorder A personality disorder characterized by a pattern of excessive emotionality and attention seeking. Once called hysterical personality disorder.
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she knew that she had to pull herself together. So many people needed her to be strong. So many people relied on her, particularly her “dear friends” and her sister. She had deep and special relationships with them all.
She told the therapist that without Morgan she would now need a man to take care of her—emotionally and every other way. She asked the therapist if she looked like a 30-year-old woman. When he declined to answer, she said, “I know you’re not supposed to say.”
When the therapist attempted to steer the conversation back to Morgan, Lucinda asked, “Do we really need to talk about that abusive lout?” Pressed on the word “abusive,” Lucinda replied that she was referring to “mental cruelty.” Morgan had, after all, called her inadequate and worthless throughout their marriage and told her that everything good in her life had been due to him. When her therapist pointed out that this seemed to contradict the rosy picture she had just painted of Morgan and their married life, she quickly changed the subject.
As the session came to a close, Lucinda’s therapist suggested that it might be useful for him to meet with Morgan. She loved the idea, saying, “Then he’ll know the competition he has!”
When he met with Morgan a few days later, the therapist heard a very different story. Morgan said, “I really loved Cindy—still do—but she was always flying off the handle, telling me I’m no good or that I didn’t care about her. She would often com- plain that I spent too much time at work—keep in mind that I never work more than 30 hours a week—and too little time attending to her needs. I just can’t take life with her anymore. It’s too draining.”
Morgan also indicated that Lucinda had virtually no close friends. She and her sis- ter might talk on the phone once a month and get together in person twice a year. He acknowledged that she drew a lot of attention from people. But, he noted “Look at how she dresses and her constant flirting. That’ll get people’s attention, keep them around for a while.”
People with histrionic personality disorder are always “on stage,” using theatri- cal gestures and mannerisms and grandiose language to describe ordinary everyday events. Like chameleons, they keep changing themselves to attract and impress an audience, and in their pursuit they change not only their surface characteristics— according to the latest fads—but also their opinions and beliefs. In fact, their speech is actually scanty in detail and substance, and they seem to lack a sense of who they really are.
Approval and praise are their lifeblood; they must have others present to witness their exaggerated emotional states. Vain, self-centered, demanding, and unable to delay gratifica- tion for long, they overreact to any minor event that gets in the way of their quest for attention. Some make suicide attempts, often to manipulate others (APA, 2013).
People with histrionic personality disorder may draw attention to themselves by exaggerating their physical ill- nesses or fatigues. They may also behave very provocatively and try to achieve their goals through sexual seduction. Most obsess over how they look and how others will perceive them, often wearing bright, eye-catching clothes. They exaggerate the depth of their relationships, considering themselves to be the intimate friends of people who see them as no more than casual acquaintances. Often they become involved with romantic partners who may be exciting but who do not treat them well.
Transient hysterical symptoms These avid Harry Potter fans expressed themselves with exaggerated emotionality and lack of restraint at the midnight launch of one of the books in the series. Similar reactions, along with fainting, tremors, and even convulsions, have been common at concerts by musical idols dating back to the 1940s. Small wonder that expressive fans of this kind are regularly described as “hysterical” or “histrionic” by the press—the same labels applied to the person- ality disorder that is marked by such behaviors and symptoms.
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In Their Words “To love oneself is the beginning of a lifelong romance.”
Oscar Wilde, An Ideal Husband (1895)
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This disorder was once believed to be more common in women than in men, and clinicians long described the “hysterical wife” (Anderson et al., 2001). Research, however, has revealed gender bias in past diagnoses (APA, 2013). When evaluating case studies of people with a mixture of histrionic and antisocial traits, clinicians in several studies gave a diagnosis of histrionic personality disorder to women more than men. Surveys suggest that 1.8 percent of adults have this personality disorder, with males and females equally affected (APA, 2013; Sansone & Sansone, 2011).
How Do Theorists Explain Histrionic Personality Disorder? The psychodynamic perspective was originally developed to help explain cases of hysteria (see Chapter 8), so it is no surprise that psychodynamic theorists continue to have a strong interest in histrionic personality disorder. Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment (Horowitz & Lerner, 2010; Bender et al., 2001). To defend against deep-seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act protectively.
Cognitive explanations look instead at the lack of substance and extreme sug- gestibility that people with histrionic personality disorder have. Cognitive theorists see these people as becoming less and less interested in knowing about the world at large because they are so self-focused and emotional. With no detailed memo- ries of what they never learned, they must rely on hunches or on other people to provide them with direction in life (Blagov et al., 2007). Some cognitive theorists also believe that people with this disorder hold a general assumption that they are helpless to care for themselves, and so they constantly seek out others who will meet their needs (Weishaar & Beck, 2006; Beck et al., 2004).
Sociocultural, particularly multicultural, theorists believe that histrionic person- ality disorder is produced in part by cultural norms and expectations. Until recently, our society encouraged girls to hold on to childhood and dependency as they grew up. The vain, dramatic, and selfish behavior of the histrionic personality may actu- ally be an exaggeration of femininity as our culture once defined it (Fowler et al., 2007). Similarly, some clinical observers claim that histrionic personality disorder is diagnosed less often in Asian and other cultures that discourage overt sexualization and more often in Hispanic American and Latin American cultures that are more tolerant of overt sexualization (Patrick, 2007; Trull & Widiger, 2003). Researchers have not, however, investigated this claim systematically.
Treatments for Histrionic Personality Disorder People with histri- onic personality disorder are more likely than those with most other personality dis- orders to seek out treatment on their own (Tyrer et al., 2003). Working with them can be very difficult, however, because of the demands, tantrums, and seductiveness they are likely to deploy. Another problem is that these clients may pretend to have important insights or to change during treatment merely to please the therapist. To head off such problems, therapists must remain objective and maintain strict profes- sional boundaries (Colli et al., 2014; Blagov et al., 2007).
Cognitive therapists have tried to help people with this disorder to change their belief that they are helpless and also to develop better, more deliberate ways of thinking and solving problems (Weishaar & Beck, 2006; Beck et al., 2004). Psycho- dynamic therapy and various group therapy formats have also been used (Horowitz & Lerner, 2010). In all these approaches, therapists ultimately aim to help the clients recognize their excessive dependency, find inner satisfaction, and become more self-reliant. Clinical case reports suggest that each of the approaches can be useful. Drug therapy appears less successful except as a means of relieving the depressive symptoms that some patients have (Bock et al., 2010; Grossman, 2004).
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In Their Words “The hysterical find too much significance in things. The depressed find too little.”
Mason cooley, american aphorist
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Portrait in Vanity King Frederick V, ruler of Denmark from 1746 to 1766, had his portrait painted at least 70 times by the same artist, Carl Pilo.
(Shaw, 2004)
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Narcissistic Personality Disorder People with narcissistic personality disorder are generally grandiose, need much admiration, and feel no empathy with others (APA, 2013). Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them. Frederick, the man whom we met at the beginning of this chap- ter, was one such person. So is Steven, a 30-year-old artist, married, with one child:
Steven came to the attention of a therapist when his wife insisted that they seek marital counseling. According to her, Steve was “selfish, ungiving and preoccupied with his work.” Everything at home had to “revolve about him, his comfort, moods and desires, no one else’s.” She claimed that he contributed nothing to the mar- riage, except a rather meager income. He shirked all “normal” responsibilities and kept “throwing chores in her lap,” and she was “getting fed up with being the chief cook and bottlewasher, tired of being his mother and sleep-in maid.”
On the positive side, Steven’s wife felt that he was basically a “gentle and good- natured guy with talent and intelligence.” But this wasn’t enough. She wanted a hus- band, someone with whom she could share things. In contrast, he wanted, according to her, “a mother, not a wife”; he didn’t want “to grow up, he didn’t know how to give affection, only to take it when he felt like it, nothing more, nothing less.”
Steve presented a picture of an affable, self-satisfied and somewhat disdainful young man. He was employed as a commercial artist, but looked forward to his evenings and weekends when he could turn his attention to serious painting. He claimed that he had to devote all of his spare time and energies to “fulfill himself,” to achieve expression in his creative work. . . .
His relationships with his present co-workers and social acquaintances were pleasant and satisfying, but he did admit that most people viewed him as a “bit self- centered, cold and snobbish.” He recognized that he did not know how to share his thoughts and feelings with others, that he was much more interested in himself than in them and that perhaps he always had “preferred the pleasure” of his own com- pany to that of others.
(Millon, 1969, pp. 261–262)
People with narcissistic personality disorder have a grandiose sense of self- importance. They exaggerate their achievements and talents, expecting others to recognize them as superior, and often appear arrogant. They are very choosy about their friends and associates, believing that their problems are unique and can be
appreciated only by other “special,” high-status people. Because of their charm, they often make favorable first impressions, yet they can rarely maintain long-term relationships (Campbell & Miller, 2011).
Like Steven, people with narcissistic personality disorder are sel- dom interested in the feelings of others. They may not even be able to empathize with such feelings (Marcoux et al., 2014; Roepke & Vater, 2014). Many take advantage of other people to achieve their
own ends, perhaps partly out of envy; at the same time they believe others envy them. Though grandiose, some react to criticism or frustration with bouts of rage, humili- ation, or embitterment (APA, 2013). Others may react with cold indifference. And still others become extremely pessimistic and filled with depression. They may have periods of zest that alternate with periods of disappointment (Ronningstam, 2011).
As many as 6.2 percent of adults display narcissistic personality disorder, up to 75 percent of them men (APA, 2013; Sansone & Sansone, 2011). Narcissistic-type behaviors and thoughts are common and normal among teenagers and do not usu- ally lead to adult narcissism (see MindTech on page 446).
Why do people often admire
arrogant deceivers—art forgers,
jewel thieves, or certain kinds
of “con” artists, for example?
▶▶ narcissistic personality disorder A personality disorder marked by a broad pattern of grandiosity, need for admira- tion, and lack of empathy.
Personality Disorders : 445
How Do Theorists Explain Narcissistic Personality Dis- order? Psychodynamic theorists more than others have theorized about narcissistic personality disorder, and they again propose that the problem begins with cold, rejecting parents. They argue that some people with this background spend their lives defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world (Roepke & Vater, 2014; Bornstein, 2005). They do so by repeatedly telling themselves that they are actually per- fect and desirable, and also by seeking admiration from others. Object relations theorists—the psychodynamic theorists who emphasize relationships— interpret the grandiose self-image as a way for these people to convince themselves that they are totally self-sufficient and without need of warm relationships with their parents or anyone else (Celani, 2014; Diamond & Meehan, 2013). In support of the psychodynamic theories, research has found that children who are abused or who lose parents through adoption, divorce, or death are at particular risk for the later development of narcissistic per- sonality disorder (Kernberg, 2010, 1992, 1989). Studies also show that people with this disorder do indeed earn relatively high shame and rejection scores on various scales and believe that other people are basically unavailable to them (Ritter et al., 2014; Bender et al., 2001).
A number of cognitive-behavioral theorists propose that narcissistic per- sonality disorder may develop when people are treated too positively rather than too negatively in early life. They hold that certain children acquire a superior and grandiose attitude when their “admiring or doting parents” teach them to “overvalue their self worth,” repeatedly rewarding them for minor accom- plishments or for no accomplishment at all (Millon, 2011; Sperry, 2003).
Many sociocultural theorists see a link between narcissistic personality disor- der and “eras of narcissism” in society (Paris, 2014). They suggest that family val-
ues and social ideals in certain societies periodically break down, producing generations of young people who are self-centered and materialistic and have short attention spans. Western cultures in particular, which encourage self-expression, individualism, and com- petitiveness, are considered likely to produce such generations of narcissism. In fact, one worldwide study conducted on the Internet found that respondents
from the United States had the highest narcissism scores, followed, in descending order, by those from Europe, Canada, Asia, and the Middle East (Foster et al., 2003).
Treatments for Narcissistic Personality Disorder Narcissistic per- sonality disorder is one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others (Campbell & Miller, 2011). The clients who consult therapists usually do so because of a related dis- order such as depression (APA, 2013). Once in treatment, the clients may try to manipulate the therapist into supporting their sense of superiority. Some also seem to project their grandiose attitudes onto their therapists and develop a love-hate stance toward them (Colli et al., 2014; Shapiro, 2004).
Psychodynamic therapists seek to help people with this disorder recognize and work through their basic insecurities and defenses (Diamond & Meehan, 2013; Messer & Abbass, 2010). Cognitive therapists, focusing on the self-centered think- ing of such individuals, try to redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notions (Beck & Weishaar, 2014; Beck et al., 2004). None of the approaches have had clear success, however (Paris, 2014).
“I’m attracted to you, but then I’m attracted to me too.”
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What specific features
of Western society
may be contributing to
today’s apparent rise in
narcissistic behavior?
B e t W e e N t h e L I N e S
Stolen Glances 22% Percentage of people who
regularly check their reflections in store windows and the like
69% Those who steal glances at least occasionally
9% Those who never look at themselves in public mirrors or windows
(Information from: Kanner, 2005, 1995)
: chapter 13446
MindTech
Selfies: Narcissistic or Not? In the art world, people have been drawing self-portraits for centuries. In recent years, however, digital technology has ushered in the era of the selfie, a cousin to the self-portrait. Safe to say, just about every cell phone user has
taken a selfie. In fact, more than 90 percent of all teens have now posted a photo of themselves online (Pew Research Foundation, 2014). These self-photos have created
such a stir that the word “selfie” was elected “Word of the Year 2013” by the Oxford English Dictionary.
As the selfie phenomenon has grown, opinions about selfies have intensified. It seems like people either love them or hate them. This is true in the field of psychology as well. Some psychologists view taking selfies as a form of narcissistic behavior, while others view them more positively.
First, the negative perspective. Many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society (Paris, 2014). They suggest that social values in society break down periodically, producing generations of self- centered, materialistic youth. Some of these theorists consider today’s selfie generation a perfect example of a current era of narcissism. This theory has gained a large following, but it is not supported by
research. One team of researchers, for example, found no relationship at all between how many selfies people post and how high they score on a narcissism personality scale (Alloway, 2014; Alloway et al., 2014).
This lack of support for the narcissism viewpoint does not mean that selfies, espe- cially repeated selfie behaviors, are completely harmless. Sherry Turkle (2013), an influential technology psychologist, believes that the near-reflexive instinct to photo- graph oneself may limit deeper engagements with the environment or experiencing events to their fullest (Eisold, 2013). Turkle also sug- gests that people who post an endless stream of selfies are often seeking external validation of their self-worth, even if that pursuit may not rise to a level of clinical narcissism.
Psychologists also observe that posting too many “selfies” may alienate those who view the poster’s social media profile (Miller, 2013). Studies have found, for example, that people often take a negative view of friends and family members who exces- sively post photos to their Facebook sites (Houghton, 2013).
On the positive side, a number of psychologists believe that the criticisms and concerns about the selfie movement have been overstated. Media psychologist Pamela Rutledge (2013) views selfies as an inevitable by-product of “technology- enabled self-expression.” She believes that selfie behaviors are simply confusing to individuals of a predigital generation. Moreover, she concludes that the selfie trend, for digital natives, can enhance explorations of identity, help identify one’s inter- ests, develop artistic expression, help people craft a meaningful narrative of their life experiences, and even reflect more realistic body images (for example, posting “selfies” without makeup). In therapy, selfies can serve as a springboard to discuss issues that clients are reluctant to broach on their own (Sifferlin, 2013).
In short, like other technological trends you’ve read about, the selfie phe nom- enon has received mixed grades from psychology researchers and practitioners so far.
What other trends in behavior—
digital or otherwise—might
suggest that our society is cur-
rently in an era of narcissism?
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Personality Disorders : 447
➤ Summing Up “DraMatiC” PerSonality DiSorDerS Four of the personality disorders in DSM-5 are marked by highly dramatic, emotional, or erratic symptoms. People with antisocial personality disorder display a pattern of disregard for and viola- tion of the rights of others. No known treatment is notably effective. People with borderline personality disorder display a pattern of instability in inter- personal relationships, self-image, and mood, along with extreme impulsivity. Treatment—particularly dialectical behavior therapy—apparently can be help- ful and lead to some improvement. People with histrionic personality disorder display a pattern of extreme emotionality and attention seeking. Clinical case reports suggest that treatment is helpful on occasion. Finally, people with nar- cissistic personality disorder display a pattern of grandiosity, need for admira- tion, and lack of empathy. It is one of the most difficult disorders to treat.
“Anxious” Personality Disorders The cluster of “anxious” personality disorders includes the avoidant, dependent, and obsessive-compulsive personality disorders. People with these patterns typically display anxious and fearful behavior. Although many of the symptoms of these personality disorders are similar to those of the anxiety and depressive disorders, researchers have not usually found direct links between this cluster and those disorders (O’Donohue et al., 2007). As with most of the other personality disorders, research support for the various explanations is very limited. At the same time, treatments for these disorders appear to be modestly to moderately helpful—considerably better than for other personality disorders.
Avoidant Personality Disorder People with avoidant personality disorder are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation (APA, 2013). They are so fearful of being rejected that they give no one an opportunity to reject them—or to accept them either:
Perhaps what made Malcolm pursue counseling was the painful awareness of his inability to socialize at a party hosted by a professor. A first-semester computer sci- ence graduate student, Malcolm watched other new students in his program frater- nize at this gathering while he suffered in silence. He wanted desperately to join [in], but, as he described it, “I was totally at a loss as to how to go about talking to any- one.” The best feeling in the world, he stated, was getting out of there. The follow- ing Monday, he came to the university counseling center, realizing he would have to be able to function in this group, but not before his first teaching experience that morning, which he described as “the most terrifying feeling I have ever en- countered.” As an undergrad, he spent most of his time alone in the computer lab working on new programs, which was what he most enjoyed as “no one was looking over my shoulder or judging me.” In contrast to this, with his teaching assistantship duties . . . he felt he constantly ran the risk of being made to look like a fool in front of a large audience.
When asked about personal relationships he had previously enjoyed, Malcolm admitted that any interaction was a source of frustration and worry. From the moment he left home for undergraduate school, he lived alone, attended functions alone, and
▶▶ avoidant personality disorder A personality disorder characterized by consistent discomfort and restraint in social situations, overwhelming feelings of inadequacy, and extreme sensitivity to negative evaluation.
(continues on the next page)
B e t W e e N t h e L I N e S
What Is the Difference Between an Egoist and an Egotist? An egoist is a person concerned pri- marily with his or her own interests. An egotist has an inflated sense of self- worth. A boastful egotist is not neces- sarily a self-absorbed egoist.
: chapter 13448
found it nearly impossible to make conversation with anyone. . . . The expectancy that people would be rejecting . . . precipitated profound gloom. . . . Despite a longing to relate and be accepted, Malcolm . . . maintained a safe distance from all emotional involvement. [He] became remote from others and from needed sources of support. He . . . had learned to be watchful, on guard against ridicule, and ever alert . . . to the most minute traces of annoyance expressed by others.
(Millon, 2011)
People like Malcolm actively avoid occasions for social contact. At the center of this withdrawal lies not so much poor social skills as a dread of criticism, disap- proval, or rejection. They are timid and hesitant in social situations, afraid of saying something foolish or of embarrassing themselves by blushing or acting nervous. Even in intimate relationships they express themselves very carefully, afraid of being shamed or ridiculed.
People with this disorder believe themselves to be unappealing or inferior to others. They exaggerate the potential difficulties of new situations, so they seldom take risks or try out new activities. They usually have few or no close friends, though they actually yearn for intimate relationships, and frequently feel depressed and lonely. As a substitute, some develop an inner world of fantasy and imagination (Millon, 2011).
Avoidant personality disorder is similar to social anxiety disorder (see Chapter 4), and many people with one of these disorders also experience the other (Eikenaes et al., 2015, 2013). The similarities include a fear of humiliation and low confidence. Some theorists believe that there is a key difference between the two disorders— namely, that people with social anxiety disorder primarily fear social circumstances, while people with the personality disorder tend to fear close social relationships (Lampe & Sunderland, 2015; Kantor, 2010). Other theorists, however, believe that the two disorders reflect the same psychopathology and should be combined (Eikenaes et al., 2015, 2013).
Around 2.4 percent of adults have avoidant personality disorder, men as fre- quently as women (APA, 2013; Sansone & Sansone, 2011). Many children and
Just a stage This child sits alone on the steps of his school as other children pass by. That behavior could be a sign of being pain- fully shy, withdrawn, easily embarrassed, and uncomfortable with people. Early tempera- ment is often linked to adult personality traits, but research has not yet clarified whether extreme shyness, a common and normal part of childhood, can in certain cases predict the development of avoidant or dependent per- sonality disorder in adulthood. ©
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Feelings of Shyness Around 48 percent of people in the United States consider themselves to be shy to some degree.
(carducci, 2000)
Personality Disorders : 449
teenagers are also painfully shy and avoid other people, but this is usually just a normal part of their development.
How Do Theorists Explain Avoidant Personality Disorder? Theorists often assume that avoidant personality disorder has the same causes as anxiety disorders—such as early traumas, conditioned fears, upsetting beliefs, or biochemical abnormalities. However, with the exception of social anxiety disorder, research has not yet tied the personality disorder directly to the anxiety disorders (Herbert, 2007). Psychodynamic, cognitive, and behavioral explanations of avoidant personality disorder are the most popular among clinicians.
Psychodynamic theorists focus mainly on the general sense of shame that people with avoidant personality disorder feel (Svartberg & McCullough, 2010). Some trace the shame to childhood experiences such as early bowel and bladder accidents. If parents repeatedly punish or ridicule a child for having such accidents, the child may develop a negative self-image. This may lead to the child’s feeling unlovable throughout life and distrusting the love of others.
Similarly, cognitive theorists believe that harsh criticism and rejection in early childhood may lead certain people to assume that others in their environment will always judge them negatively. These people come to expect rejection, misinterpret the reactions of others to fit that expectation, discount positive feedback, and gen- erally fear social involvements—setting the stage for avoidant personality disorder (Lampe, 2015; Weishaar & Beck, 2006). In several studies, participants with this dis- order were asked to recall their childhood, and their descriptions supported both the psychodynamic and the cognitive theories (Carr & Francis, 2010; Herbert, 2007). They remembered, for example, feeling criticized, rejected, and isolated; receiving little encouragement from their parents; and experiencing few displays of parental love or pride.
Behavioral theorists suggest that people with avoidant personality disorder typi- cally fail to develop normal social skills, a failure that helps maintain the disorder. In support of this position, several studies have found social skills deficits among people with avoidant personality disorder (Kantor, 2010; Herbert, 2007). Most behaviorists agree, however, that these deficits first develop as a result of the individuals avoiding so many social situations.
Treatments for Avoidant Personality Disorder People with avoidant personality disorder come to therapy in the hope of finding acceptance and affec- tion. Keeping them in treatment can be a challenge, however, for many of them soon begin to avoid the sessions. Often they distrust the therapist’s sincerity and start to fear his or her rejection. Thus, as with several of the other personality disorders, a key task of the therapist is to gain the person’s trust (Colli et al., 2014; Leichsenring & Salzer, 2014).
Beyond building trust, therapists tend to treat people with avoidant personality disorder much as they treat people with social anxiety disorder and other anxiety disorders. Such approaches have had at least modest success (Kantor, 2010; Porcerelli et al., 2007). Psychodynamic therapists try to help clients recognize and resolve the unconscious conflicts that may be operating (Leichsenring & Salzer, 2014). Cogni- tive therapists help them change their distressing beliefs and thoughts and improve their self-image (Rees & Pritchard, 2015, 2013; Weishaar & Beck, 2006). Behavioral therapists provide social skills training as well as exposure treatments that require people to gradually increase their social contacts (Herbert, 2007). Group therapy formats, especially groups that follow cognitive and behavioral principles, have the added advantage of providing clients with practice in social interactions (Herbert et al., 2005). Antianxiety and antidepressant drugs are sometimes useful in reducing the social anxiety of people with the disorder, although the symptoms may return when medication is stopped (Ripoll et al., 2011).
B e t W e e N t h e L I N e S
Shyness and the Arts In recent years, the music industry has been strongly influenced by stars with extremely shy, reticent demeanors.
• The alternative rock band My Bloody Valentine often plays with their backs to the audience and spearheaded an influential pop movement called “shoegaze” based on their ten- dency to look away or at the floor during shows.
• In early shows, indie rock musician Sufjan Stevens would nervously applaud his audience when they clapped for him.
• For many of her initial concerts, folk singer Cat Power (Chan Marshall) would not look at the audience and would weep or run offstage during shows.
• Meg White, drummer for the two- piece rock band White Stripes, appeared uncomfortable and quiet both onstage and during rarely given interviews. The group disbanded after “acute anxiety” forced her to cancel a 2007 tour.
• Grammy-award winning singer Adele has revealed, “I’m scared of audiences. One show . . . I was so nervous, I es- caped out the fire escape.”
: chapter 13450
Dependent Personality Disorder People with dependent personality disorder have a pervasive, excessive need to be taken care of (APA, 2013). As a result, they are clinging and obedient, fearing separation from their parent, spouse, or other person with whom they are in a close relationship. They rely on others so much that they cannot make the smallest deci- sion for themselves. Matthew is a case in point.
Matthew is a 34-year-old single man who lives with his mother and works as an ac- countant. He is . . . very unhappy after having just broken up with his girlfriend. His mother had disapproved of his marriage plans. . . . Matthew felt trapped and forced to choose between his mother and his girlfriend, and because “blood is thicker than water,” he had decided not to go against his mother’s wishes. . . . His mother . . . is a very domineering woman. . . . Matthew is afraid of disagreeing with [her] for fear that she will not be supportive of him and he will then have to fend for himself. He criticizes himself for being weak. . . . He alternates between resentment and a “Mother knows best” attitude. He feels that his own judgment is poor.
Matthew works at a job several grades below what his education and talent would permit. On several occasions he has turned down promotions because he didn’t want the responsibility of having to supervise other people or make indepen- dent decisions. He has worked for the same boss for 10 years . . . and is . . . highly regarded as a dependable and unobtrusive worker. He has two very close friends whom he has had since early childhood. He has lunch with one of them every single workday and feels lost if his friend is sick and misses a day.
Matthew is the youngest of four children. . . . He had considerable separation anxiety as a child . . . difficulty falling asleep unless his mother stayed in the room . . . and unbearable homesickness when he occasionally tried “sleepovers.” As a child he was teased by other boys because of his lack of assertiveness and was often called a baby. He has lived at home his whole life except for 1 year of college, from which he returned because of homesickness.
(Spitzer et al., 1994, pp. 179–180)
It is normal and healthy to depend on others, but those with dependent per- sonality disorder constantly need assistance with even the simplest matters and have extreme feelings of inadequacy and helplessness. Afraid that they cannot care for themselves, they cling desperately to friends or relatives.
As you just observed, people with avoidant personality disorder have difficulty initiating relationships. In contrast, people with dependent personality disorder have difficulty with separation. They feel completely helpless and devastated when a close relationship ends, and they quickly seek out another relationship to fill the void. Many cling persistently to relationships with partners who physically or psychologi- cally abuse them (Loas et al., 2015, 2011).
Lacking confidence in their own ability and judgment, people with this disor- der seldom disagree with others and allow even important decisions to be made for them (Millon, 2011). They may depend on a parent or spouse to decide where to live, what job to have, and which neighbors to befriend. Because they so fear rejection, they are overly sensitive to disapproval and keep trying to meet other people’s wishes and expectations, even if it means volunteering for unpleasant or demeaning tasks.
Many people with dependent personality disorder feel distressed, lonely, and sad; often they dislike themselves. Thus they are at risk for depressive, anxiety, and eating disorders (Bornstein, 2012, 2007). Their fear of separation and their feelings of helplessness may leave them particularly prone to suicidal thoughts, especially
▶▶ dependent personality disorder A personality disorder characterized by a pattern of clinging and obedience, fear of separation, and an ongoing need to be taken care of.
B e t W e e N t h e L I N e S
In Their Words “The deepest principle of human nature is the craving to be appreciated.”
William James
Personality Disorders : 451
when they believe that a current relationship is about to end (Bornstein, 2012; Kiev, 1989).
Surveys suggest that fewer than 1 percent of the population experience depen- dent personality disorder (APA, 2013; Sansone & Sansone, 2011). For years, clini- cians have believed that more women than men display this pattern, but some research suggests that the disorder is just as common in men (APA, 2013).
How Do Theorists Explain Dependent Personality Disorder? Psychodynamic explanations for dependent personality disorder are very similar to those for depression (Svartberg & McCullough, 2010). Freudian theorists argue, for example, that unresolved conflicts during the oral stage of development can give rise to a lifelong need for nurturance, thus heightening the likelihood of a depen- dent personality disorder (Bornstein, 2012, 2007, 2005). Similarly, object relations theorists say that early parental loss or rejection may prevent normal experiences of attachment and separation, leaving some children with fears of abandonment that persist throughout their lives (Caligor & Clarkin, 2010). Still other psychodynamic theorists suggest that, to the contrary, many parents of people with this disorder were overinvolved and overprotective, thus increas- ing their children’s dependency, insecurity, and separation anxiety (Sperry, 2003).
Behaviorists propose that parents of people with dependent per- sonality disorder unintentionally rewarded their children’s clinging and “loyal” behavior, while at the same time punishing acts of inde- pendence, perhaps through the withdrawal of love. Alternatively, some parents’ own dependent behaviors may have served as models for their children (Bornstein, 2012, 2007).
Cognitive theorists identify two maladaptive attitudes as helping to produce and maintain this disorder: (1) “I am inadequate and helpless to deal with the world,” and (2) “I must find a person to provide protection so I can cope.” Dichotomous (black-and-white) thinking may also play a key role: “If I am to be dependent, I must be completely helpless,” or “If I am to be independent, I must be alone.” Such thinking prevents sufferers from making efforts to be independent (Borge et al., 2010; Weishaar & Beck, 2006).
Treatments for Dependent Personality Disorder In therapy, people with dependent personality disorder usually place all responsibility for their treat- ment and well-being on the clinician. Thus a key task of therapy is to help patients accept responsibility for themselves (Colli et al., 2014; Gutheil, 2005). Because the domineering behaviors of a spouse or parent may help foster a patient’s symptoms, some clinicians suggest couple or family therapy as well, or even separate therapy for the partner or parent (Lebow & Uliaszek, 2010; Nichols, 2004).
Treatment for dependent personality disorder can be at least modestly help- ful. Psychodynamic therapy for this pattern focuses on many of the same issues as therapy for depressed people, including the transference of dependency needs onto the therapist (Svartberg & McCullough, 2010). Cognitive-behavioral therapists combine behavioral and cognitive interventions to help the clients take control of their lives. On the behavioral end, the therapists often provide assertiveness training to help the individuals better express their own wishes in relationships (Farmer & Nelson-Gray, 2005). On the cognitive end, the therapists also try to help the clients challenge and change their assumptions of incompetence and helplessness (Borge et al., 2010; Beck et al., 2004). Antidepressant drug therapy has been helpful for people whose personality disorder is accompanied by depression (Fava et al., 2002).
As with avoidant personality disorder, a group therapy format can be helpful because it provides opportunities for the client to receive support from a number
“My self-esteem was so low I just followed her around everywhere she would go.”
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: chapter 13452
of peers rather than from a single dominant person (Perry, 2005; Sperry, 2003). In addition, group members may serve as models for one another as they practice bet- ter ways to express feelings and solve problems.
Obsessive-Compulsive Personality Disorder People with obsessive-compulsive personality disorder are so preoccupied with order, perfection, and control that they lose all flexibility, openness, and effi- ciency (APA, 2013). Their concern for doing everything “right” impairs their pro- ductivity, as in the case of Joseph:
Joseph was advised to seek assistance from a therapist following several months of relatively sleepless nights and a growing immobility and indecisiveness at his job. When first seen, he reported feelings of extreme self-doubt and guilt and prolonged periods of tension and diffuse anxiety. It was established early in therapy that he always had experienced these symptoms; they were now merely more pronounced than before.
The precipitant for this sudden increase in discomfort was a forthcoming change in his academic post. New administrative officers had assumed authority at the col- lege, and he was asked to resign his deanship to return to regular departmental instruction. In the early sessions, Joseph spoke largely of his fear of facing classroom students again, wondered if he could organize his material well, and doubted that he could keep classes disciplined and interested in his lectures. It was his preoccu- pation with these matters that he believed was preventing him from concentrating and completing his present responsibilities.
At no time did Joseph express anger toward the new college officials for the demotion he was asked to accept; he repeatedly voiced his “complete confidence” in the “rationality of their decision.” Yet, when face-to-face with them, he observed that he stuttered and was extremely tremulous.
Joseph was the second of two sons, younger than his brother by three years. His father was a successful engineer, and his mother a high school teacher. Both were “efficient, orderly, and strict” parents. Life at home was “extremely well planned,” with “daily and weekly schedules of responsibility posted” and “vacations arranged a year or two in advance.” Nothing apparently was left to chance. . . . Joseph ad- opted the “good boy” image. Unable to challenge his brother either physically, intellectually, or socially, he became a “paragon of virtue.” By being punctilious, scrupulous, methodical, and orderly, he could avoid antagonizing his perfectionistic parents, and would, at times, obtain preferred treatment from them. He obeyed their advice, took their guidance as gospel, and hesitated making any decision be- fore gaining their approval. Although he recalled “fighting” with his brother before he was 6 or 7, he “restrained my anger from that time on and never upset my par- ents again.”
(Millon, 2011, 1969, pp. 278–279)
In Joseph’s concern with rules and order and doing things right, he has trouble seeing the larger picture. When faced with a task, he and others who have obsessive- compulsive personality disorder may become so focused on organization and details that they fail to grasp the point of the activity. As a result, their work is often behind schedule (some seem unable to finish any job), and they may neglect leisure activi- ties and friendships.
People with this personality disorder set unreasonably high standards for them- selves and others. Their behaviors extend well beyond the realm of conscientious- ness. They can never be satisfied with their performance, but they typically refuse
▶▶ obsessive-compulsive personality disorder A personality disorder marked by such an intense focus on orderliness, perfectionism, and control that the person loses flexibility, openness, and efficiency.
B e t W e e N t h e L I N e S
In Their Words “I don’t care about the rules. In fact, if I don’t break the rules at least 10 times in every song then I’m not doing my job properly.”
Jeff Beck, guitarist
Personality Disorders : 453
to seek help or to work with a team, convinced that others are too careless or incompetent to do the job right. Because they are so afraid of making mistakes, they may be reluctant to make decisions.
They also tend to be rigid and stubborn, particularly in their morals, ethics, and values. They live by a strict personal code and use it as a yardstick for measuring others. They may have trouble expressing much affection, and their relationships are sometimes stiff and superficial (Cain et al., 2015). In addition, they are often stingy with their time or money. Some cannot even throw away objects that are worn out or useless (APA, 2013).
According to surveys, as many as 7.9 percent of the adult population dis- play obsessive-compulsive personality disorder, with white, educated, married, and employed people receiving the diagnosis most often (APA, 2013; Sansone & Sansone, 2011). Men are twice as likely as women to display the disorder.
Many clinicians believe that obsessive-compulsive personality disorder and obsessive-compulsive disorder are closely related. Certainly, the two disorders share a number of features, and many people who suffer from one of the disorders meet the diagnostic criteria for the other disorder (Pinto et al., 2014; Gordon et al., 2013). However, it is worth noting that people with the personality disorder are more likely to suffer from either major depressive disorder, generalized anxiety disorder, or a substance use disorder than from obsessive-compulsive disorder (APA, 2013; Pena-Garijo et al., 2013). In fact, researchers have not consistently found a specific link between obsessive-compulsive personality disorder and obsessive-compulsive disorder (Starcevic & Brakoulias, 2014; Gordon et al., 2013).
How Do Theorists Explain Obsessive-Compulsive Personality Disorder? Most explanations of obsessive- compulsive personality disorder borrow heavily from those of obsessive-compulsive disorder, despite the doubts concerning a link between the two disorders. As with so many of the personality disorders, psychodynamic explana- tions dominate and research evidence is limited.
Freudian theorists suggest that people with obsessive-compulsive per- sonality disorder are anal retentive. That is, because of overly harsh toilet training during the anal stage, they become filled with anger, and they remain fixated at this stage. To keep their anger under control, they persis- tently resist both their anger and their instincts to have bowel movements. In turn, they become extremely orderly and restrained; many become passionate collectors. Other psychodynamic theorists suggest that any early struggles with parents over control and independence may ignite the aggressive impulses at the root of this personality disorder (Millon, 2011; Bartz et al., 2007).
Cognitive theorists have little to say about the origins of obsessive- compulsive personality disorder, but they do propose that illogical think- ing processes help keep it going (Weishaar & Beck, 2006; Beck et al., 2004). They point, for example, to dichotomous—“all-or-nothing”—thinking, which may produce rigidity and perfectionism. Similarly, they note that people with this disorder tend to misread or exaggerate the potential outcomes of mistakes or errors.
Treatments for Obsessive-Compulsive Personality Disorder People with obsessive-compulsive personality disorder do not usually believe there is anything wrong with them. They therefore are not likely to seek treatment unless they are also suffering from another disorder, most frequently an anxiety disorder or depression, or unless someone close to them insists that they get treatment (Bartz et al., 2007).
Toilet trouble According to Freud, toilet training often produces rage in a child. If par- ents are too harsh in their approach, the child may become fixated at the anal stage and prone to obsessive-compulsive functioning later in life.
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People with obsessive-compulsive personality disorder often respond well to psychodynamic or cognitive therapy (Messer & Abbass, 2010; Weishaar & Beck, 2006). Psychodynamic therapists typically try to help these clients recognize, expe- rience, and accept their underlying feelings and insecurities and perhaps take risks and accept their personal limitations. Cognitive therapists focus on helping the clients to change their dichotomous thinking, perfectionism, indecisiveness, pro- crastination, and chronic worrying. A number of clinicians report that people with obsessive-compulsive personality disorder, like those with obsessive-compulsive dis- order, respond well to serotonin-enhancing antidepressant drugs; however, research- ers have yet to study this issue fully (Pinto et al., 2008).
➤ Summing Up “anxioUS” PerSonality DiSorDerS Three of the personality disorders in DSM-5 are marked by anxious and fearful behavior. People with avoidant personality disorder are consistently uncomfortable and restrained in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation. People with dependent personality disorder have a persis- tent need to be taken care of, are submissive and clinging, and fear separation. People with obsessive-compulsive personality disorder are so focused on order, perfection, and control that they lose their flexibility, openness, and efficiency. A variety of treatment strategies have been used for people with these disorders and apparently have been modestly to moderately helpful.
Multicultural Factors: Research Neglect According to the current criteria of DSM-5, a pattern diagnosed as a personality disorder must “deviate markedly from the expectations of the individual’s culture” (APA, 2013). Given the importance of culture in this diagnosis, it is striking how little multicultural research has been conducted on these problems. Clinical theorists have suspicions but little compelling evidence that there are cultural differences in this realm (Iacovino et al., 2014).
The lack of multicultural research is of special concern with regard to border- line personality disorder, the pattern characterized by extreme mood fluctuations, outbursts of intense anger, self-injurious behavior, feelings of emptiness, and prob- lematic relationships because many theorists are convinced that gender and other cultural differences may be particularly important in both the development and diagnosis of this disorder.
Around 75 percent of all people who receive a diagnosis of borderline personal- ity disorder are female. Although it may be that women are biologically more prone to the disorder or that diagnostic bias is at work, this gender difference may instead be a reflection of the extraordinary traumas to which many women are subjected as children (Daigre et al., 2015). Recall, for example, that the childhoods of people with borderline personality disorder tend to be filled with emotional trauma, victimization, violence, and abuse, at times sexual abuse. It may be, a number of theorists argue, that experiences of this kind are prerequisites to the development of borderline personality disorder, that women in our society are particularly subjected to such experiences, and that, in fact, the disorder should more properly be viewed and treated as a special form of posttraumatic stress disorder (Sherry & Whilde, 2008; Hodges, 2003). In the absence of systematic research, however, alternative explana- tions like this remain untested and corresponding treatments undeveloped.
B e t W e e N t h e L I N e S
Personality Disorder Demographics 19% Percentage of people with
severe personality disorders who are racial or ethnic minority group members
59% People with severe personality disorders who are male
6% People with severe personality disorders who are unemployed
23% People with severe personality disorders who have never married
10% Impoverished people with borderline personality disorder
3% Wealthy people with borderline personality disorder
(Information from: Sareen et al., 2011; cloninger & Svrakic, 2005)
B e t W e e N t h e L I N e S
A Critical Difference People with obsessive-compulsive disorder typically do not want or like their symptoms; those with obsessive- compulsive personality disorder often embrace their symptoms and rarely wish to resist them.
Personality Disorders : 455
In a related vein, some multicultural theorists believe that borderline personality disorder may be a reaction to persistent feelings of marginality, powerlessness, and social failure (Sherry & Whilde, 2008; Miller, 1999, 1994). That is, it may be attrib- utable more to social inequalities (including sexism, racism, or homophobia) than to psychological factors.
Given such possibilities, it is most welcome that at least a few multicultural studies of borderline personality disorder have been conducted over the past decade (De Genna & Feske, 2013). In one, researchers assessed the rate of the personality disorder in racially diverse clinical populations from across the United States (Chavira et al., 2003). The study found that more Hispanic American clients qualified for a diagnosis of borderline personality disorder than did white or African American clients. Could it be that Hispanic Americans are more likely than other cultural groups to display this disorder, and—if so—why?
Finally, some multicultural theorists have argued that the features of borderline personality disorder may be perfectly acceptable traits and behaviors in certain cultures (APA, 2013). In Puerto Rican culture, for example, men are expected to display very strong emotions like anger, aggression, and sexual attraction (Sherry & Whilde, 2008; Casimir & Morrison, 1993). Could such culture-based characteristics help account for the higher rates of borderline personality disorder found among Hispanic American clients? And could these cultural-based characteristics also help explain the fact that Hispanic men and women demonstrate similar rates of this disorder, in contrast to the usual 3-to-1 female-to-male ratio found in other cultural groups (Chavira et al., 2003)?
➤ Summing Up MUltiCUltUral FaCtorS: reSearCH neGleCt Despite the field’s grow- ing focus on personality disorders, relatively little research has been done on gender and other multicultural influences. Nevertheless, many clinicians believe that multicultural factors may play key roles in the understanding, diagnosis and treatment of personality disorders, and researchers have recently begun to study this possibility.
Are There Better Ways to Classify Personality Disorders? Most of today’s clinicians believe that personality disorders represent important and troubling patterns. Yet, as you read at the beginning of this chapter, DSM-5’s person- ality disorders are particularly hard to diagnose and easy to misdiagnose, difficulties that indicate serious problems with the validity and reliability of these categories. Consider, in particular, the following problems:
1. Some of the criteria used to diagnose the DSM-5 personality disorders cannot be observed directly. To separate paranoid from schizoid personal- ity disorder, for example, clinicians must ask not only whether people avoid forming close relationships, but also why. In other words, the diag- noses often rely heavily on the impressions of the individual clinician.
Too little attention As illustrated by this diverse group of people, we live in a multicul- tural nation and world. The field of psychology has devoted considerable study to cultural and racial differences of various kinds. However, clinical researchers have given relatively little attention to multicultural differences in the development, features, and treatment of per- sonality disorders.
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In Their Words “In most of us, by the age of thirty, the character has set like plaster and will never soften again.”
William James, Principles of Psychology, 1890
: chapter 13456
2. Clinicians differ widely in their judgments about when a normal person- ality style crosses the line and deserves to be called a disorder. Some even believe that it is wrong ever to think of personality styles as mental disor- ders, however troublesome they may be.
3. The personality disorders often are very similar to one another. Thus it is common for people with personality problems to meet the diagnostic criteria for several DSM-5 personality disorders (Moore et al., 2012).
4. People with quite different personalities may qualify for the same DSM-5 personality disorder diagnosis.
In light of these problems, the leading criticism of DSM-5’s approach to per- sonality disorders is, as you read earlier, that the classification system defines such disorders by using categories—rather than dimensions—of personality. A growing number of theorists believe that personality disorders differ more in degree than in type of dysfunction. Therefore, they propose that the disorders should be classified by the severity of key personality traits (or dimensions) rather than by the presence or absence of specific traits (Morey et al., 2014). In such an approach, each key trait (for example, disagreeableness, dishonesty, or self-absorption) would be seen as vary- ing along a continuum in which there is no clear boundary between normal and abnormal. People with a personality disorder would be those who display extreme degrees of several of these key traits—degrees not commonly found in the general population (see InfoCentral on the next page).
Which key personality dimensions should clinicians use to help identify people with personality problems? Some theorists believe that they should rely on the dimensions identified in the “Big Five” theory of personality, dimensions that have received enormous attention by personality psychologists over the years.
The “Big Five” Theory of Personality and Personality Disorders A large body of research consistently suggests that the basic structure of personal- ity may consist of five “supertraits,” or factors—neuroticism, extroversion, openness to experiences, agreeableness, and conscientiousness (Curtis et al., 2014; Zuckerman, 2011). Each of these factors, which are frequently referred to as the “Big Five,” consists of a number of subfactors. Anxiety and hostility, for example, are subfactors of the neuroticism factor, while optimism and friendliness are subfactors of the extrover- sion factor. Theoretically, everyone’s personality can be summarized by a combina- tion of these supertraits. One person may display high levels of neuroticism and agreeableness, medium extroversion, and low conscientiousness and openness to experiences. In contrast, another person may display high levels of agreeableness and conscientiousness, medium neuroticism and extroversion, and low openness to experiences. And so on.
Many proponents of the Big Five model have argued further that it would be best to describe all people with personality disorders as being high, low, or in between on the five supertraits and to drop the use of personality disorder categories altogether (Glover et al., 2012; Lawton et al., 2011). Thus a particular person who currently qualifies for a diagnosis of avoidant personality disorder might instead be described as displaying a high degree of neuroticism, medium degrees of agreeable- ness and conscientiousness, and very low degrees of extroversion and openness to new experiences. Similarly, a person currently diagnosed with narcissistic personality disorder might be described in the Big Five approach as displaying very high degrees of neuroticism and extroversion, medium degrees of conscientiousness and openness to new experiences, and a very low degree of agreeableness.
B e t W e e N t h e L I N e S
In Their Words “We continue to shape our personality all our life.”
albert camus
B e t W e e N t h e L I N e S
When Does Hostility Cross the Line? 67% Percentage of young adult
drivers who consider themselves aggressive drivers
30% Percentage of elderly drivers who consider themselves aggressive drivers
14% Motorists who have shouted at or had a honking match with another driver in the past year
7% Motorists who “give the finger” when upset by other drivers
2% Motorists who have had a fist fight with another driver
(Information from: National highway traffic Safety administration, 2010; OFWW, 2004;
Kanner, 2005, 1995; herman, 1999)
457InfoCentral
EVERYDAY LYING Everyone lies on occasion. The nature, motives for, and frequency of lying varies from person to person.
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LYING A lie is a false statement that a person makes in order to deliber- ately deceive another person. Everyone lies. But there is lying, and then there is “lying.” Psychologists often distinguish several kinds of lying: everyday lying, compulsive lying, and sociopathic lying. Compulsive and sociopathic lying are often referred to, collectively, as pathological lying.
Everyday liars: Almost everyone lies on occasion
Compulsive liars: Some people consistently lie out of habit, even when nothing is gained by the lies.
Sociopathic liars: Some people lie incessantly, without any con- cern for others, in order to get their way.
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PATHOLOGICAL LYING AND PERSONALITY DISORDERS
Pathological lying is a common feature in • Antisocial personality disorder • Borderline personality disorder • Histrionic personality disorder • Narcissistic personality disorder
(Meyer, 2010)
Pathological liars often … • Tell totally pointless lies • Lie to seek attention • Tell unbelievable stories • Lie much or most of the time
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• Beware: Just as polygraphs can be fooled, participants can lower the accuracy of fMRIs.
Motives for Everyday Lying
: chapter 13458
“Personality Disorder—Trait Specified”: Another Dimensional Approach The “Big Five” approach to personality disorders is currently receiving study and may wind up being used in the next edition of the World Health Organization’s International Classification of Diseases (ICD), the classification system for medi- cal and psychiatric diagnoses used in many countries outside the United States (Aldhous, 2012). In the meantime, as you read earlier, the DSM-5 framers have designed their own alternative dimensional approach for possible use in a future revision of the DSM.
This approach begins with the notion that people whose traits significantly impair their functioning should receive a diagnosis called personality disorder— trait specified (PDTS) (APA, 2013). When assigning this diagnosis, clinicians would also identify and list the problematic traits and rate the severity of impair- ment caused by them. According to the proposal, five groups of problematic traits would be eligible for a diagnosis of PDTS: negative affectivity, detachment, antagonism, disinhibition, and psychoticism.
➤ Negative Affectivity People who display negative affectivity experience negative emotions frequently and intensely. In particular, they exhibit one or more of the following traits: emotional lability (unstable emotions), anxiousness, separation insecurity, perseveration (repetition of certain behaviors despite repeated failures), submissiveness, hostility, depressivity, suspiciousness, and strong emotional reactions (overreactions to emotionally arousing situations).
➤ Detachment People who manifest detachment tend to withdraw from other people and social interactions. They may exhibit any of the following traits: restricted emotional reactivity (little reaction to emotionally arousing situations), depressivity, suspiciousness, withdrawal, anhedonia (inability to feel pleasure or take interest in things), and intimacy avoidance. You’ll note that two of the traits in this group—depressivity and suspiciousness—are also found in the negative affectivity group.
➤ Antagonism People who display antagonism behave in ways that put them at odds with other people. They may exhibit any of the following traits: manipula- tiveness, deceitfulness, grandiosity, attention seeking, callousness, and hostility (hostility is also found in the negative affectivity group).
➤ Disinhibition People who manifest disinhibition behave impulsively, without reflecting on potential future consequences. They may exhibit any of the fol- lowing traits: irresponsibility, impulsivity, distractibility, risk taking, and imperfection/ disorganization.
➤ Psychoticism People who display psychoticism have unusual and bizarre ex- periences. They may exhibit any of the following traits: unusual beliefs and expe- riences, eccentricity, and cognitive and perceptual dysregulation (odd thought processes and sensory experiences).
If a person is impaired significantly by any of the five trait groups, or even by just 1 of the 25 traits that make up those groups, he or she would qualify for a diagnosis of personality disorder—trait specified. In such cases, the diagnostician would indicate which traits are impaired.
Consider, for example, Matthew, the unhappy 34-year-old accountant described on page 450. As you’ll recall, Matthew meets the criteria for a diagnosis of depen- dent personality disorder under DSM-5’s current categorical approach, based largely on his lifetime of extreme dependence on his mother, friends, and coworkers.
▶▶ personality disorder—trait speci- fied (PDtS) A personality disorder currently undergoing study for possible inclusion in a future revision of DSM-5. People would receive this diagnosis if they had significant impairment in their functioning as a result of one or more very problematic traits.
B e t W e e N t h e L I N e S
In Their Words “We try me playing cocky, but I just don’t have the arrogance. Apparently, I’m too “vulnerable” for ferocity. I’m not witty. Funny. Sexy. Or mysterious. By the end of the session, I am no one at all.”
Katniss, The Hunger Games
Personality Disorders : 459
Using the alternative dimensional approach suggested in DSM-5, a diagnostician would instead observe that Matthew is significantly impaired by several of the traits that characterize the negative affectivity trait group. He is, for example, greatly impaired by “sep- aration insecurity.” This trait has prevented him from completing college, living on his own, marrying his girlfriend, ever disagreeing with his mother, advancing at work, and broadening his social life. In addition, Matthew seems to be impaired significantly by the traits of “anxiousness,” “submissiveness,” and “depressivity.” Given this picture, his therapist might assign him a diagnosis of personal- ity disorder—trait specified, with problematic traits of separation insecurity, anxiousness, submissiveness, and depressivity.
According to this dimensional approach, when clinicians assign a diagnosis of personality disorder—trait specified, they also must rate the degree of dysfunctioning caused by each of the person’s traits, using a five-point scale ranging from “little or no impair- ment” (Rating = 0) to “extreme impairment” (Rating = 4).
Consider Matthew once again. He would probably warrant a rating of “0” on most of the 25 traits listed in the DSM-5 pro- posal, a rating of “3” on the trait of anxiousness and depressivity, and a rating of “4” on the traits of separation insecurity and sub- missiveness. Altogether, he would receive the following cumber- some, but informative, diagnosis:
Diagnosis: Personality Disorder—Trait Specified Separation insecurity: Rating 4 Submissiveness: Rating 4 Anxiousness: Rating 3 Depressivity: Rating 3 Other traits: Rating 0
This dimensional approach to personality disorders may indeed prove superior to DSM-5’s current categorical approach. Thus far, however, it has caused its own stir in the clinical community. Many clinicians believe that the proposed changes would give too much latitude to diagnosticians—allowing them to apply diagnoses of personality disorder to an enormous range of personality patterns. Still others worry that the requirements of the newly proposed system are too cumbersome or complicated. Only time and research will determine whether the alternative system is indeed a useful approach to the diagnosis of personality disorders.
➤ Summing Up are tHere Better WayS to ClaSSiFy PerSonality DiSorDerS? The per- sonality disorders listed in DSM-5 are commonly misdiagnosed, an indication of serious problems in the validity and reliability of the categories. Given the significant problems posed by the current categorical approach, a number of today’s theorists believe that personality disorders should instead be described and classified by a dimensional approach. One such approach, the “Big Five” model, may be included in the next edition of the World Health Organization’s International Classification of Diseases. Another dimensional approach, the “personality disorder—trait specified” model, is under study for possible inclu- sion in a future revision of DSM-5.
Dysfunctional toons Today’s animated film characters often display significant personality flaws or disorders. Some have a single dys- functional trait, as is the case for Angry Birds, while others may have “clusters” of problem- atic traits, as shown by the South Park kids. Some critics suggest that the latter (especially Cartman, second from left) show enduring grumpiness, disrespect for authority, irrever- ence, self-absorption, disregard for the feelings of others, general lack of conscience, and a tendency to get into trouble.
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PUTTING IT...together Disorders of Personality—Rediscovered and Reconsidered During the first half of the twentieth century, clinicians believed deeply in the unique, enduring patterns we call personality, and they tried to define important personality traits. They then discovered how readily people can be shaped by the situations in which they find themselves, and a backlash developed. The concept of personality seemed to lose legitimacy, and for a while it became almost an obscene word in some circles. The clinical category of personality disorders went through a similar rejection. When psychodynamic and humanistic theorists dominated the clinical field, neurotic character disorders—a set of diagnoses similar to today’s per- sonality disorders—were considered useful clinical categories, but their popularity declined as other models grew in influence.
During the past 25 years, serious interest in personality and personality disorders has rebounded. In case after case, clinicians have concluded that rigid personality traits do seem to pose special problems, and they have developed new tests and
interview guides to assess these disorders, setting in motion a wave of systematic research. So far, only the antisocial and borderline personal- ity disorders have received much study. However, with DSM-5 now considering a new— dimensional— classification approach for possible use in the future, additional research is likely to follow. This may allow clinicians to better answer some pressing questions: How common are the various personality disorders? How useful are personality disorder categories? How effective is a dimensional approach to diagnosing these disorders? And which treatments are most effective?
One of the most important questions is, “Why do people develop troubled patterns of personality?” As you have read, psychological, as
opposed to biological and sociocultural, theories have offered the most sugges- tions so far, but these explanations are not very precise and they do not have strong research support. Given the current enthusiasm for biological explanations, genetic and biological factors are beginning to receive considerable study, a shift in the waters that should soon enable researchers to determine possible interactions between biological and psychological causes. And one would hope that sociocul- tural factors will be studied as well. As you have seen, sociocultural theorists have only occasionally offered explanations for personality disorders, and multicultural factors have received little research. However, sociocultural factors may well play an important role in these disorders and certainly should be examined more carefully.
DSM-5’s proposal of a dimensional classification approach eventually may lead to major changes in the field’s understanding, diagnosis, and treatment of personal- ity disorders. Now that clinicians have rediscovered personality disorders, they must determine the most appropriate ways to think about, explain, and treat them.
C li n i C al C h o i C e s Now that you’ve read about personality disorders, try the interactive case study for this chapter. See if you are able to identify Alicia’s symptoms and sug- gest a diagnosis based on her symptoms. What kind of treatment would be most effective for Alicia? Go to LaunchPad to access Clinical Choices.
KEY TERMS personality, p. 421
personality traits, p. 421
personality disorder, p. 421
comorbidity, p. 422
categorical, p. 422
dimensional, p. 422
paranoid personality disorder, p. 425
schizoid personality disorder, p. 427
schizotypal personality disorder, p. 428
antisocial personality disorder, p. 431
borderline personality disorder, p. 436
dialectical behavior therapy (DBT), p. 439
histrionic personality disorder, p. 441
narcissistic personality disorder, p. 444
avoidant personality disorder, p. 447
dependent personality disorder, p. 450
obsessive-compulsive personality disorder, p. 452
anal retentive, p. 453
Big Five theory, p. 456
personality disorder—trait specified (PDTS), p. 458
Personality Disorders : 461
QuickQuiz
1. What is a personality disorder? pp. 421–424
2. Describe the social relationship prob- lems caused by each of the personality disorders. pp. 421–454
3. What are the three “odd” personality disorders, and what are the symptoms of each? pp. 424–430
4. What explanations and treatments have been applied to the paranoid, schizoid, and schizotypal personality disorders? pp. 426–430
5. What are the “dramatic” personality disorders, and what are the symptoms of each disorder? pp. 431–445
6. How have theorists explained antisocial personality disorder and borderline per- sonality disorder? What are the leading treatments for these disorders, and how effective are they? pp. 433–441
7. What are the leading explanations and treatments for the histrionic and narcissistic personality disorders? How strongly does research support these explanations and treatments? pp. 443–445
8. What is the name of the cluster that includes the avoidant, dependent, and obsessive-compulsive personal- ity disorders? What are the leading explanations and treatments for these
disorders, and to what extent are they supported by research? pp. 447–454
9. What kinds of problems have clini- cians run into when using a categori- cal approach to the classification and diagnosis of personality disorders? pp. 455–456
10. Describe two dimensional approaches that have been proposed to identify and describe personality disorders. pp. 456–459
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T O P I C O V E R V I E W
Childhood and Adolescence
Childhood Anxiety Disorders Separation Anxiety Disorder Treatments for Childhood Anxiety Disorders
Childhood Depressive and Bipolar Disorders Major Depressive Disorder Bipolar Disorder and Disruptive Mood Dysregulation Disorder
Oppositional Defiant Disorder and Conduct Disorder What Are the Causes of Conduct Disorder? How Do Clinicians Treat Conduct Disorder?
Elimination Disorders Enuresis Encopresis
Neurodevelopmental Disorders Attention-Deficit/Hyperactivity Disorder Autism Spectrum Disorder Intellectual Disability
Putting It Together: Clinicians Discover Childhood and Adolescence
Disorders Common Among Children and Adolescents
B illy, a 7-year-old . . . child, was brought to a mental health clinic by his mother because “he is unhappy and always complaining about feeling sick.” . . . His mother describes Billy as a child who has never been very happy and never wanted to play with other children. From the time he started nursery school,
he has complained about stomachaches, headaches, and various other physical problems. . . .
Billy did well in first grade, but in second grade he is now having difficulty complet- ing his work. He takes a lot of time to do his assignments and frequently feels he has to do them over again so that they will be “perfect.” Because of Billy’s frequent somatic complaints, it is hard to get him off to school in the morning. If he is allowed to stay home, he worries that he is falling behind in his schoolwork. When he does go to school, he often is unable to do the work, which makes him feel hopeless about his situation. . . .
His worries have expanded beyond school, and frequently he is clinging and de- manding of his parents. He is fearful that if his parents come home late or leave and go somewhere without him that something may happen to them. . . .
Although Billy’s mother acknowledges that he has never been really happy, in the last 6 months, she feels, he has become much more depressed. He frequently lies around the house, saying that he is too tired to do anything. He has no interest or enjoyment in playing. His appetite has diminished. He has trouble falling asleep at night and often wakes up in the middle of the night or early in the morning. Three weeks ago, he talked, for the first time, about wanting to die. . . .
(Spitzer et al., 1994)
Ricky Smith was a 7-year-old. . . . During her initial call to the clinic, Mrs. Smith said her son was “out of control.” She said Ricky “was all over the place” and “constantly getting into trouble.” . . .
Ricky . . . said his teacher, Mrs. Candler, was always yelling at him and sending notes home to his mother. [He] initially said he did not know why the teacher yelled at him but then said it was mostly about not paying attention or following class rules. . . .
Ricky . . . said he had a few friends but often had to keep to himself. This was because Mrs. Candler made him spend much of the school day in a corner of the classroom to complete his work. Unfortunately, little of the work was successfully finished. Ricky said he felt bored, sad, tired, and angry in the classroom. . . .
Ricky said his mother yelled at him a lot. . . . He said he felt happiest when riding his bike because nobody yelled at him and he could “go wherever I want.” . . .
Mrs. Smith said Ricky was almost intolerable in the classroom, . . . crying when asked to do something, stomping his feet, and being disrespectful to the teacher. . . . [She also] said her son was generally “out of control” at home. He would not listen to her commands and often ran around the house until he got what he wanted. She and her son often argued about his homework, chores, [and] misbehavior. . . . [In addition,] Ricky often fidgeted and lost many of his school materials. He was disorganized and paid little attention to long-term consequences. The child was also difficult to control in public places, such as a supermarket or church. . . .
Ricky’s teacher . . . added that [his] attention was sporadic and insufficient. . . . Ricky was getting out of his seat more and more, requiring a constant response. . . .
(Kearney, 2013, pp. 62–64)
: chapter 14464
Billy and Ricky are both displaying psychological disorders. Their disorders are disrupting the boys’ family ties, school performances, and social relationships, but each disorder does so in a particular way and for particular reasons. Billy, who may qualify for a diagnosis of major depressive disorder, struggles constantly with sadness, worry, and perfectionism, along with stomachaches and other physical ailments. Ricky’s main problems, on the other hand, are that he cannot concentrate and is overly active and impulsive—difficulties that characterize attention-deficit/hyperactivity disorder (ADHD).
Abnormal functioning can occur at any time in life. Some patterns of abnor- mality, however, are more likely to emerge during particular periods—during childhood, for example, or, at the other end of the spectrum, during old age. In this chapter you will read about disorders that commonly have their onset during childhood or early adolescence. In the next chapter you’ll learn about problems that are more common among the elderly.
Childhood and Adolescence People often think of childhood as a carefree and happy time—yet it can also be frightening and upsetting (see Figure 14-1). In fact, children of all cultures typically have at least some emotional and behavioral problems as they encounter new people and situations. Surveys reveal that worry is a common experience: close to half of all children in the United States have multiple fears, particularly concerning school, health, and personal safety ( Jovanovic et al., 2014; Szabo & Lovibond, 2004). Bed- wetting, nightmares, temper tantrums, and restlessness are other problems that many
children contend with. Adolescence can also be a difficult period. Physical and sexual changes, social and academic pressures, school violence, personal doubts, and temptations cause many teenagers to feel nervous, confused, and depressed.
A particular concern among children and adolescents is that of being bullied (see InfoCentral on page 466). Surveys throughout the world have revealed repeatedly that bullying ranks as a major
problem in the minds of most young respondents, often a bigger problem than rac- ism and peer pressure to try sex or alcohol (Hong et al., 2015; Isolan et al., 2013; Smith, 2011, 2010). More generally, over 25 percent of students report being bul- lied frequently, and more than 70 percent report having been bullied at least once.
20%
44%
34%
3%
22%
17%
3%
17%18%
30%
General worries
School performance
Family finances
Getting into a good college
Physical appearance
Areas of Childhood Stress
Child respondents
Parent respondents
Percentage of Respondents
Who Say Child Experiences
Stress
figure 14-1 Are parents aware of their children’s stress? Not always, according to a large sur- vey of parents and their children ages 8 to 17. For example, although 44 percent of the child respondents report that they worry about school, only 34 percent of the parent respon- dents believe that their children are worried about school. (Information from: Munsey, 2010.)
all people who are bullied are
upset by it, but some seem
to be more traumatized than
others. Why might this be so?
B e t W e e N t h e L I N e S
Children in Need As many as half of students identified with significant emotional disturbances may drop out of high school.
(aSca, 2010; planty et al., 2008; Gruttadaro, 2005)
Disorders Common Among Children and Adolescents : 465
Typically, kids who have been bullied react with feelings of humiliation, anxiety, or dislike for school. Just as troubling, the technological advances of today’s world have broadened the ways in which children and adolescents can be bullied, and cyberbullying— bullying and humiliating by e-mail, text messages, and Facebook—is now on the rise (Sampasa-Kanyinga et al., 2014).
Beyond these common concerns and psychological difficulties, at least one-fifth of all children and adolescents in North America also experience a diagnosable psy- chological disorder (NIMH, 2015; Winter & Bienvenu, 2011). Boys with disorders outnumber girls, even though most of the adult psychological disorders are more common among women.
Some disorders displayed by children—childhood anxiety disorders, childhood depression, and disruptive disorders—have adult counterparts, although they are also distinct in certain ways. Other childhood disorders—elimination disorders, for example—usually disappear or radically change form by adulthood. There are also disorders that begin at birth or in childhood and persist in stable forms into adult life. These include autism spectrum disorder and intellectual disability (previously called mental retardation), the former marked by a lack of responsiveness to the environment, the latter by an extensive disturbance in intellect.
Childhood Anxiety Disorders Anxiety is, to a degree, a normal part of childhood. Since children have had fewer experiences than adults, their world is often new and scary. They may be frightened by common events, such as the beginning of school, or by special upsets, such as moving to a new house or becoming seriously ill. In addition, each generation of children is confronted by new sources of anxiety. Today’s children, for example, are repeatedly warned, both at home and at school, about the dangers of Internet browsing and networking, child abduction, drugs, and terrorism.
Children may also be strongly affected by parental problems or inadequacies. If, for example, parents typically react to events with high levels of anxiety or if they overprotect their children, the children may be more likely to respond to the world
Multiple traumas A number of children in the Boston area developed posttraumatic stress disorder and/or other psychological disorders in the aftermath of the Boston Marathon bomb- ing in 2013. It turns out that their disorders were triggered not only by witnessing (in per- son or on television) the devastation produced by the bombing, but also by the door-to-door searches for the suspects conducted by police in the days following the bombing (Comer, 2014). Here a woman carries her child from their home as a SWAT team enters to conduct one such search.AP
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Targeted for Bullying Surveys suggest that as many as 9 of 10 gay, lesbian, transgender, or bisexual middle and high school students are physically and/or verbally harassed each year (McKinley, 2010). The harassment ranges from taunts to beatings.
InfoCentral
0
10
20
30
40
50
Threatened by peers and classmates
Ridiculed or called names
Slandered by lies and rumors
Pushed and shoved
Left out or ignored
Threatened or injured by a weapon
28 %
44% 43%
36%
29%
7%
CHILD AND ADOLESCENT BULLYING Bullying is the repeated inf liction of force, threats, or coercion in order to intimidate, hurt, or dominate another—less powerful— person. It is particularly common among children and adolescents. Members of certain minority groups, such as LGBT individuals,
are more likely to be bullied. Over the past decade, clinicians and educators have learned that bullying is much more common and more harmful than previously thought.
CYBERBULLYING Cyberbullying takes place through email, text messaging, websites and apps, instant messaging, chat rooms or posted videos or photos (CDC, 2013). Around 40% of all children and teens have been bullied online at least once. About 21% are bullied online regularly. Girls are twice as likely as boys to be cyberbullied on a regular basis. (BSA, 2014; NSPCC, 2013; Sedghi, 2013; Hinduja & Patchin, 2010)
Why do teens cyberbully?
hitting, pushing, tripping
name-calling, mean taunting, sexual comments, threatening
spreading rumors, posting embarrassing images, rejection from group
EFFECTS OF BULLYING:
Depression
Suicidal thinking and attempts
Anxiety
Low self-esteem
Sleep problems
Somatic symptoms
Substance use and abuse
School problems and/or phobias
Antisocial behavior (CDC, 2013, 2011; Hertz & Donato, 2013)
BULLIES TEND TO:
Display antisocial behaviors
Perform poorly in school
Drop out of school
Bring weapons to school
Drink alcohol
Smoke cigarettes
Use drugs (Hertz & Donato, 2013; CDC, 2011)
SCHOOL BULLYING Much bullying takes place at school. Around 2/3 of all school bullying occurs in hallways, schoolyards, bathrooms, cafeterias, or buses. A full 1/3 occurs in classrooms, while teachers are present (BSA, 2014). It is estimated that 40% of school bullying goes unreported (BSA, 2014).
The Nature of School Bullying
Features of School Antibullying Programs • Increased supervision of students
• Delivery of consequences for bullying
• School-wide implementation of antibullying policies
• Cooperation among school staff, parents, and professionals across disciplines
• Identi�cation of risk factors for bullying
Victim deserves it
To get back at victim
For entertainment
To embarrass victim
They want to be mean
To show off for friends
0 10 20 30 40 50 60
58%
58%
28%
21%
14%
11%
100 80 60 40 20 0
Victims who report incidents to their social network
Victims who initially tell a parent
Victims who initially tell a teacher
Users who witness cyberbullying on their social media site Witnesses who usually ignore cyberbullying on their social media site
37%
17%
1%
95%
35%
TYPES OF BULLYING
(BSA, 2014; Knowthenet, 2013)
Social Media and Cyberbullying
Verbal Physical
Relational/Social
Older than 50 Younger than 50
39% 47%
(Harris Interactive, 2014; Ratliffe, 2013; NFER, 2010)
People bullied as teenagers
Bullying prevention programs in schools reduce bullying up to 25% (BSA, 2014).
(BSA, 2014; CDC, 2013)
(BSA, 2014; Knowthenet, 2013)
BULLYING IS ON THE RISE…
(CDC, 2013; Hertz & Donato, 2013)
Disorders Common Among Children and Adolescents : 467
with anxiety (Platt, Williams, & Ginsburg, 2015). Similarly, if parents repeatedly reject, disappoint, or avoid their children, the world may seem an unpleasant and anxious place for them. And if parents are divorced, become seriously ill, or must be separated from their children for a long period, childhood anxiety may result. Beyond such environmental problems, there is genetic evidence that some children are prone to an anxious temperament (Rogers et al., 2013).
For some children, anxieties become long-lasting and overwhelming. These children may be suffering from an anxiety disorder. Surveys indicate that between 14 and 25 percent of all children and adolescents may experience an anxiety disor- der (Mash & Wolfe, 2015; Mian, 2014). Some of the childhood anxiety disorders are similar to their adult counterparts. Childhood specific phobias, for example, usually look and operate just like the phobias of adulthood (Pilecki & McKay, 2011), and a number of untreated childhood phobias grow into adult ones.
More often, however, the anxiety disorders of childhood take on a somewhat different character from that of adult anxiety disorders. Typically they are dominated by behavioral and somatic symptoms rather than cognitive ones—symptoms such as clinging, sleep difficulties, and stomach pains (Morris & Ale, 2011; Schulte & Petermann, 2011). They tend to center on specific, sometimes imaginary, objects and events, such as monsters or thunder- storms, rather than broad concerns about the future or one’s place in the world (APA, 2013; Davis & Ollendick, 2011). And they are more often than not triggered by current events and situations (Felix et al., 2011).
Separation Anxiety Disorder Separation anxiety disorder, one of the most common anxi- ety disorders among children, follows this profile (APA, 2013). The disorder is common (but not unique) to childhood, begins as early as the preschool years, and at least 4 percent of all chil- dren experience it (Mash & Wolfe, 2015; APA, 2013). Sufferers feel extreme anxiety, often panic, whenever they are separated from home or a parent. Jonah’s symptoms began when he was a preschooler and continued into kindergarten.
Jonah, age 4, began crying as soon as his parents tried to place him in the car for the 30-minute trip to his grandparents’ house. This was going to be his first over- night weekend there. He had always been difficult on Tuesday afternoons when his grandmother came to his house to care for him—and, for that matter, whenever Mia, his mother, tried to take him to a play date—but this was an entirely new level of upset.
Jonah screamed that he would not get in the car. “I only want to be here with you! If you make me go, I’ll never see you again! What if you like it better without me? What if Granny decides to keep me? What if you die?” Exasperated, Brandon, Jonah’s father, picked up his son and carried him to the car. Jonah cried all the way to his grandparents’ house. At their door, Jonah hugged his mother as though he would never let go.
Jonah finally went inside his grandparents’ house. Eventually, Mia and Brandon left. Two hours later, they received a phone call from Mia’s mother. An inconsolable Jonah had been crying nonstop since his parents had left. Reluctantly, Mia agreed to pick Jonah up, cancelling her and Brandon’s weekend getaway.
That night, Jonah refused to sleep in his own room, insisting on sleeping be- tween his parents. This was something they had tolerated occasionally in the past, but, beginning that night, it became a regular sleeping arrangement. During the
Oh, that first day! The first day of kinder- gar ten is overwhelming for this child and perhaps also for his mother. Such anxiety reactions to the beginning of school and to being temporarily separated from one’s par- ents are common among young children.
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▶▶ separation anxiety disorder A dis- order marked by excessive anxiety, even panic, whenever the person is separated from home, a parent, or another attach- ment figure.
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next several months, Jonah became hysterical every time Mia or Brandon tried to get him to leave the house for a play date or journey elsewhere.
Five months later, Jonah began kindergarten. That first day lasted all of two hours. The principal called, asking Mia to come get Jonah. Mia was hardly surprised. Her son had cried, screamed, and even kicked the whole ride to school, and his dis- tress only escalated as she drove off. Though sympathetic, the principal explained that Jonah’s nonstop crying was affecting all the other children. “Perhaps tomorrow Jonah will have a better day,” he said. But the next day, Jonah’s reaction was the same. And the next day. And the next day.
Children like Jonah have great trouble traveling away from their family, and they often refuse to visit friends’ houses, go on errands, or attend camp or school (see Table 14-1). Many cannot even stay alone in a room and cling to their parent around the house. Some also have temper tantrums, cry, or plead to keep their parents from leaving them. The children may fear that they will get lost when separated from their parents or that the parents will meet with an accident or illness. As long as the children are near their parents and not threatened by separation, they may func- tion quite normally. At the first hint of separation, however, the dramatic pattern of symptoms may be set in motion.
Separation anxiety disorder may further take the form of a school phobia, or school refusal, a common problem in which children fear going to school and often stay home for a long period (APA, 2013). Many cases of school phobia, however, have causes other than separation fears, such as social or academic fears, depression, and fears of specific objects or persons at school.
Treatments for Childhood Anxiety Disorders Despite the high prevalence of childhood and adolescent anxiety disorders, around two-thirds of anxious children go untreated (Winter & Bienvenu, 2011). Among the children who do receive treatment, psychodynamic, cognitive-behavioral, family, and group therapies, separately or in combination, have been used most often. Each approach has had some degree of success; however, cognitive-behavioral therapy has fared the best across a number of studies ( James et al., 2015; Mohatt et al., 2014). Such treatments parallel the adult anxiety approaches that you read about in Chap- ter 4, but they are tailored to the child’s cognitive abilities, unique life situation,
and limited control over his or her life. In addition, clinicians may offer psychoeducation, provide parent training, and arrange school interventions to treat anxious children (Lewin, 2011).
Clinicians have also used drug therapy in a number of cases of childhood anxiety disorders, often in combination with psycho- therapy (Mohatt et al., 2014). Drug therapy often appears to be helpful, but it has begun only recently to receive much research attention (Comer et al., 2011, 2010).
Because children typically have difficulty recognizing and understanding their feelings and motives, many therapists, par- ticularly psychodynamic therapists, use play therapy as part of treatment (Landreth, 2012). In this approach, the children play with toys, draw, and make up stories; in doing so they reveal the conflicts in their lives and their related feelings. The therapists then introduce more play and fantasy to help the children work through their conflicts and change their emotions and behavior. In addi- tion, because children are often excellent hypnotic subjects, some therapists use hypnotherapy to help them overcome intense fears.
table: 14-1
Dx Checklist
Separation Anxiety Disorder
1. Individual displays fear or anxiety concerning separation from attachment figures, anxiety that is unreasonable or excessive for his or her age group.
2. Individual’s excessive anxiety features three or more of the following symptoms: • Repeated separation-related upset • Repeated loss-related concern • Repeated fear of experiencing separation-caused events • Repeated resistance to leaving home • Repeated resistance to being alone • Repeated resistance to sleep- aways • Repeated separation- focused nightmares • Repeated separation-triggered physical symptoms.
3. Individual’s symptoms last 4 or more weeks for children and at least 6 months for adults.
4. Significant distress or impairment.
(Information from: APA, 2013)
“This weekend I’m going to finally go through that closet and get rid of all those monsters.”
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Disorders Common Among Children and Adolescents : 469
➤ Summing Up CHILDHOOD ANXIETY DISORDERS Emotional and behavioral problems are common in childhood and adolescence. A particular concern among children is that of being bullied. In addition, at least 20 percent of all children and adoles- cents in the United States have a diagnosable psychological disorder.
Anxiety disorders are particularly common among children and adolescents. This group of problems includes separation anxiety disorder, which is charac- terized by excessive anxiety, often panic, whenever a child is separated from a parent. Various treatments have been used for children with anxiety disorders, including play therapy.
Childhood Depressive and Bipolar Disorders Like Billy, the boy you read about at the beginning of this chapter, around 2 percent of children and 8 percent of adolescents currently experience a major depressive disorder (Mash & Wolfe, 2015). As many as 20 percent of adolescents experience at least one depressive episode during their teen years. In addition, many clinicians believe that children may experience bipolar disorder.
Major Depressive Disorder Very young children lack some of the cognitive skills—a genuine sense of the future, for example—that help produce clinical depression (Hankin et al., 2008). Never- theless, if life situations or biological predispositions are significant enough, even very young children sometimes have severe downward turns of mood (Tang et al., 2014). Depression in the young may be triggered by negative life events (particularly losses), major changes, rejection, or ongoing abuse. Childhood depression commonly features such symptoms as headaches, stomach pain, irritability, and a disinterest in toys and games (AACAP, 2013).
Clinical depression is much more common among teenagers than among young children. Adolescence is, under the best of circumstances, a difficult and confusing time, marked by angst, hormonal and bodily changes, mood changes, complex relationships, and new explorations (see MindTech on the next page). For some teens, these “normal” upsets of adolescence cross the line into clinical depression. As you read in Chapter 7, suicidal thoughts and attempts are particularly common among adolescents—one in eight teens persistently thinks about suicide each year—and depression is the leading cause of such thoughts and attempts (Nock et al., 2013; Spirito & Esposito- Smythers, 2008).
Interestingly, while there is no difference between the rates of depression in boys and girls before the age of 13, girls are twice as likely as boys to be depressed by the age of 16 (Frost et al., 2015; Merikangas et al., 2010). Why this gender shift? Several factors have been suggested, including hormonal changes and the fact that females increasingly experience more stressors than males. One explanation also focuses on teenage girls’ growing dissatisfac- tion with their bodies. Whereas boys tend to like the increase in muscle mass and other body changes that accompany puberty, girls often detest the increases in body fat and weight gain that they experience during puberty and beyond. Raised in a society that values extreme thinness as the aesthetic female ideal, many adolescent girls feel imprisoned by their own bodies, have low self-esteem, and become depressed (Stice et al., 2000). Many also develop eating disorders, as you saw in Chapter 9.
Grief camp A number of “grief camps” have been developed around the country for chil- dren and teenagers who have lost a loved one. At one such program, this young girl, whose uncle was killed while fighting in Iraq, puts a clipping representing what she feels about his death into a bag.
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▶▶ play therapy A treatment approach that helps children express their conflicts and feelings indirectly by drawing, play- ing with toys, and making up stories.
: chapter 14470
For years, it was generally believed that childhood and teenage depression would respond well to the same treatments that have been of help to depressed adults— cognitive-behavioral therapy and antidepressant drugs—and, in fact, many studies have indicated the effectiveness of such approaches (Straub et al., 2014; Vela et al., 2011). Some recent developments, however, have raised questions about these approaches for teenagers.
MindTech
Parent Worries on the Rise Parents have always worried about their children—about their health, their safety, their grades, and their future. But in today’s digital world, parent anxiety is rising to new heights as these traditional concerns are being
joined by a major new focus—worry about their children’s online experiences and behaviors (Fondas, 2014).
What exactly do parents worry about when their chil- dren go online, and who is worrying the most? Researchers Danah Boyd and Eszter Hargittai (2013) surveyed more than 1,000 parents across the United States and found that safety is at the heart of parents’ anxiety. Almost two-thirds of the surveyed parents, whose children ranged in age from 10 to 14 years, were “extremely concerned” about their children being hurt by a stranger whom they might meet online. Additionally, many parents reported having extreme concern about their children being exposed to online pornography (57 percent of parents), being exposed to online violence (35 percent), and being the victim or perpetrator of online bullying (32 percent and 17 percent, respectively). Almost all of the surveyed parents expressed at least some degree of concern about each of these areas.
These areas of anxiety were not distributed evenly among parents. African American, Hispanic American, and Asian
American parents were much more likely than white American parents to have these concerns. Urban par- ents were more fearful than suburban and rural parents. Lower-income parents had more anxiety about online bullying than did wealthier parents.
Mothers expressed more fear than fathers about their children being bullied online. Parents of daugh- ters were more concerned than parents of sons about their children meeting harmful strangers and being exposed to violence online. And politically conservative and moderate parents expressed significantly more anxiety than liberal parents about their children view- ing pornography or meeting strangers online.
In the early days of the Internet, parents would address concerns of this kind by supervising and restricting their children’s online time and access. But those “good old days” are now gone, given the increasing number of U.S. teens who own a smartphone (almost half of them) and the easy access teens have to computers and tablets in so many locations outside the home (Fondas, 2014). In turn, parental anxiety continues to rise.
What can today’s
parents do to address
their concerns about
their children’s online
experiences and
behaviors?
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Disorders Common Among Children and Adolescents : 471
In one development, the National Institute of Mental Health recently sponsored a massive six-year study called the Treatments for Adolescents with Depression Study (TADS), which compared the effec- tiveness of cognitive-behavioral therapy alone, antidepressant therapy alone, cognitive-behavioral and antidepressant therapy combined, and placebo therapy for teenage depression (TADS, 2010, 2007, 2004). Three major surprises emerged from this highly regarded study. First, neither antidepressants alone nor cognitive-behavioral therapy alone was as effective for teenage depression as was a combination of anti- depressants and cognitive-behavioral therapy. Second, antidepressants alone tended to be more helpful to depressed teens than cognitive- behavioral therapy alone. And third, cognitive-behavioral therapy alone was barely more helpful than placebo therapy. Many research- ers believe that certain peculiarities in the participant population of the TADS study may have been responsible for the poor showing of cognitive-behavioral therapy. However, other clinical theorists believe that the TADS study is a definitive research undertaking and that many depressed teens may in fact respond less favorably to cognitive-behavioral therapy than adults do.
A second development has been the discovery that antidepressant drugs may be very dangerous for some depressed children and teenagers. As you read in Chap- ter 7, the U.S. Food and Drug Administration (FDA) concluded in 2004, based on a number of clinical reports, that the drugs may produce an increased risk of suicidal behavior for certain children and adolescents, especially during the first few months of treatment. Thus, the FDA ordered that all antidepressant containers carry “black box” warnings stating that the drugs “increase the risk of suicidal thinking and behavior in children.”
Arguments about the wisdom of this FDA order have since followed. Although most clinicians agree that the drugs may indeed increase the risk of suicidal thoughts and attempts in as many as 2 to 4 percent of young patients, some have noted that the overall risk of suicide may actually be reduced for the vast majority of children who take the drugs (Isacsson & Rich, 2014; Vela et al., 2011). They point out, for example, that suicides among children and teenagers decreased by 30 percent in the decade leading up to 2004, as the number of antidepressant prescriptions provided to children and teenagers were soaring.
While the findings of the TADS study and questions about antidepressant drug safety continue to be sorted out, these two developments serve to highlight once again the importance of research, particularly in the treatment realm. We are reminded that treatments that work for individuals of a certain age, gender, race, or ethnic background may be ineffective or even dangerous for other groups of people.
Bipolar Disorder and Disruptive Mood Dysregulation Disorder For decades, bipolar disorder was thought to be exclusively an adult disorder, and it was believed that its earliest age of onset is the late teens (APA, 2013). However, since the mid-1990s, clinical theorists have done an about-face, and many of them now believe that many children display bipolar disorder. A review of national diag- nostic trends found that the number of children—often very young children—and adolescents diagnosed and treated for bipolar disorder in United States increased 40-fold from 1994 to 2003 (Moreno et al., 2007). For example, the number of pri- vate office visits for children with bipolar disorders increased from 20,000 in 1994 to 800,000 in 2003. And this rise has continued since 2003 (Mash & Wolfe, 2015).
Most theorists believe that these numbers reflect not an increase in the preva- lence of bipolar disorders among children but rather a new diagnostic trend. The
Separation and depression This 3-year- old boy hugs his father as the soldier departs for deployment to Iraq. Given research evi- dence that extended family separations often produce depression in children, clinical theo- rists have been particularly worried about the thousands of children from military families who were left behind during the wars in Afghanistan and Iraq.
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In Their Words “It is an illusion that youth is happy, an illusion of those who have lost it.”
W. Somerset Maugham, Of Human Bondage, 1915
: chapter 14472
question is whether this trend is accurate. Many clinical theorists believe that the diagnosis of bipolar disorder is currently being overapplied to children and adoles- cents (Mash & Wolfe, 2015; Paris, 2014). They suggest that the label has become a clinical catchall that is being applied to almost every explosive, aggressive child. In fact, symptoms of rage and aggression, along with depression, dominate the clinical picture of most children who receive a bipolar diagnosis (Roy et al., 2013). The children may not even manifest the symptoms of mania or the mood swings that characterize adult bipolar disorder.
The DSM-5 task force agreed that the childhood bipolar label has in fact been overapplied over the past two decades. To help rectify this, DSM-5 now includes a new category, disruptive mood dysregulation disorder, which is used to describe children with patterns of severe rage (see Table 14-2). It is expected that more such children will receive this diagnosis in the coming years and that the number of childhood bipolar disorder diagnoses will decrease correspondingly.
This issue is particularly important because the rise in diagnoses of bipolar disorder has been accompanied by an increase in the number of children who are prescribed adult medications (Toteja et al., 2014; Chang et al., 2010; Grier et al., 2010). Around one-half of children in treatment for bipolar disorder receive an antipsychotic drug; one-third receive an antibipolar, or mood stabilizing, drug; and many others receive antidepressant or stimulant drugs. Yet relatively few of these drugs have been tested on and approved specifically for use with children.
➤ Summing Up CHILDHOOD DEPRESSIVE AND BIPOLAR DISORDERS Two percent of children and 8 percent of adolescents experience depression. In recent years, the TADS study and the FDA “black box” ruling have raised questions about the most appropriate treatments for teens with depression. In addition, the past two decades have witnessed an enormous increase in the number of children and adolescents who receive diagnoses of bipolar disorder. Such diagnoses are expected to decrease now that DSM-5 has added a new childhood category, disruptive mood dysregulation disorder.
table: 14-2
Dx Checklist
Disruptive Mood Dysregulation Disorder
1. For at least a year, individual repeatedly displays severe outbursts of temper that are extremely out of proportion to triggering situations and different from ones displayed by most other people of his or her age.
2. The outbursts occur at least three times per week and are present in at least two settings (home, school, with peers).
3. Individual repeatedly displays irritable or angry mood between the outbursts.
4. Individual receives initial diagnosis between 6 and 18 years of age.
(Information from: APA, 2013)
Are children being medicated properly? A group of children in London protests against the common practice of prescribing adult medi- cations and high dosages of medications for children with psychological disorders. Around half of all children treated for childhood bipolar disorder receive antipsychotic drugs.
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Disorders Common Among Children and Adolescents : 473
Oppositional Defiant Disorder and Conduct Disorder Most children break rules or misbehave on occasion. If they consistently display extreme hostility and defiance, however, they may qualify for a diagnosis of opposi- tional defiant disorder or conduct disorder. Those with oppositional defiant dis- order are persistently argumentative or defiant, angry or irritable, and, in some cases, vindictive (APA, 2013). They may argue repeatedly with adults, ignore adult rules and requests, deliberately annoy other people, and feel much anger and resentment. As many as 10 percent of children qualify for a diagnosis of oppositional defiant disorder (Mash & Wolfe, 2015; Wilkes & Nixon, 2015). The disorder is more common in boys than in girls before puberty but equal in both sexes after puberty.
Children with conduct disorder, a more severe problem, repeatedly violate the basic rights of others (APA, 2013). They are often aggressive and may be physi- cally cruel to people or animals, deliberately destroy other people’s property, skip school, steal, or run away from home (see Table 14-3). Many threaten or harm their victims, committing such crimes as firesetting, shoplifting, forgery, breaking into buildings or cars, mugging, and armed robbery. As they get older, their acts of physi- cal violence may include rape or, in rare cases, homicide. The symptoms of conduct disorder are apparent in this summary of a clinical interview with a 15-year-old boy named Derek:
Questioning revealed that Derek was getting into . . . serious trouble of late, having been arrested for shoplifting 4 weeks before. Derek was caught with one other youth when he and a dozen friends swarmed a convenience store and took everything they could before leaving in cars. This event followed similar others at [an electron- ics] store and a . . . clothing store. Derek blamed his friends for his arrest because they apparently left him behind as he straggled out of the store. He was charged only with shoplifting, however, after police found him holding just three candy bars and a bag of potato chips. Derek expressed no remorse for the theft or any care for the store clerk who was injured when one of the teens pushed her into a glass case. When informed of the clerk’s injury, for example, Derek replied, “I didn’t do it, so what do I care?”
The psychologist questioned Derek further about other legal violations and discovered a rather extended history of trouble. Derek was arrested for vandalism 10 months earlier for breaking windows and damaging cars on school property. He received probation for 6 months because this was his first offense. Derek also boasted of other exploits for which he was not caught, including several shoplifting episodes, . . . joyriding, and missing school. Derek missed 23 days (50 percent) of school since the beginning of the academic year. In addition, he described break- in attempts of his neighbors’ apartments. . . . Only rarely during the interview did Derek stray from his bravado.
(Kearney, 2013, pp. 87–88)
Conduct disorder usually begins between 7 and 15 years of age (APA, 2013). As many as 10 percent of children, three-quarters of them boys, qualify for this diagnosis (Mash & Wolfe, 2015; Nock et al., 2006). Children with a relatively mild conduct disorder often improve over time, but a severe case may continue into adulthood and develop into antisocial personality disorder or other psychological problems. Usually, the earlier the onset of the conduct disorder, the poorer the even- tual outcome. Research indicates that more than 80 percent of those who develop conduct disorder first display a pattern of oppositional defiant disorder (APA, 2013; Lahey, 2008). More than one-third of children with conduct disorder also display
table: 14-3
Dx Checklist
Conduct Disorder
1. Individual repeatedly behaves in ways that violate the rights of other people or ignores the norms or rules of society, beyond the violations displayed by most other people of his or her age.
2. At least three of the following features are present over the past year (and at least one in the past 6 months): • Frequent bullying or threatening of others • Frequent provoking of physical fights • Using dangerous weapons • Physical cruelty to people • Physical cruelty to animals • Stealing during confrontations with a victim • Forcing someone into sexual activity • Fire-setting • Deliberately destroying others’ property • Breaking into a house, building, or car • Frequent lying • Stealing items of value under nonconfrontational circumstances • Frequent staying out beyond curfews, starting before the age of 13 • Running away from home overnight at least twice • Frequent truancy from school, starting before the age of 13.
3. Significant impairment.
(Information from: APA, 2013)
▶▶ disruptive mood dysregulation disorder A childhood disorder marked by severe recurrent temper outbursts and a persistent irritable or angry mood.
▶▶ oppositional defiant disorder A disorder in which children are per- sistently argumentative, defiant, angry, irritable, and perhaps vindictive.
▶▶ conduct disorder A disorder in which a child repeatedly violates the basic rights of others and displays significant aggression.
: chapter 14474
attention-deficit/hyperactivity disorder (ADHD), a disorder that you will read about shortly ( Jiron, 2010).
Some clinical theorists believe that there are actually several kinds of conduct disorder, including (1) the overt-destructive pattern, in which individuals display openly aggressive and confrontational behaviors; (2) the overt-nondestructive pattern, dominated by openly offensive but nonconfrontational behav- iors such as lying; (3) the covert-destructive pattern, characterized by secretive destructive behaviors such as violating other people’s property, breaking and entering, and setting fires; and (4) the covert- nondestructive pattern, in which individuals secretly com- mit nonaggressive behaviors, such as being truant from school (McMahon et al., 2010; McMahon & Frick, 2007, 2005).
Other researchers distinguish yet another pattern of aggres- sion found in certain cases of conduct disorder, relational aggres- sion, in which the individual is socially isolated and primarily engages in social misdeeds such as slandering others, spreading rumors, and manipulating friendships (Ostrov et al., 2014). Relational aggression is more common among girls than boys.
Many children with conduct disorder are suspended from school, placed in foster homes, or incarcerated (Weyandt et al., 2011). When children between the ages of 8 and 18 break the law, the legal system often labels them juvenile delinquents (Wiklund et al., 2014; Jiron, 2010). Boys are much more involved in juvenile crime than girls, although the gap between them is narrowing. After steadily rising during the 1990s, the number of arrests of teenagers for serious crimes has fallen by one-third during the past decade (U.S. Department of Justice, 2014, 2010).
What Are the Causes of Conduct Disorder? Many cases of conduct disorder, particularly those marked by destructive behaviors, have been linked to genetic and biological factors (Kerekes et al., 2014; Wallace et al., 2014). In addition, a number of cases have been tied to drug abuse, poverty, trau- matic events, and exposure to violent peers or community violence (Wymbs et al., 2014; Weyandt et al., 2011). Most often, conduct disorder has been tied to troubled parent–child relationships, inadequate parenting, family conflict, marital conflict, and family hostility (Mash & Wolfe, 2015; Henggeler & Sheidow, 2012). Children whose parents reject, leave, coerce, or abuse them or fail to provide appropriate and consis- tent supervision are apparently more likely to develop conduct problems. Children also seem more prone to this disorder when their parents themselves are antisocial, display excessive anger, or have substance use, mood, or schizophrenic disorders (Advokat et al., 2014).
How Do Clinicians Treat Conduct Disorder? Because aggressive behaviors become more locked in with age, treatments for conduct disorder are generally most effective with children younger than 13 (APA, 2013). A number of interventions, from sociocultural to child-focused, have been developed in recent years to treat children with the disorder. As you will see, several of these have had modest (and at times moderate) success, but clearly no one of them alone is the answer for this difficult problem. Today’s clinicians are increasingly combining several approaches into a wide-ranging treatment program.
Sociocultural Treatments Given the importance of family factors in con- duct disorder, therapists often use family interventions. One such approach, used with preschoolers, is called parent–child interaction therapy (Hembree-Kigin & McNeil,
“Is this the story you want to tell on your college application?”
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Narrowing the Gender Gap One of every three teens arrested for violent crimes is female.
(Department of Justice, 2008; Scelfo, 2005)
Disorders Common Among Children and Adolescents : 475
2013; Zisser & Eyberg, 2010). Here therapists teach parents to work with their child positively, to set appropriate limits, to act consistently, to be fair in their discipline decisions, and to establish more appropriate expectations regarding the child. The therapists also try to teach the child better social skills. A related family intervention for very young children, video modeling, works toward the same goals with the help of video tools (Webster-Stratton & Reid, 2010).
When children reach school age, therapists often use a family intervention called parent management training. In this approach, (1) parents are again taught more effec- tive ways to deal with their children, and (2) parents and children meet together in behavior-oriented family therapy (Kazdin, 2012, 2010, 2002; Forgatch & Patterson, 2010). Typically, the family and therapist target particular behaviors for change, then the parents are taught how to better identify problem behaviors, stop rewarding unwanted behaviors, and reward proper behaviors in a consistent manner. Like the family interventions for preschool-age children, parent management training has often achieved a measure of success.
Other sociocultural approaches, such as residential treatment in the commu- nity and programs at school, have also helped some children improve. In one such approach, treatment foster care, delinquent boys and girls with conduct disorder are assigned to a foster home in the community by the juvenile justice system
(Henggeler & Sheidow, 2012). While there, the children, foster parents, and birth parents all receive training and treatment, followed by more treatment and support for the children and their biological parents after the children leave foster care.
In contrast to these sociocultural interven- tions, institutionalization in so-called juvenile
training centers has not met with much success (Stahlberg et al., 2010; Heilbrun et al., 2005). In fact, such institutions frequently serve to strengthen delinquent behavior rather than resocialize young offenders.
Child-Focused Treatments Treatments that focus primarily on the child with conduct disorder, particularly cognitive-behavioral interventions, have had some success in recent years (Kazdin, 2015, 2012, 2010, 2007). In an approach called problem-solving skills training, therapists combine modeling, practice, role-playing, and systematic rewards to help teach children constructive thinking and positive social behaviors. During therapy sessions, the therapists may play games and solve tasks with the children and later help the children apply the lessons and skills derived from the games and tasks to real-life situations.
In another child-focused approach, the Coping Power Program, children with conduct problems participate in group sessions that teach them to manage their anger more effectively, view situations in perspective, solve problems, become aware of their emotions, build social skills, set goals, and handle peer pressure.
Studies indicate that child-focused approaches such as these do indeed help reduce aggressive behaviors and prevent sub- stance use in adolescence (Lochman et al., 2012, 2011, 2010). Recently, psychotropic medications have also been used for children with conduct disorder. Studies suggest, for example, that stimulant drugs may be helpful in reducing their aggressive behaviors at home and at school (Gorman et al., 2015).
Prevention It may be that the best hope for dealing with the problem of conduct disorder lies in prevention programs that begin in the earliest stages of childhood (Hektner et al., 2014).
how might juvenile training
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Prevention: Scared straight Rather than waiting for children or adolescents to develop antisocial patterns, many clinicians call for better prevention programs. In one such pro- gram, “at risk” children visit nearby prisons where inmates describe how drugs, gang life, and other antisocial behaviors led to their imprisonment.
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Underlying Problems There are approximately 110,000 teen- agers in the United States incarcerated each year. Three-quarters of them re- port mental health problems.
(Nordal, 2010)
: chapter 14476
These programs try to change unfavorable social conditions before a conduct dis- order is able to develop. The programs may offer training opportunities for young people, recreational facilities, and health care and may try to ease the stresses of poverty and improve parents’ child-rearing skills. All such approaches work best when they educate and involve the family.
Elimination Disorders Children with elimination disorders repeatedly urinate or pass feces in their clothes, in bed, or on the floor. They already have reached an age at which they are expected to control these bodily functions, and their symptoms are not caused by physical illness.
Enuresis Enuresis is repeated involuntary (or in some cases intentional) bed-wetting or wet- ting of one’s clothes. It typically occurs at night during sleep but may also occur dur- ing the day. Children must be at least 5 years of age to receive this diagnosis (APA, 2013). The problem may be triggered by stressful events, such as a hospitalization, entrance into school, or family problems. In some cases it is the result of physical or psychological abuse (see PsychWatch on page 478).
The prevalence of enuresis decreases with age. As many as 33 percent of 5-year- old children have some bed-wetting and as many as 10 percent meet the criteria for enuresis; in contrast, 3 to 5 percent of 10-year-olds and 1 percent of 15-year-olds have enuresis (Mash & Wolfe, 2015; APA, 2013). Those with enuresis typically have a close relative (parent, sibling) who has had or will have the same disorder.
Research has not favored one explanation for enuresis over the others (Kim et al., 2014; Friman, 2008). Psychodynamic theorists explain it as a symptom of broader anxiety and underlying conflicts. Family theorists point to disturbed family interactions. Behaviorists view the problem as the result of improper, unrealistic, or coercive toilet training. And biological theorists suspect that children with this disorder often have a small bladder capacity or weak bladder muscles.
Most cases of enuresis correct themselves even without treatment. However, therapy, particularly behavioral therapy, can speed up the process (Axelrod et al., 2014; Christophersen & Friman, 2010). In a widely used classical conditioning approach, the bell-and-battery technique, a bell and a battery are wired to a pad con- sisting of two metallic foil sheets, and the entire apparatus is placed under the child at bedtime (Mowrer & Mowrer, 1938). A single drop of urine sets off the bell, awakening the child as soon as he or she starts to wet. Thus the bell (unconditioned stimulus) paired with the sensation of a full bladder (conditioned stimulus) produces the response of waking. Eventually, a full bladder alone awakens the child.
Another effective behavioral treatment method is dry-bed training, in which chil- dren receive training in cleanliness and retention control, are awakened periodically during the night, practice going to the bathroom, and are appropriately rewarded. Like the bell-and-battery technique, this behavioral approach is often effective.
Encopresis Encopresis, repeatedly defecating into one’s clothing, is less common than enuresis, and it is also less well researched (Mash & Wolfe, 2015; APA, 2013). This problem seldom occurs at night during sleep. It is usually involuntary, starts at the age of 4 or older, and affects about 1.5 to 3 percent of all children (see Table 14-4). The disorder is much more common in boys than in girls.
The Bedwetter Outrageous comedian Sarah Silverman holds up a copy of her best-selling 2010 book The Bedwetter. In this memoir, she writes extensively about her childhood experiences with enuresis and other emotional difficulties—always with a blend of self- revelation, pain, and humor.
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▶▶ enuresis A childhood disorder marked by repeated bed-wetting or wetting of one’s clothes.
▶▶ encopresis A childhood disorder characterized by repeated defecating in inappropriate places, such as one’s clothing.
Disorders Common Among Children and Adolescents : 477
Encopresis causes intense social problems, shame, and embarrassment (NLM, 2015; Mosca & Schatz, 2013). Children who suffer from it usually try to hide their condition and to avoid situations, such as camp or school, in which they might embarrass themselves. It may stem from stress, biological factors such as constipa- tion, improper toilet training, or a combination of these factors. Because physical problems are so often linked to this disorder, a medical examination is typically conducted first.
The most common and successful treatments for encopresis are behavioral and medical approaches or a combination of the two (NLM, 2015; Collins et al., 2012; Christophersen & Friman, 2010). Treatment may include biofeedback training (see pages 118–119) to help the children better detect when their bowels are full; trying to eliminate the children’s constipation; and stimulating regular bowel functioning with high-fiber diets, mineral oil, laxatives, and lubricants. Family therapy has also proved helpful.
table: 14-4
Comparison of Childhood Disorders
Disorder Usual Age of Identification
Prevalence Among All Children
Gender with Greater Prevalence
Elevated Family History
Recovery by Adulthood
Separation anxiety disorder Before 12 years 4%–10% Females Yes Usually
Conduct disorder 7–15 years 1%–10% Males Yes Often
ADHD Before 12 years 5% Males Yes Often
Enuresis 5–8 years 5% Males Yes Usually
Encopresis After 4 years 1.5%–3% Males Unclear Usually
Specific learning disorders 6–9 years 5% Males Yes Often
Autism spectrum disorder 0–3 years 1.6% Males Yes Sometimes
Intellectual disability Before 10 years 1%–3% Males Unclear Sometimes
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PsychWatch
A problem that affects all too many children and has an enormous im-pact on their psychological devel- opment is child abuse, the nonaccidental use of excessive physical or psychological force by an adult on a child, often with the intention of hurting or destroying the child. At least 5 percent of children in the United States are physically abused each year (Mash & Wolfe, 2015). Surveys suggest that 1 of every 10 children is the victim of severe violence, such as being kicked, bitten, hit, beaten, or threatened with a knife or a gun. In fact, some re- searchers believe that physical abuse and neglect are the leading causes of death among young children.
Overall, girls and boys are physically abused at approximately the same rate. Although such abuse occurs in all socio- economic groups, it is apparently more common among the poor (Romero- Martínez et al., 2014; Fowler et al., 2013).
Abusers are usually the child’s parents (Ben-Natan et al., 2014). Clinical investi- gators have learned that abusive parents often have poor impulse control, low self-esteem, higher levels of depression, and weak parenting skills (Easterbrooks et al., 2013; Tolan et al., 2006). Many were abused themselves as children and have had poor role models (Romero- Martínez et al., 2014; McCaghy et al., 2006). In some cases, they are dealing with stressors such as marital discord or unemployment (Bor et al., 2013).
Studies suggest that the victims of child abuse may suffer immediate psychological effects such as anxiety, depression, bed-wetting, and perfor- mance and behavior problems in school (Keeshin et al., 2014; Buckingham & Daniolos, 2013). They may also ex- perience long-term negative effects, including lack of social acceptance, more arrests during adolescence and adulthood, a higher number of medi- cal and psychological disorders in their adult years, more abuse of alcohol and other substances, more impulsive and
risk-taking behaviors, a heightened risk of becoming criminally violent, a higher unemployment rate, and a higher suicide rate (Afifi et al., 2014; Sujan et al., 2014; Faust et al., 2008). Moreover, as many as one-third of those who are abused grow up to be abusive, neglectful, or inadequate parents themselves (Romero- Martínez et al., 2014; Yaghoubi-Doust, 2013).
Two forms of child abuse have re- ceived special attention: psychological and sexual abuse. Psychological abuse may include severe rejection, excessive discipline, scapegoating and ridicule, isolation, and refusal to provide help for a child with psychological problems. It probably accompanies all forms of physi- cal abuse and neglect and often occurs by itself. Child sexual abuse, the use of a child for gratification of adult sexual desires, may occur outside or within the home (Murray, Nguyen, & Cohen, 2014; Faust et al., 2008). Surveys suggest that at least 13 percent of women and 4 percent of men are forced into sexual contact with an adult during childhood, many of them with a parent or step-parent (Mash & Wolfe, 2015). Child sexual abuse
appears to be equally common across all socioeconomic classes, races, and ethnic groups (Murray et al., 2014).
A variety of therapies have been used in cases of child abuse, including groups sponsored by Parents Anonymous, which help parents to develop insight into their behavior, provide training on alternatives to abuse, and teach coping and parent- ing skills (PA, 2014; Miller et al., 2007; Tolan et al., 2006). In addition, prevention programs, often in the form of home visi- tations and parent training, have proved promising (Beasley et al., 2014; Rubin et al., 2014).
Research suggests that the psycho- logical needs of children who have been abused should be addressed as early as possible (Murray et al., 2014; Roesler & McKenzie, 1994). Clinicians and educators have launched valuable early detection programs that (1) educate all children about child abuse, (2) teach them skills for avoiding or escaping from abusive situations, (3) encourage children to tell another adult if they are abused, and (4) assure them that abuse is never their own fault (Miller et al., 2007; Finkelhor et al., 1995).
Child Abuse
“Memories so strong that I can smell and taste them now” That is how actor and filmmaker Tyler Perry (left) describes his recollections of the physical and sexual abuse he suffered as a child. Similarly, mega-celebrity and producer Oprah Winfrey (right) has pub- licly discussed her childhood experiences of sexual abuse. The two have collaborated to bring attention to child abuse.AP
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Disorders Common Among Children and Adolescents : 479
➤ Summing Up CONDUCT DISORDER AND ELIMINATION DISORDERS Children with oppo- sitional defiant disorder and conduct disorder exceed the normal breaking of rules and act very aggressively. Those with oppositional defiant disorder argue repeatedly with adults, ignore adult rules and requests, and feel intense anger and resentment. Those with conduct disorder, a more severe pattern, repeatedly violate the basic rights of others. Children with this disorder often are violent and cruel and may deliberately destroy property, steal, and run away. Clinicians have treated children with conduct disorders by using approaches such as parent–child interaction therapy, parent management training, treatment foster care, problem-solving skills training, and the Coping Power Program. A number of prevention programs have been developed.
Children with an elimination disorder—enuresis or encopresis—repeatedly urinate or pass feces in inappropriate places. Behavioral approaches, such as the bell-and-battery technique, are effective treatments for enuresis.
Neurodevelopmental Disorders Neurodevelopmental disorders are a group of disabilities in the functioning of the brain that emerge at birth or during very early childhood and affect the indi- vidual’s behavior, memory, concentration, and/or ability to learn. As you read at the beginning of this chapter, many of the disorders first displayed during childhood subside as the person ages. However, the neurodevelopmental disorders often have a significant impact throughout the person’s life. For example, at least half of those with attention-deficit/hyperactivity disorder, one of the neurodevelopmental disorders, carry some version of their disorder with them into adulthood. Moreover, the vast majority of those with autism spectrum disorder and intellectual disability, two other neurodevelopmental disorders, continue to display the symptoms of their disorders in largely unchanged form throughout adulthood.
Researchers have investigated each of these disorders extensively. In addition, although this was not always so, clinicians now have a range of treatment approaches that can make a major difference in the lives of people with these problems.
Attention-Deficit/Hyperactivity Disorder Children with attention-deficit/hyperactivity disorder (ADHD) have great difficulty attending to tasks, or behave overactively and impulsively, or both (APA, 2013) (see Table 14-5 on the next page). ADHD often appears before the child starts school, as with Ricky, one of the boys we met at the beginning of this chapter. Steven is another child whose symptoms began very early in life:
Steven’s mother cannot remember a time when her son was not into something or in trouble. As a baby he was incredibly active, so active in fact that he nearly rocked his crib apart. All the bolts and screws became loose and had to be tightened peri- odically. Steven was also always into forbidden places, going through the medicine cabinet or under the kitchen sink. He once swallowed some washing detergent and had to be taken to the emergency room. As a matter of fact, Steven had many more accidents and was more clumsy than his older brother and younger sister. . . . He al- ways seemed to be moving fast. His mother recalls that Steven progressed from the crawling stage to a running stage with very little walking in between.
(continues on the next page)
▶▶ neurodevelopmental disorders A group of disabilities in the function- ing of the brain that emerge at birth or during very early childhood and affect a person’s behavior, memory, concentra- tion, and/or ability to learn.
▶▶ attention-deficit/hyperactivity disorder (ADHD) A disorder marked by the inability to focus attention, or over- active and impulsive behavior, or both.
B e t W e e N t h e L I N e S
In Their Words “Children nowadays are tyrants. They contradict their parents, gobble their food, and tyrannize their teachers.”
Socrates, 425 b.c.
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Trouble really started to develop for Steven when he entered kindergarten. Since his entry into school, his life has been miserable and so has the teacher’s. Steven does not seem capable of attending to assigned tasks and following instructions. He would rather be talking to a neighbor or wandering around the room without the teacher’s permission. When he is seated and the teacher is keeping an eye on him to make sure that he works, Steven’s body still seems to be in motion. He is either tapping his pencil, fidgeting, or staring out the window and daydreaming. Steven hates kindergarten and has few long-term friends; indeed, school rules and demands appear to be impossible challenges for him. The effects of this mismatch are now showing in Steven’s schoolwork and attitude. He has fallen behind academically and has real difficulty mastering new concepts; he no longer follows directions from the teacher and has started to talk back.
(Gelfand, Jenson, & Drew, 1982, p. 256)
The symptoms of ADHD often feed into one another. Children who have trouble focusing attention may keep turning from task to task until they end up trying to run in several directions at once. Similarly, children who move constantly may find it hard to attend to tasks or show good judgment. In many cases, one of these symptoms stands out much more than the other. About half of the children with ADHD also have learning or communication problems; many perform poorly in school; a number have difficulty interacting with other children; and about 80 percent misbehave, often quite seriously (Mash & Wolfe, 2015; Goldstein, 2011). It is also common for these children to have anxiety or mood problems (Humphreys et al., 2015; Tsang et al., 2015).
Around 5 percent of all children display ADHD at any given time, as many as 70 percent of them boys (APA, 2013; Merikangas et al., 2011). The disorder usually
table: 14-5
Dx Checklist
Attention-Deficit/Hyperactivity Disorder
1. Individual presents one or both of the following patterns:
(a) For 6 months or more, individual frequently displays at least six of the following symptoms of inattention, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Unable to properly attend to details, or frequently makes careless errors • Finds it hard to maintain attention • Fails to listen when spoken to by others • Fails to carry out instructions and finish work • Disorganized • Dislikes or avoids mentally effortful work • Loses items that are needed for successful work • Easily distracted by irrelevant stimuli • Forgets to do many everyday activities.
(b) For 6 months or more, individual frequently displays at least six of the following symptoms of hyperactivity and impulsivity, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Fidgets, taps hands or feet, or squirms • Inappropriately wanders from seat • Inappropriately runs or climbs • Unable to play quietly • In constant motion • Talks excessively • Interrupts questioners during discussions • Unable to wait for turn • Barges in on others’ activities or conversations.
2. Individual displayed some of the symptoms before 12 years of age.
3. Individual shows symptoms in more than one setting.
4. Individual experiences impaired functioning.
(Information from: APA, 2013)
B e t W e e N t h e L I N e S
ADHD and School • More than 90 percent of children with
ADHD underachieve scholastically. On average, they have more failing grades and lower grade point aver- ages than other children.
• At least one-quarter of children with ADHD do not complete high school.
(rapport et al., 2008)
Disorders Common Among Children and Adolescents : 481
persists throughout childhood. Many children show a marked lessening of symp- toms as they move into mid-adolescence, but as many as 60 percent of affected children continue to have ADHD as adults (Weyandt et al., 2014). The symptoms of restlessness and overactivity are not usually as pronounced in adult cases.
ADHD is a difficult disorder to assess properly (Batstra et al., 2014). Ideally, the child’s behavior should be observed in several environments (school, home, with friends) because the symptoms of hyperactivity and inattentiveness must be present across multiple settings in order for ADHD to be diagnosed (Burns et al., 2014; APA, 2013). Because children with ADHD often give poor descriptions of their symptoms, it is important to obtain reports of the child’s symp- toms from his or her parents and teachers. And, finally, although diagnostic interviews, ratings scales, and psychological tests can be helpful in the assessment of ADHD, studies suggest that many children receive their diagnosis from pediatricians or family physicians rather than mental health professionals and that at most one-third of such diagnoses are based on psychological or educational testing (Millichap, 2010).
What Are the Causes of ADHD? Today’s clinicians generally consider ADHD to have several interacting causes. Biological factors have been identified in many cases, particu- larly abnormal activity of the neurotransmitter dopamine and abnormalities in the striatal region of the brain (Advokat et al., 2014; Hale et al., 2010). The disorder has also been linked to high levels of stress and to family dysfunctioning (Montejo et al., 2015; Rapport et al., 2008). In addition, sociocultural theorists have noted that ADHD symptoms and a diagnosis of ADHD may themselves create social problems and produce additional symptoms in the child. That is, children who are hyperactive tend to be viewed negatively by their peers and by their parents, and they often view themselves negatively as well (Martin, 2014; Chandler, 2010).
How Is ADHD Treated? Almost 80 percent of all children and adolescents with ADHD receive treatment (Winter & Bienvenu, 2011). There is, however, dis- agreement in the field about which kind of treatment is most effective. The most commonly used approaches are drug therapy, behavioral therapy, or a combination of the two (Sibley et al., 2014).
Millions of children and adults with ADHD are currently treated with methyl- phenidate, a stimulant drug that has been available for decades, or with certain other stimulants. Although a variety of manufacturers now produce methylphe- nidate, the drug continues to be known to the public by its most famous trade name, Ritalin. As researchers have confirmed Ritalin’s quieting effect on children with ADHD and its ability to help them focus, solve complex tasks, perform bet- ter at school, and control aggression, use of the drug has increased enormously— according to some estimates, at least a threefold increase since 1990 alone (Mash &
Wolfe, 2015; Sibley et al., 2014). Today, an esti- mated 2.2 million children in the United States, 3 percent of all schoolchildren, regularly take Ritalin or other stimulant drugs for ADHD. Collectively, the drugs are the most common treatment for the disorder.
Although widely used, Ritalin and other stimulant drugs have raised certain concerns. First, many clinicians worry about the possible long-term effects of the drugs (Berg et al., 2014; Waugh, 2013), and others question whether the favorable findings of the drug studies (most of which have been done on white American children) are applicable to children from minority
“Playing” attention A range of techniques have been used to help understand and treat children with ADHD, including a computer program called Play Attention. Here, under the watchful eye of a behavior specialist, a child wears a bike helmet that measures brain waves while she performs tasks that require attention.
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▶▶ methylphenidate A stimulant drug, known better by the trade name Ritalin, commonly used to treat ADHD.
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groups. Second, investigations indicate that ADHD is overdiag- nosed in the United States, so many children who are receiving the stimulants may, in fact, not really be in need of them (Batstra et al., 2014; Rapport et al., 2008).
Behavioral therapy has been used to help treat many people with ADHD. Parents and teachers learn how to reward children for their attentiveness or self-control, often by using a token economy program (Coates et al., 2015; DuPaul et al., 2011). Such operant conditioning treatments have been helpful for a num- ber of children, especially when combined with stimulant drug therapy (Sibley et al., 2014; Dendy, 2011). Combining behavioral and drug therapies is also desirable because, according to research, children who receive both treatments require lower levels of medication, meaning, of course, that they are less subject to the medication’s possible side effects (Hoza et al., 2008).
Multicultural Factors and ADHD Throughout this book, you have seen that race often affects how people are diag- nosed and treated for various psychological disorders. Thus, you should not be totally surprised that race also seems to come into play with regard to ADHD.
A number of studies indicate that African American and Hispanic American children with significant attention and activity problems are less likely than white American children with similar symptoms to be assessed for ADHD, receive a diagnosis of ADHD, or undergo treatment for it (Morgan et al., 2014; Bussing et al., 2005, 2003, 1998). Moreover, among those who do receive such a diagnosis and treatment, children from racial minorities are less likely than white American children to be treated with stimulant drugs or a combination of stimulants and behavioral therapy—the interventions that seem to be of most help to those with ADHD (Pham et al., 2010). Finally, among those children who do receive stimu- lant drug treatment for ADHD, children from racial minorities are less likely than white American children to receive the promising (but more expensive) long-acting stimulant drugs that have been developed in recent years (Sugrue et al., 2014; Cooper, 2004).
In part, these racial differences are tied to economic factors. Studies consistently show that poorer children are less likely than wealthier ones to be identified as having ADHD and are less likely to receive effective treatment, and racial minority families have, on average, lower incomes and weaker insurance coverage than white American families. Some clinical theorists further believe that social bias and ste- reotyping may contribute to the racial differences in diagnosis and treatment. They argue that our society often views the symptoms of ADHD as medical problems when exhibited by white American children but as indicators of poor parenting, lower IQ, substance use, or violence when displayed by African American and Hispanic American children (Duval-Harvey & Rogers, 2010; Kendall & Hatton, 2002). This notion has been supported by the research finding that, all symptoms being equal, teachers and parents are more likely to conclude that overactive white American children have ADHD but that overactive African American or His- panic American children have other kinds of difficulties (Hillemeier et al., 2007; Raymond, 1997; Samuel et al., 1997).
Whatever the reason—economic disadvantage, social bias, racial stereotyping, or other factors—it appears that children from racial minority groups are less likely to receive a proper ADHD diagnosis and treatment. While many of today’s theorists correctly raise the possibility that ADHD may be generally overdiagnosed, it is important to recognize that children from certain segments of society may, in fact, be underdiagnosed and undertreated.
Behavioral intervention Educational pro- grams use behavioral principles that clearly spell out targeted behaviors and program rewards and systematically reinforce appro- priate behaviors. Such programs can be particularly helpful for children with ADHD.
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In Their Words “I want to thank my mom and my dad up in heaven for disobeying the doctor’s orders and not medicating their hyper- active girl and finding out what she was into instead.”
audra McDonald, accepting a tony award for best Broadway performance, 2014
Disorders Common Among Children and Adolescents : 483
Autism Spectrum Disorder Autism spectrum disorder, a pattern first identified by psychiatrist Leo Kanner in 1943, is marked by extreme unresponsiveness to other people, severe commu- nication deficits, and highly rigid and repetitive behaviors, interests, and activities (APA, 2013) (see Table 14-6). These symptoms appear early in life, typically before 3 years of age. Just a few decades ago, the disorder seemed to affect around 1 out of every 2,000 children. However, in recent years there has been a steady increase in the number of children diagnosed with autism spectrum disorder, and it now appears that as many as 1 in 68 children display this pattern (CDC, 2015, 2014). Jennie is one such child:
[At school] Jennie was often nonresponsive to others, especially her classmates, and rarely made eye contact with anyone. When left alone, Jennie would usually stand, put her hands over her throat, stick out her tongue, and make strange but soft noises. This would last for hours if she were left alone. When seated, Jennie rocked back and forth in her chair but never fell. Her motor skills seemed excellent and she could use crayons and manipulate paper when asked to do so. Her dexterity was also evident in her aggression, however. Jennie often grabbed people’s jewelry and eyeglasses and flung them across the room. She moved quickly enough to accom- plish this in less than two seconds. . . . Jennie was most aggressive when introduced to something or someone new. . . .
. . . Jennie did not speak and vocalized only when making her soft sounds. The volume of her sounds rarely changed. . . . [She] made no effort to communicate with others and was often oblivious to others. . . . Despite her lack of expressiveness, Jennie did understand and adhere to simple requests from others. She complied readily when told to get her lunch, use the bathroom, or retrieve an item in the classroom. . . .
Jennie had a “picture book” with photographs of items she might want or need. . . . When shown the book and asked to point, Jennie either pushed the book onto the desk if she did not want anything or pointed to one of five photographs (i.e., a lunch box, cookie, glass of water, favorite toy, or toilet) if she did want something. . . .
[Her parents] said Jennie “had always been like this.” . . . Both said Jennie was “different” as a baby when she resisted being held and when she failed to talk by age 3 years. . . .
(Kearney, 2013, pp. 125–126)
Around 80 percent of all cases of autism spectrum disorder occur in boys. As many as 90 percent of children with the disorder remain significantly disabled into adulthood. They have great difficulty maintaining employment, performing household tasks, and leading independent lives (Sicile-Kira, 2014). Even the highest- functioning adults with autism typically have problems with closeness and empathy and have restricted interests and activities.
The individual’s lack of responsiveness and social reciprocity—extreme aloofness, lack of interest in other people, low empathy, and inability to share attention with others—has long been considered a central feature of autism. Like Jennie, children with autism typically do not reach for their parents during infancy. Instead they may arch their backs when they are held and appear not to recognize or care about those around them. In a similar vein, unlike other children of the same age, autistic chil- dren typically do not include others in their play and do not represent social expe- riences when they are playing; they often fail to see themselves as others see them and have no desire to imitate or be like others (Bodison, 2015; Boyd et al., 2011).
Communication problems take various forms in autism spectrum disorder. Many autistic people have great difficulty understanding speech or using language for
table: 14-6
Dx Checklist
Autism Spectrum Disorder
1. Individual displays continual deficiencies in various areas of communication and social inter- action, including the following: • Social-emotional reciprocity • Nonverbal communication • Development and maintenance of relationships.
2. Individual displays significant restriction and repetition in behaviors, interests, or activities, including two or more of the following: • Exaggerated and repeated speech patterns, move- ments, or object use • Inflexible demand for same routines, state- ments, and behaviors • Highly restricted, fixated, and overly intense interests • Over- or under- reactions to sensory input from the environment.
3. Individual develops symptoms by early childhood.
4. Individual experiences significant impairment.
(Information from: APA, 2013)
▶▶ autism spectrum disorder A devel- opmental disorder marked by extreme unresponsiveness to others, severe com- munication deficits, and highly repetitive and rigid behaviors, interests, and activities.
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conversational purposes. In fact, like Jennie, half fail to speak or develop effective language skills (Paul & Gilbert, 2011). Those who do talk may have rigid and repetitious speech patterns. One of the most common speech peculiarities is echolalia, the exact echoing of phrases spoken by others. The individuals repeat the words, but with no sign of understanding or intent of communi- cating. Another speech oddity is pronominal reversal, or confusion of pronouns—for example, the use of “you” instead of “I.” When hungry, a child with autism spectrum disorder might say, “Do you want dinner?”
The nonverbal behaviors of these individuals are often at odds with their efforts at verbal communication. They may not, for example, use a proper tone when talking. It is also common for autistic persons to show few or no facial expressions or body gestures. In addition, a number are unable to maintain proper eye contact during interactions. Recall, for example, that Jennie
“rarely made eye contact with anyone.” Autistic people also display a wide range of highly rigid and repetitive behaviors,
interests, and activities that extend beyond speech patterns. Typically they become very upset at minor changes in objects, persons, or routines and resist any efforts to change their own repetitive behaviors. Recall that Jennie was most aggressive when introduced to something or someone new.
Similarly, some children with the disorder react with tantrums if a parent wears an unfamiliar pair of glasses, a chair is moved to a different part of the room, or a word in a song is changed. Kanner (1943) labeled such reactions a perseveration of sameness. Many also become strongly attached to particular objects—plastic lids, rubber bands, buttons, water. They may collect these objects, carry them, or play with them constantly. Some are fascinated by movement and may watch spinning objects, such as fans, for hours.
People with autism may display motor movements that are unusual, rigid, and repetitive. They may jump, flap their arms, twist their hands and fingers, rock, walk on their toes, spin, and make faces. These acts are called self-stimulatory behaviors. Some autistic individuals also perform self-injurious behaviors, such as repeatedly lunging into or banging their head against a wall, pulling their hair, or biting them- selves (Aman & Farmer, 2011).
The symptoms of autism spectrum disorder suggest a very disturbed and contra- dictory pattern of reactions to stimuli (see PsychWatch on the next page). Sometimes the individuals seem overstimulated by sights and sounds and appear to be trying to block them out (called hyperreactivity), while at other times they seem understimu- lated and appear to be performing self-stimulatory actions (called hyporeactivity). They may, for example, fail to react to loud noises yet turn around when they hear soda being poured.
What Are the Causes of Autism Spectrum Disorder? A variety of explanations have been offered for autism spectrum disorder. This is one disorder for which sociocultural explanations have probably been overemphasized. In fact, such explanations initially led investigators in the wrong direction. More recent work in the psychological and biological spheres has persuaded clinical theorists that cognitive limitations and brain abnormalities are the primary causes of this disorder.
Sociocultural cauSeS At first, theorists thought that family dysfunction and social stress were the primary causes of autism spectrum disorder. When he first identified this disorder, for example, Kanner argued that particular personality characteristics of the parents created an unfavorable climate for development and contributed to the disorder (Kanner, 1954, 1943). He saw these parents as very intelligent yet
Blocking out the world An 8-year-old child with autism spectrum disorder peers vacantly through a hole in the netting of a baseball bat- ting cage, seemingly unaware of other children and activities at the playground.
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On the Rise: Estimates of Autism Prevalence 1985 1 per 2000 children
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(cDc, 2015; Falco, 2014; park, 2014; rice et al., 2012)
Disorders Common Among Children and Adolescents : 485
cold—“refrigerator parents.” These claims had enormous influence on the public and on the self-image of the parents themselves, but research has totally failed to support a picture of rigid, cold, rejecting, or disturbed parents (Sicile-Kira, 2014; Vierck & Silverman, 2011).
Similarly, some clinical theorists have proposed that a high degree of social and environmental stress is a factor in the disorder. Once again, however, research has not supported this notion. Investigators who have compared autistic children with nonautistic children have found no differences in the rate of parental death, divorce, separation, financial problems, or environmental stimulation (Landrigan, 2011).
PSychological cauSeS According to certain theorists, people with autism spec- trum disorder have a central perceptual or cognitive disturbance that makes normal communication and interactions impossible. One influential explanation holds that those with the disorder fail to develop a theory of mind—an awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information that they have no way of knowing (Begeer et al., 2015; Kimhi et al., 2014).
By 3 to 5 years of age, most normal children can take the perspective of another person into account and use it to anticipate what the person will do. In a way, they learn to read others’ minds. Let us say, for example, that we watch Jessica place a marble in a container and then we observe Frank move the marble to a nearby room while Jessica is taking a nap. We know that later Jessica will search first in the
PsychWatch
Most people are familiar with the savant syndrome, thanks to Dustin Hoffman’s portrayal of a man with autism in the movie Rain Man. The savant skills that Hoffman portrayed—counting 246 toothpicks in the instant after they fall to the floor, memorizing the phone book through the Gs, and doing numerical cal- culations at lightning speed—were based on the astounding talents of certain real- life people who are otherwise limited by autism spectrum disorder or intellectual disability.
A savant (French for “learned” or “clever”) is a person with a major mental disorder or intellectual handicap who has some spectacular ability. Often these abilities are remarkable only in light of the handicap, but sometimes they are remarkable by any standard (Treffert, 2014; Yewchuk, 1999). A common savant skill is calendar calculating, the ability to calculate what day of the week a date will fall on, such as New Year’s Day in 2050. A common musical skill such people may possess is the ability to play a piece of
classical music flawlessly from memory after hearing it only once. Other individu- als can paint exact replicas of scenes they saw years ago.
Some theorists believe that savant skills do indeed represent special forms of cognitive functioning; others propose
that the skills are merely a positive side to certain cognitive deficits (Treffert, 2014; Howlin, 2012; Scheuffgen et al., 2000). Special memorization skills, for ex- ample, may be facilitated by the very nar- row and intense focus that people with autism often have.
A Special Kind of Talent
Special insights One of the highest-achieving autistic people in the world is Dr. Temple Grandin, a professor at Colorado State University. Applying her personal perspective and unique visualization skills, she has developed insight into the minds and sensitivities of cattle and has designed more humane animal- handling equipment and facilities. She argues that autistic savants and animals share cognitive similarities.Im
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▶▶ theory of mind An awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information that they have no way of knowing.
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container for the marble because she is not aware that Frank moved it. We know that because we take Jessica’s perspective into account. A normal child would also anticipate Jessica’s search correctly. An autistic child would not. He or she would expect Jessica to look in the nearby room because that is where the marble actually is. Jessica’s own mental processes would be unimportant to the person.
Studies show that people with autism spectrum disorder do indeed have this kind of “mind-blindness,” although they are not the only kinds of individuals with this limitation (Loukusa et al., 2014). They thus have great difficulty taking part in make-believe play, using language in ways that include the perspectives of others, developing relationships, or participating in human interactions. Why do autistic people have this and other cognitive limitations? Some theorists believe that they suffered early biological problems that prevented proper cognitive development.
Biological cauSeS For years researchers have tried to determine what biological abnormalities might cause theory-of-mind deficits and the other features of autism spectrum disorder. They have not yet developed a complete biological explanation, but they have uncovered some promising leads. First, examinations of the relatives of autistic people keep suggesting a genetic factor in this disorder (Egawa et al., 2015). The prevalence of autism among their siblings, for example, is as high as 1 per 10, a rate much higher than the general population’s (Risch et al., 2014). Moreover, the prevalence of autism among the identical twins of autistic people is 60 percent.
Some studies have also linked autism spectrum disorder to prenatal difficulties or birth complications (Reichenberg et al., 2011). For example, the chances of develop- ing the disorder are higher when the mother had rubella (German measles) dur- ing pregnancy, was exposed to toxic chemicals before or during pregnancy, or had complications during labor or delivery.
Finally, researchers have identified specific biological abnormalities that may contrib- ute to autism spectrum disorder. One line of research has pointed to the cerebellum (Mosconi et al., 2015; Pierce & Courchesne, 2002, 2001). Brain scans and autopsies show abnormal development in this brain area occurring early in the life of autistic people. Scientists have long known that the cerebellum coordinates movement in the body, but they now suspect that it also helps control a person’s ability to shift atten- tion rapidly. It may be that people whose cerebellum develops abnormally will have great difficulty adjusting their level of attention, following verbal and facial cues, and making sense of social information—all key features of autism.
In a similar vein, neuroimaging studies indicate that many autistic children have increased brain volume and white matter and structural abnormalities in the brain’s limbic system, brain stem nuclei, and amygdala (Travers et al., 2015; Bauman, 2011). Many people with autism spectrum disorder also have reduced activity in the brain’s temporal and frontal lobes when they perform language and motor tasks (Taylor et al., 2014).
Given such findings, many researchers believe that this disorder may in fact have multiple biological causes (NINDS, 2015). Perhaps each of the relevant biological factors (genetic, prenatal, birth, and postnatal) can eventually lead to a common problem in the brain—a “final common pathway,” such as neurotransmitter abnor- malities, that produces the cognitive problems and other features of the disorder.
Finally, because it has received so much attention over the past 20 years, it is worth mentioning a biological explanation for autism spectrum disorder that has not been borne out—the MMR vaccine theory. In 1998 a team of investigators published a study suggesting that a postnatal event—the vaccine for measles, mumps, and rubella (MMR vaccine)—might produce autistic symptoms in some children (Wakefield et al., 1998). The researchers suggested that for certain children, this vaccine, which is usually given to children between the ages of 12 and 15 months, produces an increase in the measles virus throughout the body which in turn causes the onset of a powerful stomach disease and, ultimately, autism spectrum disorder.
▶▶ cerebellum An area of the brain that coordinates movement in the body and perhaps helps control a person’s ability to shift attention rapidly.
B e t W e e N t h e L I N e S
DSM-5 Controversy: Loss of Services? Past editions of the DSM included a dis- order called Asperger’s disorder, a diag- nosis given to individuals who displayed the severe social deficits and unusual behaviors found in autism but other- wise had normal language, adaptive, and cognitive skills. However, DSM-5 has eliminated Asperger’s disorder as a distinct disorder. Individuals with that pattern now receive a diagnosis of ei- ther autism spectrum disorder or social communication disorder—a less severe disorder characterized by persistent problems in communication and social relationships. Many parents worry that children who receive this latter diagno- sis will no longer qualify for the special educational services previously made available for children with Asperger’s disorder.
Disorders Common Among Children and Adolescents : 487
However, virtually all research conducted since 1998 has argued against this theory (Taylor et al., 2014; Ahearn, 2010). First, epidemiological studies repeat-
edly have found that children throughout the world who receive the MMR vaccine have the same prevalence of autism as those who do not receive the vaccine. Second, accord- ing to research, children with autism do not have more measles viruses in their bodies than children without autism. Third, autistic chil- dren do not have the special stomach disease
proposed by this theory. Finally, careful reexaminations of the original study have indicated that it was methodologically flawed and perhaps manipulated and that it actually failed to demonstrate any relationship between the MMR vaccine and the development of autism spectrum disorder (Lancet, 2010). Unfortunately, despite this clear refutation, many concerned parents now choose to withhold the MMR vaccine from their young children, leaving them highly vulnerable to diseases that can be extremely dangerous.
How Do Clinicians and Educators Treat Autism Spectrum Disorder? Treatment can help people with autism spectrum disorder adapt better to their environment, although no treatment yet known totally reverses the autistic pattern. Treatments of particular help are cognitive-behavioral therapy, communication training, parent training, and community integration. In addition, psychotropic drugs and certain vitamins have sometimes helped when combined with other approaches (Sicile-Kira, 2014; Ristow et al., 2011).
cognitive-Behavioral theraPy Behavioral approaches have been used in cases of autism for more than 35 years to teach new, appro- priate behaviors, including speech, social skills, classroom skills, and self-help skills, while reducing negative, dysfunctional ones. Most often, the therapists use modeling and operant conditioning. In modeling, they demonstrate a desired behavior and guide autistic individuals to imitate it. In operant conditioning, they reinforce desired behaviors, first by shaping them—breaking them down so they can be learned step by step—and then rewarding each step clearly and consis- tently. With careful planning and execution, these procedures often produce new, more functional behaviors.
A pioneering, long-term study compared the progress of two groups of children with autism spectrum disorder (Lovaas, 2003, 1987; McEachin et al., 1993). Nine- teen received intensive behavioral treatments, and 19 served as a control group. The treatment began when the children were 3 years old and continued until they were 7. By the age of 7, the behavioral group was doing better in school and scoring higher on intelligence tests than the control group. Many were able to go to school in regular classrooms. The gains continued into the research participants’ teenage years. Given the favorable findings of this and similar studies, many clinicians now consider early behavioral programs to be the preferred treatment for autism spec- trum disorder (Boyd et al., 2014).
Therapies for people with autism spectrum disorder, particularly behavioral therapies, tend to provide the most benefit when they are started early in the chil- dren’s lives (Estes et al., 2015). Very young autistic children often begin with services at home, but ideally, by the age of 3 they attend special programs outside the home. A federal law lists autism spectrum disorder as 1 of 10 disorders for which school districts must provide a free education from birth to age 22, in the least restrictive or most appropriate setting possible. Typically, services are provided by education,
Learning to communicate Behaviorists have had success teaching many children with autism spectrum disorder to communicate. Here a speech language specialist combines behavioral techniques with the use of a com- munication board to teach a 3-year-old child how to express herself better and understand others.
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health, or social service agencies until the children reach 3 years of age; then the department of education for each state determines which services will be offered.
Given the recent increases in the prevalence of autism spectrum disorder, many school districts are now trying to provide education and training for autistic children in special classes that operate at the district’s own facilities (Iadarola et al., 2015). However, most school districts remain ill-equipped to meet the profound needs of students with autism. The most fortunate autistic students are sent by their school districts to attend special schools, where education and therapy are combined. At such schools, specially trained teachers help the children improve their skills, behav- iors, and interactions with the world. Higher-functioning autistic students may eventually spend at least part of their school day returning to standard classrooms in their own school district (Hartford & Marcus, 2011).
communication training As you read earlier, even when given intensive behavioral treatment, half of the people with autism spectrum disorder remain speechless. To help address this, they are often taught other forms of communication, including sign language and simultaneous communication, a method combining sign language and speech. They may also learn to use augmentative communication systems, such as “communication boards” or computers that use pictures, symbols, or written words to represent objects or needs (Lerna et al., 2014; Prelock et al., 2011). A child may point to a picture of a fork to give the message “I am hun- gry,” for instance, or point to a radio for “I want music.” Recall, for example, the use of a “picture book” by Jennie, the child whose case introduced this section.
Parent training Today’s treatment programs for autism spectrum disorder involve parents in a variety of ways. Behavioral programs, for example, often train parents so that they can use behavioral techniques at home (Bearss et al., 2015; Sicile-Kira, 2014). Instruc-
tion manuals for parents and home visits by teachers and other professionals are typically included in such programs. Research consistently has demonstrated that the behavioral gains produced by trained parents are often equal to or greater than those generated by teachers.
In addition to parent-training programs, individual therapy and support groups are becoming more available to help the parents of autistic children deal with their own emotions and needs (Clifford & Minnes, 2013; Hastings, 2008). A number of parent associations and lobbies also offer emotional support and practical help.
community integration Many of today’s school-based and home-based programs for autism spectrum disorder teach self-help, self-management, and living, social, and work skills as early as possible to help the individuals function better in their communities. In addition, greater numbers of carefully run group homes and sheltered workshops are now available for teenagers and young adults with autism. These and related programs help those with autism become a part of their community; they also reduce the concerns of aging parents whose children will always need supervision.
Intellectual Disability Ed Murphy, aged 26, can tell us what it’s like to be considered “mentally retarded”:
What is retardation? It’s hard to say. I guess it’s having problems thinking. Some people think that you can tell if a person is retarded by looking at them. If you think
The iPad breakthrough A child works on an iPad as his teacher looks on. A major new trend in the training and treatment of autism spectrum disorder is the use of electronic tablets. They are effective augmentative com- munication systems, and they also seem to provide enormous cognitive stimulation and pleasure for people with autism.
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Disorders Common Among Children and Adolescents : 489
that way you don’t give people the benefit of the doubt. You judge a person by how they look or how they talk or what the tests show, but you can never really tell what is inside the person.
(Bogdan & Taylor, 1976, p. 51)
For much of his life Ed was labeled mentally retarded and was educated and cared for in special institutions. During his adult years, clinicians discovered that Ed’s intel- lectual ability was in fact higher than had been assumed. In the meantime, however, he had lived the childhood and adolescence of a person labeled mentally retarded, and his statement reveals the kinds of difficulties often faced by people with this disorder.
In DSM-5, the term “mental retardation” has been replaced by intellectual dis- ability. This term is applied to a varied population, including children in institutional wards who rock back and forth, young people who work in special job programs, and men and women who raise and support their families by working at unde- manding jobs. As many as 3 of every 100 people meet the criteria for this diagnosis (NLM, 2015; APA, 2013). Around three-fifths of them are male, and the vast major- ity display a mild level of the disorder.
People receive a diagnosis of intellectual disability (ID) when they display general intellectual functioning that is well below average, in combination with poor adaptive behavior (APA, 2013). That is, in addition to having a low IQ (a score of 70 or below), a person with ID has great difficulty in areas such as communication, home living, self-direction, work, or safety. The symptoms also must appear before the age of 18 (see Table 14-7).
Assessing Intelligence Educators and clinicians administer intelligence tests to measure intellectual functioning (see Chapter 3). These tests consist of a variety of questions and tasks that rely on different aspects of intelligence, such as knowledge, reasoning, and judgment. Having difficulty in just one or two of these subtests or areas of functioning does not necessarily reflect low intelligence (see PsychWatch on page 491). It is an individual’s overall test score, or intelligence quotient (IQ), that is thought to indicate general intellectual ability.
Many theorists have questioned whether IQ tests are indeed valid. Do they actually measure what they are supposed to measure? The
correlation between IQ and school per- formance is rather high—around .50— indicating that many children with lower IQs do, as one might expect, per- form poorly in school, while many of those with higher IQs perform better
(Sternberg et al., 2001). At the same time, the correlation also suggests that the relationship is far from perfect. That is, a particular child’s school performance is often higher or lower than his or her IQ might predict. Moreover, the accuracy of IQ tests at measuring extremely low intelligence has not been evaluated adequately, so it is difficult to properly assess people with severe intellectual disability (AAIDD, 2013, 2010).
Intelligence tests also appear to be socioculturally biased, as you read in Chapter 3. Children reared in households at the middle and upper socioeconomic levels tend to have an advantage on the tests because they are regularly exposed to the kinds of language and thinking that the tests evaluate. The tests rarely measure the “street sense” needed
table: 14-7
Dx Checklist
Intellectual Disability
1. Individual displays deficient intellectual functioning in areas such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits are reflected by clinical assessment and intelligence tests.
2. Individual displays deficient adaptive functioning in at least one area of daily life, such as communication, social involvement, or personal independence, across home, school, work, or community settings. The limitations extend beyond those displayed by most other persons of his or her age and necessitate ongoing support at school, work, or independent living.
3. The deficits begin during the developmental period (before the age of 18).
(Information from: APA, 2013)
are there other kinds of
intelligence that IQ tests
might fail to assess?
▶▶ augmentative communication system A method for enhancing the communication skills of people with autism spectrum disorder, intellectual disability, or cerebral palsy by teaching them to point to pictures, symbols, let- ters, or words on a communication board or computer.
▶▶ intellectual disability (ID) A disor- der marked by intellectual functioning and adaptive behavior that are well below average. Previously called mental retardation.
▶▶ intelligence quotient (IQ) A score derived from intelligence tests that theo- retically represents a person’s overall intellectual capacity.
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for survival by people who live in poor, crime-ridden areas—a kind of know-how that certainly requires intel- lectual skills. Members of cultural minorities and people for whom English is a second language also often appear to be at a disadvantage in taking these tests.
If IQ tests do not always measure intelligence accu- rately and objectively, then the diagnosis of intellectual disability also may be biased. That is, some people may receive the diagnosis partly because of test inadequacies, cultural differences, discomfort with the testing situation, or the bias of a tester.
Assessing Adaptive Functioning Diagnosti- cians cannot rely solely on a cutoff IQ score of 70 to determine whether a person suffers from intellectual disability. Some people with a low IQ are quite capable of managing their lives and functioning independently, while others are not. The cases of Brian and Jeffrey show the range of adaptive abilities.
Brian comes from a lower-income family. He always has functioned adequately at home and in his community. He dresses and feeds himself and even takes care of himself each day until his mother returns home from work. He also plays well with his friends. At school, however, Brian refuses to participate or do his homework. He seems ineffective, at times lost, in the classroom. Referred to a school psychologist by his teacher, he received an IQ score of 60.
Jeffrey comes from an upper-middle-class home. He was always slow to develop and sat up, stood, and talked late. During his infancy and toddler years, he was put in a special stimulation program and given special help and attention at home. Still, Jeffrey has trouble dressing himself today and cannot be left alone in the backyard lest he hurt himself or wander off into the street. Schoolwork is very difficult for him. The teacher must work slowly and provide individual instruction for him. Tested at age 6, Jeffrey received an IQ score of 60.
Brian seems well adapted to his environment outside school. However, Jeffrey’s limitations are pervasive. In addition to his low IQ score, Jeffrey has difficulty meet- ing challenges at home and elsewhere. Thus a diagnosis of intellectual disability may be more appropriate for Jeffrey than for Brian.
Several scales have been developed to assess adaptive behavior. Here again, however, some people function better in their lives than the scales predict, while others fall short. Thus to properly diagnose intellectual disability, clinicians should probably observe the adaptive functioning of each individual in his or her everyday environment, taking both the person’s background and the community’s standards into account. Even then, such judgments may be subjective, as clinicians may not be familiar with the standards of a particular culture or community.
What Are the Features of Intellectual Disability? The most consis- tent feature of intellectual disability is that the person learns very slowly (Sturmey & Didden, 2014; AAIDD, 2013, 2010). Other areas of difficulty are attention, short-term memory, planning, and language. Those who are institutionalized with this disorder are particularly likely to have these limitations. It may be that the
Getting a head start Studies suggest that IQ scores and school performances of children from poor neighborhoods can be improved by enriching their daily environments at a young age. The teachers in this classroom try to stim- ulate and enrich the lives of preschool children in a Head Start program in Oregon.
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▶▶ mild ID A level of intellectual disability (IQ between 50 and 70) at which people can benefit from education and can sup- port themselves as adults.
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unstimulating environment and minimal interactions with staff in many institutions contribute to such difficulties. Traditionally, four levels of intellectual disability have been distinguished: mild (IQ 50–70), moderate (IQ 35–49), severe (IQ 20–34), and profound (IQ below 20).
mild id Some 80 to 85 percent of all people with intellectual disability fall into the category of mild ID (IQ 50–70). This is sometimes called the “educable” level because the individuals can benefit from schooling and can support themselves as adults. Mild ID is not usually recognized until children enter school and are assessed there. They demonstrate rather typical language, social, and play skills, but they need
PsychWatch
Between 15 and 20 percent of chil-dren, boys more often than girls, develop slowly and function poorly compared with their peers in a single area such as learning, communication, or motor coordination (APA, 2013; Goldstein et al., 2011). The children do not suffer from intellectual disability, and in fact they are often very bright, yet their problems may interfere with school performance, daily living, and in some cases social interac- tions. Similar difficulties may be seen in the children’s close biological relatives (APA, 2013; Watson et al., 2008). Accord- ing to DSM-5, many of these children are suffering from a specific learning disorder, communication disorder, or developmen- tal coordination disorder—each a kind of neurodevelopmental disorder (APA, 2013).
Children with a specific learning disorder have significant difficulties in acquiring reading, writing, arithmetic, or mathematical reasoning skills. Across the United States, children with such prob- lems comprise the largest subgroup of those placed in special education classes (Watson et al., 2008). Some of these chil- dren read slowly or inaccurately or have difficulty understanding the meaning of what they are reading, difficulties also known as dyslexia (Boets, 2014). Others spell or write very poorly. And still others have great trouble remembering number facts, performing calculations, or reason- ing mathematically.
The communication disorders include language disorder, speech sound disor-
der, and childhood-onset fluency disorder (stuttering) (APA, 2013). Children with language disorder have persistent difficul- ties acquiring, using, or comprehending spoken or written language. They may, for example, have trouble using language to express themselves, struggle at learning new words, confine their speech to short simple sentences, or show a general lag in language development. Children with speech sound disorder have persistent difficulties in speech production. Some, for example, cannot make correct speech sounds at an appropriate age, resulting in
speech that sounds like baby talk. People who display stuttering have a disturbance in the fluency and timing of their speech, characterized by repeating, prolonging, or interjecting sounds, pausing before finish- ing a word, or having excessive tension in the muscles they use for speech.
Finally, children with developmental coordination disorder perform coordi- nated motor activities at a level well below that of others their age (APA, 2013). Younger children with this disorder are very clumsy and slow to master skills such as tying shoelaces, buttoning shirts, and zipping pants. Older children with the disorder may have great difficulty assem- bling puzzles, building models, playing ball, and printing or writing.
Studies have linked these various disorders to genetic defects, brain ab- normalities, birth injuries, lead poisoning, inappropriate diet, sensory or perceptual dysfunction, and poor teaching (Richlan, 2014; APA, 2013; Yeates et al., 2010; Golden, 2008). Research has been lim- ited, however, and the precise causes of the disorders remain unclear.
Some of the disorders respond to special treatment approaches (McArthur et al., 2013; Feifer, 2010; Miller, 2010). Reading therapy, for example, is very helpful in mild cases of dyslexia, and speech therapy brings about complete recovery in many cases of speech sound disorder. Furthermore, the various disor- ders often disappear before adulthood, even without any treatment.
Reading and ’Riting and ’Rithmetic
A special pair of glasses One of several explanations for dyslexia is that some people with this disorder have a significant visual pro- cessing problem. Thus various kinds of special 3D glasses, modeled here by this child, have been developed to help diagnose and treat the disorder.
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assistance when under stress—a limitation that becomes increasingly apparent as academic and social demands increase. Interestingly, the intellectual performance of individuals with mild ID often seems to improve with age; some even seem to leave the label behind when they leave school, and they go on to function well in the community (Sturmey & Didden, 2014; Sturmey, 2008). Their jobs tend to be unskilled or semiskilled.
Research has linked mild ID mainly to sociocultural and psychological causes, particularly poor and unstimulating environments during a child’s early years, inad- equate parent–child interactions, and insufficient learning experiences (Sturmey & Didden, 2014; Sturmey, 2008). These relationships have been observed in studies comparing deprived and enriched environments. In fact, some community pro- grams have sent workers into the homes of young children with low IQ scores to help enrich the environment there, and their interventions have often improved the children’s functioning. When continued, programs of this kind also help improve the person’s later performance in school and adulthood (Ramey et al., 2012; Ramey & Ramey, 2007, 2004, 1992).
Although sociocultural and psychological factors seem to be the leading causes of mild ID, at least some biological factors also may be operating. Studies suggest, for example, that a mother’s moderate drinking, drug use, or malnutrition during preg- nancy may lower her child’s intellectual potential (Hart & Ksir, 2014). Malnourish- ment during a child’s early years also may hurt his or her intellectual development, although this effect can usually be reversed at least partly if a child’s diet is improved before too much time goes by.
moderate, Severe, and Profound id Approximately 10 percent of those with intellectual disability function at a level of moderate ID (IQ 35–49). They typi- cally receive their diagnosis earlier in life than do individuals with mild ID, as they demonstrate clear deficits in language development and play during their preschool years. By middle school they further show significant delays in their acquisition of reading and number skills and adaptive skills. By adulthood, however, many individuals with moderate ID manage to develop a fair degree of communication skill, learn to care for themselves, benefit from vocational training, and can work in unskilled or semiskilled jobs, usually under supervision. Most also function well in the community if they have supervision (AAIDD, 2013, 2010).
Animal connection At the National Aquar- ium in Havana, Cuba, therapists host regular sessions of stroking and touching dolphins, sea tortoises, and sea lions for children. These ses- sions have helped many children with autism spectrum disorder and others with intellectual disability to become more spontaneous, inde- pendent, and sociable. AP
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▶▶ moderate ID A level of intellectual disability (IQ between 35 and 49) at which people can learn to care for themselves and can benefit from vocational training.
▶▶ severe ID A level of intellectual dis- ability (IQ between 20 and 34) at which people require careful supervision and can learn to perform basic work in struc- tured and sheltered settings.
▶▶ profound ID A level of intellectual disability (IQ below 20) at which people need a very structured environment with close supervision.
▶▶ Down syndrome A form of intellec- tual disability caused by an abnormality in the 21st chromosome.
Disorders Common Among Children and Adolescents : 493
Approximately 3 to 4 percent of people with intellectual disability display severe ID (IQ 20–34). They typically demonstrate basic motor and communica- tion deficits during infancy. Many also show signs of neurological dysfunction and have an increased risk for brain seizure disorder. In school, they may be able to string together only two or three words when speaking. They usually require care- ful supervision, profit somewhat from vocational training, and can perform only basic work tasks in structured and sheltered settings. Their understanding of com- munication is usually better than their speech. Most are able to function well in the community if they live in group homes, in community nursing homes, or with their families (AAIDD, 2013, 2010).
Around 1 to 2 percent of all people with intellectual disability function at a level of profound ID (IQ below 20). This level is very noticeable at birth or early infancy. With training, people with profound ID may learn or improve basic skills such as walking, some talking, and feeding themselves. They need a very structured environment, with close supervision and considerable help, including a one-to-one relationship with a caregiver, in order to develop to the fullest (AAIDD, 2013, 2010).
Severe and profound levels of intellectual disability often appear as part of larger syndromes that include severe physical handicaps. The physical problems are often even more limiting than the individual’s low intellectual functioning and in some cases can be fatal.
What Are the Biological Causes of Intellectual Disability? As you read earlier, the primary causes of mild ID are environmental, although biologi- cal factors may also be operating in many cases. In contrast, the main causes of mod- erate, severe, and profound ID are biological, although people who function at these levels also are strongly affected by their family and social environment (Sturmey & Didden, 2014; Fletcher, 2011). The leading biological causes of intellectual disability are chromosomal abnormalities, metabolic disorders, prenatal problems, birth com- plications, and childhood diseases and injuries.
chromoSomal cauSeS The most common of the chromosomal disorders that lead to intellectual disability is Down syndrome, named after Langdon Down, the British physician who first identified it. Down syndrome occurs in around 1 of every 1,000 live births, but the rate increases significantly when the mother’s age is
Reaching higher Today people with Down syndrome are viewed as individuals who can learn and accomplish many things in their lives. Eddie Gordon, a teenager with Down syn- drome, is lifted into the air in celebration by his Timberline High School baseball teammates. He has just rounded the bases during his turn as an honorary lead-off batter.AP
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In Their Words “The IQ test was invented to predict academic performance, nothing else. If we wanted something that would predict life success, we’d have to invent another test completely.”
robert Zajonc, psychologist, 1984
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over 35. Many older expectant mothers are now encouraged to undergo prenatal testing during the early months of pregnancy to identify Down syndrome and other chromosomal abnormalities.
People with Down syndrome may have a small head, flat face, slanted eyes, high cheekbones, and, in some cases, protruding tongue. The latter may affect their ability to pronounce words clearly. They are often very affectionate with family members but in general display the same range of personality characteristics as people in the general population.
Several types of chromosomal abnormalities may cause Down syndrome (NICHD, 2015). The most common type (94 percent of cases) is trisomy 21, in which the person has three free-floating 21st chromosomes instead of two. Most people with Down syndrome range in IQ from 35 to 55. The individuals appear to age early, and many even show signs of neurocognitive decline as they approach 40 (Powell et al., 2014; Lawlor et al., 2001). It may be that Down syndrome and early neurocognitive decline often occur together because the genes that produce them are located close to each other on chromosome 21 (Rohn et al., 2014; Lamar et al., 2011).
Fragile X syndrome is the second most common chromosomal cause of intellec- tual disability. Children born with a fragile X chromosome (that is, an X chromo- some with a genetic abnormality that leaves it prone to breakage and loss) generally display mild to moderate degrees of intellectual dysfunctioning, language impair- ments, and, in some cases, behavioral problems (Hahn et al., 2015; Hagerman, 2011). Typically, they are shy and anxious.
metaBolic cauSeS In metabolic disorders, the body’s breakdown or production of chemicals is disturbed. The metabolic disorders that affect intelligence and develop- ment are typically caused by the pairing of two defective recessive genes, one from each parent. Although one such gene would have no influence if it were paired with a normal gene, its pairing with another defective gene leads to major problems for the child.
The most common metabolic disorder to cause intellectual disability is phenyl- ketonuria (PKU ), which strikes 1 of every 14,000 children. Babies with PKU appear normal at birth but cannot break down the amino acid phenylalanine. The chemical builds up and is converted into substances that poison the system, causing severe intellectual dysfunction and several other symptoms (NICHD, 2015; Waisbren, 2011). Today infants can be screened for PKU, and if started on a special diet before 3 months of age, they may develop normal intelligence.
Children with Tay-Sachs disease, another metabolic disorder resulting from a pairing of recessive genes, progressively lose their mental functioning, vision, and motor ability over the course of two to four years, and eventually die. One of every 30 persons of Eastern European Jewish ancestry carries the recessive gene respon- sible for this disorder, so that 1 of every 900 Jewish couples is at risk for having a child with Tay-Sachs disease.
Prenatal and Birth-related cauSeS As a fetus develops, major physical problems in the pregnant mother can threaten the child’s prospects for a normal life (AAIDD, 2013, 2010; Bebko & Weiss, 2006). When a pregnant woman has too little iodine in her diet, for example, her child may be born with cretinism, also called severe congenital hypothyroidism, marked by an abnormal thyroid gland, slow development, intellectual disability, and a dwarflike appearance. This condition is rare today because the salt in most diets now contains extra iodine. Also, any infant born with this problem may quickly be given thyroid extract to bring about normal development.
Other prenatal problems may also cause intellectual disability. As you saw in Chapter 10, children whose mothers drink too much alcohol during pregnancy may be born with fetal alcohol syndrome, a group of very serious problems
B e t W e e N t h e L I N e S
About the Sex Chromosome • The 23rd chromosome, whose abnor-
mality causes Fragile X syndrome, is the smallest human chromosome.
• The 23rd chromosome determines a person’s sex and thus is also referred to as the sex chromosome.
• In males, the 23rd chromosome pair consists of an X chromosome and a Y chromosome.
• In females, the 23rd chromosome pair consists of two X chromosomes.
Disorders Common Among Children and Adolescents : 495
that includes mild to severe ID (Bakoyiannis et al., 2014; Hart & Ksir, 2014). In fact, a generally safe level of alcohol consumption during pregnancy has not been established by research. In addition, certain maternal infections during pregnancy— rubella (German measles) and syphilis, for example—may cause childhood problems that include intellectual disability.
Birth complications also can lead to problems in intellectual functioning. A prolonged period without oxygen (anoxia) during or after delivery can cause brain damage and intellectual disability in a baby. In addition, although premature birth does not necessarily lead to long-term problems for children, researchers have found that some babies with a premature birth weight of less than 3.5 pounds display low intelligence (AAIDD, 2013, 2010; Taylor, 2010).
childhood ProBlemS After birth, particularly up to age 6, certain injuries and accidents can affect intellectual functioning and in some cases lead to intellectual disability. Poisonings, serious head injuries caused by accident or abuse, excessive exposure to X rays, and excessive use of certain drugs pose special dangers (AAIDD, 2013, 2010; Evans, 2006). For example, a serious case of lead poisoning from eat- ing lead-based paints or inhaling high levels of automobile fumes can cause ID in children. Mercury, radiation, nitrite, and pesticide poisoning may do the same. In addition, certain infections, such as meningitis and encephalitis, can lead to intellectual disability if they are not diagnosed and treated in time (AAIDD, 2013, 2010; Durkin et al., 2000).
Interventions for People with Intellectual Disability The quality of life attained by people with intellectual disability depends largely on sociocultural factors: where they live and with whom, how they are educated, and the growth opportunities available at home and in the community. Thus intervention programs for these individuals try to provide comfortable and stimulating residences, a proper education, and social and economic opportunities. At the same time, the programs seek to improve the self-image and self-esteem of those with intellectual disability. Once these needs are met, formal psychological or biological treatments are also of help in some cases.
What iS the ProPer reSidence? Until recent decades, parents of children with intel- lectual disability would send them to live in public institutions—state schools—as early as possible (Harris, 2010). These overcrowded institutions provided basic care, but residents were neglected, often abused, and isolated from society.
During the 1960s and 1970s, the public became more aware of these sorry conditions and, as part of the broader deinstitutionalization movement (see Chapter 12), demanded that many people with intellectual disability be released from the state schools (Harris, 2010). In many cases, the releases were done with- out adequate preparation or supervision. Like people with schizophrenia who were suddenly deinstitutionalized, those with intellectual disability were virtually dumped into the community. Often they failed to adjust and had to be insti- tutionalized once again.
Since that time, reforms have led to the creation of small institutions and other community residences (group homes, halfway houses, local branches of larger institutions, and independent residences) that teach self-sufficiency, devote more staff time to patient care, and offer educational and medical services. Many of these settings follow the prin- ciples of normalization first started in Denmark and Sweden—they attempt to provide living conditions similar
▶▶ fetal alcohol syndrome A group of problems in a child, including lower intel- lectual functioning, low birth weight, and irregularities in the hands and face, that result from excessive alcohol intake by the mother during pregnancy.
▶▶ state school A state-supported institution for people with intellectual disability.
▶▶ normalization The principle that insti- tutions and community residences should provide people with intellectual disability types of living conditions and opportuni- ties that are similar to those enjoyed by the rest of society.
Life lessons The normalization movement calls for people with intellectual disability to be taught whatever skills are needed for normal and independent living. Here a psychologist (left) gives cooking lessons to young adults with ID as part of a national program called You and I. The program also provides lessons in dating, self-esteem, social skills, and sex education.
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to those enjoyed by the rest of society; flexible routines; and normal developmental experiences, including opportunities for self-determination, sexual fulfillment, and economic freedom (Merrick et al., 2014; Hemmings, 2010).
Today the vast majority of children with intellectual disability live at home rather than in an institution. During adulthood and as their parents age, however, some people with intellectual disability require levels of assistance and opportunities that their families are unable to provide. A community residence becomes an appropriate alternative for them. Most people with intellectual disability, including almost all with mild ID, now spend their adult lives either in the family home or in a com- munity residence (Sturmey & Didden, 2014; Sturmey, 2008).
Which educational ProgramS Work BeSt? Because early intervention seems to offer such great promise, educational programs for people with intellectual dis- ability may begin during the earliest years. The appropriate education depends on the person’s level of functioning. Educators hotly debate whether special classes or mainstreaming is most effective once the children enter school (McKenzie et al., 2013; Hardman et al., 2002). In special education, children with intellectual disability are grouped together in a separate, specially designed educational program. In contrast, in mainstreaming, or inclusion, they are placed in regular classes with students from the general school population. Neither approach seems consistently superior. It may well be that mainstreaming is better for some areas of learning and for some children and that special classes are better for others.
Teacher preparedness is another factor that may play into decisions about main- streaming and special education classes. Many teachers report feeling inadequately prepared to provide training and support for children with intellectual disability, especially children who have additional problems. Brief training courses for teach- ers appear to address such concerns (Hallahan et al., 2014; Campbell et al., 2003).
Teachers who work with students with intellectual disability often use operant conditioning principles to improve their students’ self-help, communication, social, and academic skills (Sturmey & Didden, 2014; Sturmey, 2008; Ardoin et al., 2004). They break learning tasks down into small steps, giving positive reinforcement for each increment of progress. Additionally, many institutions, schools, and private homes have set up token economy programs—the operant conditioning programs that have also been used to treat institutionalized patients who have schizophrenia.
When iS theraPy needed? Like anyone else, people with intellectual disability sometimes have emotional and behav- ioral problems. Around 30 percent or more have a psycho- logical disorder other than intellectual disability (Sturmey & Didden, 2014; Bouras & Holt, 2010). Furthermore, some suffer from low self-esteem, interpersonal problems, and difficulties adjusting to community life. These problems are helped to some degree by either individual or group therapy. Large numbers of people with intellectual disabil- ity also take psychotropic medications (Sturmey & Didden, 2014). Many clinicians argue, however, that too often the medications are used simply for the purpose of making the individuals easier to manage.
hoW can oPPortunitieS for PerSonal, Social, and occuPational groWth Be increaSed? People need to feel effective and competent in order to move forward in life. Those with intellectual disability are most likely to feel
What might be the benefits of
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▶▶ special education An approach to educating children with intellectual disability in which they are grouped together and given a separate, specially designed education.
▶▶ mainstreaming The placement of children with intellectual disability in regular school classes. Also known as inclusion.
▶▶ sheltered workshop A protected and supervised workplace that offers job opportunities and training at a pace and level tailored to people with various psy- chological disabilities.
Working for money, independence, and self-respect This 28-year-old waiter serves beverages in a café in Slovakia. He is one of five waiters with intellectual disability who work at the café.
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effective and competent if their communities allow them to grow and to make many of their own choices. Denmark and Sweden, where the normalization movement began, have again been leaders in this area, developing youth clubs that encourage those with intellectual disability to take risks and function independently. The Special Olym- pics program has also encouraged those with intellectual disability to be active in setting goals, to participate in their environment, and to interact socially with others (Crawford et al., 2015; Marks et al., 2010).
Socializing, sex, and marriage are difficult issues for people with intellectual disability and their families, but with proper training and practice, they usually can learn to use contraceptives and carry out responsible family planning. National advocacy organizations and a number of clinicians currently offer guidance in these matters, and some have developed dating skills programs (AAIDD, 2013, 2010, 2008; Segal, 2008).
Some states restrict marriage for people with intellectual disability. These laws are rarely enforced, though, and in fact many people with mild ID marry. Contrary to popular myths, the marriages can be very successful. And although some may be incapable of raising children, many are quite able to do so, either on their own or with special help and community services (Sturmey & Didden, 2014; AAIDD, 2013, 2010; Sturmey, 2008).
Finally, adults with intellectual disability—whatever the severity—need the personal and financial rewards that come with holding a job (AAIDD, 2013, 2010; Kiernan, 2000). Many work in sheltered workshops, protected and supervised workplaces that train them at a pace and level tailored to their abilities. After training in the workshops, many with mild or moderate ID move on to hold regular jobs.
Although training programs for people with intellectual disability have improved greatly in quality over the past 35 years, there are too few of them. Consequently, most participants do not receive a complete range of educational and occupational training services. Additional programs are required so that more people with intel- lectual disability may achieve their full potential, as workers and as human beings.
➤ Summing Up NEURODEVELOPMENTAL DISORDERS Neurodevelopmental disorders are a group of disabilities in the functioning of the brain that emerge at birth or dur- ing very early childhood and affect the person’s behavior, memory, concentra- tion, and/or ability to learn.
Children with attention-deficit/hyperactivity disorder (ADHD) attend poorly to tasks, behave overactively and impulsively, or both. Ritalin and other stimu- lant drugs and behavioral programs are often effective treatments. The disorder extends into adulthood for many individuals.
People with autism spectrum disorder are extremely unresponsive to others, have severe communication deficits, and display very rigid and repetitive behav- iors, interests, and activities. The leading explanations of this disorder point to cognitive deficits such as failure to develop a theory of mind and biological abnormalities such as abnormal development of the cerebellum. Although no treatment totally reverses the autistic pattern, significant help is available in the form of cognitive-behavioral treatments, communication training, training and treatment for parents, and community integration.
People with intellectual disability are significantly below average in intel- ligence and adaptive ability. Mild ID, by far the most common level of intel- lectual disability, has been linked primarily to environmental factors such as
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Normal needs People with intellectual dis- ability have normal interpersonal and sexual needs, and many, such as this engaged couple, demonstrate considerable ability to express intimacy.
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In Their Words “The boy will come to nothing.”
Jakob Freud, 1864 (referring to his 8-year-old son Sigmund, after he had
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unstimulating environments during a child’s early years, inadequate parent– child interactions, and insufficient learning experiences. Moderate, severe, and profound ID are caused primarily by biological factors, although people who function at these levels also are affected enormously by their family and social environment. The leading biological causes of intellectual disability are chromo- somal abnormalities, metabolic disorders, prenatal problems, birth complica- tions, and childhood diseases and injuries.
Today intervention programs for people with intellectual disability emphasize the importance of a comfortable and stimulating residence, either the family home or a small institution or group home that follows the principles of normal- ization. Other important interventions include proper education, therapy for psychological problems, and programs offering training in socializing, sex, mar- riage, parenting, and occupational skills.
PUTTING IT...together Clinicians Discover Childhood and Adolescence Early in the twentieth century, mental health professionals virtually ignored chil- dren. At best, they viewed them as small adults and treated their psychological disor- ders as they would adult problems (Peterson & Roberts, 1991). Today the problems and needs of young people have caught the attention of researchers and clinicians. Although all of the leading models have been used to help explain and treat these problems, the sociocultural perspective—especially the family perspective—is con- sidered to play a special role.
Because children and adolescents have limited control over their lives, they are particularly affected by the attitudes and reactions of family members. Clinicians must therefore deal with those attitudes and reactions as they try to address the problems of the young. Treatments for conduct disorder, ADHD, intellectual dis- ability, and other problems common among children and adolescents typically fall short unless clinicians educate and work with the family as well.
At the same time, clinicians who work with children and adolescents have learned that a narrow focus on any one model can lead to prob- lems. For years, autism spectrum disorder was explained exclusively by family factors, misleading theorists and therapists alike and adding to the pain of parents already devastated by their child’s disorder. In addition, in the past, the sociocultural model often led professionals wrongly to accept anxiety among young children and depression among teenagers as inevitable, given the many new experiences confronted by the former and the latter group’s preoccupation with peer approval.
The increased clinical focus on the young has also been accompanied by more attention to young people’s human and legal rights. Clinicians and educators have called on government agencies to protect the rights
and safety of this often powerless group. In doing so, they hope to fuel the fights for better educational resources and against child abuse and neglect, sexual abuse, malnourishment, and fetal alcohol syndrome.
As the problems and, at times, mistreatment of young people receive more attention, the special needs of these individuals are becoming more visible. Thus the study and treatment of psychological disorders common among children and adolescents are likely to continue at a rapid pace. Now that clinicians and public officials have “discovered” this population, they are not likely to underestimate their needs and importance again.
C li n i C al C h o i C e s Now that you’ve read about disorders common among children and adolescents, try the interactive case study for this chapter. See if you are able to identify Gabriel’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for Gabriel? Go to LaunchPad to access Clinical Choices.
Disorders Common Among Children and Adolescents : 499
KEY TERMS separation anxiety disorder, p. 467
play therapy, p. 468
disruptive mood dysregulation disorder, p. 472
oppositional defiant disorder, p. 473
conduct disorder, p. 473
enuresis, p. 476
encopresis, p. 476
neurodevelopmental disorders, p. 479
attention-deficit/hyperactivity disorder (ADHD), p. 479
methylphenidate (Ritalin), p. 481
autism spectrum disorder, p. 483
echolalia, p. 484
theory of mind, p. 485
cerebellum, p. 486
augmentative communication system, p. 488
intellectual disability (ID), p. 489
intelligence quotient (IQ), p. 489
mild ID, p. 491
moderate ID, p. 492
severe ID, p. 493
profound ID, p. 493
Down syndrome, p. 493
fragile X syndrome, p. 494
recessive genes, p. 494
phenylketonuria (PKU), p. 494
fetal alcohol syndrome, p. 494
rubella, p. 495
syphilis, p. 495
state school, p. 495
normalization, p. 495
special education, p. 496
mainstreaming, p. 496
sheltered workshop, p. 497
QuickQuiz
1. What are the prevalence rates and gender ratios for the various disorders common among children and adoles- cents? pp. 464–495
2. What are the different kinds of child- hood anxiety and mood-related disorders? What are today’s leading explanations and treatments for these disorders? pp. 465–472
3. What is disruptive mood dysregulation disorder, and why might DSM-5’s addi- tion of this new category affect future diagnoses of childhood bipolar disor- der? p. 472
4. Describe oppositional defiant disorder and conduct disorder. What factors help cause conduct disorder, and how is this disorder treated? pp. 473–476
5. What are enuresis and encopresis? How are these disorders treated? pp. 476–477
6. What are the symptoms of attention- deficit/hyperactivity disorder? What are today’s leading explanations for it? What are the current treatments for ADHD, and how effective are they? pp. 479–482
7. What is autism spectrum disorder, and what are its possible causes? What are
the overall goals of treatment for this disorder, and which interventions have been most helpful? pp. 483–488
8. Describe the different levels of intellec- tual disability. pp. 490–493
9. What are the leading environmental and biological causes of intellectual dis- ability? pp. 491–495
10. What kinds of residences, educational programs, treatments, and community programs are helpful to persons with intellectual disability? pp. 495–497
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T O P I C O V E R V I E W
Old Age and Stress
Depression in Later Life
Anxiety Disorders in Later Life
Substance Misuse in Later Life
Psychotic Disorders in Later Life
Disorders of Cognition Delirium Alzheimer’s Disease and Other Neurocognitive Disorders
Issues Affecting the Mental Health of the Elderly
Putting It Together: Clinicians Discover the Elderly
Disorders of Aging and Cognition
H arry appeared to be in perfect health at age 58. . . . He worked in the municipal water treatment plant of a small city, and it was at work that the first overt signs of Harry’s mental illness appeared. While responding to a minor emergency, he became confused about the correct order in which to pull the levers that
controlled the flow of fluids. As a result, several thousand gallons of raw sewage were discharged into a river. Harry had been an efficient and diligent worker, so after puzzled questioning, his error was attributed to the flu and overlooked.
Several weeks later, Harry came home with a baking dish his wife had asked him to buy, having forgotten that he had brought home the identical dish two nights before. Later that week, on two successive nights, he went to pick up his daughter at her job in a restaurant, apparently forgetting that she had changed shifts and was now work- ing days. A month after that, he quite uncharacteristically argued with . . . the phone company; he was trying to pay a bill that he had already paid three days before. . . .
Months passed and Harry’s wife was beside herself. She could see that his prob- lem was worsening. Not only had she been unable to get effective help, but Harry himself was becoming resentful and sometimes suspicious of her attempts. He now insisted there was nothing wrong with him, and she would catch him narrowly watch- ing her every movement. . . . Sometimes he became angry—sudden little storms without apparent cause. . . . More difficult for his wife was Harry’s repetitiveness in conversation: He often repeated stories from the past and sometimes repeated isolated phrases and sentences from more recent exchanges. There was no context and little continuity to his choice of subjects. . . .
Two years after Harry had first allowed the sewage to escape, he was clearly a changed man. Most of the time he seemed preoccupied; he usually had a vacant smile on his face, and what little he said was so vague that it lacked meaning. . . . Gradually his wife took over getting him up, toileted, and dressed each morning. . . .
Harry’s condition continued to worsen slowly. When his wife’s school was in session, his daughter would stay with him some days, and neighbors were able to offer some help. But occasionally he would still manage to wander away. On those occasions he greeted everyone he met—old friends and strangers alike—with “Hi, it’s so nice.” That was the extent of his conversation, although he might repeat “nice, nice, nice” over and over again. . . . When Harry left a coffee pot on a unit of the electric stove until it melted, his wife, desperate for help, took him to see another doctor. Again Harry was found to be in good health. [However] the doctor ordered a [brain scan and eventually concluded] that Harry had “Pick-Alzheimer disease.” . . . Because Harry was a veteran . . . [he qualified for] hospitalization in a . . . veterans’ hospital about 400 miles away from his home. . . .
At the hospital the nursing staff sat Harry up in a chair each day and, aided by volun- teers, made sure he ate enough. Still, he lost weight and became weaker. He would weep when his wife came to see him, but he did not talk, and he gave no other sign that he recognized her. After a year, even the weeping stopped. Harry’s wife could no longer bear to visit. Harry lived on until just after his sixty-fifth birthday, when he choked on a piece of bread, developed pneumonia as a consequence, and soon died.
(Heston, 1992, pp. 87–90)
Harry suffered from a form of Alzheimer’s disease. This term is familiar to almost everyone in our society. It seems as if each decade is marked by a disease that everyone dreads—a diagnosis no one wants to hear because it feels like a death sentence. Cancer used to be such a diagnosis, then AIDS. But medical
: chapter 15502
science has made remarkable strides with those diseases, and patients who now develop them have reason for great hope. Alzheimer’s disease, on the other hand, remains incurable and almost untreatable, although, as you will see later, researchers are currently making enormous progress toward understanding it and reversing, or at least slowing, its march.
What makes Alzheimer’s disease particularly frightening is that it means not only eventual physical death but also, as in Harry’s case, a slow psychological death—a progressive deterioration of one’s memory and related cognitive faculties. Significant cognitive deterioration, previously called dementia, is now categorized as neurocog- nitive disorder. There are many types of neurocognitive disorders listed in DSM-5 (APA, 2013). Alzheimer’s disease is the most common one.
Although neurocognitive disorders are currently the most publicized and feared psychological problems among the elderly, they are hardly the only ones. A variety of psychological disorders are tied closely to later life. As with childhood disorders, some of the disorders of old age are caused primarily by pressures that are particularly likely to appear at that time of life, others by unique traumatic experiences, and still others—like neurocognitive disorders—by biological abnormalities.
Old Age and Stress Old age is usually defined in our society as the years past age 65. By this account, around 43 million people in the United States are “old,” representing 13.6 percent of the total population; this is a 14-fold increase since 1900 (CDC, 2014; NCHS, 2014) (see Figure 15-1). It has also been estimated that there will be 70 million elderly people in the United States by the year 2030—more than 20 percent of the popula- tion. Not only is the overall population of the elderly on the rise, but also the number of people over 85 will double in the next 10 years. Indeed, people over 85 represent the fastest-growing segment of the population in the United States and in most countries around the world. Older women outnumber older men by almost 3 to 2 (NCHS, 2014).
Like childhood, old age brings special pressures, unique upsets, and major biological changes (Gerst-Emerson et al., 2014). People become more prone to illness and injury as they age (Nunes et al., 2014). About half of adults over 65 have two or three chronic illnesses, and 15 percent have four or more (NCHS, 2014). In addition, elderly people are likely to be contending with the stress of loss—the loss of spouses, friends, and adult children; of former activities and roles; of hearing and vision (Heine & Browning, 2014). Many lose their sense of purpose after they retire (Murayama et al., 2014). Some also have to adjust to the loss of favored pets and possessions.
The stresses of aging need not necessarily cause psychological problems (see PsychWatch on the next page). In fact, some older people, particularly those who seek social contacts and those who maintain a sense of control over their lives, use the changes that come with aging as opportunities for learning and growth (Murayama et al., 2014). For example, the number of elderly—often physically limited—people who use the Internet to connect with people of similar ages and interests doubled between 2000 and 2004, doubled again between 2004 and 2007, and doubled yet again by 2010 (Oinas-Kukkonen & Mantila, 2010). For other elderly people, however, the stresses of old age do lead to psychological difficulties. Studies indicate that more than 20 percent of elderly people meet the criteria for a mental disorder and as many as half of all elderly people would benefit from some degree of mental health services, yet fewer than 20 percent actually receive them (APA, 2014). Geropsychology, the field of psychology dedicated to the mental health of elderly people, has developed
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figure 15-1 On the rise The population of people age 65 and older in the United States has increased 14-fold since the beginning of the twentieth century. The percentage of elderly people in the population increased from 4 percent in 1900 to 13 percent in 2010. It is currently 13.6 percent and is expected to be more than 20 percent in 2030. (Information from: CDC, 2014; NCHS, 2014; U.S. Census Bureau, 2012; Cummings & Coffey, 2011; Edelstein et al., 2008.)
▶▶ geropsychology The field of psychol- ogy concerned with the mental health of elderly people.
Disorders of Aging and Cognition : 503
almost entirely within the last four decades, and at present only 4 percent of clinicians work primarily with elderly persons (APA, 2014; Fiske et al., 2011).
The psychological problems of elderly people may be divided into two groups. One group consists of disorders that may be common among people in all age groups but are often connected to the process of aging when they occur in an elderly person. These include depres- sive, anxiety, and substance use disorders. The other group consists of disorders of cognition, such as delirium, mild neurocognitive disorders, and major neurocognitive disorders that result from brain abnormali- ties. As in Harry’s case, these brain abnormalities are most often tied to aging, but they also can sometimes occur when people are younger. Elderly people with one of these psychological problems often display other such problems. For example, many who suffer from neurocognitive disorders also deal with depres- sion and anxiety (Lebedeva et al., 2014).
Depression in Later Life Depression is one of the most common mental health problems of older adults. The features of depression are the same for elderly people as for younger people, includ- ing feelings of profound sadness and emptiness; low self-esteem, guilt, and pessimism; and loss of appetite and sleep disturbances. Depression is particularly common
PsychWatch
Clinicians suggest that aging need not inevitably lead to psychological prob-lems. Nor apparently does it always lead to physical problems.
There are currently 65,000 centenar- ians in the United States—people who are 100 years old or older. When research- ers have studied these people—often called the “oldest old”—they have been surprised to learn that centenarians are on average more healthy, positive, clear- headed, and agile than those in their 80s and early 90s (da Rosa et al., 2014; Zhou et al., 2011). Although some certainly ex- perience cognitive decline, more than half remain perfectly alert. Many of the oldest old are, in fact, still employed, sexually active, and able to enjoy the outdoors and the arts. What is their greatest fear? The fear of significant cognitive decline. According to one study, many people in their 90s and older fear the prospect of mental deterioration more than they fear death (Boeve et al., 2003).
Some scientists believe that people who live this long carry “longevity” genes that make them resistant to disabling or
terminal infections (Garatachea et al., 2014; He et al., 2014). Indeed, centenar- ians are 20 times more likely than other elderly people to have had a relative who also lived to a very old age (D.I., 2014). Other researchers point to engaged lifestyles and “robust” personalities that help the oldest old meet life’s challenges with optimism and a sense of challenge (da Rosa et al., 2014; Martin et al., 2010,
2009). The centenarians themselves often credit a good frame of mind or regular behaviors that they have maintained for many years—for example, eating health- ful food, getting regular exercise, and not smoking (D.I., 2014). Said one 96-year-old retired math and science teacher, “You can’t sit. . . . You have to keep moving” (Duenwald, 2003).
The Oldest Old
Welcome to the club A 100-year-old woman and a 99-year- old man chat during a party for centenar- ians in Woodbridge, Connecticut.
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among those who have recently undergone a trauma, such as the loss of a spouse or close friend or the development of a serious physical illness (Draper, 2014).
[Oscar] was an 83-year-old married man with an episode of major depressive disor- der. . . . He said that about one and one-half years prior to beginning treatment, his brother had died. In the following months, two friends whom he had known since childhood died. Following these losses, he became increasingly anxious [and] grew more and more pessimistic. Reluctantly, he acknowledged, “I even thought about ending my life.”. . .
During . . . treatment, [Oscar] discussed his relationship with his brother. He discussed how distraught he was to watch his brother’s physical deterioration from an extended illness. He described the scene at his brother’s deathbed and the moment “when he took his final breath.” He experienced guilt over the failure to carry out his brother’s funeral services in a manner he felt his brother would have wanted. While initially characterizing his relationship with his brother as loving and amiable, he later acknowledged that he disapproved of many ways in which his brother acted. Later in therapy, he also reviewed different facets of his past relation- ships with his two deceased friends. He expressed sadness that the long years had ended. . . . [Oscar’s] life had been organized around visits to his brother’s home and outings with his friends. . . . [While] his wife had encouraged him to visit with other friends and family, it became harder and harder to do so as he became more depressed.
(Hinrichsen, 1999, p. 433)
Overall, as many as 20 percent of people become depressed at some point during old age (APA, 2014; Mathys & Belgeri, 2010). The rate is highest in older women. This rate among the elderly is about the same as that among younger adults—even lower, according to some studies (Dubovsky & Dubovsky, 2011). However, it climbs much higher (as high as 32 percent) among aged people who live in nursing homes, as opposed to those in the community (CDC, 2014; Mathys & Belgeri, 2010).
Several studies suggest that depression raises an elderly person’s chances of developing significant medical problems (Taylor, 2014; Coffey & Coffey, 2011).
Making a difference To help prevent feel- ings of unimportance and low self-esteem, some older people now offer their expertise to young people who are trying to master new skills, undertake business projects, and the like (Murayama et al., 2014). This elderly man, who volunteers regularly at an elementary school, is teaching math to a first-grader. ©
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Bereavement and Gender 11.4 million Number of widows in the
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(U.S. census Bureau, 2010, 2005; etaugh, 2008)
Disorders of Aging and Cognition : 505
For example, older depressed people with high blood pressure are almost three times as likely to suffer a stroke as older nondepressed people with the same condi-
tion. Similarly, elderly people who are depressed recover more slowly and less completely from heart attacks, hip fractures, pneumonia, and other infections and illnesses. Small wonder that among the elderly, increases in clinical depres- sion are tied to increases in the death rate (Aziz & Steffens, 2013).
As you read in Chapter 7, elderly people are also more likely to commit suicide than young people, and often their suicides are related to depression (Draper, 2014). The overall rate of suicide in the United States is 12.1 per 100,000 people; among the elderly it is more than 16 per 100,000.
Like younger adults, older people who are depressed may be helped by cognitive-behavioral therapy, interpersonal therapy, antidepressant medica- tions, or a combination of these approaches (Cleare et al., 2015; Dines et al., 2014). Both individual and group therapy formats have been used. More than half of elderly patients with depression improve with these various treatments. It is, however, sometimes difficult for older people to use anti- depressant drugs effectively and safely because the body breaks the drugs down differently in later life (Dubovsky & Dubovsky, 2011). Moreover, among elderly people, antidepressant drugs have a higher risk of causing some cognitive impairment. Electroconvulsive therapy, applied with certain modifications, has been used for elderly people who are severely depressed and unhelped by other approaches (Coffey & Kellner, 2011).
Anxiety Disorders in Later Life Anxiety is also common among elderly people (APA, 2014). At any given time, as many as 11 percent of elderly individuals in the United States experience at least one of the anxiety disorders. Surveys indicate that generalized anxiety disorder is particularly common, affecting up to 7 percent of all elderly people (ADAA, 2014). The rate of anxiety also increases throughout old age. For example, people over 85 years of age report higher rates of anxiety than those between 65 and 84 years. In fact, all of these numbers may be low, as anxiety in the elderly often goes unrecog- nized by healthcare professionals (APA, 2014; Jeste et al., 2005).
There are many things about aging that may heighten the anxiety levels of cer- tain people (Bower et al., 2015; Lenze et al., 2011). Declining health, for example, has often been pointed to, and in fact, older persons who have significant medical illnesses or injuries report more anxiety than those who are healthy or injury-free. Researchers have not, however, been able to determine why some people who face such problems in old age become anxious while others in similar circumstances remain relatively calm (see InfoCentral on the next page).
Older adults with anxiety disorders have been treated with psychotherapy of various kinds, particularly cognitive-behavioral therapy (Bower et al., 2015; McKenzie & Teri, 2011). Many also receive antianxiety medications or certain anti- depressant drugs, just as younger sufferers do. Again, however, all such drugs must be used cautiously with older people (Dubovsky & Dubovsky, 2011).
Substance Misuse in Later Life Although alcohol use disorder and other substance use disorders are significant problems for many older persons, the prevalence of such patterns actually appears to decline after age 65, perhaps because of declining health or reduced income
Is it more likely that positive
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The power of music The look on the face of this nursing home resident as she listens to music on her iPod underscores the repeated research finding that music helps improve the physical and emotional functioning of many elderly people.
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Losing a Spouse Widowed men suffer more depression, other psychological disorders, and physical illnesses than widowed women (Etaugh, 2008; Fields, 2004; Wortman et al., 2004; Canetto, 2003).
InfoCentral
THE AGING POPULATION The number and proportion of elderly people in the United States and around the world are ever-growing. This acceleration has important consequences, requiring each society to pay particu- lar attention to aging-related issues in healthcare, housing, the
economy, and other such realms. In particular, as the number and proportion of elderly people increase, so too do the number and proportion of the population who experience aging-related psy- chological difficulties.
(NAELA, 2014; United Nations, 2013)
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Aging and Marriage
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PSYCHOLOGICAL DISORDERS AMONG THE ELDERLY
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(MarketWatch, 2014; United Nations, 2013; WHO, 2012)
THE ELDERLY POPULATION IS ITSELF AGING
(MarketWatch, 2014; United Nations, 2013; WHO, 2012)
2013
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(MarketWatch, 2014; United Nations, 2013; WHO, 2012)
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100:85 100:62Aging and Gender The world elderly population is predominantly female.
(NAELA, 2014; United Nations, 2013)
(NAELA, 2014; United Nations, 2013)
Disorders of Aging and Cognition : 507
(Thompson, 2015). The majority of older adults do not misuse alcohol or other substances, despite the fact that aging can sometimes be a time of considerable stress and in our society people often turn to alcohol and drugs during times of stress. Accurate data about the rate of substance abuse among older adults are difficult to gather because many elderly people do not suspect or admit that they have such a problem.
Surveys find that 3 to 7 percent of older people, particularly men, have alcohol use disorder in a given year (Trevisan, 2014). Men under 30 are four times as likely as men over 60 to display a behavioral problem associated with excessive alcohol use, such as repeated falling, spells of dizziness or blacking out, secretive drinking, or social withdrawal. Older patients who are institutionalized, however, do display high rates of problem drinking. For example, alcohol problems among older people admitted to general and mental hospitals range from 15 percent to 49 percent, and estimates of alcohol-related problems among patients in nursing homes range from 10 percent to 20 percent (McConnaughey, 2014; Klein & Jess, 2002).
Researchers often distinguish between older problem drinkers who have had alcohol use disorder for many years, perhaps since their 20s, and those who do not start abusing alcohol until their 50s or 60s (in what is sometimes called “late-onset alcoholism”) (Thompson, 2015; Volfson & Oslin, 2011). The latter group typically begins abusive drinking as a reaction to the negative events and pressures of grow- ing older, such as the death of a spouse, living alone, or unwanted retirement. Alcohol use disorder in elderly people is treated much as it is in younger adults (see Chapter 10): through such interventions as detoxification, Antabuse, Alcoholics Anonymous (AA), and cognitive-behavioral therapy (APA, 2014).
A leading substance problem in the elderly is the misuse of prescription drugs (NIH, 2014). Most often the misuse is unintentional. In the United States, people over the age of 50 buy 77 percent of all prescription drugs and 61 percent of all over-the-counter drugs (NCHS, 2014; Statistic Brain, 2014). Elderly people—those who are over 65 years of age—receive twice as many prescriptions as younger persons (Dubovsky & Dubovsky, 2011). Around half take at least five prescription drugs and two over-the-counter drugs (NCHS, 2014). Thus their risk of confus- ing medications or skipping doses is high. To help address this problem, physicians and pharmacists often try to simplify medications, educate older patients about
Racing to mental health Gerontologists propose that elderly people need to pursue pleasurable and personally meaningful activi- ties. The elderly women on the left compete in a race at the 2013 National Senior Games in Ohio. In contrast, the elderly gentleman on the right, also interested in racing, watches a com- petition at the Saratoga Springs horse racing track with the daily racing form on his head. Which of these two activities might be more likely to contribute to successful psychological functioning during old age?
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their prescriptions, clarify directions, and teach them to watch for undesired effects. However, physicians themselves are sometimes to blame in cases of prescription drug misuse, perhaps overprescribing medications for elderly patients or unwisely mixing certain medicines (Metsälä & Vaherkoski, 2014).
Yet another drug-related problem, apparently on the increase, is the misuse of powerful medi- cations at nursing homes. Research suggests that antipsychotic drugs are currently being given to almost 30 percent of the total nursing home population in the United States, despite the fact that many of the residents do not display psychotic functioning (Mort et al., 2014; Lagnado, 2007). Apparently, these powerful and (for some elderly patients) dangerous drugs are often given to sedate and manage the patients.
Psychotic Disorders in Later Life Elderly people have a higher rate of psychotic symptoms than younger people (Colijn et al., 2015; Devanand, 2011). Among aged people, these symptoms are usu- ally caused by underlying medical conditions such as neurocognitive disorders, the disorders of cognition that you will read about in the next section. Some elderly people, though, suffer from schizophrenia or delusional disorder.
Actually, schizophrenia is less common in older people than in younger ones. In fact, many people with schizophrenia find that their symptoms lessen in later life (Dickerson et al., 2014). Improvement can occur in people who have had schizo- phrenia for 30 or more years, particularly in such areas as social skills and work capacity, as we are reminded by the remarkable late-life improvement of the Nobel Prize recipient John Nash, the subject of the book and movie A Beautiful Mind. Among those whose schizophrenia does emerge for the first time during old age, women outnumber men by at least 2 to 1 (Ames et al., 2010).
Another kind of psychotic disorder found among the elderly is delusional disorder, in which people develop beliefs that are false but not bizarre (Colijn et al., 2015). This disorder is rare in most age groups—around 2 of every 1,000
“All of a sudden, everyone seems younger than I am.”
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Medications for the Elderly 70% Percentage of elderly persons
who take cardiovascular drugs
47% Percentage of elderly persons who take cholesterol-lowering drugs
18% Percentage of elderly persons who take diabetes drugs
14% Percentage of elderly persons who take antidepressant drugs
(Information from: NchS, 2014)
Disorders of Aging and Cognition : 509
persons—but its prevalence appears to increase in the elderly population (APA, 2013). Older people with a delusional disorder may develop deeply held suspicions of persecution; they believe that other people—often family members, doctors, or friends—are conspiring against, cheating, spying on, or maligning them. They may become irritable, angry, or depressed or pursue legal action because of such ideas. It is not clear why this disorder increases among elderly people, but some clinicians suggest that the rise is related to the deficiencies in hearing, social isolation, greater stress, or heightened poverty with which many elderly persons contend.
➤ Summing Up DisOrDers Of Later Life The problems of elderly people are often linked to the losses and other stresses and changes that accompany advancing age. As many as 50 percent of the elderly would benefit from mental health ser- vices, yet fewer than 20 percent receive them. Depression is a common mental health problem among those in this age group. Older people may also suffer from anxiety disorders. Between 4 and 6 percent exhibit alcohol use disorder in any given year, and many others misuse prescription drugs. In addition, some elderly people display psychotic disorders such as schizophrenia or delusional disorder.
Disorders of Cognition Most of us worry from time to time that we are losing our memory and other mental abilities (Glauberman, 2014). You rush out the door without your keys, you meet a familiar person and cannot remember her name, or you forget that you have seen a particular film. Actually such mishaps are a common and quite normal feature of stress or of aging. As people move through middle age, these memory difficulties and lapses of attention increase, and they may occur regularly by the age of 60 or 70 (see MindTech on the next page). Sometimes, however, people have memory and other cognitive changes that are far more extensive and problematic.
In Chapter 5 you saw that problems in memory and related cognitive processes can occur without biological causes, in the form of dissociative disorders. More often, though, significant cognitive problems do involve biological factors, particularly when they appear late in life. The leading such disorders among the elderly are delirium, major neurocognitive disorder, and mild neurocognitive disorder.
Delirium Delirium is a major disturbance in attention and orientation to the environment (see Table 15-1). As the person’s focus becomes less clear, he or she has great diffi- culty concentrating and thinking in an organized way, leading to misinterpretations, illusions, and, on occasion, hallucinations (Lin et al., 2015). Sufferers may believe that it is morning in the middle of the night or that they are home when actually they are in a hospital room.
This state of massive confusion typically develops over a short period of time, usually hours or days (APA, 2013). Delirium may occur in any age group, includ- ing children, but is most common in elderly people. Fewer than 0.5 percent of the nonelderly population experience delirium, compared with 1 percent of people over 55 years of age and 14 percent of those over 85 years of age (Tune & DeWitt, 2011). When elderly people enter a hospital to be treated for a general medical condition, 1 in 10 of them shows the symptoms of delirium. At least another 10 percent develop delirium during their stay in the hospital (Bagnall & Faiz, 2014;
table: 15-1
Dx Checklist
Delirium
1. Over the course of hours or a few days, individual experiences fast-moving and fluctuating disturbances in attention and orientation to the environment.
2. Individual also displays a significant cognitive disturbance.
(Information from: APA, 2013)
▶▶ delirium A rapidly developing, acute disturbance in attention and orientation that makes it very difficult to concen- trate and think in a clear and organized manner.
: chapter 15510
Inouye, 2006; Inouye et al., 2003). Around 17 percent of patients admitted for surgery develop delirium (de Castro et al., 2014). Sixty percent of nursing home residents older than 75 years of age have some delirium, compared with 35 percent of similar people living independently with the assistance of home health services (Tune & DeWitt, 2011).
Fever, certain diseases and infections, poor nutrition, head injuries, strokes, and stress (including the trauma of surgery) may all cause delirium (Lawlor & Bush, 2014; Eeles & Bhat, 2010). So may intoxication by certain substances, such as pre- scription drugs. Partly because older people face so many of these problems, they are more likely than younger ones to experience delirium. If a clinician accurately
MindTech
Remember to Tweet; Tweet to Remember Social media sites such as Facebook and Twitter, and the Internet in general, are often thought of as the province of the young. However, elderly people are going online and joining social networking sites at increasing rates (Pew
Internet, 2014). Some 45 percent of all elderly people online now use Facebook; 9 percent use Pinterest; 5 percent tweet, and 1 percent use Instagram—all sizable increases from previous years.
Social networking among the elderly is much more than just an interesting statistic; it may be downright therapeutic. Several studies have found that online activity actually helps elderly people maintain and possibly improve their cognitive skills, coping skills, social pleasures, and emotions (Piatt, 2013; Szalavitz, 2013). Clinical theorists have offered several possible explanations for this phenomenon. It may be, for example, that the cognitive stimulation derived from Internet activity activates memory and other cognitive faculties or that the engagement with the world and family provided by the Internet through social networking directly satisfies social and emotional needs. Whatever the reason, more and more studies indicate that elderly people who are wired often function and feel better than those who do not pursue online activities.
One study in Italy, for example, focused on residents from two elder-care homes in the towns of Cremona and Brescia (Manuel-Logan, 2011). Some of the elderly residents were pro- vided with laptops, given online tutorials, and set up with accounts on Facebook, Twitter, and other social networking sites. It turned out that, compared with other elderly residents
at the facilities, those who used social networking displayed better memory and attention span and were generally “sharper” and more alert.
In another study, researchers at the University of Arizona recruited 42 adults, ages 68 to 91, and trained 14 of them on Facebook (Piatt, 2013; Wohltmann, 2013). The study found a 25 percent improvement in the cognitive performances of the 14 participants, including improvements in their mental “updating” skills—the ability to quickly add or delete material from their working memory.
Many elderly people resist the Internet and social networking, saying things like “It’s not for me” or “You can’t teach an old dog new tricks.” However, this growing body of research suggests that they may want to embrace social networking and the Internet for better functioning and for better mental health.
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identifies delirium, it can often be easy to correct—by treating the underlying infection, for example, or changing the patient’s drug prescription. However, the syndrome typically fails to be recognized for what it is (Traynor et al., 2015). One pioneering study on a medical ward, for example, found that admission doctors detected only 1 of 15 consecutive cases of delirium (Cameron et al., 1987). Incorrect diagnoses of this kind may contribute to a high death rate for older people with delirium (Dasgupta & Brymer, 2014).
Alzheimer’s Disease and Other Neurocognitive Disorders People with a neurocognitive disorder experience a significant decline in at least one (often more than one) area of cognitive functioning, such as memory and learning, attention, visual perception, planning and decision making, language ability, or social awareness (APA, 2013). Those who have certain types of neurocognitive disorders may also undergo personality changes—they may behave inappropriately, for example—and their symptoms may worsen steadily.
If the person’s cognitive decline is substantial and interferes significantly with his or her ability to be independent, a diagnosis of major neurocognitive disorder is in order. If the decline is modest and does not interfere with independent function- ing, the appropriate diagnosis is mild neurocognitive disorder (see Table 15-2).
There are currently 44 million people with neurocognitive disorders around the world, with 4.6 million new cases emerging each year (Hollingworth et al., 2011). The number of cases is expected to reach 135 million by 2050 unless a cure is found (Sifferlin, 2013). The occurrence of neurocognitive disorders is closely related to age (see Figure 15-2 on the next page). Among people 65 years of age, the prevalence is around 1 to 2 percent, increasing to as much as 50 percent among those over the age of 85 (ASHA, 2015; Apostolova & Cummings, 2008).
As you read earlier, Alzheimer’s disease is the most common type of neu- rocognitive disorder, accounting for around two-thirds of all cases (Burke, 2011). Alzheimer’s disease sometimes appears in middle age (early onset), but in the vast majority of cases it occurs after the age of 65 (late onset), and its prevalence increases markedly among people in their late 70s and early 80s (Zhao et al., 2014). At least 17 percent of those with Alzheimer’s also experience major depressive disorder (Chi et al., 2014).
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Dx Checklist
Major Neurocognitive Disorder
1. Individual displays substantial decline in at least one of the following areas of cognitive function: • Memory and learning • Attention • Perceptual-motor skills • Planning and decision-making • Language ability • Social awareness.
2. Cognitive deficits interfere with the individual’s everyday independence.
Mild Neurocognitive Disorder
1. Individual displays modest decline in at least one of the following areas of cognitive function: • Memory and learning • Attention • Perceptual-motor skills • Planning and decision-making • Language ability • Social awareness.
2. Cognitive deficits do not interfere with the individual’s everyday independence.
(Information from: APA, 2013)
▶▶ neurocognitive disorder A disorder marked by a significant decline in at least one area of cognitive functioning.
▶▶ major neurocognitive disorder A neurocognitive disorder in which the decline in cognitive functioning is sub- stantial and interferes with a person’s ability to be independent.
▶▶ mild neurocognitive disorder A neurocognitive disorder in which the decline in cognitive functioning is mod- est and does not interfere with a person’s ability to be independent.
▶▶ alzheimer’s disease The most com- mon type of neurocognitive disorder, marked most prominently by memory impairment.
B e t W e e N t h e L I N e S
Universal Concern In a survey of more than 3,000 adults across the United States, 84 percent of the respondents expressed concern that they or a family member would be affected by Alzheimer’s disease (Shriver, 2014, 2011).
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Alzheimer’s disease is a gradually progressive disease in which memory impair- ment is the most prominent cognitive dysfunction (APA, 2013). Technically, suffer- ers receive a DSM-5 diagnosis of mild neurocognitive disorder due to Alzheimer’s disease during the early and mild stages of the syndrome and major neurocognitive disorder due to Alzheimer’s disease during the later, more severe stages (see Table 15-3).
Alzheimer’s disease is named after Alois Alzheimer, the German physician who formally identified it in 1907. Alzheimer first became aware of the syndrome in 1901 when a new patient, Auguste D., was placed under his care:
On November 25, 1901, a . . . woman with no personal or family history of mental illness was admitted to a psychiatric hospital in Frankfurt, Germany, by her husband, who could no longer ignore or hide quirks and lapses that had overtaken her in recent months. First, there were unexplainable bursts of anger, and then a strange series of memory problems. She became increasingly unable to locate things in her own home and began to make surprising mistakes in the kitchen. By the time she arrived at Städtische Irrenanstalt, the Frankfurt Hospital for the Mentally Ill and Epi- leptics, her condition was as severe as it was curious. The attending doctor, senior physician Alois Alzheimer, began the new file with these notes. . . .
She sits on the bed with a helpless expression. “What is your name?” Auguste. “Last name?” Auguste. “What is your husband’s name?” Auguste, I think. “How long have you been here?” (She seems to be trying to remember.) Three weeks. It was her second day in the hospital. Dr. Alzheimer, a thirty-seven-year-old neu-
ropathologist and clinician, . . . observed in his new patient a remarkable cluster of symptoms: severe disorientation, reduced comprehension, aphasia (language im- pairment), paranoia, hallucinations, and a short-term memory so incapacitated that when he spoke her full-name, Frau Auguste D____, and asked her to write it down, the patient got only as far as “Frau” before needing the doctor to repeat the rest.
He spoke her name again. She wrote “Augu” and again stopped. When Alzheimer prompted her a third time, she was able to write her entire first
name and the initial “D” before finally giving up, telling the doctor, “I have lost myself.”
Her condition did not improve. It became apparent that there was nothing that anyone at this or any other hospital could do for Frau D. except to insure her safety and try to keep her as clean and comfortable as possible for the rest of her days. Over the next four and a half years, she became increasingly disoriented, delusional, and incoherent. She was often hostile.
“Her gestures showed a complete helplessness,” Alzheimer later noted in a published report. “She was disoriented as to time and place. From time to time she would state that she did not understand anything, that she felt confused and totally lost. . . . Often she would scream for hours and hours in a horrible voice.”
By November 1904, three and a half years into her illness, Auguste D. was bed- ridden, incontinent, and largely immobile. . . . Notes from October 1905 indicate that she had become permanently curled up in a fetal position with her knees drawn up to her chest, muttering but unable to speak, and requiring assistance to be fed.
(Shenk, 2001, pp. 12–14)
▶▶ senile plaques Sphere-shaped deposits of beta-amyloid protein that form in the spaces between certain brain cells and in certain blood vessels as people age. People with Alzheimer’s dis- ease have an excessive number of such plaques.
▶▶ neurofibrillary tangles Twisted pro- tein fibers that form within certain brain cells as people age. People with Alzheim- er’s disease have an excessive number of such tangles.
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figure 15-2 substantial cognitive decline and age The occurrence of substantial cognitive decline is closely related to age. Fewer than 1 percent of all 60-year-olds have major neu- rocognitive disorders, compared with as many as 50 percent of those who are 85. (Informa- tion from: ASHA, 2015; Advokat et al., 2014; Ames et al., 2010; Nussbaum & Ellis, 2003.)
Disorders of Aging and Cognition : 513
Although some people with Alzheimer’s disease may survive for as many as 20 years, the time between onset and death is typically 8 to 10 years (Advokat et al., 2014; Soukup, 2006). It usually begins with mild memory problems, lapses of attention, and difficulties in language and communication. As symptoms worsen, the person has trouble completing complicated tasks or remembering important appointments. Eventually sufferers also have difficulty with simple tasks, forget distant memories, and have changes in personality that often become very noticeable. For example, a gentle man may become uncharacteristically aggressive.
People with Alzheimer’s disease may at first deny that they have a problem, but they soon become anxious or depressed about their state of mind; many also become agitated. A woman from Virginia describes her memory loss as the disease progresses:
Very often I wander around looking for something which I know is very pertinent, but then after a while I forget about what it is I was looking for. . . . Once the idea is lost, everything is lost and I have nothing to do but wander around trying to figure out what it was that was so important earlier.
(Shenk, 2001, p. 43)
As the neurocognitive symptoms intensify, people with Alzheimer’s disease show less and less awareness of their limitations. They may withdraw from others during the late stages of the disorder, become more confused about time and place, wander, and show very poor judgment. Eventually they become fully dependent on other people. They may lose almost all knowledge of the past and fail to recognize the faces of even close relatives. They also become increasingly uncomfortable at night and take frequent naps during the day (Ferman et al., 2015). During the late phases of the disorder, they require constant care.
People with Alzheimer’s usually remain in fairly good health until the later stages of the disease. As their mental functioning declines, however, they become less active and spend much of their time just sitting or lying in bed. This makes them prone to develop illnesses such as pneumonia, which can result in death (Park et al., 2014). Alzheimer’s disease is currently responsible for close to 84,000 deaths each year in the United States (NCHS, 2014), which makes it the sixth leading cause of death in the country, the third leading cause among the elderly (CDC, 2015).
In most cases, Alzheimer’s disease can be diagnosed with certainty only after death, when structural changes in the person’s brain, such as excessive senile plaques and neuro- fibrillary tangles, can be fully examined. Senile plaques are sphere-shaped deposits of a small molecule known as the beta-amyloid protein that form in the spaces between cells in the hippo- campus, cerebral cortex, and certain other brain regions, as well as in some nearby blood vessels. The formation of plaques is a normal part of aging, but it is exceptionally high in people with Alzheimer’s disease (Zhao et al., 2014; Selkoe, 2011, 2000, 1992). Neurofibrillary tangles, twisted protein fibers found within the cells of the hippocampus and certain other brain areas, also occur in all people as they age, but again people with Alzheimer’s disease form an extraordinary number of them.
Biological culprits Tissue from the brain of a person with Alzheimer’s disease shows excessive amounts of plaque (large yellow-black sphere at lower right of photo) and neurofibrillary tangles (several smaller yellow blobs throughout photo).
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Dx Checklist
Neurocognitive Disorder Due to alzheimer’s Disease
1. Individual displays the features of major or mild neurocognitive disorder.
2. Memory impairment is a promi- nent feature.
3. Genetic indications or family history of Alzheimer’s disease under score diagnosis, but are not essential to diagnosis.
4. Symptoms are not due to other types of disorders or medical problems.
(Information from: APA, 2013)
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Scientists do not fully understand what role excessive num- bers of plaques and tangles play in Alzheimer’s disease, but they suspect they are very important. Today’s leading explanations for this disease center on these plaques and tangles and on the various factors that may contribute to their formation.
What Are the Genetic Causes of Alzheimer’s Disease? To understand the genetic theories of Alzheimer’s disease, we must first appreciate the nature and role of proteins. Proteins are fundamental components of all living cells, includ- ing, of course, brain cells. They are large molecules made up of chains of carbon, hydrogen, oxygen, nitrogen, and sulfur. There are many different kinds of proteins, each with a different func- tion. Collectively, they are essential for the proper functioning of an organism.
The plaques and tangles that are so plentiful in the brains of Alzheimer’s patients seem to occur when two important
proteins start acting in a frenzied manner. Abnormal activity by the beta-amyloid protein is, as we noted above, key to the repeated formation of plaques. Abnormal activity by another protein, tau, is key to the excessive formation of tangles. One of the leading theories holds that the many plaques formed by beta-amyloid proteins cause tau proteins in the brain to start breaking down, resulting in tangles and the death of many neurons (Khan, 2015; Hughes, 2011).
What causes this chain of events? Genetic factors are a major culprit. However, the genetic factors that are responsible differ for the early-onset and late-onset types of Alzheimer’s disease.
Early-OnsEt alzhEimEr’s DisEasE As we noted earlier, Alzheimer’s disease occurs before the age of 65 in relatively few cases. Such cases typically run in families. Researchers have learned that this form of Alzheimer’s disease can be caused by abnormalities in the genes responsible for the production of two proteins—the beta-amyloid precursor protein (beta-APP) and the presenilin protein. Apparently, some families transmit mutations, or abnormal forms, of one or both of these genes— mutations that lead ultimately to abnormal beta-amyloid protein buildups and, in turn, to plaque formations (Zhao et al., 2014).
latE-OnsEt alzhEimEr’s DisEasE The vast majority of Alzheimer cases develop after the age of 65 and do not run in families. This late-onset form of the disease appears to result from a combination of genetic, environmental, and lifestyle factors. However, the genetic factor at play in late-onset Alzheimer’s disease is different from those involved in early-onset Alzheimer’s disease.
A gene called the apolipoprotein E (ApoE) gene is normally responsible for the production of a protein that helps carry various fats into the bloodstream. This gene comes in various forms. About 30 percent of the population inherit the form called ApoE-4, and those people may be particularly vulnerable to the development of Alzheimer’s disease (Shu et al., 2014; Hollingworth et al., 2011). Apparently, the ApoE-4 gene form promotes the excessive formation of beta-amyloid proteins, helping to spur the formation of plaques and, in turn, the breakdown of the tau protein, the formation of numerous tangles, the death of many neurons, and, ulti- mately, the onset of Alzheimer’s disease.
Although the ApoE-4 gene form appears to be a major contributor to the devel- opment of Alzheimer’s disease, it is important to recognize that not everyone with this form of the gene develops the disease. Other factors—perhaps environmental, lifestyle, or stress-related—may also have a significant impact in the development of late-onset Alzheimer’s disease (Chin-Chan et al., 2015; Nation et al., 2011).
Screening for Alzheimer’s disease A neuropsychologist guides a patient through a psychomotor test—the gesture imitation test— to help screen for neurocognitive disorders such as Alzheimer’s disease.
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Leading Causes of Death Among the Elderly #1 Heart disease
#2 Cancer
#3 Chronic low respiratory disease
#4 Cerebrovascular disease
#5 Alzheimer’s disease
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an altErnativE GEnEtic thEOry Of alzhEimEr’s DisEasE As you have just read, the leading genetic theories of Alzheimer’s disease point to gene forms, such as ApoE-4, that produce abnormal beta-amyloid protein buildups and plaque forma- tions, which, in turn, lead to abnormal activity of tau proteins and the formation of numerous tangles. In recent years, however, some researchers have come to believe that abnormal tau protein activity is not always the result of these abnormal beta- amyloid protein buildups (Peterson et al., 2014; Karch, Jeng, & Goate, 2013). These researchers have identified other gene forms in Alzheimer’s patients that seem to be directly associated with tau protein abnormalities and tangle formations. Thus it may be that there are multiple genetic causes for the formation of numerous tangles and the onset of Alzheimer’s disease: (1) gene forms that start the ball rolling by first promoting beta-amyloid protein formations and plaques and (2) gene forms that more directly promote tau protein abnormalities and tangle formations.
How Do Brain Structure and Biochemical Activity Relate to Alzheimer’s Disease? We know that genetic factors may predispose people to Alzheimer’s disease, but we still need to know what abnormalities in brain structure and/or biochemical activity result from such factors and help promote Alzheimer’s disease. Researchers have identified a number of possibilities.
Certain brain structures seem to be especially important in memory. Among the most important structures in short-term memory is the prefrontal cortex, located just behind the forehead; the temporal lobes (which include the hippocampus and amygdala); and the diencephalon (which includes the mammillary bodies, thalamus, and hypothalamus). Research indicates that Alzheimer’s disease involves damage to or improper functioning of one or more of these brain structures (Hsu et al., 2015; Ishii & Iadecola, 2015) (see Figure 15-3).
Cerebral cortex Large neurons shrink. Amyloid deposits develop in spaces between cells.
Basal forebrain Acetylcholine-secreting neurons shrink or die.
Locus ceruleus Neurons die.
Hippocampus Large neurons shrink or die. Amyloid deposits develop in spaces between cells. Neurofibrillary tangles develop within neurons.
Hypothalamus Selected neurons die.
Thalamus Selected neurons shrink or die.
Amygdala Amyloid deposits develop in spaces between cells. Neurofibrillary tangles develop within neurons.
figure 15-3 the aging brain In old age, the brain undergoes changes that affect cognitive functions such as memory, learning, and rea- soning to some degree. The same changes occur to an excessive degree in people with Alzheimer’s disease. (Information from: Selkoe, 2011, 1992.)
B e t W e e N t h e L I N e S
DSM-5 Controversy: Normal Decline? DSM-5 has added the category mild neurocognitive disorder, characterized by modest declines in memory or other cognitive functions, in order to help clinicians detect individuals in the early stages of major neurocognitive disor- der (e.g., Alzheimer’s disease). Critics worry, however, that many people who display normal forgetfulness and other common features of growing older will incorrectly receive a diagnosis of mild neurocognitive disorder.
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Similarly, certain biochemical activities seem to be especially important in memory. In order for new information to be acquired and stored, certain proteins must be produced in key brain cells. Several chemicals—for example, acetylcholine, glutamate, RNA (ribonucleic acid), and calcium—are responsible for the production of the memory-linked proteins. Researchers have found that if the activity of any of these chemicals is disturbed, the proper production of proteins may be prevented and the formation of memories interrupted (Canas et al., 2014; Berridge, 2011). Correspondingly, they have found that abnormal activity by these chemicals may contribute to the symptoms of Alzheimer’s disease.
Other Explanations of Alzheimer’s Disease Several lines of research suggest that certain substances found in nature may act as toxins, damage the brain, and contribute to the development of Alzheimer’s disease. For example, researchers have detected high levels of zinc in the brains of some Alzheimer’s patients (Xu et al., 2014; Schrag et al., 2011). This finding has gained particular attention because in some animal studies zinc has been observed to trigger a clumping of the beta-amyloid protein, similar to the plaques found in the brains of Alzheimer’s patients.
Another line of research suggests that the environmental toxin lead may contribute to the development of Alzheimer’s disease (Lee & Freeman, 2014; Ritter, 2008). Lead was phased out of gasoline products between 1976 and 1991, leading to an 80 percent drop of lead levels in people’s blood. How- ever, many of today’s elderly were exposed to high levels of lead in the 1960s and 1970s, regularly inhaling air pollution from vehicle exhausts—an expo- sure that might have damaged or destroyed many of their neurons. Several studies suggest that this earlier absorption of lead and other pollutants may be having a negative effect on the current cognitive functioning of these individuals (Richardson et al., 2014).
Two other explanations for Alzheimer’s disease have also been offered. One is the autoimmune theory. On the basis of certain irregularities found in the immune systems of people with Alzheimer’s disease, several researchers have speculated that changes in aging brain cells may trigger an autoimmune response (that is, a mistaken attack by the immune system against itself ) that helps lead to the disease (Marchese et al., 2014). The other explanation is a
viral theory. Because Alzheimer’s disease resembles Creutzfeldt-Jakob disease, another type of neurocognitive disorder that is known to be caused by a slow-acting virus, some researchers propose that a similar virus may cause Alzheimer’s disease (Head, 2013; Prusiner, 1991). To date, however, no such virus has been detected in the brains of Alzheimer’s victims.
Assessing and Predicting Alzheimer’s Disease As you read earlier, most cases of Alzheimer’s disease can be diagnosed with absolute certainty only after death, when an autopsy is performed. However, brain scans, which reveal abnormalities in the liv- ing brain, now are used commonly as assessment tools and often provide clinicians with consider- able confidence in their diagnoses of Alzheimer’s disease (Haris et al., 2015). In addition, several research teams currently are trying to develop tools that can identify those people who are likely to develop Alzheimer’s disease and other types of neurocognitive disorders.
One promising line of work, for example, comes from the laboratory of neuro scientist Lisa Mosconi and her colleagues (Mosconi et al., 2014, 2010, 2008; Mosconi, 2013). Using a special kind of PET scan, this research team examined
Would people be better off
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Slipping away Because of their short-term memory problems, people with advanced cases of Alzheimer’s disease, one form of neu- rocognitive disorder, are often unable to draw or paint or do other simple tasks. In addition, their long-term memory deficits may prevent them from recognizing even close relatives or friends.
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activity in certain parts of the hippocampus in dozens of elderly research partici- pants and then conducted follow-up studies of them for up to 24 years. (Recall that the hippocampus plays a major role in memory.) Eventually, 43 percent of the study’s participants developed either a mild or major neurocognitive disorder due to Alzheimer’s disease. The researchers found that those who developed such cognitive impairments had displayed lower hippocampus activity on their initial PET scans than the participants who remained healthy. Overall, the PET scans, administered years before the onset of symptoms, predicted mild neurocognitive impairment with an accuracy rate of 71 percent and major neurocognitive impair- ment with an accuracy rate of 83 percent.
As you will see shortly, the most effective interventions for Alzheimer’s disease and other types of neurocognitive disorders are those that help prevent these prob- lems, or at least ones that are applied early. Clearly, then, it is essential to have tools that identify the disorders as early as possible, preferably years before the onset of symptoms (Rabin, 2013). That is what makes the research advances in assessment and diagnosis so exciting.
Other Types of Neurocognitive Disorders There are a number of neurocognitive disorders in addition to Alzheimer’s disease (APA, 2013). Vascular neurocognitive disorder, for example, follows a cerebrovascular accident, or stroke, dur- ing which blood flow to specific areas of the brain was cut off, thus damaging the areas ( Jia et al., 2014). In many cases, the patient may not even be aware of the stroke (Moorhouse & Rockwood, 2010). Like Alzheimer’s disease, this disorder is progressive, but its symptoms begin suddenly rather than gradually. Moreover, the person’s cognitive functioning may continue to be normal in areas of the brain that have not been affected by the stroke, in contrast to the broad cognitive deficiencies usually displayed by Alzheimer’s patients. Some people have both Alzheimer’s disease and vascular neurocognitive disorder.
Frontotemporal neurocognitive disorder, also known as Pick’s disease, is a rare disor- der that affects the frontal and temporal lobes. It has a clinical picture similar to Alzheimer’s disease, but the two diseases can be distinguished at autopsy.
Neurocognitive disorder due to prion disease, also called Creutzfeldt-Jakob disease, has symptoms that include spasms of the body. As we observed earlier, this disorder is
Part of the game? National Football League great John Mackey shows off his Super Bowl V and Hall of Fame rings. Mackey died at age 69 in 2011 of frontotemporal neurocognitive disor- der, a condition marked by extreme confusion and the need for full-time assistance. Many cases of neurocognitive disorder, like Mackey’s, are apparently the result of repeated sports injuries to the head.AP
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Would You Want to Know? 78% Percentage of U.S. adults who
would want to have a test done to diagnose a disease even if there were no treatment or cure available
22% Percentage of U.S. adults who would not want to know
(Information from: Siemens healthcare, 2013)
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caused by a slow-acting virus that may live in the body for years before the disease develops. Once launched, however, the disease has a rapid course.
Neurocognitive disorder due to Huntington’s disease is an inherited progressive disease in which memory prob- lems, along with personality changes and mood difficul- ties, worsen over time. People with Huntington’s have movement problems, too, such as severe twitching and spasms. Children of people with Huntington’s disease have a 50 percent chance of developing it.
Parkinson’s disease, the slowly progressive neurologi- cal disorder marked by tremors, rigidity, and unsteadi- ness, can result in neurocognitive disorder due to Parkinson’s disease, particularly in older people or those whose cases are advanced.
Yet other neurocognitive disorders may be caused by HIV infections, traumatic brain injury, substance abuse, or
various medical conditions such as meningitis or advanced syphilis.
What Treatments Are Currently Available for Alzheimer’s Disease and Other Neurocognitive Disorders? Treatments for the cognitive features of Alzheimer’s disease and most other types of neurocognitive disorders have been at best modestly helpful. A number of approaches have been applied, including drug therapy, cognitive techniques, behavioral interventions, sup- port for caregivers, and sociocultural approaches.
DruG trEatmEnt The drugs currently prescribed for Alzheimer’s patients are designed to affect acetylcholine and glutamate, the neurotransmitters that play important roles in memory. Such drugs include donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda). The short-term mem- ory and reasoning ability of some Alzheimer’s patients who take these drugs improve slightly, as do their use of language and their ability to cope under pressure ( Jessen, 2014). Although the benefits of the drugs are limited and their side effects can be problematic, these drugs have been approved by the FDA. Clinicians believe that they may be of greatest use to people in the earlier, milder stages of Alzheimer’s disease. Another approach, taking vitamin E, either alone or in combination with one of these drugs, also seems to help slow down cognitive decline among people in the milder stages of Alzheimer’s disease (Dysken et al., 2014, 2009). Other possible drug treatments are being investigated currently (Medina & Avila, 2014).
The drugs just discussed are each prescribed after a person has developed Alzheimer’s disease. In contrast, studies suggest that certain substances now avail- able on the marketplace for other kinds of problems may help prevent or delay the onset of Alzheimer’s disease. For example, some studies have found that women who took estrogen, the female sex hormone, for years after menopause cut their risk of developing Alzheimer’s disease in half (Li et al., 2014; Kawas et al., 1997). Other studies have suggested that the long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen and naprosyn (drugs found in Advil, Motrin, Nuprin, and other pain relievers) may help reduce the risk of Alzheimer’s disease, although recent findings on this possibility have been mixed (Advokat et al., 2014).
cOGnitivE tEchniquEs Cognitive treatments have been used in cases of Alzheim- er’s disease, with some temporary success (Nelson & Tabet, 2015). In Japan, for example, a number of people with the disease meet regularly in classes, performing simple calculations and reading essays and novels aloud. Proponents of this approach claim that it serves as a mental exercise that helps rehabilitate those parts of the
Victims of Parkinson’s disease Two of today’s most famous victims of Parkinson’s disease, boxing legend Muhammad Ali (left) and actor Michael J. Fox (right), chat playfully prior to testifying before a Senate funding subcommittee about the devastating effects the disease has had on their lives and those of other people.
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Busy Mind, Healthier Brain Researchers have found fewer plaques and tangles in the brains of lab mice that live in intellectually and physically stimulating environments—with chew toys, running wheels, and tunnels—than in those of mice that live in less stimu- lating settings (Lazarov et al., 2005).
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brain linked to memory, reasoning, and judgment. Similarly, some research suggests that cognitive activities, including computer-based cognitive stimulation programs, may help prevent or delay the onset of Alzheimer’s disease (Szalavitz, 2013). One study of 700 people in their 80s found that those research participants who had pursued cognitive activities over a five-year period (for example, writing letters, following the news, reading books, or attending concerts or plays) were less likely to develop Alzheimer’s disease than were mentally inactive participants (Wilson et al., 2012, 2007).
BEhaviOral intErvEntiOns Behavioral interventions have also been somewhat successful in helping Alzheimer’s patients. It has become increasingly clear across many studies that physical exercise helps improve cognitive functioning—for people of all ages and states of health. There is evidence that regular physical exercise may also help reduce the risk of developing Alzheimer’s disease and other types of neurocognitive disorders (Paillard et al., 2015; Nation et al., 2011). Correspondingly, physical exercise is often a part of treatment programs for people with the disorders.
Behavioral interventions of a different kind have been used to help improve specific symptoms displayed by Alzheimer’s patients. The approaches typically focus on changing everyday patient behaviors that are stressful for the family, such as wandering at night, loss of bladder control, demands for attention, and inadequate personal care (Lancioni et al., 2011; Lindsey, 2011). The behavioral therapists use a combination of role-playing exercises, modeling, and practice to teach family members how and when to use reinforcement in order to shape more positive behaviors.
suppOrt fOr carEGivErs Caregiving can take a heavy toll on the close relatives of people with Alzheimer’s disease and other types of neurocognitive disorders (Kang et al., 2014). Almost 90 percent of all people with Alzheimer’s disease are cared for by their relatives (Alzheimer’s Association, 2014, 2007). It is hard to take care of someone who is becoming increasingly lost, helpless, and medically ill. And it is very painful to witness mental and physical decline in someone you love.
Cognitive fitness center A number of senior-living community programs now include cognitive fitness centers where elderly people sit at computers and work on memory and cog- nition software programs. Clinicians hope that “cognitive calisthenics” of this kind will help prevent or reverse certain symptoms of aging.
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One of the most frequent reasons for the institutionalization of people with Alzheimer’s disease is that overwhelmed caregivers can no longer cope with the difficulties of keeping them at home (Di Rosa et al., 2011; Apostolova & Cummings, 2008). Many care givers experience anger and depression, and their own physical and mental health often declines (Kang et al., 2014). Clinicians now recognize that one of the most important aspects of treating Alzheimer’s disease and other types of neurocognitive disorders is to focus on the emotional needs of the caregivers, includ- ing their needs for regular time out, education about the disease, and psychotherapy (Mittelman & Bartels, 2014). Some clinicians also provide caregiver support groups.
sOciOcultural apprOachEs Sociocultural approaches play an impor- tant role in treatment (Fouassier et al., 2015; Pongan et al., 2012) (see MediaSpeak on the next page). A number of day-care facilities for patients with neurocognitive disorders have been developed, providing treatment programs and activities for outpatients during the day and returning them to their homes and families at night. There are also many assisted-living facilities in which those suffering from neurocognitive impairment live in apartments tailored to their limitations, receive needed supervision, and take part in various activities that bring more joy and stimulation to their lives. Studies suggest that such facilities often help slow the cognitive decline of residents and enhance their enjoyment of life. In addition, a growing number of practical devices, such as tracking beacons worn on the wrists of Alzheimer’s patients and shoes that contain a GPS tracker,
have been developed to help locate patients who may wander off (Cavallo et al., 2015; Schiller, 2014).
Given the progress now unfolding in the understanding and treatment of Alzheimer’s disease and other types of neurocognitive disorders, researchers are looking forward to important advances in the coming years. The brain changes responsible for these disorders are tremendously complex, but most investigators believe that exciting breakthroughs are just over the horizon.
A therapeutic environment Some long- term care facilities have designed their buildings to address the cognitive and emotional needs of the elderly residents. In this facility, a woman with Alzheimer’s disease is drawn to and touches some of her room’s stimulating objects and is, at the same time, comforted by the room’s soothing colors and decorations.
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Much more than a pet Bella, a smooth collie, is stroked by her owner, a man with Alzheimer’s disease. Bella is one of many dogs trained to assist people with neurocognitive dis- orders in various tasks, including bringing them home if they get lost. The owner can command Bella to take him home, or his family can also summon the dog home with a special device. ©
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MediaSpeak Focusing on Emotions
By Pam Belluck, New York Times, January 1, 2011
Margaret Nance was, to put it mildly, a difficult case. Agitated, combative, often reluctant to eat, she would hit staff members and fellow residents at nursing homes, several of which kicked her out. But when Beati- tudes nursing home agreed to an urgent plea to accept her, all that changed.
Disregarding typical nursing-home rules, Beatitudes allowed Ms. Nance, 96 and afflicted with Alzheimer’s, to sleep, be bathed and dine whenever she wanted, even at 2 a.m. She could eat anything, too, no matter how unhealthy, including unlimited chocolate.
And she was given a baby doll, a move that seemed so jarring that a supervisor initially objected until she saw how calm Ms. Nance became when she rocked, caressed and fed her “baby,” often agreeing to eat herself after the doll “ate” several spoonfuls.
Dementia patients at Beatitudes are allowed practi- cally anything that brings comfort, even an alcoholic “nip at night,” said Tena Alonzo, director of research. “Whatever your vice is, we’re your folks,” she said. . . .
It is an unusual posture for a nursing home, but Beatitudes is actually following some of the latest sci- ence. Research suggests that creating positive emo- tional experiences for Alzheimer’s patients diminishes distress and behavior problems. . . . [Some studies also] recommend making cosmetic changes to rooms and buildings to affect behavior or mood. [One such study] found that brightening lights in dementia facilities decreased depression, cognitive deterioration and loss of functional abilities. . . .
One program for dementia pa- tients cared for by relatives at home creates specific activities related to something they once enjoyed: ar- ranging flowers, filling photo albums, snapping beans.
“A gentleman who loved fishing could still set up a tackle box, so we gave him a plastic tackle box” to set up every day, said the program’s developer, Laura N. Gitlin, a sociologist . . . at Johns Hopkins University. . . .
Beatitudes, which takes about 30 moderate to severe dementia sufferers, introduced its program 12 years ago, focusing on individualized care. . . .
Beatitudes eliminated anything potentially considered restraining, from deep-seated wheelchairs that hinder standing up to bedrails (some beds are lowered and protected by mats). It drastically reduced antipsychot- ics and medications considered primarily for “staff con- venience,”. . . Ms. Alonzo said.
It encouraged keeping residents out of diapers if possible, taking them to the toilet to preserve feelings
of independence. . . . Beatitudes also changed activity program- ming, [instructing] staff members [to] conduct one-on-one activities: block-building, coloring, simply conversing. . . .
These days, hundreds of Arizona physicians, medical students, and
staff members at other nursing homes have received Beatitudes’ training, and several Illinois nursing homes are adopting it. . . .
January 01, 2011, “The Vanishing Mind: Giving Alzheimers Patients Their Way, Even Doses of Chocolate” by Pam Belluck. From New York Times 1/1/2011, © 2011 The New York Times. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmission of this content without express written permission is prohibited.
If alzheimer’s disease is a
biologically caused disorder,
why would increasing patients’
comfort levels make such a
difference?
Finding the right activity This patient picks tomatoes from a garden at Résidence Les Aurélias, a residential treat- ment home for people with Alzheimer’s disease in France. The staff recognized this patient’s interest in horticulture and cre- ated a therapeutic garden where she could be active and find pleasure and satisfaction.
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➤ Summing Up DisOrDers Of COgNitiON Older people are more likely than people of other age groups to experience delirium, a fast-developing disturbance marked by great difficulty focusing attention, staying oriented, concentrating, and fol- lowing an orderly sequence of thought.
Neurocognitive disorders, characterized by a significant decline in cognitive function, become increasingly common in older age groups. There are many types of neurocognitive disorders, the most common being Alzheimer’s dis- ease. Alzheimer’s disease has been linked to an unusually high number of senile plaques and neurofibrillary tangles in the brain. According to a leading explana- tion of late-onset Alzheimer’s disease—the most common kind of Alzheimer’s disease—people who inherit ApoE-4, a particular form of the apolipoprotein E (ApoE) gene, are particularly vulnerable to the development of Alzheimer’s disease.
A number of other causes have also been proposed for this disease, includ- ing high levels of zinc, lead, or other toxins; immune system problems; and a virus of some kind.
Researchers are making significant strides at better assessing Alzheimer’s dis- ease and other types of neurocognitive disorders and even at identifying those who will eventually develop these disorders. Drug, cognitive, and behavioral therapies have been used to treat Alzheimer’s disease, with limited success. Addressing the needs of caregivers is now also recognized as a key part of treat- ment. In addition, sociocultural approaches such as day-care facilities are on the rise. Major treatment breakthroughs are expected in the coming years.
Issues Affecting the Mental Health of the Elderly As the study and treatment of elderly people have progressed, three issues have raised concern among clinicians: the problems faced by elderly members of racial and ethnic minority groups, the inadequacies of long-term care, and the need for a health-maintenance approach to medical care in an aging world.
First, discrimination based on race and ethnicity has long been a problem in the United States (see Chapter 2), and many people suffer as a result, particularly those who are old. To be both old and a member of a minority group is considered a kind of “double jeopardy” by many observers. For older women in minority groups, the difficulties are sometimes termed “triple jeopardy,” as many more older women than older men live alone, are widowed, and are poor. Clinicians must take into account their older patients’ race, ethnicity, and gender as they try to diagnose and treat their mental health problems (Ng et al., 2014; Sirey et al., 2014) (see Figure 15-4).
Some elderly people in minority groups face language barriers that interfere with their medical and mental health care. Others may hold cultural beliefs that pre- vent them from seeking services. Additionally, many members of minority groups do not trust the majority establishment or do not know about medical and mental health services that are sensitive to their culture and their particular needs (Ayalon & Huyck, 2001). As a result, it is common for elderly members of racial and ethnic minority groups to rely largely on family members or friends for remedies and health care.
Today, 8 to 20 percent of elderly people live with their children or other rela- tives, usually because of increasing health problems (Keefer, 2015; Span, 2009). In the United States, this living arrangement is more common for elderly people from ethnic minority groups than for elderly white Americans. Elderly Asian Ameri- cans are most likely to live with their children, African Americans and Hispanic
B e t W e e N t h e L I N e S
Maximum Age The maximum attainable age by human beings is thought to be 122 years (Basaraba, 2014; Durso et al., 2010).
B e t W e e N t h e L I N e S
Aging, Gender, and Race 83.8 years Average life expectancy for
Hispanic American women today
81.1 years Average life expectancy for white American women today
77.7 years Average life expectancy for African American women today
78.5 years Average life expectancy for Hispanic American men today
76.4 years Average life expectancy for white American men today
71.4 years Average life expectancy for African American men today
(Information from: NchS, 2014)
Disorders of Aging and Cognition : 523
Americans are less likely to do so, and white Americans are least likely (Etaugh, 2008; Armstrong, 2001).
Second, many older people require long-term care, a general term that may refer variously to the services offered outside the family in a partially supervised apart- ment, a senior housing complex for mildly impaired elderly persons, or a nursing home where skilled medical and nursing care are available around the clock (Samos et al., 2010). The quality of care in such residences varies widely.
At any given time in the United States, only about 4 percent of the entire elderly population actually live in nursing homes (1.5 million people), but as many as 20 percent of people 85 years and older do eventually wind up being placed in such facilities (CDC, 2015). Thus many older adults live in fear of being “put away.” They
African Americans (8.9%)
Hispanic Americans (7.3%)
Asian Americans and American Indians (4.7%)
White Americans (79.6%)
2013
African Americans (11%)
Hispanic Americans (19.8%)
Asian Americans and American Indians (10%)
White Americans (59.2%)
2050
figure 15-4 ethnicity and old age The elderly population is becoming racially and ethnically more diverse. In the United States today, almost 80 percent of all people over the age of 65 are white Americans. By 2050, white Americans will comprise only 59 percent of the elderly. (Information from: NCHS, 2014; Pirkl, 2009; Hobbs, 1997.)
Every little bit helps In line with research findings that all kinds of physical exercise help improve cognitive functioning, these elderly persons participate in an “arm chair” exercise program at the Dominica Association, a com- munity center in Bradford, West Yorkshire, in the United Kingdom.Pa
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C li n i C al C h o i C e s Now that you’ve read about disorders of aging and cognition, try the interactive case study for this chap- ter. See if you are able to identify Fred’s symptoms and suggest a diagnosis based on his symptoms. What kind of treatment would be most effective for Fred? Go to LaunchPad to access Clinical Choices.
fear having to move, losing independence, and living in a medical environment. Many also worry about the cost of long-term care facilities. Around-the-clock nursing care is expensive, and nursing home costs continue to rise. Most health insurance plans available today do not adequately cover the costs of long-term or permanent placement (Durso et al., 2010). Worry over these issues can greatly harm the mental health of older adults, perhaps leading to depression and anxiety as well as family conflict.
Finally, clinical scientists suggest that the current generation of young adults should take a health-maintenance, or wellness promotion, approach to their own aging process. In other words, they should do things that promote physical and mental health—avoid smoking, eat well-balanced and healthful meals, exercise regularly, engage in positive social relationships, and take advantage of psychoeducational, stress management, and other mental health programs (CDC, 2014). There is a growing belief that older adults will adapt more readily to changes and negative events if their physical and psychological health is good.
➤ Summing Up issues affeCtiNg tHe MeNtaL HeaLtH Of tHe eLDerLY In studying and treating the problems of old age, clinicians have become concerned about three issues: the problems of elderly members of racial and ethnic minority groups, inadequacies of long-term care, and the need for health maintenance by young adults.
PUTTING IT...together Clinicians Discover the Elderly Early in the twentieth century, mental health professionals focused little on the elderly. But like the problems of children, those of aging people have now caught the attention of researchers and clinicians. Current work is changing how we un-
derstand and treat the psychological problems of the elderly. No longer do clinicians simply accept depression or anxiety in elderly people as inevitable. No longer do they overlook the dangers of prescription drug misuse by the elderly. And no longer do they underestimate the dangers of delirium or the prevalence of neurocognitive disorders. Similarly, geropsychologists have become more aware of the importance of ad- dressing the health care and financial needs of the elderly as keys to their psychological well-being.
As the elderly population lives longer and grows ever larger, the needs of people in this age group are becoming more visible. Thus the study and treatment of their psychological problems will probably continue
at a rapid pace. Clinicians and public officials are not likely to underestimate their needs and importance again.
Particularly urgent is neurocognitive impairment and its devastating impact on the elderly and their families. As you have read throughout the chapter, the complexity of the brain makes neurocognitive disorders difficult to understand, diagnose, and treat. However, researchers are now making important discoveries on a regular basis. To date, this research has largely focused on the biological aspects of these disorders, but the disorders have such a powerful impact on patients and their families that psychological and sociocultural investigations are also starting to grow by leaps and bounds.
B e t W e e N t h e L I N e S
Varied Life Spans 79 years Average human life span
200 years Life span of some marine clams
90 years Life span of killer whales
50 years Life span of bats
2 years Life span of mice
17 days Life span of male houseflies
(Durso et al., 2010; cDc, 2011)
Disorders of Aging and Cognition : 525
KEY TERMS geropsychology, p. 502
delirium, p. 509
neurocognitive disorder, p. 511
major neurocognitive disorder, p. 511
mild neurocognitive disorder, p. 511
Alzheimer’s disease, p. 511
senile plaques, p. 513
beta-amyloid protein, p. 513
neurofibrillary tangles, p. 513
tau protein, p. 514
early-onset Alzheimer’s disease, p. 514
beta-amyloid precursor protein, p. 514
presenilin, p. 514
late-onset Alzheimer’s disease, p. 514
apolipoprotein E (ApoE) gene, p. 514
ApoE-4, p. 514
acetylcholine, p. 516
glutamate, p. 516
ribonucleic acid (RNA), p. 516
calcium, p. 516
zinc, p. 516
lead, p. 516
autoimmune theory, p. 516
viral theory, p. 516
vascular neurocognitive disorder, p. 517
Pick’s disease, p. 517
Creutzfeld-Jakob disease, p. 517
Huntington’s disease, p. 518
Parkinson’s disease, p. 518
donepezil, p. 518
rivastigmine, p. 518
galantamine, p. 518
memantine, p. 518
vitamin E, p. 518
day-care facilities, p. 520
assisted-living facilities, p. 520
discrimination, p. 522
long-term care, p. 523
health-maintenance approach, p. 524
QuickQuiz
1. What is geropsychology? What kinds of special pressures and upsets are faced by elderly persons? pp. 502–503
2. How common is depression among the elderly? What are the possible causes of this disorder in aged persons, and how is it treated? pp. 503–505
3. How prevalent are anxiety disorders among the elderly? How do theorists explain the onset of these disorders in aged persons, and how do clinicians treat them? p. 505
4. Describe and explain the kinds of substance abuse patterns that some- times emerge among the elderly. pp. 505–508
5. What kinds of psychotic disorders may be experienced by elderly persons? pp. 508–509
6. What is delirium? pp. 509–511
7. How common are neurocognitive disorders among the elderly? Describe the clinical features and course of Alzheimer’s disease. pp. 511–514
8. What are the possible causes of Alzheimer’s disease? pp. 513–516
9. Can Alzheimer’s disease be predicted? What kinds of interventions are applied in cases of this and other neurocogni- tive disorders? pp. 516–521
10. What issues regarding aging have raised particular concern among clinicians? pp. 522–524
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
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T O P I C O V E R V I E W
Law and Mental Health How Do Clinicians Influence the Criminal Justice System? How Do the Legislative and Judicial Systems Influence Mental Health Care? In What Other Ways Do the Clinical and Legal Fields Interact?
What Ethical Principles Guide Mental Health Professionals?
Mental Health, Business, and Economics Bringing Mental Health Services to the Workplace The Economics of Mental Health
Technology and Mental Health
The Person Within the Profession
Putting It Together: Operating Within a Larger System
Law, Society, and the Mental Health Profession
D ear Jodie:
There is a definite possibility that I will be killed in my attempt to get Reagan. It is for this very reason that I am writing you this letter now. As you well know by now, I love you very much. The past seven months I have left you dozens
of poems, letters and messages in the faint hope you would develop an interest in me. . . . Jodie, I would abandon this idea of getting Reagan in a second if I could only win your heart and live out the rest of my life with you, whether it be in total obscurity or whatever. I will admit to you that the reason I’m going ahead with this attempt now is because I just cannot wait any longer to impress you. I’ve got to do something now to make you understand in no uncertain terms that I am doing all of this for your sake. By sacrificing my freedom and possibly my life I hope to change your mind about me. This letter is being written an hour before I leave for the Hilton Hotel. Jodie, I’m asking you please to look into your heart and at least give me the chance with this historical deed to gain your respect and love. I love you forever.
John Hinckley
John W. Hinckley Jr. wrote this letter to actress Jodie Foster in March 1981. Soon after writing it, he stood waiting, pistol ready, outside the Washington Hilton Hotel. Moments later, President Ronald Reagan came out of the hotel, and the popping of pistol fire was heard. As Secret Service agents pushed Reagan into the limousine, a police officer and the president’s press secretary fell to the pavement. The president had been shot, and by nightfall most of America had seen the face and heard the name of the disturbed young man from Colorado.
As you have seen throughout this book, the psychological dysfunction- ing of an individual does not occur in isolation. It is influenced—sometimes caused—by societal and social factors, and it affects the lives of relatives, friends, and acquaintances. The case of John Hinckley demonstrates in powerful terms that individual dysfunction may, in some cases, also affect the well-being and rights of people the person does not know.
By the same token, clinical scientists and practitioners do not conduct their work in isolation. As they study and treat people with psychological problems, they affect and are affected by other institutions of society. We have seen, for example, how the government regulates the use of psychotropic medications, how clinicians helped carry out the government’s policy of deinstitutionaliza- tion, and how clinicians have called the psychological ordeals of Vietnam, Iraq, and Afghanistan combat veterans to the attention of society.
In short, like their clients, clinical professionals operate within a complex social system. Just as we must understand the social context in which abnormal behavior occurs in order to understand the behavior, so must we understand the context in which this behavior is studied and treated. This chapter focuses on the relationship between the mental health field and three major forces in society—the legislative/judicial system, the business/economic arena, and the world of technology.
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Law and Mental Health Two social institutions have a particularly strong impact on the mental health pro- fession: the legislative and judicial systems. These institutions—collectively, the legal field—have long been responsible for protecting both the public good and the rights of individuals. Sometimes the relationship between the legal field and the mental health field has been friendly, and those in the two fields have worked together to protect the rights and meet the needs of troubled people and of society at large. At other times they have clashed, and one field has imposed its will on the other.
This relationship has two distinct aspects. On the one hand, mental health pro- fessionals often play a role in the criminal justice system, as when they are called upon to help the courts assess the mental stability of people accused of crimes. They responded to this call in the Hinckley case, as you will see, and in thousands of other cases. This aspect of the relationship is sometimes termed psychology in law; that is, clinical practitioners and researchers operate within the legal system. On the other hand, there is another aspect to the relationship, called law in psychology. The legisla- tive and judicial systems act upon the clinical field, regulating certain aspects of men- tal health care. The courts may, for example, force some people to enter treatment, even against their will. In addition, the law protects the rights of patients.
The intersections between the mental health field and the legal and judicial systems are collectively referred to as forensic psychology (APA, 2015). Forensic psychologists or psychiatrists (or related mental health professionals) may perform such varied activities as testifying in trials, researching the reliability of eyewitness testimony, or helping police profile the personality of a serial killer on the loose.
How Do Clinicians Influence the Criminal Justice System? To arrive at just and appropriate punishments, the courts need to know whether defendants are responsible for the crimes they commit and capable of defending them- selves in court. If not, it would be inappropriate to find defendants guilty or punish them in the usual manner. The courts have decided that in some instances people who suffer from severe mental instability may not be responsible for their actions or may not be able to defend themselves in court, and so should not be punished in the usual way. Although the courts make the final judgment as to mental instability, their decisions are guided to a large degree by the opinions of mental health professionals.
When people accused of crimes are judged to be mentally unstable, they are usually sent to a mental institution for treatment, a process called criminal commitment. Actually there are several forms of criminal commitment. In one, people are judged mentally unstable at the time of their crimes and so innocent of wrongdoing. They may plead not guilty by reason of insanity (NGRI) and bring mental health professionals into court to support their claim. When people are found not guilty on this basis, they are committed for treatment until they improve enough to be released.
In a second form of criminal commitment, people are judged men- tally unstable at the time of their trial and so are considered unable to understand the trial procedures and defend themselves in court. They are committed for treatment until they are competent to stand trial. Once again, the testimony of mental health professionals helps determine the defendant’s psychological functioning.
These judgments of mental instability have stirred many arguments. Some people consider the judgments to be loopholes in the legal sys- tem that allow criminals to escape proper punishment for wrongdoing. Others argue that a legal system simply cannot be just unless it allows
Would-be assassin Few courtroom decisions have spurred as much debate or legislative action as the jury’s verdict that John Hinckley, having been captured in the act of shooting President Ronald Reagan, was not guilty by reason of insanity.
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Growing Involvement It is estimated that mental health prac- titioners participate in 1 million court cases in the United States each year.
(Kambam & Benedek, 2010).
Law, Society, and the Mental Health Profession : 529
for extenuating circumstances, such as mental instability. The practice of criminal commitment differs from country to country. In this chapter you will see primar- ily how it operates in the United States. Although the specific procedures of each country may differ, most countries grapple with the same issues and decisions that you will read about here.
Criminal Commitment and Insanity During Commission of a Crime Consider once again the case of John Hinckley. Was he insane at the time he shot the president? If insane, should he be held responsible for his actions? On June 21, 1982, 15 months after he shot four men in the nation’s capital, a jury pro- nounced Hinckley not guilty by reason of insanity. Hinckley thus joined Richard Lawrence, a house painter who shot at Andrew Jackson in 1835, and John Schrank, a saloonkeeper who shot former president Teddy Roosevelt in 1912, as a would-be assassin who was found not guilty by reason of insanity.
It is important to recognize that “insanity” is a legal term. That is, the definition of “insanity” used in criminal cases was written by legislators, not by clinicians. Defendants may have mental disorders but not necessarily qualify for a legal defini- tion of insanity. Modern Western definitions of insanity can be traced to the murder case of Daniel M’Naghten in England in 1843. M’Naghten shot and killed Edward Drummond, the secretary to British prime minister Robert Peel, while trying to shoot Peel. Because of M’Naghten’s apparent delusions of persecution, the jury found him to be not guilty by reason of insanity. The public was outraged by this decision, and their angry outcry forced the British law lords to define the insan- ity defense more clearly. This legal definition, known as the M’Naghten test, or M’Naghten rule, stated that having a mental disorder at the time of a crime does not by itself mean that the person was insane; the defendant also had to be unable to know right from wrong. The state and federal courts in the United States adopted this test as well.
In the late nineteenth century some state and federal courts in the United States, dissatisfied with the M’Naghten rule, adopted a different test—the irresistible impulse test. This test, which had first been used in Ohio in 1834, emphasized the inability to control one’s actions. A person who committed a crime during an uncontrollable “fit of passion” was considered insane and not guilty under this test.
For years state and federal courts chose between the M’Naghten test and the irresistible impulse test to determine the sanity of criminal defendants. For a while a third test, called the Durham test, also became popular, but it was soon replaced in most courts. This test, based on a decision handed down by the Supreme Court in 1954 in the case of Durham v. United States, stated simply that people are not criminally responsible if their “unlawful act was the product of mental disease or mental defect.” This test was meant to offer more flexibility in court decisions, but it proved too flexible. Insanity defenses could point to such problems as alcoholism or other forms of substance abuse and conceivably even headaches or ulcers, which were listed as psychophysiological disorders in DSM-I.
In 1955 the American Law Institute (ALI) developed a test that combined aspects of the M’Naghten, irresistible impulse, and Durham tests. The American Law Institute test held that people are not criminally responsible if at the time of a crime they had a mental disorder or defect that prevented them from knowing right from wrong or from being able to control themselves and follow the law. For a time the new test became the most widely accepted legal test of insanity. After the Hinckley verdict, however, there was a public uproar over the “liberal” ALI guidelines, and people called for tougher standards.
Partly in response to this uproar, the American Psychiatric Association recom- mended in 1983 that people should be found not guilty by reason of insanity only if they did not know right from wrong at the time of the crime; an inability to control themselves and to follow the law should no longer be sufficient grounds
▶▶ forensic psychology The branch of psychology concerned with intersec tions between psychological practice and research and the judicial system.
▶▶ criminal commitment A legal proc ess by which people accused of a crime are judged mentally unstable and sent to a treatment facility.
▶▶ not guilty by reason of insanity (NGRI) A verdict stating that defendants are not guilty of a crime because they were insane at the time of the crime.
▶▶ M’Naghten test A legal standard that holds people to be insane at the time they committed a crime if, because of a mental disorder, they did not know the nature of the act or did not know right from wrong.
▶▶ irresistible impulse test A legal standard that holds people to be insane at the time they committed a crime if they were driven to do so by an uncon trollable “fit of passion.”
▶▶ Durham test A legal standard that holds people to be insane at the time they committed a crime if their act was the result of a mental disorder or defect.
▶▶ American Law Institute test A legal standard that holds people to be insane at the time they committed a crime if, because of a mental disorder, they did not know right from wrong or could not resist an uncontrollable impulse to act.
B e t W e e N t h e L I N e S
In Their Words “I think John Hinckley will be a threat the rest of his life. He is a time bomb.”
U.S. attorney, 1982
“Without doubt, [John Hinckley] is the least dangerous person on the planet.”
attorney for John hinckley, applying for increased privileges for his client, 2003
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for a judgment of insanity. In short, the association was calling for a return to the M’Naghten test. This test now is used in all cases tried in federal courts and in about half of the state courts. The more liberal ALI standard is still used in the remaining state courts, except in Idaho, Kansas, Montana, and Utah, which have more or less done away with the insanity plea altogether.
People suffering from severe mental disorders in which confu- sion is a major feature may not be able to tell right from wrong or to control their behavior. It is therefore not surprising that around two-thirds of defendants who are acquitted of a crime by reason of insanity qualify for a diagnosis of schizophrenia (Almeida et al., 2010; Steadman et al., 1993). The vast majority of these acquitted defen- dants have a history of past hospitalization, arrest, or both. About half who successfully plead insanity are white, and 86 percent are male. Their mean age is 32 years. The crimes for which defendants
are found not guilty by reason of insanity vary greatly, although approximately 65 percent are violent crimes of some sort. At least 15 percent of those acquitted are accused specifically of murder (see Figure 16-1).
What ConCerns are raised by the insanity defense? Despite the changes in the insanity tests, criticism of the insanity defense continues (MacKinnon & Fiala, 2015; Slovenko, 2011, 2004, 2002). One concern is the fundamental difference between the law and the science of human behavior. The law assumes that indi- viduals have free will and are generally responsible for their actions. Several models of human behavior, in contrast, assume that physical or psychological forces act to determine the individual’s behavior. Inevitably, then, legal definitions of insanity and responsibility will differ from those suggested by clinical research.
A second criticism points to the uncertainty of scientific knowledge about abnormal behavior. During a typical insanity defense trial, the testimony of defense clinicians conflicts with that of clinicians hired by the prosecution, and so the jury must weigh the claims of “experts” who disagree in their assessments. Some people see this lack of professional agreement as evidence that clinical knowledge in some areas may be too incomplete to be allowed to influence important legal decisions (Bartol & Bartol, 2015). Others counter that the field has made great strides—for example, developing several psychological scales to help clinicians discriminate more consistently between the sane and insane as defined by the M’Naghten standard (Pinals & Mossman, 2012; Rogers, 2008).
Even with helpful scales in hand, however, clinicians making judgments of legal insanity face a problem that is difficult to overcome: they must evaluate a defen- dant’s state of mind during an event that took place weeks, months, or years earlier. Because mental states can and do change over time and across situations, clinicians can never be entirely certain that their assessments of mental instability at the time of the crime are accurate.
Perhaps the most common criticism of the insanity defense is that it allows dangerous criminals to escape punishment. Granted, some people who successfully plead insanity are released from treatment facilities just months after their acquittal. Yet the number of such cases is quite small (Asmar, 2014; Steadman et al., 1993; Callahan et al., 1991). According to surveys, the public dramatically overestimates the percentage of defendants who plead insanity, guessing it to be 30 to 40 percent, when in fact it is less than 1 percent. Moreover, only a minority of these defendants fake or exaggerate their psychological symptoms, and only 26 percent of those who plead insanity are actually found not guilty on this basis. In all, less than 1 of every 400 defendants in the United States is found not guilty by reason of insanity, and, in most such cases, the prosecution has agreed to the appropriateness of the plea (see PsychWatch on the next page).
Physical assault (38%)
Murder (15%)
Other violent crimes (12%)
Other minor offenses (10%)
Robbery (7%)
Property crimes (18%)
figure 16-1 Crimes for which people are found not guilty by reason of insanity (NGRI) Reviews of NGRI verdicts in a number of states show that most people who are acquit- ted on this basis had been charged with a violent crime. (Information from: Novak et al., 2007; APA, 2003; Steadman et al., 1993; Callahan et al., 1991.)
B e t W e e N t h e L I N e S
33 Years Later Currently 60 years of age, John Hinck- ley is a patient at St. Elizabeths Hospital in Washington, DC. A federal judge has granted him furlough privileges, includ- ing a 17-day visit to his mother’s home in Virginia each month. When away from his mother’s house during these visits, he is required to carry a GPS- equipped cell phone.
Law, Society, and the Mental Health Profession : 531
PsychWatch
1977 In Michigan, Francine Hughes poured gasoline around the bed where her husband, Mickey, lay in a drunken stupor. Then she lit a match and set him on fire. At her trial she explained that he had beaten her repeatedly for 14 years and had threatened to kill her if she tried to leave him. The jury found her not guilty by reason of temporary insanity, making her into a symbol for many abused women across the nation.
1978 David “Son of Sam” Berkowitz, a serial killer in New York City, explained that a barking dog had sent him demonic messages to kill. Although two psychia- trists assessed him as psychotic, he was found guilty of his crimes. Long after his trial, he said that he had actually made up the delusions.
1979 Kenneth Bianchi, one of the pair known as the Hillside Strangler, entered a plea of not guilty by reason of insanity but was found guilty along with his cousin of sexually assaulting and murdering women in the Los Angeles area in late 1977 and early 1978. He claimed that he had mul- tiple personalities.
1980 In December, Mark David Chapman murdered John Lennon. Chapman later explained that he had killed the rock music legend because he believed Lennon to be a “sell-out.” Pleading not guilty by reason of insanity, he also described hearing the voice of God, con- sidered himself his generation’s “catcher in the rye” (from the J. D. Salinger novel), and compared himself with Moses. Chapman was convicted of murder.
1981 In an attempt to prove his love for actress Jodie Foster, John Hinckley Jr. tried to assassinate President Ronald Reagan. Hinckley was found not guilty by reason of insanity and was committed to St. Elizabeth’s Hospital for the criminally insane in Washington, DC, where he remains today.
1992 Jeffrey Dahmer, a 31-year-old mass murderer in Milwaukee, was tried for
the killings of 15 young men. Dahmer apparently drugged some of his victims, performed crude lobotomies on them, and dismembered their bodies and stored their parts to be eaten. Despite a plea of not guilty by reason of insanity, the jury found him guilty as charged. He was beaten to death by another inmate in 1995.
1994 On June 23, 1993, 24-year-old Lorena Bobbitt cut off her husband’s penis with a 12-inch kitchen knife while he slept. Her defense attorneys argued that after years of abuse by John Bobbitt, his wife suffered a brief psychotic episode and was seized by an “irresistible impulse” to cut off his penis after he came home drunk and raped her. In 1994, the jury found her not guilty by reason of tem- porary insanity. She was committed to a state mental hospital and released a few months later.
2003 For three weeks in October 2002, John Allen Muhammad and Lee Boyd Malvo went on a sniping spree in the
Washington, DC, area, shooting 10 people dead and wounding 3 others. Attorneys for Malvo, a teenager, argued that he had acted under the influence of the middle-aged Muhammad and that he should be found not guilty of the crimes by reason of insanity. The jury, though, found Malvo guilty of capital murder and sentenced him to life in prison.
2006 On June 20, 2001, Andrea Yates, a 36-year-old woman, drowned each of her five children in the bathtub. Yates had a history of postpartum depression and postpartum psychosis: she believed that she was the devil, that she had failed to be a good mother, and that her chil- dren were not developing correctly. She pleaded not guilty by reason of insan- ity. After an initial verdict of guilty was overturned, Yates was found not guilty by reason of insanity in 2006 and sent to a mental health facility for treatment.
2011 In 2002, Brian David Mitchell abducted a 14-year-old teenager named Elizabeth Smart from her home and held her until she was rescued nine months later. After years of trial delays, Mitchell was brought to trial for the crime of kid- napping. He pleaded not guilty by reason of insanity, saying that he was acting out delusions (“revelations from God”) when he committed this crime. After deliberat- ing for just five hours, the jury found him guilty of kidnapping. He was sentenced to life in prison without parole in 2011.
2012 On July 20, 2012, James Holmes, a 25-year-old neuroscience doctoral student, entered a cinema in Aurora, Colorado, and opened fire on the movie- goers, killing 12 and injuring 70. In the months after his arrest and incarceration, Holmes, who had no prior criminal record, tried to commit suicide three times. Although Holmes pleaded not guilty by reason of insanity, a jury found him guilty of multiple counts of murder and attempted murder in 2015. He was sen- tenced to life in prison without parole.
Famous Insanity Defense Cases
Rejecting the insanity plea James Holmes sits in a courtroom in Colorado in 2012, a few days after killing 12 moviegoers and injuring 70 others in the town of Aurora. In 2015, a jury rejected his plea of not guilty by reason of insanity, and, instead, found him guilty of murder and attempted murder.
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During most of U.S. history, a successful insanity plea amounted to the equiva- lent of a long-term prison sentence. In fact, treatment in a mental hospital often resulted in a longer period of confinement than a verdict of guilty would have brought (Bartol & Bartol, 2015). Because hospitalization resulted in little if any improvement, clinicians were reluctant to predict that the offenders would not repeat their crimes.
Today, however, offenders are being re- leased from mental hospitals earlier and earlier. This trend is the result of the in- creasing effectiveness of drug therapy and other treatments in institutions, the growing reaction against extended institutionalization, and more emphasis on patients’ rights (Slovenko, 2011, 2009, 2004). In 1992, in the case of Foucha v. Louisiana, the U.S. Supreme Court clarified that the only acceptable basis for determining the release of hospitalized offenders is whether or not they are still “insane”; they cannot be kept indefinitely in mental hospitals solely because they are dangerous. Some states are able to maintain control over offenders even after their release from hospitals. The states may insist on community treatment, monitor the patients closely, and rehospitalize them if necessary (Swanson & Swartz, 2014).
What other VerdiCts are aVailable? Over the past four decades, at least 20 states have added another verdict option—guilty but mentally ill. Defendants who receive this verdict are found to have had a mental illness at the time of their crime, but the illness was not fully related to or responsible for the crime. The option of guilty but mentally ill enables jurors to convict a person they view as dangerous while also suggesting that the individual receive needed treatment. Defendants found to be guilty but mentally ill are given a prison term with the added recom- mendation that they also undergo treatment if necessary.
After initial enthusiasm for this verdict option, legal and clinical theorists have increasingly found it unsatisfactory. According to research, it has not reduced the number of not guilty by reason of insanity verdicts, and it often confuses jurors (Bartol & Bartol, 2015). In addition, as critics point out, appropriate mental health care is supposed to be available to all prisoners anyway, regardless of the verdict. That is, the verdict of guilty but mentally ill may differ from a guilty verdict in name only.
Some states allow still another kind of defense, guilty with diminished capacity, in which a defendant’s mental dysfunctioning is viewed as an extenuating circumstance that the court should take into consideration in determining the precise crime of which he or she is guilty (Slovenko, 2011; Leong, 2000). The defense lawyer argues that because of mental dysfunctioning, the defendant could not have intended to commit a particular crime. The person can then be found guilty of a lesser crime— of manslaughter (unlawful killing without intent), say, instead of murder in the first degree (planned murder). The famous case of Dan White, who shot and killed Mayor George Moscone and City Supervisor Harvey Milk of San Francisco in 1978, illustrates the use of this verdict.
Defense attorney Douglas Schmidt argued that a patriotic, civic-minded man like Dan White—high school athlete, decorated war veteran, former fireman, police- man, and city supervisor—could not possibly have committed such an act unless something had snapped inside him. The brutal nature of the two final shots to each man’s head only proved that White had lost his wits. White was not fully responsible for his actions because he suffered from “diminished capacity.” Although White killed Mayor George Moscone and Supervisor Harvey Milk, he had not planned his
after patients have been crimi-
nally committed to institutions,
why might clinicians be hesitant
to later declare them unlikely to
commit the same crime again?
“Effectively misleading psychopath” In 2002 Brian David Mitchell abducted a 14-year-old teenager named Elizabeth Smart at knifepoint from her home and held her until she was rescued nine months later. For seven years following his capture, Mitchell was declared incompetent to stand trial. Finally, in 2010, a federal court judge called him an “effectively misleading psychopath” and scheduled him for trial. Mitchell was found guilty of kidnapping and sentenced to life in prison, despite his not guilty by reason of insanity plea.
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▶▶ guilty but mentally ill A verdict stating that defendants are guilty of committing a crime but are also suffer ing from a mental illness that should be treated during their imprisonment.
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actions. On the day of the shootings, White was mentally incapable of planning to kill, or even of wanting to do such a thing.
Well known in forensic psychiatry circles, Martin Blinder, professor of law and psy- chiatry at the University of California’s Hastings Law School in San Francisco, brought a good measure of academic prestige to White’s defense. White had been, Blinder explained to the jury, “gorging himself on junk food: Twinkies, Coca-Cola. . . . The more he consumed, the worse he’d feel and he’d respond to his ever-growing depression by consuming ever more junk food.” Schmidt later asked Blinder if he could elaborate on this. “Perhaps if it were not for the ingestion of this junk food,” Blinder responded, “I would suspect that these homicides would not have taken place.” From that moment on, Blinder became known as the author of the Twinkie defense. . . .
Dan White was convicted only of voluntary manslaughter, and was sentenced to seven years, eight months. (He was released on parole January 6, 1984.) Psychiatric testimony convinced the jury that White did not wish to kill George Moscone or Harvey Milk.
The angry crowd that responded to the verdict by marching, shouting, trashing City Hall, and burning police cars was in good part homosexual. Gay supervisor Harvey Milk had worked well for their cause, and his loss was a serious setback for human rights in San Francisco. Yet it was not only members of the gay community who were appalled at the outcome. Most San Franciscans shared their feelings of outrage.
(Coleman, 1984, pp. 65–70)
Because of possible miscarriages of justice, many legal experts have argued against the “diminished capacity” defense. A number of states have even eliminated it, including California shortly after the Dan White verdict (Gado, 2008).
What are sex-offender statutes? Since 1937, when Michigan passed the first “sexual psychopath” law, a number of states have placed sex offenders in a special legal category (Perillo et al., 2014; Ewing, 2011). These states believe that some of those who are repeatedly found guilty of sex crimes have a mental disorder, so the states categorize them as mentally disordered sex offenders.
Justice served? People held mass protests in San Francisco after Dan White was convicted of voluntary manslaughter rather than premedi- tated murder in the killings of Mayor George Moscone and Supervisor Harvey Milk, who was one of the nation’s leading gay activists. For many, the 1979 verdict highlighted the serious pitfalls of the “diminished capacity” defense.Bi
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The Aftermath Convicted of voluntary manslaughter in 1979, Dan White was released from prison in 1984. He committed suicide in 1985.
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People classified in this way are convicted of a criminal offense and are thus judged to be responsible for their actions. Nevertheless, mentally disordered sex offenders are sent to a mental health facility instead of a prison. In part, such laws reflect a belief held by many legislators that such sex offenders are psychologically disturbed. On a practical level, the laws help protect sex offenders from the physical abuse that they often receive in prison society.
Over the past two decades, however, most states have been changing or abolish- ing their mentally disordered sex offender laws, and at this point only a handful still have them. There are several reasons for this trend. First, the state laws often require that in order to be classified as a mentally disordered sex offender, the person must be a good candidate for treatment, a judgment that is difficult for clinicians to make for this population (Marshall et al., 2011). Second, there is evidence that racial bias often affects the use of the mentally disordered sex offender classification. From a defendant’s perspective, this classification is considered an attractive alternative to imprisonment—an alternative available to white Americans much more often than to members of racial minority groups. White Americans are twice as likely as Afri- can Americans or Hispanic Americans who have been convicted of similar crimes to be granted mentally disordered sex offender status.
But perhaps the primary reason that mentally disordered sex offender laws have lost favor is that state legislatures and courts are now less concerned than they used to be about the rights and needs of sex offenders, given the growing number of sex crimes taking place across the country (Laws & Ward, 2011), particularly ones in which children are victims. In fact, in response to public outrage over the high number of sex crimes, 21 states and the federal government have instead passed sexually violent predator laws (or sexually dangerous persons laws). These new laws call for certain sex offenders who have been convicted of sex crimes and have served their sentence in prison to be removed from prison before their release and com- mitted involuntarily to a mental hospital for treatment if a court judges them likely to engage in further “predatory acts of sexual violence” as a result of “mental abnormality” or “personality disorder” (Perillo et al., 2014; Miller, 2010). That is, in contrast to the mentally disordered sex offender laws, which call for sex offend- ers to receive treatment instead of imprisonment, the sexually violent predator laws require certain sex offenders to receive imprisonment and then, in addition, be com- mitted for a period of involuntary treatment. The constitutionality of the sexually violent predator laws was upheld by the Supreme Court in the 1997 case of Kansas v. Hendricks by a 5-to-4 margin.
Criminal Commitment and Incompetence to Stand Trial Regard- less of their state of mind at the time of a crime, defendants may be judged to be mentally incompetent to stand trial. The competence requirement is meant to ensure that defendants understand the charges they are facing and can work with their lawyers to prepare and conduct an adequate defense (Ragatz et al., 2014; Reisner et al., 2013). This minimum standard of competence was specified by the Supreme Court in the case of Dusky v. United States (1960).
The issue of competence is most often raised by the defendant’s attorney, although prosecutors, arresting police officers, and even the judge may raise it as well (Reisner et al., 2013). When the issue of competence is raised, the judge orders a psychological evaluation, usually on an inpatient basis (see Table 16-1). As many as 60,000 competency evaluations are conducted in the United States each year (Bartol & Bartol, 2015). Approximately 20 percent of defendants who receive such an evaluation are found to be incompetent to stand trial. If the court decides that the defendant is incompetent, he or she is typically assigned to a mental health facility until competent to stand trial.
A famous case of incompetence to stand trial is that of Jared Lee Loughner. On January 8, 2011, Loughner went to a political gathering at a shopping center
Incompetent to stand trial Jared Loughner, shown here in a police photo taken on the day of his shooting rampage in 2011 in Tucson, Arizona. For 18 months following his crime, Loughner was ruled incompetent to stand trial.
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▶▶ mental incompetence A state of mental instability that leaves defendants unable to understand the legal charges and proceedings they are facing and unable to prepare an adequate defense with their attorney.
Law, Society, and the Mental Health Profession : 535
in Tucson, Arizona, and opened fire on 20 people. Six were killed and 14 injured, including U.S. representative Gabrielle Giffords. Giffords, the apparent target of the attack, survived, although she was shot in the head. After Loughner underwent five weeks of psychiatric assessment, a judge ruled that he was incompetent to stand trial. It was not until 18 months later, after extended treatment with antipsychotic drugs, that Loughner was ruled competent to stand trial. In November 2012, he pleaded guilty to murder and was sentenced to life imprisonment.
Many more cases of criminal commitment result from decisions of mental incompetence than from verdicts of not guilty by reason of insanity (Roesch et al., 2010). However, the majority of criminals currently institutionalized for psycholog- ical treatment in the United States are not from either of these two groups. Rather, they are convicted inmates whose psychological problems have led prison officials to decide they need treatment, either in mental health units within the prison or in mental hospitals (Metzner & Dvoskin, 2010) (see Figure 16-2).
It is possible that an innocent defendant, ruled incompetent to stand trial, could spend years in a mental health facility with no opportunity to disprove the criminal accusations against him or her. Some defendants have, in fact, served longer “sentences” in mental health facilities await- ing a ruling of competence than they would have served in prison had they been convicted. Such a possibility was reduced when the Supreme Court ruled, in the case of Jackson v. Indiana (1972), that an incompetent defendant cannot be indefinitely committed. After a reasonable amount of time, he or she should either be found competent and tried, set free, or transferred to a mental health facility under civil commitment procedures.
Until the early 1970s, most states required that mentally incompe- tent defendants be committed to maximum security institutions for the “criminally insane.” Under current law, however, the courts have more flexibility. In fact, when the charges are relatively minor, such defendants are often treated on an outpatient basis, an arrangement often called jail diversion because the disturbed person is “diverted” from jail to the com- munity for mental health care (Hernandez, 2014).
Prisoners General population
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figure 16-2 Prison and mental health According to studies conducted in several Western coun- tries, psychological disorders are much more prevalent in prison populations than in the general population. For example, schizophre- nia is four times more common and personality disorders (particularly antisocial personality disorder) are five times more common among prisoners than among nonprisoners. (Informa- tion from: Andreoli et al., 2014; Butler et al., 2006; Fazel & Danesh, 2002.)
table: 16-1
Multicultural Issues: Race and Forensic Psychology
• Psychologically disturbed people from racial minority groups are more likely than disturbed white Americans to be sent to prison, as opposed to mental health facilities.
• Among defendants evaluated for competence to stand trial, those from racial minority groups are more likely than white American defendants to be referred for inpatient evaluations.
• When nonwhite and white defendants are evaluated for competence to stand trial, the defendants from racial minority groups are more likely to be found incompetent to stand trial.
• In New York State, 42 percent of all people ordered into involuntary outpatient commitment are African American, 34 percent are white American, and 21 percent are Hispanic American. In contrast, these three groups comprise, respectively, 17 percent, 61 percent, and 16 percent of New York’s general population.
(Information from: Haroules, 2007; Pinals et al., 2004; Grekin et al., 1994; Arvanites, 1989)
: chapter 16536
➤ Summing Up How Do CLINICIANs INFLueNCe tHe CRIMINAL JustICe systeM? One of the ways in which the mental health profession interacts with the legislative and judicial systems is that clinicians may help assess the mental stability of people accused of crimes. Evaluations by clinicians may help judges and juries decide whether defendants are responsible for crimes or capable of defending them- selves in court.
If defendants are judged to have been mentally unstable at the time they committed a crime, they may be found not guilty by reason of insanity and placed in a treatment facility rather than a prison. In federal courts and about half the state courts, insanity is judged in accordance with the M’Naghten test. Other states use the broader American Law Institute test.
The insanity defense has been criticized on several grounds, and some states have added an additional option, guilty but mentally ill. Another verdict option is guilty with diminished capacity. A related category consists of convicted sex offenders, who are considered in some states to have a mental disorder and are therefore assigned to treatment in a mental health facility.
Regardless of their state of mind at the time of the crime, defendants may be found mentally incompetent to stand trial, that is, incapable of fully understand- ing the charges or legal proceedings that confront them. These defendants are typically sent to a mental hospital until they are competent to stand trial.
How Do the Legislative and Judicial Systems Influence Mental Health Care? Just as clinical science and practice have influenced the legal system, so the legal system has had a major impact on clinical practice. First, courts and legislatures have developed the process of civil commitment, which allows certain people to be forced into mental health treatment. Although many people who show signs of mental disturbance seek treatment voluntarily, a large number are not aware of their problems or are simply not interested in undergoing therapy. For such people, civil commitment procedures may be put into action.
Second, the legal system, on behalf of the state, has taken on the responsibility of protecting patients’ rights during treatment. This protection extends not only to patients who have been involuntarily committed but also to those who seek treat- ment voluntarily, even on an outpatient basis.
Civil Commitment Every year in the United States, large numbers of people with mental disorders are involuntarily committed to treatment. Typically they are committed to mental institutions, but 45 states also have some form of outpatient civil commitment laws that allow patients to be forced into community treatment pro- grams (Morrissey et al., 2014; Swanson & Swartz, 2014). Civil commitments have long caused considerable debate. In some ways the law provides more protection for people suspected of being criminals than for people suspected of being psychotic (Strachan, 2008; Burton, 1990).
Why Commit? Generally our legal system permits involuntary commitment of indi- viduals when they are considered to be in need of treatment and dangerous to themselves or others. People may be dangerous to themselves if they are suicidal or if they act recklessly (for example, drinking a drain cleaner to prove that they are immune to its chemicals). They may be dangerous to others if they seek to harm them or if they unintentionally place others at risk. The state’s authority to commit disturbed people rests on its duties to protect the interests of the individual and of society.
“Outpatient” care Prison inmates await treatment at a mental health treatment facility in California. The majority of those criminally committed for psychological treatment in the United States are prisoners who develop psychological disorders that have little or nothing to do with the crimes that led to their incarceration.
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In Their Words “Our [legal] confusion is eliminated, we believe, if we resort to that quintes- sential twentieth-century solution to hard problems: We refer the problem to an expert.”
(Winslade and ross, 1983)
Law, Society, and the Mental Health Profession : 537
What are the ProCedures for CiVil Commitment? Civil commitment laws vary from state to state. Some basic procedures, however, are common to most of these laws. Often family members begin commitment proceedings. In response to a son’s psychotic behavior and repeated assaults on other people, for example, his parents may try to persuade him to seek admission to a mental institution. If the son refuses, the parents may go to court and seek an involuntary commitment order. If the son is a minor, the process is simple. The Supreme Court has ruled that a hearing is not necessary in such cases, as long as a qualified mental health professional considers commitment necessary. If the son is an adult, however, the process is more involved. The court usually will order a mental examination and allow the person to contest the commitment in court, often represented by a lawyer.
The Supreme Court has ruled that before an individual can be committed, there must be “clear and convincing” proof that he or she is mentally ill and has met the state’s criteria for involuntary commitment. The ruling does not suggest what criteria should be used. That matter is still left to each state. But, whatever the state’s criteria, clinicians must offer clear and convincing proof that the person meets those criteria. When is proof clear and convincing, according to the court? When it provides 75 percent certainty that the criteria of commitment have been met. This is far less than the near-total certainty (“beyond a reasonable doubt”) required to convict people of committing a crime.
emergenCy Commitment Many situations require immediate action; no one can wait for commitment proceedings when a life is at stake. Consider, for example, an emergency patient who is suicidal or hearing voices demanding hostile actions against others. He or she may need immediate treatment and round-the-clock supervision. If treatment could not be given in such situations without the patient’s full consent, the consequences could be tragic.
Therefore, many states give clinicians the right to certify that certain patients need temporary commitment and medication. In past years, these states required certification by two physicians (not necessarily psychiatrists in some of the states). Today states may allow certification by other mental health professionals as well. The clinicians must declare that the state of mind of the patient makes them dan- gerous to themselves or others. By tradition, the certifications are often referred to
Dangerous to oneself The public often thinks that the term “dangerous to oneself” refers exclusively to those who are suicidal. There are, however, other ways that people may pose a danger to themselves, be in need of treatment, and be subject to civil commit- ment. This sequence of photos shows a man being attacked by a lion at the zoo after he crossed a barbed wire fence to “preach” to two of the animals.AF
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▶▶ civil commitment A legal process by which a person can be forced to undergo mental health treatment.
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as two-physician certificates, or 2 PCs. The length of such emergency commitments varies from state to state, but three days is often the limit. Should clinicians come to believe that a longer stay is necessary, formal commit- ment proceedings may be initiated during the period of emergency commitment.
Who is dangerous? In the past, people with mental disorders were actually less likely than others to commit violent or dangerous acts. This low rate of violence was apparently related to the fact that so many such people lived in institutions. As a result of deinstitutionalization, however, hundreds of thousands of people with severe disturbances now live in the community, and many of them receive little, if any, treatment. Some are indeed dangerous to themselves or others.
Although approximately 90 percent of people with mental disorders are in no way violent or dangerous, studies now suggest at least a small relationship between
severe mental disorders and violent behavior (Glied & Frank, 2014; Palijan et al., 2010). The disorders with the strongest relationships to violence are severe sub- stance use disorder, impulse control disorder, antisocial personality disorder, and psychotic disorders (Ten Have et al., 2014; Volavka, 2013). Of these, substance use disorder appears to be the single most influential factor. For example, schizophrenia compounded by substance use disorder has a stronger relationship to violence than schizophrenia alone does.
A judgment of dangerousness is often required for involuntary civil commitment. But can mental health professionals accurately predict who will commit violent acts? Research suggests that psychiatrists and psychologists are wrong more often than right when they make long-term predictions of violence (Pistone, 2013; Mills et al., 2011; Palijan et al., 2010). Most often they overestimate the likelihood that a patient will eventually be violent. Their short-term predictions—that is, predic- tions of imminent violence—tend to be more accurate (Stanislaus, 2013; Otto & Douglas, 2010). Researchers are now working, with some success, to develop new assessment techniques that use statistical approaches and are more objective in their predictions of dangerousness than are the subjective judgments of clinicians (Pinals & Mossman, 2012).
What are the Problems With CiVil Commitment? Civil commitment has been criticized on several grounds (Evans & Salekin, 2014; Falzer, 2011; Winick, 2008). First is the difficulty of assessing a person’s dangerousness. If judgments of danger- ousness are often inaccurate, how can one justify using them to deprive people of liberty? Second, the legal definitions of “mental illness” and “dangerousness” are vague. The terms may be defined so broadly that they could be applied to almost anyone an evaluator views as undesirable. Indeed, many civil libertarians worry about involuntary commitment being used to control people, as was done in the former Soviet Union and now seems to be taking place in China, where mental hospitals house people with unpopular political views. A third problem is the some- times questionable therapeutic value of civil commitment. Research suggests that many people committed involuntarily do not respond well to therapy.
trends in CiVil Commitment The flexibility of the involuntary commitment laws probably reached a peak in 1962. That year, in the case of Robinson v. California, the Supreme Court ruled that imprisoning people who suffered from drug addiction might violate the Constitution’s ban on cruel and unusual punishment, and it rec- ommended involuntary civil commitment to a mental hospital as a more reasonable
Failure to predict A school surveillance camera shows Dylan Klebold and Eric Harris in the midst of their killing rampage at Columbine High School in Littleton, Colorado, in 1999. Although the teenagers had built a violent Web site, threatened other students, had prob- lems with the law, and, in the case of one of the boys, received treatment for psychological problems, professionals were not able to pre- dict or prevent their violent behavior.
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Illusion of Knowledge 75% Percentage of psychologists
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90% Percentage of same psycholo- gists who feel confident that their legal knowledge in this realm is accurate.
(thomas, 2014)
Law, Society, and the Mental Health Profession : 539
action. This ruling encouraged the civil commitment of many kinds of “social deviants,” and many such individuals found it difficult to obtain release from the
hospitals to which they were committed. During the late 1960s and early 1970s,
reporters, novelists, civil libertarians, and others spoke out against the ease with which so many people were being unjustifiably committed to mental hospitals. As the public became more aware of these issues, state legislatures started
to pass stricter standards about involuntary commitment (Pekkanen, 2007, 2002). Some states, for example, spelled out specific types of behavior that a person had to show before he or she could be determined to be dangerous. Rates of involuntary commitment then declined and release rates rose. Fewer people are institutionalized through civil commitment procedures today than in the past.
Protecting Patients’ Rights Over the past two decades, court decisions and state and federal laws have significantly expanded the rights of patients with mental disorders, in particular the right to treatment and the right to refuse treatment (Lepping & Raveesh, 2014).
hoW is the right to treatment ProteCted? When people are committed to mental institutions and do not receive treatment, the institutions become, in effect, prisons for the unconvicted. To many patients in the late 1960s and the 1970s, large state mental institutions were just that, and some patients and their attorneys began to demand that the state honor their right to treatment. In the landmark case of Wyatt v. Stickney, a suit on behalf of institutionalized patients in Alabama in 1972, a federal court ruled that the state was constitutionally obligated to provide “adequate treatment” to all people who had been committed involuntarily. Because conditions in the state’s hospitals were so terrible, the judge laid out goals that state officials had to meet, including more therapists, better living conditions, more privacy, more social interactions and physical exercise, and a more proper use of physical restraint and medication. Other states have since adopted many of these standards.
Another important decision was handed down in 1975 by the Supreme Court in the case of O’Connor v. Donaldson. After being held in a Florida mental institution for more than 14 years, Kenneth Donaldson sued for release. He argued that he and his fellow patients were receiving poor treatment, were being largely ignored by the staff, and were allowed little personal freedom. The Supreme Court ruled in his favor, fined the hospital’s superintendent, and said that such institutions must review patients’ cases periodically. The justices also ruled that the state cannot continue to institutionalize people against their will if they are not danger- ous and are capable of surviving on their own or with the willing help of responsible family members or friends.
To help protect the rights of patients, Congress passed the Protection and Advocacy for Mentally Ill Individuals Act in 1986. This law set up protection and advocacy systems in all states and gave public advocates who worked for patients the power to investigate possible abuse and neglect and to correct those problems legally.
In recent years, public advocates have argued that the right to treatment also should be extended to the tens of thousands of people with severe mental disorders who are repeatedly released from hospitals into ill-equipped communities. Many such people have no place to go and are unable to care for themselves, often winding up homeless or in prisons (Ogden, 2014; Althouse, 2010). A number of advocates are now suing
how are people who have
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Hospital neglect While some countries increasingly have attended to the rights of patients in recent decades, including their rights to treatment and to humane treatment conditions, other countries, especially poor ones, have lagged behind. This scene inside a government-run center for mental patients in Jakarta, Indonesia, underscores this point.
▶▶ right to treatment The legal right of patients, particularly those who are invol untarily committed, to receive adequate treatment.
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federal and state agencies throughout the country, demanding that they fulfill the promises of the community mental health movement (see Chapter 12).
hoW is the right to refuse treatment ProteCted? During the past two decades, the courts have also decided that patients, particularly those in institu- tions, have the right to refuse treatment (Ford & Rotter, 2014; Perlin, 2004, 2000). Most of the right-to-refuse-treatment rulings center on biological treatments. These treatments are easier to impose on patients without their cooperation than psychotherapy, and they often are more hazardous. For example, state rulings have consistently granted patients the right to refuse psychosurgery, the most irreversible form of physical treatment—and often the most dangerous.
Some states have also acknowledged a patient’s right to refuse electroconvulsive therapy (ECT ), the treatment used in many cases of severe depression (see Chapter 6). However, the right-to-refuse issue is more complex with regard to ECT than to psychosurgery. ECT is very effective for many people with severe depression, yet it can cause great upset and can also be misused. Today many states grant patients— particularly voluntary patients—the right to refuse ECT. Usually a patient must be informed fully about the nature of the treatment and must give written consent to it. A number of states continue to permit ECT to be forced on committed patients, whereas others require the consent of a close relative or other third party in such cases.
In the past, patients did not have the right to refuse psychotropic medications. As you have read, however, many psychotropic drugs are very powerful, and some pro- duce effects that are unwanted and dangerous. As these harmful effects have become more apparent, some states have granted patients the right to refuse medication. Typically, these states require physicians to explain the purpose of the medication to patients and obtain their written consent. If a patient’s refusal is considered incompetent, dangerous, or irrational, the state may allow it to be overturned by an independent psychiatrist, medical committee, or local court. However, the refusing patient is supported in this process by a lawyer or other patient advocate.
What other rights do Patients haVe? Court decisions have protected still other patient rights over the past several decades. Patients who perform work in mental institutions, particularly private institutions, are now guaranteed at least a minimum wage. In addition, according to a court decision, patients released from state mental hospitals have a right to aftercare and to an appropriate community residence, such as a group home. And more generally, people with psychological disorders should receive treatment in the least restrictive facility available. If an inpatient program at a community mental health center is available and appropriate, for example, then that is the facility to which they should be assigned, not a mental hospital.
the “rights” debate Certainly, people with psychological disorders have civil rights that must be protected at all times. However, many clinicians express concern that the patients’ rights rulings and laws may unintentionally deprive these patients of opportunities for recovery. Consider the right to refuse medication. If medica- tions can help a patient with a severe mental disorder to recover, doesn’t the patient have the right to that recovery? If confusion causes the patient to refuse medication, can clinicians in good conscience delay medication while legal channels are cleared?
Despite such legitimate concerns, keep in mind that the clinical field has not always done an effective job of protecting patients’ rights. Over the years, many patients have been overmedicated and received improper treatments. Furthermore, one must ask whether the field’s present state of knowledge justifies clinicians’ over- riding of patients’ rights. Can clinicians confidently say that a given treatment will help a patient? Can they predict when a treatment will have harmful effects? Since clinicians themselves often disagree, it seems appropriate for patients, their advocates, and outside evaluators to also play key roles in decision making.
Executing the mentally ill Charles Singleton, a man who killed a store clerk in Arkansas, was sentenced to death in 1979, and then developed schizophrenia at some point after the trial. Inasmuch as the United States does not allow executions if a person cannot understand why he or she is being executed, state officials wanted Singleton to take medica- tions to clear up his psychosis. After years of legal appeals, the U.S. Supreme Court ruled in 2003 that Singleton was by then taking medica- tions voluntarily, and he was executed by lethal injection in 2004.
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▶▶ malpractice suit A lawsuit charging a therapist with improper conduct in the course of treatment.
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➤ Summing Up How Does tHe LeGAL systeM INFLueNCe MeNtAL HeALtH CARe? Courts may be called upon to commit noncriminals to mental hospitals for treatment, a process called civil commitment. Society allows such involuntary commitment for people considered to be in need of treatment and dangerous to themselves or others. Laws and criteria governing civil commitment procedures vary from state to state, but the Supreme Court has ruled that, whatever the state’s crite- ria, clinicians must offer clear and convincing evidence that the individuals are mentally ill and meet the state’s criteria for civil commitment.
The courts and legislatures also affect the mental health profession by speci- fying legal rights to which patients are entitled. The rights that have received the most attention are the right to treatment and the right to refuse treatment.
In What Other Ways Do the Clinical and Legal Fields Interact? Mental health and legal professionals may influence each other’s work in other ways as well. During the past 25 years, their paths have crossed in four key areas: malpractice suits, professional boundaries, jury selection, and psychological research of legal topics.
Malpractice Suits The number of malpractice suits against therapists has risen sharply in recent years. Claims have been made against clinicians in response to a patient’s attempted suicide, sexual activity with a patient, failure to obtain informed consent for a treatment, negligent drug therapy, omission of drug therapy that would speed improvement, improper termination of treatment, and wrongful commitment (Sher, 2015; Reich & Schatzberg, 2014). Studies suggest that malprac- tice suits, or the fear of them, can have significant effects on clinical decisions and practice, for better or for worse (Appelbaum, 2011; Feldman et al., 2005).
Professional Boundaries Over the past two decades, the legislative and judicial systems have helped to change the boundaries that distinguish one clinical profession from another. In particular, they have given more authority to psycholo- gists and blurred the lines that once separated psychiatry from psychology. A grow- ing number of states, for example, are ruling that psychologists can admit patients to the state’s hospitals, a power previously held only by psychiatrists.
In 1991, with the blessing of Congress, the Department of Defense (DOD) started to reconsider the biggest difference of all between the practices of psychiatrists and psychologists— the authority to prescribe drugs, a role previ- ously denied to psychologists. The DOD set up a trial training program for Army psychologists. Given the apparent success of this trial program,
the American Psychological Association later recommended that all psychologists be allowed to attend a special educational program in prescription services and receive certification to prescribe medications if they pass. New Mexico, Louisiana, Illinois, and the U.S. territory of Guam now do grant prescription privileges to psycholo- gists who receive special pharmacology training (APA, 2014).
Jury Selection During the past 30 years, more and more lawyers have turned to clinicians for psychological advice in conducting trials (Crouter, 2015; Hope, 2010). A new breed of clinical specialists, known as “jury specialists,” has evolved. They advise lawyers about which potential jurors are likely to favor their side and which
Fear of litigation Psychologists are not the only ones who fear litigation for providing help to others. It is becoming a worldwide con- cern. A woman who fell off this escalator at a department store in Shanghai, China, was left unattended despite the presence of numerous onlookers. The reason? Fear of litigation. Inci- dents of good Samaritans becoming victims of litigation have become more frequent in China and other countries.
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strategies are likely to win jurors’ support during trials. The jury specialists make their suggestions on the basis of surveys, interviews, analyses of jurors’ backgrounds and attitudes, and laboratory enactments of upcoming trials. However, it is not clear that a clinician’s advice is more valid than a lawyer’s instincts or that the judgments of either are particularly accurate.
Psychological Research of Legal Topics Psychologists have sometimes conducted studies and developed expertise on topics of great importance to the criminal justice system. In turn, these studies influence how the system carries out
its work. Psychological investigations of two topics, eyewitness testimony and patterns of criminality, have gained particular attention.
eyeWitness testimony In criminal cases, testimony by eyewitnesses is extremely influential. It often determines whether a defendant will be found guilty or not guilty. But how accurate is eyewitness testimony? This question has become urgent, as a troubling number of prisoners (many on death row) have had their convictions overturned after DNA evidence revealed that they could not have committed the crimes of which they had been convicted. It turns out that more than 75 percent of such wrongful convictions were based in large part on mistaken eyewitness testimony (Wise et al., 2014).
Most eyewitnesses undoubtedly try to tell the truth about what or who they saw. Yet research indicates that eyewitness testimony can be highly unre- liable, partly because most crimes are unexpected and fleeting and therefore not the sort of events remembered well (Houston et al., 2013). During the crime, for example, lighting may be poor or other distractions may be present. Witnesses may have had other things on their minds, such as concern for their
own safety or that of bystanders. Such concerns may greatly impair later memory. In laboratory studies, researchers have found it easy to fool research participants
who are trying to recall the details of an observed event simply by introducing misinformation (Morgan et al., 2013; Laney & Loftus, 2010). After a suggestive description by the researcher, stop signs can be transformed into yield signs, white cars into blue ones, and Mickey Mouse into Minnie Mouse (Pickel, 2004; Loftus, 2003). In addition, laboratory studies indicate that persons who are highly suggest- ible have the poorest recall of observed events (Liebman et al., 2002).
As for identifying actual perpetrators, research has found that accuracy is heav- ily influenced by the method used in identification (Bartol & Bartol, 2015; Garrett, 2011). The traditional police lineup, for example, is not always a highly reliable technique, and the errors that witnesses make when looking at lineups tend to stick (Wells et al., 2015, 2011; Wells, 2008). Researchers have also learned that witnesses’ confidence is not necessarily related to accuracy (Wise et al., 2014; Ghetti et al., 2004). Witnesses who are “absolutely certain” may be no more correct in their recollections than those who are only “fairly sure.” Yet the degree of a witness’s confidence often influences whether jurors believe his or her testimony.
Psychological investigations into the memories of eyewitnesses have not yet undone the judicial system’s reliance on or respect for those witnesses’ testimony. Nor should it. The distance between laboratory studies and real-life events is often great, and the findings from such studies must be applied with care. Still, eyewitness research has begun to make an impact. Studies of hypnosis and of its ability to create false memories, for example, have led most states to prohibit eyewitnesses from testifying about events or details if their recall of the events was initially helped by hypnosis.
Patterns of Criminality A growing number of television shows, movies, and books suggest that clinicians often play a major role in criminal investigations by providing police with psychological profiles of perpetrators—“He’s probably white, in his 30s, has a history of animal torture, has few friends, and is subject to emotional outbursts.” The study of criminal behavior patterns and of profiling has increased
Eyewitness error Psychological research indicates that eyewitness testimony is often invalid. Here a woman talks to the man whom she had identified as her rapist back in 1984. DNA testing eventually proved that a different person had raped her, and the incorrectly iden- tified man was released — after having served 11 years of a life sentence in prison.
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Law, Society, and the Mental Health Profession : 543
in recent years; however, it is not nearly as revealing or influential as the media and the arts would have us believe (Kocsis & Palermo, 2013; Salfati, 2011).
On the positive side, researchers have gathered information about the psycho- logical features of various criminals, and they have indeed found that perpetrators of particular kinds of crimes—serial murder or serial sexual assault, for example— frequently share a number of traits and background features (see PsychWatch). But while such traits are often present, they are not always present, and so applying pro- file information to a particular crime can be wrong and misleading (Hickey, 2015;
PsychWatch
In late 2001, a number of anthrax-tainted letters were mailed to people through-out eastern parts of the United States, leading to five deaths and to severe illness in 13 other people. After years of work, in 2008 the FBI identified a biodefense researcher named Bruce Ivins as the killer. With a murder indictment imminent, Ivins committed suicide on July 29, 2008. It ap- peared that the FBI had finally found the perpetrator of these terrible deeds.
Although Ivins’ suicide left behind unanswered questions, the FBI has con- cluded that this troubled man was indeed the anthrax killer. He appears to have been one of a growing list of serial killers who have fascinated and horrified Ameri- cans over the years: Theodore Kaczynski (“Unabomber”), Ted Bundy, David Berkowitz (“Son of Sam”), Albert DeSalvo, John Wayne Gacy, Jeffrey Dahmer, John Allen Muhammad, Lee Boyd Malvo, Dennis Rader (“BTK killer”), and more.
The FBI estimates that there are be- tween 35 and 100 serial killers at large in the United States at any given time (FBI, 2014). Worldwide, 3,900 such killers have been identified since the year 1900 (Aamodt, 2014).
Each serial killer follows his or her own pattern, but many of them appear to have certain characteristics in common (Hickey, 2015; FBI, 2014; Fox & Levin, 2014). Most—but certainly not all—are white males between 25 and 34 years old, of average to high intelligence, generally clean-cut, smooth-talking, attractive, and skillful manipulators.
A number of serial killers seem to dis- play severe personality disorders (Hickey,
2015; Dogra et al., 2012; Waller, 2010). Lack of conscience and an utter disregard for people and the rules of society— key features of antisocial personality disorder—are typical. Narcissistic think- ing is quite common as well. The feeling of being special may even give the killer an unrealistic belief that he will not get caught (Kocsis, 2008; Wright et al., 2006). Often it is this sense of invincibility that leads to his capture.
Sexual dysfunction and fantasy also seem to play a part (FBI, 2014; Arndt et al., 2004). Studies have found that vivid fantasies, often sexual and sadistic, may help drive the killer’s behavior (Homant & Kennedy, 2006). Some clinicians also
believe that the killers may be trying to overcome general feelings of powerless- ness by controlling, hurting, or eliminating those who are momentarily weaker (Fox & Levin, 2014). A number of the killers were abused as children—physically, sexually, and emotionally (Hickey, 2015; Wright et al., 2006).
Despite such profiles and suspicions, clinical theorists do not yet understand why serial killers behave as they do. But most agree with Park Dietz, a highly re- garded forensic expert, when he asserts, “It’s hard to imagine any circumstance under which they should be released to the public again” (Douglas, 1996, p. 349).
Serial Murderers: Madness or Badness?
Serial murder by mail In 2001, a hazardous-material worker sprays his colleagues as they depart the Senate Office Building after searching the building for traces of anthrax, an acute infectious disease caused by a spore-forming bacterium.
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Aamodt, 2014). Increasingly, police are consulting psycho- logical profilers, and this practice appears to be helpful as long as the limitations of profiling are recognized (Kocsis & Palermo, 2013).
A reminder of the limitations of profiling comes from the case of the snipers who terrorized the Washington, DC, area for three weeks in October 2002, shooting 10 people dead and seriously wounding 3 others. Most of the profiling done by FBI psychologists had suggested that the sniper was acting alone; it turned out that the attacks were conducted by a pair: a middle-aged man, John Allen Muhammad, and a teenage boy, Lee Boyd Malvo. Although profiles had suggested a young thrill-seeker, Muhammad was 41. Profilers had believed the attacker to be white, but neither Muhammad nor Malvo was white. The prediction of a male attacker was correct, but then again female serial killers are relatively rare.
➤ Summing Up otHeR CLINICAL–LeGAL INteRACtIoNs Mental health and legal profession- als also cross paths in four other areas. First, malpractice suits against therapists have increased in recent years. Second, the legislative and judicial systems help define professional boundaries. Third, lawyers may solicit the advice of men- tal health professionals regarding the selection of jurors and case strategies. Fourth, psychologists may investigate legal phenomena such as eyewitness testimony and patterns of criminality.
What Ethical Principles Guide Mental Health Professionals? Discussions of the legal and mental health systems may sometimes give the impres- sion that clinicians as a group are uncaring and are considerate of patients’ rights and needs only when they are forced to be. This, of course, is not true. Most clini- cians care greatly about their clients and strive to help them while at the same time respecting their rights and dignity (Pope & Vasquez, 2016, 2011). In fact, clinicians do not rely exclusively on the legislative and court systems to ensure proper clinical practice. They also regulate themselves by continually developing and revising ethi- cal guidelines for their work and behavior. Many legal decisions do nothing more than place the power of the law behind these already existing professional guidelines.
Each profession within the mental health field has its own code of ethics. The code of the American Psychological Association (2014, 2010, 2002) is typical. This code, highly respected by other mental health professionals and public officials, includes specific guidelines:
1. Psychologists are permitted to offer advice in self-help books, on DVDs, on television and radio programs, in newspaper and magazines, and in other places, provided they do so responsibly and professionally and base their ad- vice on appropriate psychological literature and practices. Psychologists are bound by these same ethical requirements when they offer advice and ideas online, whether on individual Web pages, blogs, bulletin boards, or chat rooms. Internet-based professional advice has proved difficult to regulate, however,
Misleading profile Police search for clues outside a Home Depot in Virginia in 2002, hoping to identify and capture the serial sniper who killed 10 people and terrorized residents throughout Washington, DC; Maryland; and Virginia. Psychological profiling in this case offered limited help and even misled the police in certain respects.
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▶▶ confidentiality The principle that certain professionals will not divulge the information they obtain from a client.
Law, Society, and the Mental Health Profession : 545
because the number of such offerings keeps getting larger and larger and so many advice-givers do not appear to have any profes- sional training or credentials.
2. Psychologists may not conduct fraudulent research, plagiarize the work of others, or publish false data. During the past 35 years cases of scientific fraud or misconduct have been discovered in all of the sciences, including psychology. These acts have led to misunder- standings of important issues, taken scientific research in the wrong direction, and damaged public trust. Unfortunately, the impressions created by false findings may continue to influence the thinking of both the public and other scientists for years.
3. Psychologists must acknowledge their limitations with regard to patients who are disabled or whose gender, ethnicity, language, socioeconomic status, or sexual orientation differs from that of the therapist. This guideline often requires psychotherapists to obtain additional training or supervision, consult with more knowledge- able colleagues, or refer clients to more appropriate professionals.
4. Psychologists who make evaluations and testify in legal cases must base their assessments on sufficient information and substantiate their findings appropriately. If an adequate examination of the in- dividual in question is not possible, psychologists must make clear the limited nature of their testimony.
5. Psychologists may not take advantage of clients and students, sexu- ally or otherwise. This guideline relates to the social problem of sexual harassment, as well as the problem of therapists who take sexual advantage of clients in therapy. The code specifically forbids a sexual relationship with a present or former therapy client for at least two years after the end of treatment—and even then such a relationship is permit- ted only in “the most unusual circumstances.” Furthermore, psychologists may not accept as clients people with whom they have previously had a sexual relationship.
Research has clarified that clients may suffer great emotional damage from sexual involvement with their therapists (Pope & Vasquez, 2016, 2011; Pope & Wedding, 2014). How many therapists actually have a sexual relationship with a client? On the basis of various surveys, reviewers have estimated that 4 to 5 percent of today’s therapists engage in some form of sexual misconduct with patients, down from 10 percent more than a decade ago.
Although the vast majority of therapists do not engage in sexual behavior of any kind with clients, their ability to control private feelings is apparently another matter. In surveys, more than 80 percent of therapists reported having been sexually attracted to a client, at least on occasion (Pope & Vasquez, 2016, 2011; Pope & Wedding, 2014). Although few of these therapists acted on their feelings, most of them felt guilty, anxious, or concerned about the attraction. Given such issues, it is not surprising that sexual ethics training is given high priority in many of today’s clinical training programs.
6. Psychologists must follow the principle of confidentiality. All of the state and federal courts have upheld laws protecting therapist confidentiality (Fisher, 2013; Nagy, 2011). For peace of mind and to ensure effective therapy, clients must be able to trust that their private exchanges with a therapist will not be repeated to others. There are times, however, when the principle of confi- dentiality must be compromised (Pope & Vasquez, 2016, 2011). A therapist in training, for example, must discuss cases on a regular basis with a supervisor, and clients must be informed that such discussions are taking place.
The ethics of giving professional advice Today’s psychologists are bound by the field’s ethics code to base their advice on psycho- logical theories and findings. In 2006, the enormously popular Phil McGraw (“Dr. Phil”) surrendered his Texas psychologist license so that he could be free to use his own best judg- ment when giving advice on television and in books.
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A second exception arises in cases of outpatients who are clearly danger- ous. The 1976 case of Tarasoff v. Regents of the University of California, one of the most important cases to affect client–therapist relationships, concerned an outpatient at a University of California hospital. He had confided to his therapist that he wanted to harm his former girlfriend, Tanya Tarasoff. Several days after ending therapy, the former patient fulfilled his promise. He stabbed Tanya Tarasoff to death.
Should confidentiality have been broken in this case? The therapist, in fact, felt that it should. Campus police were notified, but the patient was released after some questioning. In their suit against the hospital and therapist, the victim’s parents argued that the therapist should have also warned them and their daughter that the patient intended to harm Ms. Tarasoff. The California Supreme Court agreed: “The protective privilege ends where the public peril begins.”
The current code of ethics for psychologists thus declares that therapists have a duty to protect—a responsibility to break confidentiality, even with- out the client’s consent, when it is necessary “to protect the client or others from harm.” Since the Tarasoff ruling, most states have passed “duty to protect” bills that clarify the rules of confidentiality for therapists and protect them from certain civil suits (Knoll, 2015).
Mental Health, Business, and Economics The legislative and judicial systems are not the only social institutions with which mental health professionals interact. The business and economic fields are two other sectors that influence and are influenced by clinical practice and study.
Bringing Mental Health Services to the Workplace Untreated psychological disorders are, collectively, among the 10 leading categories of work-related disorders and injuries (Negrini et al., 2014; Kemp, 1994). Almost one-third of all employees are estimated to experience psychological problems that are serious enough to affect their work (Larsen et al., 2010). Psychological problems contribute to 60 percent of all absenteeism from work, up to 90 percent of industrial accidents, and to 65 percent of work terminations. Alcohol abuse and other sub- stance use disorders are particularly damaging. The business world has often turned to clinical professionals to help prevent and correct such problems.
Two common means of providing mental health care in the workplace are employee assistance programs and stress-reduction seminars (Sledge & Lazar, 2014; Merrick et al., 2011; Daw, 2001). Employee assistance programs are mental health services made available by a place of business. They are run either by mental health profes- sionals who work directly for the company or by outside mental health agencies. Stress-reduction, or problem-solving, seminars are workshops or group ses- sions in which mental health professionals teach employees techniques for coping, solving problems, and handling and reducing stress. Businesses believe that employee assistance programs and stress-reduction seminars save them money in the long run by preventing psychological problems from interfering with work performance and by reducing employee insurance claims.
The Economics of Mental Health You have already seen how economic decisions by the government may influence the clinical field’s treatment of people with severe mental disorders. For example, the desire of the state and federal governments to reduce costs was an important con- sideration in the country’s deinstitutionalization movement, which contributed to
Institutional ethics During the American Psychological Association Conference in 2007, these protesters rallied against participation by psychologists in “enhanced interrogations” (i.e., torture questioning) of suspected terrorists. Despite concerns of this kind, a 2015 report revealed that, over a period of several years, the APA did in fact aid the Department of Defense and the CIA in the development of such techniques, gave advice to interrogators, and adjusted professional guidelines to allow psychologist involvement in such interroga- tions. These revelations led to several changes in APA leadership and to an APA membership vote banning psychologists from direct and indirect involvement in all national security interrogations—both enhanced and noncoercive.
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the premature release of hospital patients into the community. Economic decisions by government agencies may affect other kinds of clients and treatment programs as well.
As you read in Chapter 12, government funding for services to people with psychological disorders has risen sharply over the past five decades, from $1 billion in 1963 to around $171 billion today (Rampell, 2013; Gill, 2010). Around 30 per- cent of that money is spent on prescription drugs, but much of the rest is targeted for income support, housing subsidies, and other such expenses rather than direct mental health services (Feldman et al., 2014). The result is that government funding for mental health services is, in fact, insufficient. People with severe mental disorders are hit hardest by the funding shortage. The number of people on waiting lists for community-based services grew from 200,000 in 2002 to 393,000 in 2008 (Daly, 2010), and that number has continued to rise in recent years.
Government funding currently covers around two-thirds of all mental health services, leaving a mental health expense of tens of billions of dollars for individual patients and their private insurance companies (Rampell, 2013; Nordal, 2010; Mark et al., 2008, 2005). This large economic role of private insurance companies has had a significant effect on the way clinicians go about their work. As you’ll remember from Chapter 1, to reduce their expenses, most of these companies have developed
managed care programs, in which the insur- ance company decides which therapists clients may choose from, the cost of sessions, and the number of sessions for which a client may be reimbursed (Lustig et al., 2013; Turner, 2013). These and other insurance plans may also control expenses through the use of peer review systems, in which clini- cians who work for the insurance company peri-
odically review a client’s treatment program and recommend that insurance benefits be either continued or stopped. Typically, insurers require reports or session notes from the therapist, often including intimate personal information about the patient.
As you also read in Chapter 1, many therapists and clients dislike managed care programs and peer reviews. They believe that the reports required of therapists breach confidentiality, even when efforts are made to protect anonymity, and that the importance of therapy in a given case is sometimes difficult to convey in a brief report. They also argue that the priorities of managed care programs inevitably shorten therapy, even if longer-term treatment would be advisable in particular cases. The priorities may also favor treatments that offer short-term results (for example, drug therapy) over more costly approaches that might yield more promising long-term improvement. As in the medical field, there are disturbing stories about patients who are prema- turely cut off from mental health services by their managed care programs.
Yet another major problem with insurance coverage in the United States—both managed care and other insurance programs—is that reimbursements for mental disorders tend to be lower than those for medical disorders (Sipe et al., 2015). As you have read, the government has tried to address this problem in recent years by passing federal parity laws that direct insurance companies to provide equal coverage for mental and medical problems (see pages 17–18). The mental health provisions of the Affordable Care Act (ACA), commonly known as “Obamacare,” designate mental health care as 1 of 10 types of “essential health benefits” that must be provided by all insurers (SAMHSA, 2014; Calmes & Pear,
Caught in an economic spiral Group home residents and mental health advocates rally at the legislative office building in Raleigh, North Carolina, to protest a Medicaid payment law change. This change could result in resi- dents with severe mental disorders losing their group homes and having nowhere to live.
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▶▶ duty to protect The principle that therapists must break confidentiality in order to protect a person who may be the intended victim of a client.
▶▶ employee assistance program A mental health program offered by a business to its employees.
▶▶ stress-reduction seminars Work shops or group sessions offered by businesses, in which mental health pro fessionals teach employees how to cope, solve problems, and/or reduce stress. Also known as problem-solving seminars.
▶▶ managed care program An insur ance program in which the insurance company decides the cost, method, pro vider, and length of treatment.
▶▶ peer review system A system by which clinicians paid by an insurance com pany may periodically review a patient’s progress and recommend the continua tion or termination of insurance benefits.
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2013). The act further requires mental health parity and demands that insur- ers allow new and continued membership to people with preexisting mental conditions. All of this is promising, but it is not yet clear that such provisions will, in fact, yield better treatment for people with psychological problems.
Technology and Mental Health Technology is always changing and, like most other fields, the mental health field must work hard to keep pace with that change. This is not a new state of affairs. Technological change occurred 25, 50, 100 years ago and beyond. What is new, however, is the remarkable rate of technological change in the world today. As you have seen throughout this book, the digital and hyperconnected world in which we now live has had significant effects—both positive and negative—on the mental health field (see MindTech on the next page).
Consider for a moment the nature and breadth of technological change in today’s world. Around 3.1 billion people across the world currently use the Internet—310 million in North America alone (IWS, 2015). It has become the primary medium through which people access all kinds of informa- tion. Closely aligned with the Internet, cell phone use has expanded. There
are currently 6.8 billion cell phone owners worldwide—90 percent of the world population (Fernholz, 2014). Over 80 percent of all cell phone owners use them for texting, among other services—itself a relatively new form of technology (Duggan, 2013) (see Figure 16-3).
Video games have emerged as yet another force in our digital society. Sixty per- cent of Americans play such games on computers, cell phones, or consoles (ESA, 2015). Often gaming is a social experience: more than half of gamers play with other individuals in person, and some interact online with numerous other players in virtual game environments called MMOGs (Massively Multiplayer Online Games).
Finally, there is the spectacular growth of social networking among people of all ages. The number of social network users (on Facebook, Twitter, Pinterest, Tumblr, Instagram, and other such sites) is currently more than 2 billion worldwide and is continuing to rise (eBizMBA, 2015; Statista, 2015). Consider, for example, the remarkable growth of Twitter, the online social networking and micro-blogging service, launched less than a decade ago, that enables users to send and receive brief text-based messages to and from large numbers of friends, colleagues, and other
Percentage of teenagers who use method to contact friends daily
Cell phone call
Text messaging
39%
63%
E-mail 6%
Face-to-face talk 35%
Landline call 19%
Instant messaging 22%
Social network site 29%
figure 16-3 How do today’s teenagers connect each day with their friends? A large survey of American teenagers reveals that 63 percent of teenagers use text messaging each day to connect with their friends, 35 percent talk face-to-face with them, and 6 percent e-mail them. (Information from: Pew Internet, 2013.)
Extending psychology’s reach A child meets with a psychologist (left on screen) and physician (right) located several towns away. Long-distance therapy by Skype is an increas- ingly used form of cybertherapy. AP P
ho to
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Law, Society, and the Mental Health Profession : 549
MindTech
New Ethics for a Digital Age The American Psychological Association’s code of ethics states that psy- chologists who operate on the Internet (offer cybertherapy, for example) are bound by the same ethical requirements as those who operate more
conventionally. That seems reasonable enough, except for one thing: operating online opens up a world of brand-new ethical issues that the code of ethics does not even begin to cover.
Two leading clinical theorists, Kenneth Pope and Danny Wedding (2014), have spent the last decade com- piling a list of ethical dilemmas and nightmares that can emerge as a by-product of therapists conducting therapy in the digital age. Let’s say, for example, that a therapist in Boston and a client in Atlanta use Skype to conduct therapy sessions. Seems straightforward enough, but it turns out that this arrangement raises complex legal and ethical questions. Is the Massachusetts-based thera- pist actually practicing without a license in Georgia? Should the therapist follow Massachusetts’ or Georgia’s laws regarding confidentiality, duty to protect, and other therapist requirements? What happens if the laws in the therapist’s state conflict with the laws in the client’s state? Is long-distance online therapy covered by the therapist’s malpractice insurance? And so on.
Many therapists believe that because they do not conduct cybertherapy, they are untouched by digital concerns. Yet those same therapists likely use computers to keep notes of therapy sessions, maintain client billing information, score psycho- logical tests, and the like. Thus, they might be alarmed to know that the following breaches of privacy have occurred more than a few times (Pope & Wedding, 2014):
➤ A laptop containing confidential patient information is hacked or is stolen from an office or car trunk.
➤ A virus, worm, or other kind of malware infects a therapist’s computer and up- loads confidential files to a Web site or to everyone listed in his or her address book.
➤ Someone reads a therapist’s laptop monitor—and obtains confidential information—while sitting next to the therapist in an airport or on a flight.
➤ A therapist e-mails a message containing confiden- tial client information to a colleague, but acciden- tally sends it to the wrong e-mail address.
➤ A therapist sells a computer, not realizing that con- fidential information is still recoverable because a truly thorough form of scrubbing was not used.
The digital age in which therapists treat clients presents many new ethical con- cerns and potential problems. Certainly, the field’s code of ethics must address these issues sooner rather than later. So too must each individual therapist. As Pope and Wedding (2014) point out, “When we use digital devices to handle the most sensi- tive and private information about our clients, we must remember to live up to an ancient precept: First, do no harm.”
What other ethical problems
might emerge as a result of the
mental health field’s increasing
use of new technologies?
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“Oops! I just deleted all your files. Can you repeat everything you’ve ever told me?”
: chapter 16550
people. Currently, 500 million tweets (Twitter messages) are sent each day (DMR, 2015).
Given these changes and trends in technology, it is not surprising that the focus, tools, and research directions of the mental health field have themselves expanded over the past decade. As you have observed throughout this book, for example, our digital world provides new triggers for the expression of abnormal behavior: Internet gambling has intensified the problem of gambling disorder (see pages 342–343); the misuse of social networks and texting has fed problems such as bully- ing, sexual exhibitionism, and pedophilia (see pages 368, 465); violent video games may sometimes contribute to cases of antisocial behavior; and so on.
Similarly, our fast-moving digital world greatly affects clinical treat- ment. Cybertherapy—in such forms as long-distance therapy enabled by Skype (see page 57), virtual reality-enhanced treatments (see page 163), Internet-based support groups (see pages 57, 68), and countless mental health apps (see page 21)—has become a major force in mental health care. The options offered by cybertherapy have many virtues, but they have also produced serious problems such as poor quality control and the spread of psychological misinformation (see page 57).
Clearly, the growing impact of technological change on the mental health field presents significant challenges. Few of the technological applications discussed throughout this book are well understood, and few have been subjected to com- prehensive research. Yet the relationship between technology and mental health is expected to expand still further in the coming years. It behooves everyone in the field to understand and be ready for this growth and its implications.
The Person Within the Profession The actions of clinical researchers and practitioners not only influence and are influenced by other forces in society but also are closely tied to their personal needs and goals (see InfoCentral on the next page). You have seen that the human strengths, imperfections, wisdom, and clumsiness of clinical professionals may affect their theoretical orientations, their interactions with clients, and the kinds of clients with whom they choose to work. You have also seen how personal leanings may sometimes override professional standards and scruples and, in extreme cases, lead clinical scientists to commit research fraud and clinical practitioners to engage in sexual misconduct with clients.
Surveys of the mental health of therapists have found that as many as 84 percent report having been in therapy at least once (Pope & Wedding, 2014; Pope et al., 2006; Pope & Tabachnick, 1994). Their reasons are largely the same as those of other clients, with relationship problems, depression, and anxiety topping the list. It is not clear why so many therapists have psychological problems. Perhaps it is because their jobs are highly stressful; research suggests that therapists often experience some degree of job burnout (Clay, 2011; Rosenberg & Pace, 2006). Or perhaps therapists are simply more aware of their own negative feelings or are more likely to pursue treatment for their problems. Alternatively, people with personal concerns may be more inclined to choose clinical work as a profession. Whatever the reason, clini- cians bring to their work a set of psychological issues that may, along with other important factors, affect how they listen and respond to clients.
The science and profession of abnormal psychology seek to understand, predict, and change abnormal functioning. But we must not lose sight of the fact that mental health researchers and clinicians are human beings, living within a society of human beings, working to serve human beings. The mixture of discovery, misdirection,
“I can’t wait to see what you’re like online.”
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B e t W e e N t h e L I N e S
In Their Words “I spent . . . two hours chatting with Einstein. . . . He is cheerful, assured and likable, and understands as much about psychology as I do about physics, so we got on together very well.”
Sigmund Freud, 1927
551InfoCentral
PERSONAL AND PROFESSIONAL ISSUES Like everyone else, clinicians have personal needs, perspectives, goals, and problems, each of which may affect their work. Thera- pists typically try to minimize the impact of such variables on their
interactions with clients—called countertransference by Freud. However, research suggests that, to at least some degree, personal therapist issues inf luence how clinicians deal with clients.
THE EARLY YEARS Common events in the early lives of therapists • Experiencing personal distress
• Witnessing the distress of others
• Observing the behaviors and emotions of others; becoming psychologically minded
• Reading
• Being in therapy
• Being a con�dant to others
• Modeling the behavior of others
• Learning from a mentor (Farber et al., 2005)
Top 5 reasons people become therapists
help people understand
and help oneself
understand others
intellectual stimulation
professional autonomy
THE EMOTIONAL SIDE
0 25 50 75
100
97% 91% 88% 66%
might commit suicide
condition might worsen
colleagues might criticize
their work
malpractice complaint
90% 63% 52% expressed anger toward a client
angry fantasies regarding a client
expressed disappointment toward a client
Therapists’ anger toward clients
? ? ? Top qualities clinicians
look for in choosing a therapist • Competence
• Warmth and caring
• Clinical experience and professional reputation
• Openness
• Active therapeutic style
• Flexibility (Norcross et al., 2009)
0 20 40 60 80 100
84%
61%
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CLINICIANS IN THERAPY
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CLINICAL CAREERS How satisfi ed are clinical psychologists with their careers?
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30
40
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38% Very satisfied
41% Quite satisfied
10% Slightly satisfied
4% Slightly dissatisfied
5% Quite dissatisfied
3% Very dissatisfied
(Norcross et al., 2005)
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ETHICS IN CLINICAL PRACTICE Although the �eld’s code of ethics explicitly forbids it, some therapists engage in sexual relationships with their clients. This is the profession’s most egregious violation of trust and boundaries and typically causes signi�cant psychological harm to clients.
Who has had a sexual relationship with a client?
• Ambivalence
• Guilt
• Emptiness and isolation
• Sexual confusion
• Inability to trust
• Confusion of roles and boundaries
• Emotional damage
• Suppressed rage
• Heightened risk of suicide
• Cognitive dysfunction
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Psychotherapy Diagnosis/assessment
Research/writing
Teaching
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56%
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Academic PsychologistsPrivate Practitioners
How do clinical psychologists spend their professional time?
Therapists’ fears regarding clients
: chapter 16552
promise, and frustration that you have encountered throughout this book is thus to be expected. When you think about it, could the study and treatment of human behavior really proceed in any other way?
➤ Summing Up etHICAL, eCoNoMIC, teCHNoLoGICAL, AND PeRsoNAL FACtoRs Each clinical profession has a code of ethics. The psychologists’ code includes pro- hibitions against engaging in fraudulent research and against taking advantage of clients and students, sexually or otherwise. It also establishes guidelines for respecting patient confidentiality. The case of Tarasoff v. Regents of the Univer- sity of California helped to determine the circumstances in which therapists have a duty to protect clients or others from harm and must break confidentiality.
Clinical practice and study also intersect with the business and economic worlds. Clinicians often help address psychological problems in the workplace. In addition, private insurance companies often set up managed care programs whose procedures influence—sometimes adversely—the length, nature, and quality of therapy.
The remarkable technological advances of recent times have affected the mental health field, just as they have affected all other fields and professions. These advances have, for example, sometimes produced new triggers for psy- chopathology and have generated various kinds of cybertherapy.
Finally, mental health activities are affected by the personal needs, values, and goals of the human beings who provide the clinical services. These factors inevitably affect the choice, direction, and even quality of their work.
PUTTING IT...together Operating Within a Larger System At one time, clinical researchers and professionals conducted their work largely in isolation. Today their activities have numerous ties to the legislative, judicial, and economic systems and to technological forces as well. One reason for this growing interconnectedness is that the clinical field has reached a high level of respect and acceptance in our society. Clinicians now serve millions of people in many ways. They have much to say about almost every aspect of society, from education to ecology, and are widely looked to as sources of expertise. When a field becomes so prominent, it inevitably affects how other institutions are run. It also attracts public scrutiny, and various institutions begin to keep an eye on its activities.
When people with psychological problems seek help from a therapist, they are entering a complex system consisting of many interconnected parts. Just as their personal problems have grown within a social structure, so will their treatment be affected by the various parts of a larger system—the therapist’s values and needs, legal and economic factors, societal attitudes, technological changes, and yet other forces. These many forces influence clinical research as well.
The effects of this larger system on an individual’s psychological needs can be posi- tive or negative, like a family’s impact on each of its members. When the system pro- tects a client’s rights and confidentiality, for example, it is serving the client well. When economic, legal, or other societal forces limit treatment options, cut off treatment prematurely, or stigmatize a person, the system is adding to the person’s problems.
Because of the enormous growth and impact of the mental health profession in our society, it is important that we understand the profession’s strengths and weaknesses. As you have seen throughout this book, the field has gathered much
B e t W e e N t h e L I N e S
Business and Mental Health Between 2009 and 2012, U.S. pharma- ceutical companies paid an estimated $4 billion to physicians for promotional speaking, research, consulting, travel, and meals. Half of the top earners were psychiatrists.
(Weber & Ornstein, 2012)
B e t W e e N t h e L I N e S
Psychological Research and the Supreme Court Citing a large body of psychological research on the unformed character, cog- nitive limitations, and impressionable nature of adolescents, the Supreme Court ruled in 2010 that individuals under 18 years of age cannot be pun- ished with life in prison without parole, except in cases of homicide.
Law, Society, and the Mental Health Profession : 553
KEY TERMS forensic psychology, p. 528
criminal commitment, p. 528
not guilty by reason of insanity (NGRI), p. 528
M’Naghten test, p. 529
irresistible impulse test, p. 529
Durham test, p. 529
American Law Institute (ALI) test, p. 529
guilty but mentally ill, p. 532
guilty with diminished capacity, p. 532
mentally disordered sex offenders, p. 533
sexually violent predator laws, p. 534
mental incompetence, p. 535
civil commitment, p. 536
two-physician certificate (2 PC), p. 538
dangerousness, p. 538
right to treatment, p. 539
right to refuse treatment, p. 539
malpractice suit, p. 541
professional boundaries, p. 541
jury selection, p. 541
eyewitness testimony, p. 542
psychological profiles, p. 542
code of ethics, p. 544
confidentiality, p. 545
duty to protect, p. 546
employee assistance programs, p. 546
stress-reduction seminars, p. 546
managed care program, p. 547
peer review system, p. 547
cybertherapy, p. 549
QuickQuiz
1. Briefly explain the M’Naghten, irresist- ible impulse, Durham, and ALI tests of insanity. Which tests are used today to determine whether defendants are not guilty by reason of insanity? pp. 529–530
2. Explain the guilty but mentally ill, di- minished capacity, mentally disordered sex offender, and sexually violent pred- ator verdicts and laws. pp. 532–534
3. What are the reasons behind and the procedures for determining whether defendants are mentally incompetent to stand trial? pp. 534–535
4. What are the reasons for civil commit- ment, and how is it carried out? What criticisms have been made of civil com- mitment? pp. 536–539
5. What rights have court rulings and legislation guaranteed to patients with psychological disorders? pp. 539–540
6. How do the legislative and judicial sys- tems affect the professional boundaries of clinical practice? p. 541
7. What have clinical researchers learned about eyewitness memories and about patterns of criminality? How accurate and influential is the practice of psy- chological profiling in criminal cases? pp. 542–544
8. What key issues are covered by the psychologist’s code of ethics? Under what conditions must therapists break the principle of confidentiality? pp. 544–546
9. What kinds of programs for the preven- tion and treatment of psychological problems have been established in business settings? What trends have emerged in recent years in the funding and insurance of mental health care? pp. 546–548
10. Describe how the mental health field has been affected by and dealt with the technological advances of recent years. pp. 548–550
Visit LaunchPad www.macmillanhighered.com/launchpad/comerfund8e to access the e-book, new interactive case studies, videos, activities, and LearningCurve quizzes, as well as study aids including flashcards, FAQs, and research exercises.
knowledge, especially during the past several decades. What mental health profes- sionals do not know and cannot do, however, still outweighs what they do know and can do. Everyone who turns to the clinical field—directly or indirectly—must recognize that it is young and imperfect. Society is vastly curious about behavior and often in need of information and help. What we as a society must remember, however, is that the field is still putting it all together.
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ABAB design A single-subject experimental design in which behavior is measured during a baseline period, after a treatment has been applied, after baseline conditions have been reintroduced, and after the treat- ment has been reintroduced. Also called a reversal design.
Abnormal psychology The scientific study of abnormal behavior undertaken to describe, predict, explain, and change abnormal patterns of functioning.
Acceptance and commitment therapy A cognitive-behavioral therapy that teaches clients to accept and be mindful of (i.e., just notice) their dysfunctional thoughts or worries.
Acetylcholine A neurotransmitter that has been linked to depression and dementia.
Acute stress disorder A disorder in which fear and related symptoms are experienced soon after a traumatic event and last less than a month.
Addiction Persistent, compulsive dependence on a substance or behavior.
Adjustment disorders Disorders character- ized by clinical symptoms such as depressed mood or anxiety in response to significant stressors.
Affect An experience of emotion or mood. Aftercare A program of post-hospitalization
care and treatment in the community. Agoraphobia An anxiety disorder in which
a person is afraid to be in public places or situations from which escape might be dif- ficult (or embarrassing) or help unavailable if panic-like symptoms were to occur.
Agranulocytosis A life-threatening drop in white blood cells. This condition is some- times produced by the atypical antipsy- chotic drug clozapine.
Alcohol Any beverage containing ethyl alcohol, including beer, wine, and liquor.
Alcohol dehydrogenase An enzyme that breaks down alcohol in the stomach before it enters the blood.
Alcohol use disorder A pattern of behavior in which a person repeatedly abuses or depends on alcohol. Also known as alcoholism.
Alcoholics Anonymous (AA) A self-help organization that provides support and guidance for people with alcoholism.
Alcoholism A pattern of behavior in which a person repeatedly abuses or depends on alcohol. Also known as alcohol use disorder.
Alogia A decrease in speech or speech con- tent; a symptom of schizophrenia. Also known as poverty of speech.
Alprazolam A benzodiazepine drug shown to be effective in the treatment of anxiety disorders. Marketed as Xanax.
GLOSSARY Altruistic suicide Suicide committed by people who intentionally sacrifice their lives for the well-being of society.
Alzheimer’s disease The most common type of neurocognitive disorder, usually occurring after the age of 65, marked most prominently by memory impairment.
Amenorrhea The absence of menstrual cycles.
American Law Institute test A legal test for insanity that holds people to be insane at the time of committing a crime if, because of a mental disorder, they did not know right from wrong or could not resist an uncontrollable impulse to act.
Amnesia Loss of memory. Amniocentesis A prenatal procedure used to
test the amniotic fluid that surrounds the fetus for the possibility of birth defects.
Amphetamine psychosis A syndrome char- acterized by psychotic symptoms brought on by high doses of amphetamines. Similar to cocaine psychosis.
Amphetamines Stimulant drugs that are manufactured in the laboratory.
Amygdala A structure in the brain that plays a key role in emotion and memory.
Anal stage In psychoanalytic theory, the second 18 months of life, during which the child’s focus of pleasure shifts to the anus.
Analog observation A method for observing behavior in which people are observed in artificial settings such as clinicians’ offices or laboratories.
Analogue experiment A research method in which the experimenter produces abnormal-like behavior in laboratory par- ticipants and then conducts experiments on the participants.
Anesthesia A lessening or loss of sensation of touch or of pain.
Anomic suicide Suicide committed by individuals whose social environment fails to provide stability, thus leaving them without a sense of belonging.
Anorexia nervosa A disorder marked by the pursuit of extreme thinness and by an extreme loss of weight.
Anoxia A complication of birth in which the baby is deprived of oxygen.
Antabuse (disulfiram) A drug that causes intense nausea, vomiting, increased heart rate, and dizziness when taken with alcohol. It is often taken by people who are trying to refrain from drinking alcohol.
Antagonist drugs Drugs that block or change the effects of an addictive drug.
Antianxiety drugs Psychotropic drugs that help reduce tension and anxiety. Also called minor tranquilizers or anxiolytics.
Antibipolar drugs Psychotropic drugs that help stabilize the moods of people suffering from a bipolar disorder. Also known as mood stabilizers.
Antibodies Bodily chemicals that seek out and destroy foreign invaders such as bacteria or viruses.
Antidepressant drugs Psychotropic drugs that improve the mood of people with depression.
Antigen A foreign invader of the body, such as a bacterium or virus.
Antipsychotic drugs Drugs that help cor- rect grossly confused or distorted thinking.
Antisocial personality disorder A person- ality disorder marked by a general pattern of disregard for and violation of other people’s rights.
Anxiety The central nervous system’s physi- ological and emotional response to a vague sense of threat or danger.
Anxiety disorder A disorder in which anxiety is a central symptom.
Anxiety sensitivity A tendency to focus on one’s bodily sensations, assess them illogi- cally, and interpret them as harmful.
Anxiolytics Drugs that reduce anxiety. Arbitrary inference An error in logic in
which a person draws negative conclu- sions on the basis of little or even contrary evidence.
Aripiprazole An atypical antipsychotic drug whose brand name is Abilify.
Asperger’s disorder One of the patterns found in autism spectrum disorder, in which a person displays profound social impairment yet maintains a relatively high level of cognitive functioning and language skills.
Assertiveness training A cognitive- behavioral approach to increasing assertive behavior that is socially desirable.
Assessment The process of collecting and interpreting relevant information about a client or research participant.
Asthma A medical problem marked by nar- rowing of the trachea and bronchi, which results in shortness of breath, wheezing, coughing, and a choking sensation.
Asylum A type of institution that first became popular in the sixteenth century to provide care for persons with mental disor- ders. Most became virtual prisons.
Attention-deficit/hyperactivity disorder (ADHD) A disorder marked by the inability to focus attention, or overactive and impulsive behavior, or both.
Attribution An explanation of things we see going on around us that points to particular causes.
Atypical antipsychotic drugs A relatively new group of antipsychotic drugs whose biological action is different from that of the conventional antipsychotic drugs. Also known as second-generation antipsychotic drugs.
Auditory hallucination A hallucination in which a person hears sounds or voices that are not actually present.
: GlossaryG-2
Bipolar II disorder A type of bipolar disorder marked by mild manic (hypo- manic) and major depressive episodes.
Birth complications Problematic biological conditions during birth that can affect the physical and psychological well-being of the child.
Blind design An experiment in which par- ticipants do not know whether they are in the experimental or the control condition.
Blunted affect A symptom of schizophrenia in which a person shows less emotion than most people.
Body dysmorphic disorder A disorder in which individuals become preoccu- pied with the belief that they have certain defects or flaws in their physical appearance. The perceived defects or flaws are imagined or greatly exaggerated.
Borderline personality disorder A per- sonality disorder characterized by repeated instability in interpersonal relationships, self-image, and mood and by impulsive behavior.
Brain circuits Networks of brain struc- tures that work together, triggering each other into action with the help of neurotransmitters.
Brain region A distinct area of the brain formed by a large group of neurons.
Brain wave The fluctuations of electrical potential that are produced by neurons in the brain.
Breathing-related sleep disorder A sleep disorder in which sleep is frequently dis- rupted by a breathing problem, causing excessive sleepiness or insomnia.
Brief psychotic disorder Psychotic symptoms that appear suddenly after a very stressful event or a period of emotional turmoil and last anywhere from a few hours to a month.
Brodmann Area 25 A brain structure whose abnormal activity has been linked to depression.
Bulimia nervosa A disorder marked by frequent eating binges that are fol- lowed by forced vomiting or other extreme compensatory behaviors to avoid gaining weight. Also known as binge-purge syndrome.
Caffeine The world’s most widely used stimulant, most often consumed in coffee.
Cannabis Substance produced from the varieties of the hemp plant, Cannabis sativa. It causes a mixture of hallucinogenic, depressant, and stimulant effects.
Case manager A community therapist who offers a full range of services for people with schizophrenia or other severe disor- ders, including therapy, advice, medication, guidance, and protection of patients’ rights.
Case study A detailed account of a person’s life and psychological problems.
Behaviors The responses an organism makes to its environment.
Bender Visual-Motor Gestalt Test A neu- ropsychological test in which a subject is asked to copy a set of nine simple designs and later reproduce the designs from memory.
Benzodiazepines The most common group of antianxiety drugs, which includes Valium and Xanax.
Bereavement The process of working through the grief that one feels when a loved one dies.
Beta-amyloid protein A small molecule that forms sphere-shaped deposits called senile plaques, linked to aging and to Alzheimer’s disease.
“Big Five” theory of personality A leading theory that holds that personality can be effectively organized and described by five broad dimensions of personality— openness, conscientiousness, extraversion, agreeableness, and neuroticism.
Binge An episode of uncontrollable eating during which a person ingests a very large quantity of food.
Binge drinking A pattern of alcohol consumption in which a person con- sumes five or more drinks on a single occasion.
Binge-eating disorder A disorder marked by frequent binges but not extreme compensatory behaviors.
Binge-eating/purging-type anorexia nervosa A type of anorexia nervosa in which people have eating binges but still lose excessive weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics.
Biofeedback A technique in which a client is given information about physiological reactions as they occur and learns to control the reactions voluntarily.
Biological challenge test A procedure used to produce panic in participants or clients by having them exercise vigorously or per- form some other potentially panic-inducing task in the presence of a researcher or therapist.
Biological model The theoretical perspec- tive that points to biological processes as the key to human behavior.
Biological therapy The use of physical and chemical procedures to help people over- come psychological problems.
Biopsychosocial theories Explanations that attribute the cause of abnormality to an interaction of genetic, biological, devel- opmental, emotional, behavioral, cognitive, social, and societal influences.
Bipolar disorder A disorder marked by alternating or intermixed periods of mania and depression.
Bipolar I disorder A type of bipolar disorder marked by full manic and major depressive episodes.
Augmentative communication system A method for enhancing the communication skills of people with autism spectrum dis- order, intellectual developmental disorder, or cerebral palsy by teaching them to point to pictures, symbols, letters, or words on a communication board or computer.
Aura A warning sensation that may precede a migraine headache.
Autism spectrum disorder A devel- opmental disorder marked by extreme unresponsiveness to others, severe commu- nication deficits, and highly repetitive and rigid behaviors, interests, and activities.
Autoerotic asphyxia A fatal lack of oxygen that people may unintentionally produce while hanging, suffocating, or strangling themselves during masturbation.
Automatic thoughts Numerous unpleasant thoughts that help to cause or maintain depression, anxiety, or other forms of psychological dysfunction.
Autonomic nervous system (ANS) The network of nerve fibers that connect the central nervous system to all the other organs of the body.
Aversion therapy A treatment in which clients are repeatedly presented with unpleasant stimuli while performing undesirable behaviors such as taking a drug.
Avoidant personality disorder A person- ality disorder characterized by consistent discomfort and restraint in social situations, overwhelming feelings of inadequacy, and extreme sensitivity to negative evaluation.
Avolition A symptom of schizophrenia marked by apathy and an inability to start or complete a course of action.
Axon A long fiber extending from the body of a neuron.
Barbiturates One group of sedative- hypnotic drugs that reduce anxiety and help produce sleep.
Baseline data A person’s initial response level on a test or scale.
Basic irrational assumptions The inaccurate and inappropriate beliefs held by people with various psychological problems, according to Albert Ellis.
Battery A series of tests, each of which measures a specific skill area.
B-cell A lymphocyte that produces antibodies.
Behavioral medicine A field that combines psychological and physical interventions to treat or prevent medical problems.
Behavioral model A theoretical perspective that emphasizes behavior and the ways in which it is learned.
Behavioral therapy A therapeutic approach that seeks to identify problem-causing behaviors and change them. Also known as behavior modification.
Glossary : G-3
Community mental health treatment A treatment approach that emphasizes com- munity care.
Comorbidity The occurrence of two or more disorders in the same person.
Compulsion A repetitive and rigid behavior or mental act that persons feel driven to perform in order to prevent or reduce anxiety.
Compulsive ritual A detailed, often elabo- rate, set of actions that a person often feels compelled to perform, always in an iden- tical manner.
Computerized axial tomography (CT scan) A composite image of the brain cre- ated by compiling X-ray images taken from many angles.
Concordance A statistical measure of the fre- quency with which family members (often both members of a pair of twins) have the same particular characteristic.
Concurrent validity The degree to which the measures gathered from one assessment tool agree with the measures gathered from other assessment techniques.
Conditioned response (CR) A response previously associated with an uncondi- tioned stimulus that comes to be produced by a conditioned stimulus.
Conditioned stimulus (CS) A previ- ously neutral stimulus that comes to be associated with a nonneutral stimulus and can then produce responses similar to those produced by the nonneutral stimulus.
Conditioning A simple form of learning. Conditions of worth According to client-
centered theorists, the internal standards by which a person judges his or her own lovability and acceptability, determined by the standards to which the person was held as a child.
Conduct disorder A disorder in which a child repeatedly violates the basic rights of others and displays aggres- sion, characterized by symptoms such as physical cruelty to people or animals, the deliberate destruction of other people’s property, and the commission of various crimes.
Confabulation A made-up description of one’s experience to fill in a gap in one’s memory.
Confederate An experimenter’s accomplice, who helps create a particular impression in a study while pretending to be just another subject.
Confidentiality The principle that certain professionals will not divulge the informa- tion they obtain from a client.
Confound In an experiment, a variable other than the independent variable that is also acting on the dependent variable.
Continuous amnesia An inability to recall newly occurring events as well as certain past events.
and guidelines for making appropriate diagnoses.
Cleaning compulsion A common compul- sion in which people feel compelled to keep cleaning themselves, their clothing, and their homes.
Client-centered therapy The humanistic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately, and con- veying genuineness.
Clinical interview A face-to-face encounter in which clinicians ask questions of clients, weigh their responses and reactions, and learn about them and their psychological problems.
Clinical psychologist A mental health pro- fessional who has earned a doctorate in clinical psychology.
Clinical psychology The study, assessment, treatment, and prevention of abnormal behavior.
Clitoris The female sex organ located in front of the urinary and vaginal open- ings. It becomes enlarged during sexual arousal.
Clozapine A commonly prescribed atypical antipsychotic drug.
Cocaine An addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.
Code of ethics A body of principles and rules for ethical behavior, designed to guide decisions and actions by members of a profession.
Cognition The capacity to think, remember, and anticipate.
Cognitive behavior Thoughts and beliefs, many of which remain private.
Cognitive-behavioral therapies Therapy approaches that seek to help clients change both counterproductive behaviors and dysfunctional ways of thinking.
Cognitive model A theoretical perspective that emphasizes the process and content of thinking as causes of psychological problems.
Cognitive therapy A therapy developed by Aaron Beck that helps people identify and change the maladaptive assumptions and ways of thinking that help cause their psy- chological disorders.
Cognitive triad The three forms of nega- tive thinking that theorist Aaron Beck theorizes lead people to feel depressed. The triad consists of a negative view of one’s experiences, oneself, and the future.
Coitus Sexual intercourse. Communication disorders Disorders
characterized by marked impairment in language and/or speech.
Community mental health center A treatment facility that provides medica- tion, psychotherapy, and emergency care to patients and coordinates treatment in the community.
Catatonia A pattern of extreme psycho- motor symptoms, found in some forms of schizophrenia, which may include catatonic stupor, rigidity, or posturing.
Catatonic excitement A form of catatonia in which a person moves excitedly, some- times with wild waving of the arms and legs.
Catatonic stupor A symptom associated with schizophrenia in which a person becomes almost totally unresponsive to the environment, remaining motionless and silent for long stretches of time.
Catharsis The reliving of past repressed feel- ings in order to settle internal conflicts and overcome problems.
Caudate nuclei Structures in the brain, within the region known as the basal gan- glia, that help convert sensory information into thoughts and actions.
Central nervous system The brain and spinal cord.
Cerebellum An area of the brain that coor- dinates movement in the body and perhaps helps control a person’s ability to shift attention rapidly.
Checking compulsion A compulsion in which people feel compelled to check the same things over and over.
Child abuse The nonaccidental use of exces- sive physical or psychological force by an adult on a child, often aimed at hurting or destroying the child.
Chlorpromazine A phenothiazine drug commonly used for treating schizophrenia. Marketed as Thorazine.
Chromosomes The structures, located within a cell, that contain genes.
Chronic headaches A medical problem marked by frequent intense aches in the head or neck that are not caused by another medical disorder.
Circadian rhythm disorder A sleep-wake disorder characterized by a mismatch between a person’s sleep-wake pattern and the sleep-wake schedule of most other people.
Circadian rhythms Internal “clocks” consisting of repeated biological fluctuations.
Cirrhosis An irreversible condition, often caused by excessive drinking, in which the liver becomes scarred and begins to change in anatomy and functioning.
Civil commitment A legal process by which an individual can be forced to undergo mental health treatment.
Clang A rhyme used by some people with schizophrenia as a guide to forming thoughts and statements.
Classical conditioning A process of learning in which two events that repeatedly occur close together in time become tied together in a person’s mind and so produce the same response.
Classification system A list of disorders, along with descriptions of symptoms
: GlossaryG-4
Delirium A rapidly developing, acute dis- turbance in attention and orientation that makes it very difficult to concentrate and think in a clear and organized manner.
Delirium tremens (DTs) A dramatic withdrawal reaction experienced by some people with alcohol use disorder. It consists of confusion, clouded consciousness, and terrifying visual hallucinations.
Delusion A strange false belief firmly held despite evidence to the contrary.
Delusion of control The belief that one’s impulses, feelings, thoughts, or actions are being controlled by other people.
Delusion of grandeur The belief that one is a great inventor, historical figure, or other specially empowered person.
Delusion of persecution The belief that one is being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized.
Delusion of reference A belief that attaches special and personal meaning to the actions of others or to various objects or events.
Delusional disorder A disorder consisting of persistent, nonbizarre delusions that are not part of a schizophrenic disorder.
Demonology The belief that abnormal behavior results from supernatural causes such as evil spirits.
Dendrite An extension located at one end of a neuron that receives impulses from other neurons.
Denial An ego defense mechanism in which a person fails to acknowledge unacceptable thoughts, feelings, or actions.
Dependent personality disorder A person- ality disorder characterized by a pattern of clinging and obedience, fear of separation, and an ongoing need to be taken care of.
Dependent variable The variable in an experiment that is expected to change as the independent variable is manipulated.
Depersonalization-derealization disorder A dissociative disorder marked by the presence of persistent and recurrent episodes of depersonalization, derealization, or both.
Depressant A substance that slows the activity of the central nervous system and in sufficient dosages causes a reduction of tension and inhibitions.
Depression A low, sad state marked by sig- nificant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms.
Depressive disorders The group of disorders marked by unipolar depression.
Derailment A common thinking disturbance in schizophrenia, involving rapid shifts from one topic of conversation to another. Also called loose associations.
Desensitization See Systematic desensitization.
Desire phase The phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction.
Criminal commitment A legal process by which people accused of a crime are instead judged mentally unstable and sent to a mental health facility for treatment.
Crisis intervention A treatment approach that tries to help people in a psychological crisis view their situation more accurately, make better decisions, act more construc- tively, and overcome the crisis.
Critical incident stress debriefing Training in how to help victims of disasters or other horrifying events talk about their feelings and reactions to the traumatic incidents.
Cross-tolerance Tolerance that a person develops for a substance as a result of regu- larly using another substance similar to it.
Culture A people’s common history, values, institutions, habits, skills, technology, and arts.
Culture-sensitive therapies Approaches that are designed to address the unique issues faced by members of minority groups.
Cyberbullying The use of e-mail, texting, chat rooms, cell phones, or other digital devices to harass, threaten, or intimidate people.
Cybertherapy The use of computer tech- nology, such as Skype or avatars, to provide therapy.
Cyclothymic disorder A disorder marked by numerous periods of hypomanic symp- toms and mild depressive symptoms.
Day center A program that offers hospital- like treatment during the day only. Also known as a day hospital.
Death darer A person who is ambivalent about the wish to die even as he or she attempts suicide.
Death ignorer A person who attempts sui- cide without recognizing the finality of death.
Death initiator A person who attempts suicide believing that the process of death is already under way and that he or she is simply quickening the process.
Death seeker A person who clearly intends to end his or her life at the time of a sui- cide attempt.
Deep brain stimulation (DBS) A treat- ment procedure for depression in which a pacemaker powers electrodes that have been implanted in Brodmann Area 25, thus stimulating that brain area.
Deinstitutionalization The discharge, begun during the 1960s, of large numbers of patients from long-term institutional care so that they might be treated in community programs.
Déjà vu The haunting sense of having previ- ously seen or experienced a new scene or situation.
Delayed ejaculation A male dysfunction characterized by persistent inability to ejac- ulate or very delayed ejaculations during sexual activity with a partner.
Control group In an experiment, a group of participants who are not exposed to the independent variable.
Conversion disorder A disorder in which bodily symptoms affect voluntary motor and sensory functions, but the symptoms are inconsistent with known medical diseases.
Conversion therapy A treatment approach that attempts to change the sexual orien- tation of a person from homosexual or bisexual to heterosexual. Also called repara- tive therapy.
Convulsion A brain seizure. Coronary arteries Blood vessels that sur-
round the heart and are responsible for car- rying oxygen to the heart muscle.
Coronary heart disease Illness of the heart caused by a blockage in the coronary arteries.
Correlation The degree to which events or characteristics vary along with each other.
Correlation coefficient (r) A statistical term that indicates the direction and the magni- tude of a correlation, ranging from –1.00 to +1.00.
Correlational method A research procedure used to determine how much events or characteristics vary along with each other.
Corticosteroids A group of hormones, including cortisol, released by the adrenal glands at times of stress.
Cortisol A hormone released by the adrenal glands when a person is under stress.
Counseling psychology A mental health specialty similar to clinical psychology that offers its own graduate training program.
Countertransference A phenomenon of psychotherapy in which therapists’ own feelings, history, and values subtly influence the way they interpret a patient’s problems.
Couple therapy A therapy format in which the therapist works with two people who share a long-term relationship.
Covert desensitization Desensitization that focuses on imagining confrontations with the frightening objects or situations while in a state of relaxation.
Covert sensitization A behavioral treat- ment for eliminating unwanted behavior by pairing the behavior with unpleasant mental images.
Crack A powerful, ready-to-smoke freebase cocaine.
C-reactive protein (CRP) A protein that spreads throughout the body and causes inflammation and various illnesses and disorders.
Cretinism A disorder marked by intellectual deficiencies and physical abnormalities; caused by low levels of iodine in the moth- er’s diet during pregnancy. Also known as severe congenital hypothyroidism.
Creutzfeldt-Jakob disease A form of neurocognitive disorder caused by a slow- acting virus that may live in the body for years before the disease unfolds.
Glossary : G-5
bizarre ways, but is not displaying a psycho- logical disorder.
Echolalia A symptom of autism or schizo- phrenia in which a person responds to state- ments by repeating the other person’s words.
Ecstasy (MDMA) A drug chemically related to amphetamines and hallucinogens, used illicitly for its euphoric and hallucinogenic effects.
Ego According to Freud, the psychological force that employs reason and operates in accordance with the reality principle.
Ego defense mechanisms According to psychoanalytic theory, strategies developed by the ego to control unacceptable id impulses and to avoid or reduce the anxiety they arouse.
Ego theory The psychodynamic theory that emphasizes the ego and considers it an independent force.
Egoistic suicide Suicide committed by people over whom society has little or no control, people who are not concerned with the norms or rules of society.
Eidetic imagery A strong visual image of an object or scene that persists in some persons long after the object or scene is removed.
Ejaculation Contractions of the muscles at the base of the penis that cause sperm to be ejected.
Electra complex According to Freud, the pattern of desires all girls experience during the phallic stage, in which they develop a sexual attraction to their father.
Electroconvulsive therapy (ECT) A treat- ment for depression in which electrodes attached to a patient’s head send an elec- trical current through the brain, causing a seizure.
Electroencephalograph (EEG) A device that records electrical impulses in the brain.
Electromyograph (EMG) A device that provides feedback about the level of mus- cular tension in the body.
Emergency commitment The tempo- rary commitment to a mental hospital of a patient who is behaving in a bizarre or violent way.
Empirically supported treatment A movement in the clinical field that seeks to identify which therapies have received clear research support for each disorder, to develop corresponding treatment guide- lines, and to spread such information to clinicians. Also known as evidence-based treatment.
Employee assistance program A mental health program offered by a business to its employees.
Encopresis A disorder characterized by repeated defecating in inappropriate places, such as one’s clothing.
Endocrine system The system of glands located throughout the body that help con- trol important activities such as growth and sexual activity.
Dissociative identity disorder A disorder in which a person develops two or more distinct personalities. Also known as multiple personality disorder.
Disulfiram (Antabuse) An antagonist drug used in treating alcohol abuse or dependence.
Dopamine The neurotransmitter whose high activity has been shown to be related to schizophrenia.
Dopamine hypothesis The theory that schizophrenia results from excessive activity of the neurotransmitter dopamine.
Double-bind hypothesis A theory that some parents repeatedly communicate pairs of messages that are mutually contradictory, helping to produce schizophrenia in their children.
Double-blind design Experimental pro- cedure in which neither the participant nor the experimenter knows whether the participant has received the experimental treatment or a placebo.
Down syndrome A form of intellectual disability caused by an abnormality in the twenty-first chromosome.
Dream A series of ideas and images that form during sleep.
Drug Any substance other than food that affects the body or mind.
Drug maintenance therapy An approach to treating substance dependence in which clients are given legally and medically supervised doses of the drug on which they are dependent or a substitute drug.
Drug therapy The use of psychotropic drugs to reduce the symptoms of psychological disorders.
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) The newest edition of the DSM, published in 2013.
Durham test A legal test for insanity that holds people to be insane at the time they committed a crime if their act was the result of a mental disorder or defect.
Duty to protect The principle that thera- pists must break confidentiality in order to protect a person who may be the intended victim of a client.
Dyslexia A type of specific learning disorder in which people show a marked impair- ment in the ability to recognize words and to comprehend what they read.
Dyssomnias Sleep-wake disorders, such as insomnia disorder and hypersomnolence disorder, in which the amount, quality, or timing of sleep is disturbed.
Dysthymia A pattern of persistent depres- sive disorder that is chronic but less severe and less disabling than repeated episodes of major depression.
Eccentric A person who deviates from con- ventional norms in odd, irregular, or even
Detoxification Systematic and medically supervised withdrawal from a drug.
Developmental coordination disorder Disorder characterized by marked impair- ment in the development and performance of coordinated motor activities.
Deviance Variance from common patterns of behavior.
Diagnosis A determination that a person’s problems reflect a particular disorder.
Diagnostic and Statistical Manual of Mental Disorders (DSM) The classifica- tion system for mental disorders developed by the American Psychiatric Association.
Dialectical behavior therapy A therapy approach developed by psychologist Marsha Linehan to treat people with borderline personality disorder and other psycho- logical disorders, consisting of cognitive- behavioral techniques in combination with various emotion regulation, mindfulness, humanistic, and other techniques.
Diathesis-stress view The view that a person must first have a predisposition to a disorder and then be subjected to imme- diate psychosocial stress in order to develop the disorder.
Diazepam A benzodiazepine drug, marketed as Valium.
Dichotomous thinking Viewing problems and solutions in rigid “either/or” terms.
Diencephalon A brain area (consisting of the mammillary bodies, thalamus, and hypothal- amus) that plays a key role in transforming short-term to long-term memory, among other functions.
Directed masturbation training A sex therapy approach that teaches women with female arousal or orgasmic disorders how to masturbate effectively and eventually reach orgasm during sexual interactions.
Disaster Response Network (DRN) A network of thousands of volunteer mental health professionals who mobilize to provide free emergency psychological services at disaster sites throughout North America.
Displacement An ego defense mechanism that channels unacceptable id impulses toward another, safer substitute.
Disruptive mood dysregulation disorder A childhood disorder marked by severe recurrent temper outbursts along with a persistent irritable or angry mood.
Dissociative amnesia A dissociative disorder marked by an inability to recall important personal events and information.
Dissociative disorders A group of disorders in which some parts of one’s memory or identity seem to be dissociated, or sepa- rated, from other parts of one’s memory or identity.
Dissociative fugue A form of dissociative amnesia in which a person travels to a new location and may assume a new identity, simultaneously forgetting his or her past.
: GlossaryG-6
Female orgasmic disorder A dysfunction in which a woman persistently fails to reach orgasm, has very low intensity orgasms, or has very delayed orgasms.
Female sexual interest/arousal disorder A female dysfunction marked by a persis- tent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensa- tions during sexual activity.
Fetal alcohol syndrome A cluster of problems in a child, including low birth weight, irregularities in the hands and face, and intellectual deficits, caused by exces- sive alcohol intake by the mother during pregnancy.
Fetishistic disorder A paraphilic disorder consisting of recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by significant distress or impairment.
Fixation According to Freud, a condition in which the id, ego, and superego do not mature properly and are frozen at an early stage of development.
Flashback The recurrence of LSD-induced sensory and emotional changes long after the drug has left the body or, in posttrau- matic stress disorder, the reexperiencing of past traumatic events.
Flat affect A symptom of schizophrenia in which the person shows almost no emotion at all.
Flibanserin A drug used to treat low sexual desire in women. Marketed as Addyi.
Flooding A treatment for phobias in which clients are exposed repeatedly and inten- sively to a feared object and made to see that it is actually harmless.
Forensic psychology The branch of psy- chology concerned with intersections between psychological practice and research and the judicial system. Also related to the field of forensic psychiatry.
Formal thought disorder A disturbance in the production and organization of thought.
Free association A psychodynamic tech- nique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.
Freebase A technique for ingesting cocaine in which the pure cocaine basic alkaloid is chemically separated from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe.
Free-floating anxiety Chronic and persis- tent feelings of anxiety that are not clearly attached to a specific, identifiable threat.
Frotteuristic disorder A paraphilic dis- order in which a person has repeated and intense sexual urges or fantasies that involve touching and rubbing against a noncon- senting person and either acts on these
Experiment A research procedure in which a variable is manipulated and the effect of the manipulation is observed.
Experimental group In an experiment, the participants who are exposed to the inde- pendent variable under investigation.
Exposure and response prevention A behavioral treatment for obsessive- compulsive disorder that exposes a client to anxiety-arousing thoughts or situations and then prevents the client from performing his or her compulsive acts. Also called expo- sure and ritual prevention.
Exposure treatments Behavioral treatments in which persons are exposed to the objects or situations they dread.
Expressed emotion The general level of criticism, disapproval, hostility, and intru- siveness expressed in a family. People recov- ering from schizophrenia are considered more likely to relapse if their families rate high in expressed emotion.
External validity The degree to which the results of a study may be generalized beyond that study.
Extrapyramidal effects Unwanted move- ments, such as severe shaking, bizarre- looking grimaces, twisting of the body, and extreme restlessness, sometimes produced by conventional antipsychotic drugs.
Eye movement desensitization and reprocessing (EMDR) An exposure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid.
Factitious disorder A disorder in which a person feigns or induces symptoms, typi- cally for the purpose of assuming the role of a sick person.
Family pedigree study A research design in which investigators determine how many and which relatives of a person with a dis- order have the same disorder.
Family systems theory A theory that views the family as a system of interacting parts whose interactions exhibit consistent pat- terns and unstated rules.
Family therapy A therapy format in which the therapist meets with all members of a family and helps them to change in thera- peutic ways.
Fantasy An ego defense mechanism in which a person uses imaginary events to satisfy unacceptable impulses.
Fear The central nervous system’s physiolog- ical and emotional response to a serious threat to one’s well-being.
Fear hierarchy A list of objects or situations that frighten a person, starting with those that are slightly feared and ending with those that are feared greatly; used in system- atic desensitization.
Endogenous depression A depression that appears to develop without external reasons and is assumed to be caused by internal factors.
Endorphins Neurotransmitters that help relieve pain and reduce emotional ten- sion. They are sometimes referred to as the body’s own opioids.
Enmeshed family pattern A family system in which members are overinvolved with each other’s affairs and overconcerned about each other’s welfare.
Enuresis A disorder marked by repeated bed-wetting or wetting of one’s clothes.
Epidemiological study A study that measures the incidence and prevalence of a disorder in a given population.
Erectile disorder A dysfunction in which a man persistently fails to attain or maintain an erection during sexual activity.
Ergot alkaloid A naturally occurring com- pound from which LSD is derived.
Essential hypertension High blood pressure caused by a combination of psychosocial and physiological factors.
Estrogen The primary female sex hormone. Ethyl alcohol The chemical compound in all
alcoholic beverages that is rapidly absorbed into the blood and immediately begins to affect the person’s functioning.
Evoked potentials The brain response pat- terns recorded on an electroencephalograph while a person performs a task such as observing a flashing light.
Excitement phase The phase of the sexual response cycle marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing.
Excoriation disorder A disorder in which persons repeatedly pick at their skin, resulting in significant sores or wounds. Also called skin-picking disorder.
Exhibitionistic disorder A paraphilic disorder in which persons have repeated sexually arousing urges or fantasies about exposing their genitals to others, and either act on these urges with nonconsenting individuals or experience clinically signifi- cant distress or impairment.
Existential anxiety According to existential theorists, a universal fear of the limits and responsibilities of one’s existence.
Existential model The theoretical perspec- tive that human beings are born with the total freedom either to face up to one’s existence and give meaning to one’s life or to shrink from that responsibility.
Existential therapy A therapy that encour- ages clients to accept responsibility for their lives and to live with greater meaning and value.
Exorcism The practice, common in early societies, of treating abnormality by coaxing evil spirits to leave the person’s body.
Glossary : G-7
Histrionic personality disorder A per- sonality disorder in which an individual displays a pattern of excessive emotionality and attention seeking. Once called hysterical personality disorder.
Hoarding disorder A disorder in which people feel compelled to save items and experience significant distress if they try to discard them, resulting in an excessive accu- mulation of items and possessions.
Hopelessness A pessimistic belief that one’s present circumstances, problems, or mood will not change.
Hormones The chemicals released by endo- crine glands into the bloodstream.
Humanistic model The theoretical perspec- tive that human beings are born with a natural inclination to be friendly, coopera- tive, and constructive and are driven to self-actualize.
Humanistic therapy A system of therapy in which clinicians try to help clients look at themselves accurately and acceptingly so that they can fulfill their positive inborn potential.
Humors According to the Greeks and Romans, bodily chemicals that influence mental and physical functioning.
Huntington’s disease An inherited disease, characterized by progressive problems in cognition, emotion, and movement, which results in neurocognitive disorder.
Hypersomnolence disorder A sleep-wake disorder characterized by an extreme need for extra sleep and feelings of excessive sleepiness.
Hypertension Chronic high blood pressure. Hypnosis A sleeplike suggestible state
during which a person can be directed to act in unusual ways, to experience unusual sensations, to remember seemingly for- gotten events, or to forget remembered events.
Hypnotic amnesia Loss of memory pro- duced by hypnotic suggestion.
Hypnotic therapy A treatment in which the patient undergoes hypnosis and is then guided to recall forgotten events or perform other therapeutic activities. Also known as hypnotherapy.
Hypnotism A procedure that places people in a trancelike mental state during which they become extremely suggestible.
Hypochondriasis A somatoform disorder in which people mistakenly fear that minor changes in their physical functioning indi- cate a serious disease. Now known as illness anxiety disorder.
Hypomanic episode An episode of mania in which the symptoms cause relatively little impairment.
Hypomanic pattern A pattern in which a person displays symptoms of mania, but the symptoms are less severe and cause less impairment than those of a manic episode.
techniques such as role playing and self- discovery exercises.
Glia Brain cells that support the neurons. Glutamate A common neurotransmitter
that has been linked to memory and to dementia.
Grief The reaction a person experiences when a loved one is lost.
Group home A special home where people with disorders or disabilities live and are taught self-help, living, and working skills.
Group therapy A therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.
Guided participation A modeling tech- nique in which a client systematically observes and imitates the therapist while the therapist confronts feared items.
Guilty but mentally ill A verdict stating that defendants are guilty of committing a crime but are also suffering from a mental illness that should be treated during their imprisonment.
Guilty with diminished capacity A legal defense argument that states that because of limitations posed by mental dysfunctioning, a defendant could not have intended to commit a particular crime and thus should be convicted of a lesser crime.
Halfway house A residence for people with schizophrenia or other severe problems, often staffed by paraprofessionals. Also known as a group home or crisis house.
Hallucination The experiencing of imagined sights, sounds, or other perceptions in the absence of external stimuli.
Hallucinogen A substance that causes pow- erful changes primarily in sensory percep- tion, including strengthening perceptions and producing illusions and hallucinations. Also called a psychedelic drug.
Hallucinosis A form of intoxication caused by hallucinogens, consisting of perceptual distortions and hallucinations.
Hardiness A set of positive attitudes and reactions in response to stress.
Health maintenance The principle that young adults should act to promote their physical and mental health to best prepare for the aging process. Also called wellness.
Helper T-cell A lymphocyte that identifies foreign invaders and then both multiplies and triggers the production of other kinds of immune cells.
Heroin One of the most addictive substances derived from opium.
High The pleasant feeling of relaxation and euphoria that follows the rush from certain recreational drugs.
Hippocampus A brain area located below the cerebral cortex that is involved in memory.
urges with nonconsenting individuals or experiences clinically significant distress or impairment.
Functional magnetic resonance imaging (fMRI) A neuroimaging technique used to visualize internal functioning of the brain or body.
Fusion The final merging of two or more subpersonalities in multiple personality disorder.
GABA See Gamma-aminobutyric acid. Gambling disorder A disorder marked by
persistent and recurrent gambling behavior, leading to a range of life problems.
Gamma-aminobutyric acid (GABA) A neurotransmitter whose low activity has been linked to generalized anxiety disorder.
Gender dysphoria A disorder in which a person persistently feels clinically significant distress or impairment due to his or her assigned gender and strongly wishes to be a member of another gender.
Gender-sensitive therapies Approaches geared to the pressures of being a woman in Western society. Also called feminist therapies.
Gene Chromosome segments that control the characteristics and traits we inherit.
General paresis An irreversible medical disorder whose symptoms include psycho- logical abnormalities, such as delusions of grandeur; caused by syphilis.
Generalized amnesia A loss of memory for events that occurred over a limited period of time as well as for certain events that occurred prior to that period.
Generalized anxiety disorder A disorder marked by persistent and excessive feel- ings of anxiety and worry about numerous events and activities.
Generic drug A marketed drug that is com- parable to a trade-named drug in dosage form, strength, and performance.
Genetic linkage study A research approach in which extended families with high rates of a disorder over several generations are observed in order to determine whether the disorder closely follows the distribution pattern of other family traits.
Genital stage In Freud’s theory, the stage beginning at approximately 12 years old, when the child begins to find sexual plea- sure in heterosexual relationships.
Genito-pelvic pain/penetration disorder A sexual dysfunction characterized by significant physical discomfort during intercourse.
Geropsychology The field of psychology concerned with the mental health of elderly people.
Gestalt therapy The humanistic therapy developed by Fritz Perls in which clini- cians actively move clients toward self- recognition and self-acceptance by using
: GlossaryG-8
develop during or shortly after the inges- tion of a substance.
In vivo desensitization Desensitization that makes use of actual objects or situations, as opposed to imagined ones.
Ion An atom or group of atoms that has a positive or negative electrical charge.
Irresistible impulse test A legal test for insanity that holds people to be insane at the time they committed a crime if they were driven to do so by an uncontrollable “fit of passion.”
Isolation An ego defense mechanism in which people unconsciously isolate and disown undesirable and unwanted thoughts, experiencing them as foreign intrusions.
Kleptomania An impulse-control disorder characterized by the recurrent failure to resist impulses to steal objects not needed for personal use or monetary value.
Korsakoff ’s syndrome An alcohol-related disorder marked by extreme confusion, memory impairment, and other neuro- logical symptoms.
Latent content The symbolic meaning behind a dream’s content.
Lateral hypothalamus (LH) A brain region that produces hunger when activated.
L-dopa A drug used in the treatment of Par- kinson’s disease, a disease in which dopa- mine is low.
Learned helplessness The perception, based on past experiences, that one has no control over one’s reinforcements.
Libido The sexual energy that fuels the id. Life change units (LCUs) A system for
measuring the stress associated with various life events.
Light therapy A treatment for seasonal affec- tive disorder in which patients are exposed to extra light for several hours. Also called phototherapy.
Lithium A metallic element that occurs in nature as a mineral salt and is an effective treatment for bipolar disorders.
Lobotomy Psychosurgery in which a sur- geon cuts the connections between the brain’s frontal lobes and the lower centers of the brain.
Localized amnesia An inability to recall any of the events that occurred over a limited period of time.
Locus ceruleus A small area of the brain that seems to be active in the regula- tion of emotions. Many of its neurons use norepinephrine.
Longitudinal study A study that observes the same participants on many occasions over a long period of time.
Long-term care Extended personal and medical support provided to elderly and other persons who may be impaired. It may
sessions that may last from 15 minutes to 2 hours.
Informed consent The requirement that researchers provide sufficient information to participants about the purpose, proce- dure, risks, and benefits of a study.
Insanity defense A legal defense in which a person charged with a criminal offense claims to be not guilty by reason of insanity at the time of the crime.
Insomnia Difficulty falling or staying asleep. Insomnia disorder A sleep-wake disorder
characterized by severe difficulty falling asleep or maintaining sleep at least three nights per week.
Institutional Review Board (IRB) An ethics committee formed in a research facility that is empowered to protect the rights and safety of human research participants. It reviews and may require changes in each proposed study at the facility before approving or disapproving the study.
Integrity test A test that is designed to measure whether the test taker is generally honest or dishonest.
Intellectual disability (ID) A disorder marked by intellectual functioning and adaptive behavior that are well below average. Previously called mental retardation.
Intelligence quotient (IQ) A score derived from intelligence tests that theoretically represents a person’s overall intellectual capacity.
Intelligence test A test designed to measure a person’s intellectual ability.
Intermittent explosive disorder An impulse-control disorder in which people periodically fail to resist aggressive impulses and commit serious assaults on others or destroy property.
Internal validity The accuracy with which a study can pinpoint one of various possible factors as the cause of a phenomenon.
International Classification of Diseases (ICD) The classification system for medical and mental disorders that is used by the World Health Organization.
Internet gaming disorder A disorder marked by persistent, recurrent, and exces- sive Internet gaming activity. Recom- mended for further study by the DSM study group.
Interpersonal psychotherapy (IPT) A treatment for unipolar depression that is based on the belief that clarifying and changing one’s interpersonal problems will help lead to recovery.
Interrater reliability A measure of the reli- ability of a test or of research results in which the consistency of evaluations across different judges is assessed. Also called inter- judge reliability.
Intoxication A cluster of undesirable behav- ioral or psychological changes, such as slurred speech or mood changes, that may
Hypothalamic-pituitary-adrenal (HPA) pathway One route by which the brain and body produce arousal and fear.
Hypothalamus A part of the brain that helps maintain various bodily functions, including eating and hunger.
Hypothesis A hunch or prediction that certain variables are related in certain ways.
Hypoxyphilia A pattern in which people strangle or smother themselves, or ask their partners to strangle or smother them, to increase their sexual pleasure.
Hysteria A term once used to describe what are now known as conversion disorder, somatization disorder, and pain disorder associated with psychological factors.
Hysterical disorder A disorder in which physical functioning is changed or lost, without an apparent physical cause.
Iatrogenic Produced or caused inadvertently by a clinician.
Id According to Freud, the psychological force that produces instinctual needs, drives, and impulses.
Ideas of reference Beliefs that unrelated events pertain to oneself in some important way.
Identification Unconsciously incorporating the values and feelings of one’s parents and fusing them with one’s identity. Also, an ego defense mechanism in which a person takes on the values and feelings of a person who is causing them anxiety.
Idiographic understanding An under- standing of the behavior of a particular individual.
Illness anxiety disorder A disorder in which people are chronically anxious about and preoccupied with the notion that they have or are developing a serious medical illness, despite the absence of somatic symptoms. Previously known as hypochondriasis.
Illogical thinking According to cognitive theories, illogical ways of thinking that may lead to self-defeating conclusions and psy- chological problems.
Immune system The body’s network of activities and cells that identify and destroy antigens and cancer cells.
Inappropriate affect Display of emo- tions that are unsuited to the situation; a symptom of schizophrenia.
Incest Sexual relations between closely related individuals.
Incidence The number of new cases of a disorder occurring in a population over a specific period of time.
Independent variable The variable in an experiment that is manipulated to deter- mine whether it has an effect on another variable.
Individual therapy A therapeutic approach in which a therapist sees a client alone for
Glossary : G-9
and medically supervised doses of a substi- tute drug, methadone.
Methamphetamine A powerful amphet- amine drug that has experienced a surge in popularity in recent years, posing major health and law enforcement problems.
Methylphenidate A stimulant drug, known better by the trade name Ritalin, commonly used to treat ADHD.
Migraine headache A very severe headache that occurs on one side of the head, often preceded by a warning sensation and some- times accompanied by dizziness, nausea, or vomiting.
Mild intellectual disability A level of intel- lectual disability (IQ between 50 and 70) at which people can benefit from education and can support themselves as adults.
Mild neurocognitive disorder Neurocog- nitive disorder in which the decline in cog- nitive functioning is modest and does not interfere with the ability to be independent.
Milieu therapy A humanistic approach to institutional treatment based on the premise that institutions can help patients recover by creating a climate that promotes self- respect, individual responsible behavior, and meaningful activity.
Mind-body dualism René Descartes’s posi- tion that the mind is separate from the body.
Mindfulness-based cognitive therapy A type of therapy that teaches clients to be mindful of (just notice and accept) their dysfunctional thoughts or worries.
Mindfulness meditation A type of medita- tion in which people are mindful of (just notice) the various thoughts, emotions, sen- sations, and other private experiences that pass through their minds and bodies.
Minnesota Multiphasic Personality Inventory (MMPI) A widely used person- ality inventory consisting of a large number of statements that subjects mark as being true or false for them.
Mixed design A research design in which a correlational method is mixed with an experimental method. Also known as quasi-experiment.
M’Naghten test A widely used legal test for insanity that holds people to be insane at the time they committed a crime if, because of a mental disorder, they did not know the nature of the act or did not know right from wrong. Also known as the M’Naghten rule.
Model A set of assumptions and concepts that help scientists explain and interpret obser- vations. Also called a paradigm.
Modeling A process of learning in which a person acquires responses by observing and imitating others. Also, a therapy approach based on the same principle.
Moderate intellectual disability A level of intellectual disability (IQ between 35 and 49) at which people can learn to care for
Marijuana One of the cannabis drugs, derived from the buds, leaves, and flowering tops of the hemp plant Cannabis sativa.
Marital therapy A therapy approach in which the therapist works with two people who share a long-term relationship. Also known as couple therapy.
Masturbation Self-stimulation of the genitals to achieve sexual arousal.
Masturbatory satiation A behavioral treat- ment in which a client masturbates for a very long period of time while fantasizing in detail about a paraphilic object. The procedure is expected to produce a feeling of boredom that becomes linked to the object.
Mean The average of a group of scores. Meditation A technique of turning one’s
concentration inward and achieving a slightly changed state of consciousness.
Melancholia A condition described by early Greek and Roman philosophers and physi- cians as consisting of unshakable sadness. Today it is known as depression.
Melatonin A hormone released by the pineal gland when a person’s surroundings are dark.
Memory The faculty for recalling past events and past learning.
Mental incompetence A state of mental instability that leaves defendants unable to understand the legal charges and proceed- ings they are facing and unable to prepare an adequate defense with their attorney.
Mental status exam A set of interview questions and observations designed to reveal the degree and nature of a client’s psychological functioning.
Mentally disordered sex offender A legal category that some states apply to certain people who are repeatedly found guilty of sex crimes.
Mentally ill chemical abusers (MICAs) People suffering from both schizophrenia (or another severe psychological disorder) and a substance-related disorder. Also called dual-diagnosis patients.
Mesmerism The method employed by Aus- trian physician F. A. Mesmer to treat hys- terical disorders; a precursor of hypnotism.
Meta-analysis A statistical method that com- bines results from multiple independent studies.
Metabolism An organism’s chemical and physical breakdown of food and the process of converting it into energy. Also, an organ- ism’s biochemical transformation of various substances, as when the liver breaks down alcohol into acetylaldehyde.
Metaworry Worrying about the fact that one is worrying so much.
Methadone A laboratory-made opioid-like drug.
Methadone maintenance program An approach to treating heroin-centered sub- stance use in which clients are given legally
range from partial support in a supervised apartment to intensive care at a nursing home.
Long-term memory The memory system that contains all the information that a person has stored over the years.
Loose associations A common thinking dis- turbance in schizophrenia, characterized by rapid shifts from one topic of conversation to another. Also known as derailment.
LSD (lysergic acid diethylamide) A hallucinogenic drug derived from ergot alkaloids.
Lycanthropy A condition in which per- sons believe themselves to be possessed by wolves or other animals.
Lymphocytes White blood cells that cir- culate through the lymph system and bloodstream, helping the body identify and destroy antigens and cancer cells.
Magnetic resonance imaging (MRI) A neuroimaging technique used to visualize internal structures of the brain or body.
Mainstreaming The placement of children with intellectual disability in regular school classes. Also known as inclusion.
Major depressive disorder A severe pattern of unipolar depression that is disabling and is not caused by such factors as drugs or a general medical condition.
Major neurocognitive disorder A neu- rocognitive disorder in which the decline in cognitive functioning is substantial and interferes with the ability to be independent.
Male hypoactive sexual desire disorder A male dysfunction marked by a persistent reduction or lack of interest in sex and hence a low level of sexual activity.
Malingering Intentionally faking illness to achieve some external gains, such as financial compensation or military deferment.
Malpractice suit A lawsuit charging a thera- pist with improper conduct or decision making in the course of treatment.
Managed care program A system of health care coverage in which the insur- ance company largely controls the nature, scope, and cost of medical or psychological services.
Mania A state or episode of euphoria or fren- zied activity in which people may have an exaggerated belief that the world is theirs for the taking.
Manifest content The consciously remem- bered content of a dream.
Mantra A sound, uttered or thought, used to focus one’s attention and to turn away from ordinary thoughts and concerns during meditation.
MAO inhibitor An antidepressant drug that prevents the action of the enzyme mono- amine oxidase.
: GlossaryG-10
Neuron A nerve cell. Neuropsychological test A test that
detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.
Neurosis Freud’s term for disorders char- acterized by intense anxiety, attributed to failure of a person’s ego defense mecha- nisms to cope with unconscious conflicts.
Neurotransmitter A chemical that, released by one neuron, crosses the synaptic space to be received at receptors on the dendrites of neighboring neurons.
Neutralizing Attempting to eliminate thoughts that one finds unacceptable by thinking or behaving in ways that make up for those thoughts and so put matters right internally.
Nicotine An alkaloid (nitrogen-containing chemical) derived from tobacco or pro- duced in the laboratory.
Nicotine patch A patch attached to the skin like a Band-Aid, with nicotine content that is absorbed through the skin, that suppos- edly eases the withdrawal reaction brought on by quitting cigarette smoking.
Nightmare disorder A parasomnia charac- terized by chronic distressful, frightening dreams.
Nocturnal penile tumescence (NPT) Erection during sleep.
Nomothetic understanding A general understanding of the nature, causes, and treatments of abnormal psychological func- tioning, in the form of laws or principles.
Nonsuicidal self-injury (NSSI) A disorder that is being studied for possible inclusion in a future edition of DSM-5, characterized by persons intentionally injuring themselves on five or more occasions over a one-year period, without the conscious intent of killing themselves.
Norepinephrine A neurotransmitter whose abnormal activity is linked to panic disorder and depression.
Normalization The principle that institutions and community residences should provide people with intellectual disability types of living conditions and opportunities that are similar to those enjoyed by the rest of society.
Norms A society’s stated and unstated rules for proper conduct.
Not guilty by reason of insanity (NGRI) A verdict stating that defendants are not guilty of committing a crime because they were insane at the time of the crime.
Object relations theory The psychody- namic theory that views the desire for relationships as the key motivating force in human behavior.
Observer drift The tendency of an observer who is rating subjects in an experiment to change criteria gradually and involuntarily, thus making the data unreliable.
Narcolepsy A sleep-wake disorder character- ized by a repeated sudden and irrepressible need to sleep during waking hours.
Narcotic Any natural or synthetic opioid-like drug.
Narcotic antagonist A substance that attaches to opioid receptors in the brain and, in turn, blocks the effects of opioids.
National Alliance on Mental Illness (NAMI) A nationwide grassroots organiza- tion that provides support, education, advo- cacy, and research for people with severe mental disorders and their families.
Natural experiment An experiment in which nature, rather than an experimenter, manipulates an independent variable.
Naturalistic observation A method of observing behavior in which clinicians or researchers observe people in their everyday environments.
Negative correlation A statistical relation- ship in which the value of one variable increases while the other variable decreases.
Negative symptoms Symptoms of schizo- phrenia that seem to be deficits in normal thought, emotions, or behaviors.
Neologism A made-up word that has meaning only to the person using it.
Nerve ending The region at the end of a neuron from which an impulse is sent to a neighboring neuron.
Neurocognitive disorder A disorder marked by a significant decline in at least one area of cognitive functioning.
Neurodevelopmental disorders A group of disabilities—including ADHD, autism spec- trum disorder, and intellectual disability—in the functioning of the brain that emerge at birth or during very early childhood and affect an individual’s behavior, memory, concentration, and/or ability to learn.
Neurofibrillary tangles Twisted protein fibers that form within certain brain cells as people age. People with Alzheimer’s disease have an excessive number of such tangles.
Neuroimaging techniques Neurological tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain scans.
Neuroleptic drugs An alternative term for conventional antipsychotic drugs, so called because they often produce undesired effects similar to the symptoms of neuro- logical disorders.
Neuroleptic malignant syndrome A severe, potentially fatal reaction to antipsy- chotic drugs, marked by muscle rigidity, fever, altered consciousness, and autonomic dysfunction.
Neurological Relating to the structure or activity of the brain.
Neurological test A test that directly mea- sures brain structure or activity.
Neuromodulator A neurotransmitter that helps modify or regulate the effect of other neurotransmitters.
themselves and can benefit from vocational training.
Monoamine oxidase (MAO) A body chemical that destroys the neurotransmitter norepinephrine.
Monoamine oxidase (MAO) inhibitors Antidepressant drugs that lower MAO activity and thus increase the level of nor- epinephrine activity in the brain.
Mood disorder A disorder affecting one’s emotional state, including major depressive disorder and bipolar disorders.
Mood stabilizing drugs Psychotropic drugs that help stabilize the moods of people suf- fering from a bipolar mood disorder. Also known as antibipolar drugs.
Moral treatment A nineteenth-century approach to treating people with mental dysfunction that emphasized moral guidance and humane and respectful treatment.
Morphine A highly addictive substance derived from opium that is particularly effective in relieving pain.
Multicultural perspective The view that each culture within a larger society has a particular set of values and beliefs, as well as special external pressures, that help account for the behavior and functioning of its members. Also called culturally diverse perspective.
Multicultural psychology The field of psychology that examines the impact of culture, race, ethnicity, gender, and similar factors on our behaviors and thoughts and focuses on how such factors may influ- ence the origin, nature, and treatment of abnormal behavior.
Multidimensional risk perspective A theory that identifies several kinds of risk factors that are thought to combine to help cause a disorder. The more factors present, the greater the risk of developing the disorder.
Munchausen syndrome An extreme and long-term form of factitious disorder in which a person produces symptoms, gains admission to a hospital, and receives treatment.
Munchausen syndrome by proxy A fac- titious disorder in which parents make up or produce physical illnesses in their children.
Muscle contraction headache A headache caused by the narrowing of muscles sur- rounding the skull. Also known as tension headache.
Muscle dysmorphobia Disorder in which people become obsessed with the incorrect belief that they are not muscular enough.
Narcissistic personality disorder A per- sonality disorder marked by a broad pattern of grandiosity, need for admiration, and lack of empathy.
Glossary : G-11
Perseveration The persistent repetition of words and statements.
Persistent depressive disorder A chronic form of unipolar depression marked by ongoing and repeated symptoms of either major or mild depression.
Personality A unique and long-term pattern of inner experience and outward behavior that leads to consistent reactions across various situations.
Personality disorder An enduring, rigid pattern of inner experience and outward behavior that repeatedly impairs a person’s sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy.
Personality disorder—trait specified (PDTS) A personality disorder currently undergoing study for possible inclusion in a future revision of DSM-5. Individuals would receive this diagnosis if they display signifi- cant impairment in functioning as a result of one or more very problematic traits.
Personality inventory A test designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either characteristic or uncharacteristic of them.
Phallic stage In psychoanalytic theory, the period between the third and fourth years when the focus of sexual pleasure shifts to the genitals.
Phalloplasty A surgical procedure designed to create a functional penis.
Phenothiazines A group of antihistamine drugs that became the first group of effec- tive antipsychotic medications.
Phenylketonuria (PKU) A metabolic dis- order caused by the body’s inability to break down the amino acid phenylalanine, resulting in intellectual disability and other symptoms.
Phobia A persistent and unreasonable fear of a particular object, activity, or situation.
Pick’s disease A neurological disease that affects the frontal and temporal lobes, causing a neurocognitive disorder.
Placebo therapy A simulated treatment that the participant in an experiment believes to be genuine.
Play therapy An approach to treating child- hood disorders that helps children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories.
Pleasure principle The pursuit of gratifica- tion that characterizes id functioning.
Plethysmograph A device used to measure sexual arousal.
Polygraph test A test that seeks to deter- mine whether the test taker is telling the truth by measuring physiological responses such as respiration level, perspiration level, and heart rate. Also known as a lie detector test.
Panic attacks Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.
Panic disorder An anxiety disorder marked by recurrent and unpredictable panic attacks.
Paranoid personality disorder A per- sonality disorder marked by a pattern of extreme distrust and suspiciousness of others.
Paraphilias Patterns in which a person has recurrent and intense sexual urges, fantasies, or behaviors involving nonhuman objects, children, nonconsenting adults, or experi- ences of suffering or humiliation.
Paraphilic disorder A disorder in which a person’s paraphilia causes great distress, interferes with social or occupational activities, or places the person or others at risk of harm—either currently or in the past.
Paraprofessional A person without previous professional training who provides services under the supervision of a mental health professional.
Parasomnias Sleep-wake disorders, such as sleepwalking, sleep terrors, and nightmare disorder, characterized by the occurrence of abnormal events during sleep.
Parasuicide A suicide attempt that does not result in death.
Parasympathetic nervous system The nerve fibers of the autonomic nervous system that help return bodily processes to normal.
Parkinsonian symptoms Symptoms similar to those found in Parkinson’s disease. Patients with schizophrenia who take con- ventional antipsychotic medications may display one or more of these symptoms.
Parkinson’s disease A slowly progressive neurological disease, marked by tremors and rigidity, that may also cause dementia.
Participant modeling A behavioral treat- ment in which people with fears observe a therapist (model) interacting with a feared object and then interact with the object themselves.
Pedophilic disorder A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children and either acts on these urges or experiences clinically significant distress or impairment.
Peer review system A system by which cli- nicians paid by an insurance company may periodically review a patient’s progress and recommend the continuation or termina- tion of insurance benefits.
Penile prosthesis A surgical implant con- sisting of a semi-rigid rod that produces an artificial erection.
Performance anxiety The fear of per- forming inadequately and a related tension experienced during sex.
Obsession A persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.
Obsessive-compulsive disorder A dis- order in which a person has recurrent and unwanted thoughts and/or a need to per- form repetitive and rigid actions.
Obsessive-compulsive personality disorder A personality disorder marked by such an intense focus on orderliness, perfec- tionism, and control that the person loses flexibility, openness, and efficiency.
Obsessive-compulsive-related disorders A group of disorders in which obsessive- like concerns drive people to repeatedly and excessively perform specific pat- terns of behavior that greatly disrupt their lives.
Oedipus complex In Freudian theory, the pattern of desires emerging during the phallic stage in which boys become attracted to their mother as a sexual object and see their father as a rival they would like to push aside.
Olanzapine An atypical antipsychotic drug whose brand name is Zyprexa.
Operant conditioning A process of learning in which behavior that leads to satisfying consequences is likely to be repeated.
Opioid Opium or any of the drugs derived from opium, including morphine, heroin, and codeine.
Opium A highly addictive substance made from the sap of the opium poppy seed.
Oppositional defiant disorder A disorder in which children are repeatedly argumen- tative and defiant, angry and irritable, and, in some cases, vindictive.
Oral stage The earliest developmental stage in Freud’s conceptualization of psycho- sexual development, during which the infant’s main gratification comes from feeding and from the body parts involved in feeding.
Orbitofrontal cortex A region of the brain in which impulses involving excretion, sexuality, violence, and other primitive activities normally arise.
Orgasm A peaking of sexual pleasure, con- sisting of rhythmic muscular contractions in the pelvic region, during which a man’s semen is ejaculated and the outer third of a woman’s vaginal wall contracts.
Orgasm phase The phase of the sexual response cycle during which a person’s sexual pleasure peaks and sexual tension is released as muscles in the pelvic region contract rhythmically.
Orgasmic reorientation A procedure for treating certain paraphilias by teaching cli- ents to respond to new, more appropriate sources of sexual stimulation.
Outpatient A person who receives a diag- nosis or treatment in a clinic, hospital, or therapist’s office but is not hospitalized overnight.
: GlossaryG-12
Psychogenic perspective The view that the chief causes of abnormal functioning are psychological.
Psychological autopsy A procedure used to analyze information about a deceased person, for example, in order to determine whether the person’s death was a suicide.
Psychological debriefing A form of crisis intervention in which victims are helped to talk about their feelings and reactions to traumatic incidents. Also called critical inci- dent stress debriefing.
Psychological profile A method of sus- pect identification that seeks to predict an unknown criminal’s psychological, emo- tional, and personality characteristics based on the individual’s pattern of criminal behavior and on research into the psycho- logical characteristics of people who have committed similar crimes.
Psychology The study of mental processes and behaviors.
Psychomotor symptoms Disturbances in movement sometimes found in certain dis- orders such as schizophrenia.
Psychoneuroimmunology The study of the connections among stress, the body’s immune system, and illness.
Psychopathology An abnormal pattern of functioning that may be described as deviant, distressful, dysfunctional, and/or dangerous.
Psychopathy See antisocial personality disorder.
Psychopharmacologist A psychiatrist who primarily prescribes medications. Also called pharmacotherapist.
Psychophysiological disorders Disorders in which biological, psychological, and socio- cultural factors interact to cause or worsen a physical illness. Also known as psychological factors affecting other medical conditions.
Psychophysiological test A test that mea- sures physical responses (such as heart rate and muscle tension) as possible indicators of psychological problems.
Psychosexual stages The developmental stages defined by Freud in which the id, ego, and superego interact.
Psychosis A state in which a person loses contact with reality in key ways.
Psychosurgery Brain surgery for mental disorders.
Psychotherapy A treatment system in which words and acts are used by a client (patient) and therapist in order to help the client overcome psychological difficulties.
Psychotropic medications Drugs that mainly affect the brain and reduce many symptoms of mental dysfunctioning.
Quasi-experiment An experiment in which investigators make use of control and experimental groups that already exist in the world at large. Also called a mixed design.
symptoms keep their internal conflicts out of awareness.
Primary personality The subpersonality that appears more often than the others in individuals with dissociative identity disorder.
Primary prevention Prevention interven- tions that are designed to prevent disorders altogether.
Private psychotherapy An arrangement in which a person directly pays a therapist for counseling services.
Proband The person who is the focus of a genetic study.
Procedural memory Memory of learned skills that a person performs without needing to think about them.
Prodromal phase The period during which the symptoms of schizophrenia are not yet prominent, but the person has begun to deteriorate from previous levels of functioning.
Profound intellectual disability A level of intellectual disability (IQ below 20) at which people need a very structured envi- ronment with close supervision.
Projection An ego defense mechanism whereby individuals attribute to other people characteristics or impulses they do not wish to acknowledge in themselves.
Projective test A test consisting of ambig- uous material that people interpret or respond to.
Protection and advocacy system The system by which lawyers and advocates who work for patients may investigate the patients’ treatment and protect their rights.
Prozac The trade name for fluoxetine, a second-generation antidepressant.
Psychedelic drugs Substances such as LSD that cause profound perceptual changes. Also called hallucinogenic drugs.
Psychiatric social worker A mental health specialist who is qualified to conduct psy- chotherapy upon earning a master’s degree or doctorate in social work.
Psychiatrist A physician who in addition to medical school has completed three to four years of residency training in the treatment of abnormal mental functioning.
Psychoanalysis Either the theory or the treatment of abnormal mental functioning that emphasizes unconscious psychological forces as the cause of psychopathology.
Psychodynamic model The theoretical perspective that sees all human functioning as being shaped by dynamic (interacting) psychological forces and explains people’s behavior by reference to unconscious internal conflicts.
Psychodynamic therapy A system of therapy whose goals are to help clients uncover past traumatic events and the inner conflicts that have resulted from them, settle those conflicts, and resume personal development.
Polysubstance use The use of two or more substances at the same time.
Positive correlation A statistical relation- ship in which the values of two variables increase together or decrease together.
Positive psychology The study and enhancement of positive feelings, traits, and abilities.
Positive symptoms Symptoms of schizo- phrenia that seem to be excesses of or bizarre additions to normal thoughts, emo- tions, or behaviors.
Positron emission tomography (PET scan) A computer-produced motion picture showing rates of metabolism throughout the brain.
Postpartum depression An episode of depression experienced by some new mothers that begins within four weeks after giving birth.
Postpartum psychosis An episode of psy- chosis experienced by a small percentage of new mothers that begins within days or weeks after giving birth.
Posttraumatic stress disorder (PTSD) A disorder in which fear and related symp- toms continue to be experienced long after a traumatic event.
Poverty of speech A decrease in speech or speech content found in some people with schizophrenia. Also known as alogia.
Predictive validity The ability of a test or other assessment tool to predict future characteristics or behaviors.
Predisposition An inborn or acquired vul- nerability for developing certain symptoms or disorders.
Prefrontal lobes Regions of the brain that play a key role in short-term memory, among other functions.
Premature ejaculation A dysfunction in which a man persistently reaches orgasm and ejaculates within one minute of begin- ning sexual activity with a partner and before he wishes to. Also called early or rapid ejaculation.
Premenstrual dysphoric disorder A dis- order marked by repeated experiences of significant depression and related symptoms during the week before menstruation.
Premenstrual syndrome (PMS) A common and normal cluster of psycholog- ical and physical discomforts that precede menses.
Premorbid The period prior to the onset of a disorder.
Preparedness A predisposition to develop certain fears.
Prevalence The total number of cases of a disorder occurring in a population over a specific period of time.
Prevention A key feature of community mental health programs that seek to prevent or minimize psychological disorders.
Primary gain In psychodynamic theory, the gain people achieve when their somatic
Glossary : G-13
Right to treatment The legal right of patients, particularly those who are invol- untarily committed, to receive adequate treatment.
Risperidone A commonly prescribed atyp- ical antipsychotic drug.
Ritalin Trade name of methylphenidate, a stimulant drug that is helpful in many cases of attention-deficit/hyperactivity disorder (ADHD).
Role play A therapy technique in which cli- ents are instructed to act out roles assigned to them by the therapist.
Rorschach test A projective test, in which a person reacts to inkblots designed to help reveal psychological features of the person.
Rosenthal effect The general finding that the results of any experiment often conform to the expectations of the experimenter.
Rush A spasm of warmth and ecstasy that occurs when certain drugs, such as heroin, are ingested.
Savant A person with a mental disorder or significant intellectual deficits who has some extraordinary ability despite the dis- order or deficits.
Schizoaffective disorder A disorder in which symptoms of both schizophrenia and a mood disorder are prominent.
Schizoid personality disorder A person- ality disorder in which a person persistently avoids social relationships and shows little emotional expression.
Schizophrenia A psychotic disorder in which personal, social, and occupational functioning deteriorate as a result of strange perceptions, disturbed thought processes, unusual emotions, and motor abnormalities.
Schizophreniform disorder A disorder in which all of the key features of schizo- phrenia are present but last only between one and six months.
Schizophrenogenic mother A type of mother—supposedly cold, domineering, and uninterested in the needs of her children—who was once thought to cause schizophrenia in her child.
Schizotypal personality disorder A per- sonality disorder characterized by extreme discomfort in close relationships, odd forms of thinking and perceiving, and behavioral eccentricities.
School phobia A pattern in which children fear going to school and often stay home for a long period of time. Also called school refusal.
Scientific method The process of systemati- cally gathering and evaluating information through careful observations to gain an understanding of a phenomenon.
Seasonal affective disorder (SAD) A mood disorder in which mood episodes are related to changes in season.
Relaxation training A treatment procedure that teaches clients to relax at will so they can calm themselves in stressful situations.
Reliability A measure of the consistency of test or research results.
Repression A defense mechanism whereby the ego prevents unacceptable impulses from reaching consciousness.
Residential treatment center A place where people formerly addicted to drugs live, work, and socialize in a drug-free envi- ronment. Also called a therapeutic community.
Resiliency The ability to avoid or recover from the effects of negative circumstances.
Resistance An unconscious refusal to partici- pate fully in therapy.
Resolution phase The fourth phase in the sexual response cycle, characterized by relaxation and a decline in arousal following orgasm.
Response inventories Tests designed to measure a person’s responses in one specific area of functioning, such as affect, social skills, or cognitive processes.
Response prevention See Exposure and response prevention.
Response set A particular way of responding to questions or statements on a test, such as always selecting “true,” regardless of the actual questions.
Restricting-type anorexia nervosa A type of anorexia nervosa in which people reduce their weight by severely restricting their food intake.
Reticular formation The brain’s arousal center, which helps people to be awake, alert, and attentive.
Retrograde amnesia A lack of memory about events that occurred before the event that triggered amnesia.
Retrospective analysis A psychological autopsy in which clinicians and researchers piece together information about a person’s suicide from the person’s past.
Reversal design A single-subject experi- mental design in which behavior is mea- sured to provide a baseline (A), then again after the treatment has been applied (B), then again after the conditions during base- line have been reintroduced (A), and then once again after the treatment is reintro- duced (B). Also known as ABAB design.
Reward A pleasurable stimulus given to an organism that encourages a specific behavior.
Reward center A dopamine-rich pathway in the brain that produces feelings of pleasure when activated.
Reward-deficiency syndrome A condition, suspected to be present in some people, in which the brain’s reward center is not readily activated by the usual events in their lives.
Right to refuse treatment The legal right of patients to refuse certain forms of treatment.
Random assignment A selection procedure that ensures that participants are randomly placed either in the control group or in the experimental group.
Rap group The initial term for group therapy sessions among veterans in which members meet to talk about and explore problems in an atmosphere of mutual support.
Rape Forced sexual intercourse or another sexual act committed against a noncon- senting person or intercourse with an underage person.
Rapid eye movement (REM) sleep The period of the sleep cycle during which the eyes move quickly back and forth, indi- cating that the person is dreaming.
Rapprochement movement An effort to identify a set of common strategies that run through the work of all effective therapists.
Rational-emotive therapy A cognitive therapy developed by Albert Ellis that helps clients identify and change the irrational assumptions and thinking that help cause their psychological disorder.
Rationalization An ego defense mechanism in which one creates acceptable reasons for unwanted or undesirable behavior.
Reaction formation An ego defense mech- anism whereby a person counters an unac- ceptable desire by taking on a lifestyle that directly opposes the unwanted impulse.
Reactive depression A depression that appears to be triggered by clear events. Also known as exogenous depression.
Reactivity The extent to which the very presence of an observer affects a person’s behavior.
Reality principle The recognition, characterizing ego functioning, that we cannot always express or satisfy our id impulses.
Receptor A site on a neuron that receives a neurotransmitter.
Regression An ego defense mechanism in which a person returns to a more primitive mode of interacting with the world.
Reinforcement The desirable or undesir- able stimuli that result from an organism’s behavior.
Relapse-prevention training A cognitive- behavioral approach to treating alcohol use disorder (and applied to certain other disorders) in which clients are taught to keep track of their drinking behavior, apply coping strategies in situations that typically trigger excessive drinking, and plan ahead for risky situations and reactions.
Relational psychoanalytic therapy A form of psychodynamic therapy that considers therapists to be active participants in the formation of patients’ feelings and reactions and therefore calls for therapists to disclose their own experiences and feelings in dis- cussions with patients.
: GlossaryG-14
who have been convicted of sex crimes and have served their sentence in prison to be removed from prison before their release and committed involuntarily to a mental hospital for treatment if a court judges them likely to engage in further acts of sexual violence due to a mental or personality abnormality. Also called sexually dangerous persons laws.
Shaping A learning procedure in which successive approximations of the desired behavior are rewarded until finally the exact and complete behavior is learned.
Sheltered workshop A supervised work- place for people who are not yet ready for competitive jobs.
Short-term memory The memory system that collects new information. Also known as working memory.
Shuttle box A box separated in the middle by a barrier that an animal can jump over in order to escape or avoid shock.
Sildenafil A drug used to treat erectile dis- order that helps increase blood flow to the penis during sexual activity. Marketed as Viagra.
Single-subject experimental design A research method in which a single partici- pant is observed and measured both before and after the manipulation of an indepen- dent variable.
Situation anxiety The various levels of anxiety produced in a person by different situations. Also called state anxiety.
Sleep apnea disorder A sleep-wake dis- order characterized by frequent awakenings each night due to periodic deprivation of oxygen to the brain during sleep.
Sleep terror disorder A parasomnia in which a person awakens suddenly during the first third of sleep, screaming out in extreme fear and agitation.
Sleepwalking disorder A parasomnia in which people repeatedly leave their beds and walk around without being conscious of the episode or remembering it later.
Social anxiety disorder A severe and persis- tent fear of social or performance situations in which embarrassment may occur.
Social communication disorder A dis- order marked by persistent problems in communication and social relationships, but without significant language difficulties or cognitive impairment. The communication and social problems are different in nature and less severe than those in autism spec- trum disorder.
Social skills training A therapy approach that helps people learn or improve social skills and assertiveness through role playing and rehearsing of desirable behaviors.
Social therapy An approach to therapy in which the therapist makes practical advice and life adjustment a central focus of treatment for schizophrenia. Therapy also focuses on problem solving, decision
spaces between certain brain cells and in certain blood vessels as people age. People with Alzheimer’s disease have an excessive number of such plaques.
Sensate focus A treatment for sexual dis- orders that instructs couples to take the focus away from orgasm or intercourse and instead spend time concentrating on the pleasure achieved by such acts as kissing, hugging, and mutual massage. Also known as nondemand pleasuring.
Separation anxiety disorder A disorder marked by excessive anxiety, even panic, whenever the individual is separated from home, a parent, or another attachment figure.
Serial murders A series of two or more killings carried out separately by the same individual(s) over a period of time—usually a month or more.
Serotonin A neurotransmitter whose abnormal activity is linked to depression, obsessive-compulsive disorder, and eating disorders.
Severe intellectual disability A level of intellectual disability (IQ between 20 and 34) at which individuals require careful supervision and can learn to perform basic work in structured and sheltered settings.
Sex-change surgery A surgical procedure that changes a person’s sex organs, features, and, in turn, sexual identity. Also known as sexual reassignment surgery.
Sex offender statute The presumption by some state legislatures that people who are repeatedly found guilty of certain sex crimes have a mental disorder and should be categorized as “mentally disordered sex offenders.” Such laws have been changed or abolished by many states over the past two decades.
Sexual dysfunction A disorder marked by a persistent inability to function normally in some area of the human sexual response cycle.
Sexual masochism disorder A paraphilic disorder in which a person has repeated and intense sexual urges, fantasies, or behav- iors that involve being humiliated, beaten, bound, or otherwise made to suffer, accom- panied by clinically significant distress or impairment.
Sexual response cycle The general sequence of behavior and feelings that occurs during sexual activity, consisting of desire, excitement, orgasm, and resolution.
Sexual sadism disorder A paraphilic dis- order in which a person has repeated and intense sexual urges or fantasies that involve inflicting suffering on others and either acts on these urges with nonconsenting indi- viduals or experiences clinically significant distress or impairment.
Sexually violent predator laws Laws passed by the federal government and many states that call for certain sex offenders
Second-generation antidepressants A relatively new group of antidepressant drugs that differ structurally from tricyclics and MAO inhibitors.
Second-generation antipsychotic drugs A relatively new group of antipsychotic drugs whose biological action is different from that of the conventional antipsychotic drugs. Also known as atypical antipsychotic drugs.
Second messengers Chemical changes within a neuron just after the neuron receives a neurotransmitter message and just before it responds.
Secondary gain In psychodynamic theory, the gain people achieve when their somatic symptoms elicit kindness from others or provide an excuse for avoiding unpleasant activities.
Secondary prevention Prevention interven- tions that are designed to address disorders quickly, before they become more serious problems.
Sedative-hypnotic drug A drug used in low doses to calm people and in higher doses to help people sleep. Also called an anxiolytic drug.
Selective amnesia An inability to recall some of the events that occurred over a limited period of time.
Selective serotonin reuptake inhibitors (SSRIs) A group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters.
Self-actualization The humanistic process by which people fulfill their potential for goodness and growth.
Self-efficacy The belief that one can master and perform needed behaviors whenever necessary.
Self-help group A group made up of people with similar problems who help and sup- port one another without the direct leader- ship of a clinician. Also called a mutual help group.
Self-hypnosis The process of hypnotizing oneself, sometimes for the purpose of for- getting unpleasant events.
Self-instruction training A cognitive treat- ment developed by Donald Meichenbaum that teaches people to use coping self- statements at times of stress, discomfort, or significant pain. Also called stress inoculation training.
Self-monitoring Clients’ observation of their own behavior.
Self-statements According to some cogni- tive theorists, statements about oneself, sometimes counterproductive, that come to mind during stressful situations.
Self theory The psychodynamic theory that emphasizes the role of the self—a person’s unified personality.
Senile plaques Sphere-shaped deposits of beta-amyloid protein that form in the
Glossary : G-15
interpreted as the loss of a loved one. Also called imagined loss.
Sympathetic nervous system The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal and fear.
Symptom A physical or psychological sign of a disorder.
Synapse The tiny space between the nerve ending of one neuron and the dendrite of another.
Syndrome A cluster of symptoms that usu- ally occur together.
Synergistic effect In pharmacology, an increase of effects that occurs when more than one substance is acting on the body at the same time.
Synesthesia A crossing over of sensory per- ceptions caused by LSD and other halluci- nogenic drugs. For example, a loud sound may be seen or a color may be felt.
Systematic desensitization A behavioral treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.
Tarantism A disorder occurring throughout Europe between 900 and 1800 a.d. in which people would suddenly start to jump around, dance, and go into convulsions. Also known as St. Vitus’s dance.
Tardive dyskinesia Extrapyramidal effects that appear in some patients after they have taken conventional antipsychotic drugs for an extended time.
Tay-Sachs disease A metabolic disorder that causes progressive loss of intellectual functioning, vision, and motor functioning, resulting in death.
Temporal lobes Regions of the brain that play a key role in transforming short-term memory to long-term memory, among other functions.
Tension headache See Muscle contraction headache.
Tertiary prevention Prevention interven- tions that are designed to provide effective treatment for moderate or severe disorders as soon as it is needed so that the disorders do not become long-term problems.
Test A device for gathering information about a few aspects of a person’s psycho- logical functioning from which broader information about the person can be inferred.
Testosterone The principal male sex hormone.
Tetrahydrocannabinol (THC) The main active ingredient of cannabis.
Thanatos According to the Freudian view, the basic death instinct that functions in opposition to the life instinct.
Thematic Apperception Test (TAT) A projective test consisting of pictures that
Stimulus generalization A phenomenon in which responses to one stimulus are also produced by similar stimuli.
Stress-management program An approach to treating generalized and other anxiety disorders that teaches clients techniques for reducing and controlling stress.
Stressor An event that creates a sense of threat by confronting a person with a demand or opportunity for change of some kind.
Stress-reduction and problem-solving seminar A workshop or series of group sessions offered by a business in which mental health professionals teach employees how to cope with and solve problems and reduce stress.
Stress response A person’s particular reac- tions to stress.
Structured interview An interview format in which the clinician asks prepared questions.
Subintentional death A death in which the victim plays an indirect, hidden, partial, or unconscious role.
Subject An individual chosen to participate in a study. Also called a participant.
Sublimation In psychoanalytic theory, the rechanneling of id impulses into endeavors that are both socially acceptable and per- sonally gratifying. Sublimation can also be used as an ego defense mechanism.
Subpersonalities The two or more distinct personalities found in individuals suffering with dissociative identity disorder. Also known as alternate personalities.
Substance use disorder A pattern of maladaptive behaviors and reactions brought about by repeated use of a sub- stance, sometimes also including tolerance for the substance and withdrawal reactions.
Suicidal behavior disorder A classification being studied for possible inclusion in a future revision of DSM-5, in which indi- viduals have tried to commit suicide within the last two years.
Suicide A self-inflicted death in which the person acts intentionally, directly, and consciously.
Suicide prevention program A program that tries to identify people who are at risk of killing themselves and to offer them crisis intervention.
Superego According to Freud, the psy- chological force that represents a person’s values and ideals.
Supportive nursing care A treatment, used to help those with anorexia nervosa in par- ticular, in which trained nurses conduct a day-to-day hospital program of increased caloric intake, nutrition education, sup- port, and, in some programs, motivational interviewing.
Symbolic loss According to Freudian theory, the loss of a valued object (for example, a loss of employment) that is unconsciously
making, development of social skills, and management of medications. Also known as personal therapy.
Sociocultural model The theoretical per- spective that emphasizes the effects of society, culture, and social and family groups on individual behavior.
Sociopathy See Antisocial personality disorder.
Sodium amobarbital (Amytal) A drug used to put people into a near-sleep state during which some can better recall for- gotten events.
Sodium pentobarbital (Pentothal) See Sodium amobarbital.
Somatic symptom disorder A disorder in which people become excessively distressed, concerned, and anxious about bodily symp- toms that they are experiencing, and their lives are greatly and disproportionately dis- rupted by the symptoms.
Somatogenic perspective The view that abnormal psychological functioning has physical causes.
Special education An approach to edu- cating children with intellectual disability in which they are grouped together and given a separate, specially designed education.
Specific learning disorder A develop- mental disorder marked by impairments in cognitive skills such as reading, writing, arithmetic, or mathematical skills.
Specific phobia A severe and persistent fear of a specific object or situation (does not include agoraphobia and social anxiety disorder).
Spectator role A state of mind that some people experience during sex, focusing on their sexual performance to such an extent that their performance and their enjoyment are reduced.
Standardization The process in which a test is administered to a large group of people whose performance then serves as a stan- dard or norm against which any individual’s score can be measured.
State-dependent learning Learning that becomes associated with the conditions under which it occurred, so that it is best remembered under the same conditions.
State hospitals Public mental institutions in the United States, run by the individual states.
State school A state-supported institution for people with intellectual disability.
Statistical analysis The application of prin- ciples of probability to the findings of a study in order to learn how likely it is that the findings have occurred by chance.
Statistical significance A measure of the probability that a study’s findings occurred by chance rather than because of the exper- imental manipulation.
Stimulant drug A substance that increases the activity of the central nervous system.
: GlossaryG-16
an unacceptable desire or act by performing another act.
Unilateral electroconvulsive therapy (ECT) A form of electroconvulsive therapy in which electrodes are attached to the head so that electrical current passes through only one side of the brain.
Unipolar depression Depression without a history of mania.
Unstructured interview An interview format in which the clinician asks sponta- neous questions that are based on issues that arise during the interview.
Vagus nerve stimulation A treatment procedure for depression in which an implanted pulse generator sends reg- ular electrical signals to a person’s vagus nerve; the nerve, in turn, stimulates the brain.
Validity The accuracy of a test’s or study’s results; that is, the extent to which the test or study actually measures or shows what it claims.
Valium The trade name of diazepam, an anti- anxiety drug.
Variable Any characteristic or event that can vary across time, locations, or persons.
Ventromedial hypothalamus (VMH) A brain region that depresses hunger when activated.
Visual hallucinations Hallucinations in which a person may either experience vague visual perceptions, perhaps of colors or clouds, or have distinct visions of people, objects, or scenes that are not there.
Voyeuristic disorder A paraphilic disorder in which a person has repeated and intense sexual desires to observe unsuspecting people in secret as they undress or to spy on couples having intercourse and either acts on these urges with nonconsenting indi- viduals or experiences clinically significant distress or impairment.
Weight set point The weight level that a person is predisposed to maintain, con- trolled in part by the hypothalamus.
Withdrawal Unpleasant, sometimes dan- gerous reactions that may occur when people who use a drug regularly stop taking or reduce their dosage of the drug.
Working through The psychoanalytic process of facing conflicts, reinter- preting feelings, and overcoming one’s problems.
Trephination An ancient operation in which a stone instrument was used to cut away a circular section of the skull, perhaps to treat abnormal behavior.
Trichotillomania A disorder in which people repeatedly pull out hair from their scalp, eyebrows, eyelashes, or other parts of their body. Also called hair-pulling disorder.
Tricyclic An antidepressant drug such as imipramine that has three rings in its molecular structure.
Trisomy A chromosomal abnormality in which a person has three chromosomes of one kind rather than the usual two.
Tube and intravenous feeding Forced nourishment sometimes provided to people with anorexia nervosa when their condi- tion becomes life-threatening.
Type A personality style A personality pat- tern characterized by hostility, cynicism, drivenness, impatience, competitiveness, and ambition.
Type B personality style A personality pat- tern in which a person is more relaxed, less aggressive, and less concerned about time.
Type I schizophrenia According to some theorists, a type of schizophrenia dominated by positive symptoms, such as delusions, hallucinations, and certain formal thought disorders.
Type II schizophrenia According to some theorists, a type of schizophrenia dominated by negative symptoms, such as flat affect, poverty of speech, and loss of volition.
Tyramine A chemical that, if allowed to accumulate, can raise blood pressure dan- gerously. It is found in many common foods and is broken down by MAO.
Ulcer A lesion that forms in the wall of the stomach or of the duodenum.
Unconditional positive regard Full, warm acceptance of a person regardless of what he or she says, thinks, or feels; a critical component of client-centered therapy.
Unconditioned response (UCR) The natural, automatic response produced by an unconditioned stimulus.
Unconditioned stimulus (UCS) A stim- ulus that produces an automatic, natural response.
Unconscious The deeply hidden mass of memories, experiences, and impulses that is viewed in Freudian theory as the source of much behavior.
Undoing An ego defense mechanism in which a person unconsciously cancels out
show people in ambiguous situations that the client is asked to interpret.
Theory of mind One’s awareness that other people base their behaviors on their own beliefs, intentions, and mental states, not on information they have no way of knowing.
Therapist A professional clinician who applies a system of therapy to help a person overcome psychological difficulties.
Therapy A systematic process for helping people overcome their psychological prob- lems. Therapy consists of a patient, a trained therapist, and a series of contacts between them.
Token economy program A behavioral program in which a person’s desirable behaviors are reinforced systematically throughout the day by the awarding of tokens that can be exchanged for goods or privileges.
Tolerance The adjustment that the brain and the body make to the regular use of certain drugs so that ever larger doses are needed to achieve the earlier effects.
Torture The use of brutal, degrading, and disorienting strategies to reduce victims to a state of utter helplessness.
Trait anxiety The general level of anxiety that a person brings to the various events in his or her life.
Tranquilizer A drug that reduces anxiety. Transcranial magnetic stimulation (TMS)
A treatment procedure for depression in which an electromagnetic coil, which is placed on or above a person’s head, sends a current into the person’s brain.
Transference According to psychodynamic theorists, the redirection toward the psy- chotherapist of feelings associated with important figures in a patient’s life, now or in the past.
Transgender experience A sense that one’s actual gender identity is different from one’s assigned gender (i.e., the gender category to which one was born physically) or that it lies outside the usual male versus female categories.
Transvestic disorder A paraphilic disorder consisting of repeated and intense sexual urges, fantasies, or behaviors that involve dressing in clothes of the opposite sex, accompanied by clinically significant dis- tress or impairment. Also known as transves- tism or cross-dressing.
Treatment A systematic procedure designed to help change abnormal behavior into more normal behavior. Also called therapy.
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Chapter 1 page 7: Frank, Jerome D., M.D., Ph.D. Persuasion and healing: A comparative study of psychotherapy, pp. 2–3. © 1961, 1973 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press.
Chapter 2 page 38: Spitzer, R. L., Skodol, A., Gibbon, M., & Williams, J. B. W. (1983). Psychopathy: A case book. New York: McGraw Hill. © McGraw- Hill Education; page 48: Wolberg, L. R. (1967). The technique of psychotherapy. WB Saunders Co. Elsevier Health Science Books, p. 662. Reprinted with permission. page 56: Republished with permission of Guilford Press, from Cognitive therapy of depression, Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979); permission conveyed through Copyright Clearance Center, Inc.; page 63: Keen, E. (1970). Three faces of being: Toward an existential clinical psychology. New York: Meredith Corp, p. 200. Reprinted by permission of Ardent Media; page 69: Sheras, P. & Worchel, S. (1979). Clinical psychology: A social psychological approach. New York: Van Nostrand, pp. 108–110.
Chapter 4 page 110: Republished with permission of University of Chicago Press, from The case of Mrs. Oak: A research analysis. In Psychotherapy and personality change: Coordinated research studies in the client-centered approach, C. R. Rogers & R. F. Dymond (Eds.), 1954; permission conveyed through Copyright Clearance Center, Inc.; pages 111, 114, 131: Ellis, A. (1962). Reason and emotion in psychotherapy. Kensington Publishing Corp. All rights reserved. Reprinted by arrangement with Kensington Publishing Corp. www.kensingtonbooks.com; page 125: Reprinted from Behavioral Research and Therapy, Vol. 6, Hogan, R. A., The implosive technique, 423–431, copyright 1968, with permission from Elsevier; page 127: Agras, W. S. (1985). Panic: Facing fears, phobias, and anxiety. New York: Worth Publishers, pp. 77–80. Reprinted with permission.
Chapter 5 page 149: Source: National Center for PTSD 2008 Appendix A. Case examples from Operation Iraqi Freedom. Iraq War Clinician Guide. Washington, DC: Department of Veteran Affairs; page 153: Davis, M., Analysis of aversive memories using the fear potentiated startle paradigm. In N. Butters & L. R. Squire (Eds.), The neuropsychology of memory, 2nd ed. (1992). Copyright Guilford Press. Reprinted with permission of The Guilford Press; page 168: Republished with permission of South-Western College Publishing, a division of Cengage Learning, from Principles of psychology, Vol. 1, James, W., 1890; permission conveyed through Copyright Clearance Center, Inc.
Chapter 6 page 183: From Willow weep for me: A black woman’s journey through depression by Meri Nana-Ama Danquah. Copyright © 1998 by Meri Nana-Ama Danquah. Used by permission of W. W. Norton & Company, Inc. Copyright © Meri Danquah. Reprinted by permission of Anne Edelstein Literary Agency. All rights reserved; page 197: Arieti, S., & Bemporad, J., 1978. Severe and mild depression: The psychotherapeutic approach. New York: Basic Books, pp. 275–284; pages 213–214: Anonymous. On madness: a personal account of rapid cycling bipolar disorder. British Journal of General Practice 2006, 56(530): 726–728. page 198: Lorand, Dynamics and therapy of depressive states. Psychoanalytic Review XXIV, 1937, pp. 337–349. Copyright Guilford Press. Reprinted with permission of The Guilford Press;
Credits page 204: Republished with permission of Guilford Press, from Cognitive therapy of depression, Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979); permission conveyed through Copyright Clearance Center, Inc.; page 207: Republished with permission of Transaction Aldine, from The silent language of psychotherapy: Social reinforcement of unconscious processes, E. Beier & D. M. Young, 2nd edition, 1984; permission conveyed through Copyright Clearance Center, Inc.; pages 216–217: Excerpt from An unquiet mind by Kay Redfield Jamison, copyright © 1995 by Kay Redfield Jamison. Used by permission of Alfred A. Knopf, an imprint of the Knopf Doubleday Publishing Group, a division of Random House LLC. All rights reserved.
Chapter 7 page 221: Yusko, D. (2008). At home, but locked in war. Retrieved from: Times Union (Albany) Online. Reprinted with permission; page 233: Gill, A. D. (1982). Vulnerability to suicide. In E. L. Bassuk, S. C. Schoonover, & A. D. Gill (Eds.), Lifelines: Clinical perspectives on suicide. New York: Plenum Press, p. 15; page 236: Berman, A. L. (1986). Helping suicidal adolescents: Needs and responses. In C. A. Corr & J. N. McNeil (Eds.), Adolescence and death. New York: Springer.
Chapter 8 page 268: Reprinted from Journal of Psychosomatic Research, Vol. 11, Holmes, T. H., & Rahe, R. H., The Social Readjustment Rating Scale, 213–218. Copyright 1967, with permission from Elsevier; page 268: Crandall, C. S., Preisler, J. J., & Aussprung, J. (1992). Measuring life event stress in the lives of college students: The Undergraduate Stress Questionnaire (USQ). Journal of Behavioral Medicine, 15(6), 627–662.
Chapter 9 pages 279: Raviv, S. (2010). Being Ana: A memoir of anorexia nervosa. Bloomington: iUniverse. Used with permission from Shani Raviv; pages 283, 285: Hall, L., with Cohn, L. (1980). Eat without fear. Santa Barbara, CA: Gürze Books. Reprinted with permission; pages 300, 301: Republished with permission of Guilford Press, from Strober, M., & Yager, J., A developmental perspective on the treatment of anorexia nervosa in adolescents. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (1985); permission conveyed through Copyright Clearance Center, Inc.
Chapter 10 page 309: Spitzer, R. L., Skodol, A., Gibbon, M., & Williams, J. B. W. (1983). Psychopathology: A case book. New York: McGraw-Hill. © McGraw-Hill Education; page 321: Allen, D. F. (Ed.). (1987). The cocaine crisis. Plenum Press: New York; page 324: Frosch, W. A., Robbins, E. S., & Stern, M. (1965). Untoward reactions to lysergic acid diethylamide (LSD) resulting in hospitalization. New England Journal of Medicine, 273, 1235–1239.
Chapter 11 pages 353, 361: Spitzer, R. L., Skodol, A., Gibbon, M., & Williams, J. B. W. (1983). Psychopathology: A case book. New York: McGraw-Hill. © McGraw-Hill Education; pages 371, 374: Janus, S. S., & Janus, C. L. (1993). The Janus report on sexual behavior. New York: Wiley. Reprinted with permission of the Janus estate.
Chapter 12 page 385: Arieti, S. (1974). Interpretation of schizophrenia. New York: Basic Books. Reprinted with permission; page 389: Anonymous, First person account: Social, economic, and medical effects of schizophrenia, Schizophrenia Bulletin, 1996, 22(1), 183–185, by permission of Oxford University Press; page 402: Excerpt from Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America by Robert Whitaker, copyright © 2010 by Robert Whitaker.
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conveyed through Copyright Clearance Center, Inc.; page 480: Republished with permission of South-Western College Publishing, a division of Cengage Learning, from Understanding child behavior disorders, Gelfand, D. M., Jenson, W. R., & Drew, C. J., 1982; permission conveyed through Copyright Clearance Center, Inc.
Chapter 15 page 501: Heston, L. L. (1992). Mending minds: A guide to the new psychiatry of depression, anxiety, and other serious mental disorders. New York: Worth Publishers, pp. 87–90. Reprinted with permission; page 504: Hinrichsen, G. A. (1999). Interpersonal psychotherapy for late-life depression. In M. Duffy (Ed.), Handbook of counseling and psychotherapy with older adults. New York: Wiley; pages 512–513: Excerpt from The forgetting: Alzheimer’s: Portrait of an epidemic, by David Shenk, copyright © 2001, 2002 by David Shenk. Used by permission of Doubleday, an imprint of the Knopf Doubleday Publishing Group, a division of Random House LLC. All rights reserved. Reproduced with permission of ICM Partners.
Chapter 16 pages 533: Copyright 1984, Lee Coleman. Used by permission.
Used by permission of Crown Books, an imprint of the Crown Publishing Group, a division of Random House LLC. All rights reserved.
Chapter 13 pages 427, 429, 448, 452: Millon, T. (2011). Disorders of personality: Introducing a DSM/ICD spectrum from normal to abnormal, 3rd ed. Hoboken, NJ: Wiley. Reproduced with permission of John Wiley & Sons Inc.; page 432: Hare, R. D. (1993). Without conscience: The disturbing world of the psychopaths among us. New York: Pocket Books. Copyright Guilford Press. Reprinted with permission of The Guilford Press; page 444: Republished with permission of South-Western College Publishing, a division of Cengage Learning, from Modern psychopathology: A biosocial approach to maladaptive learning and functioning, Millon, T., 1969; permission conveyed through Copyright Clearance Center, Inc.
Chapter 14 pages 464, 473, 483: Republished with permission of South-Western College Publishing, a division of Cengage Learning, from Casebook in child behavior disorders, Kearney, C. A., 5th ed. (2013); permission
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Aamodt, M. G., 543, 544 Abbass, A. A., 101, 445, 454 Abbey, A., 313 Abbey, S. E., 256 Abdul, P., 302 Abel, G. G., 373 Aboujaoude, E., 20 Abraham, K., 196, 219, 232 Abraham, S., 305 Abramowitz, J. S., 124, 130,
140, 261 Abramson, L. Y., 202 Accomando, B., 121 Achalia, R. M., 408 Acosta, M. C., 319, 321, 322, 323 Adam, K. S., 232 Adams, C. E., 395, 407 Adams, J. G., 156 Adams, R. E., 157 Addington, J., 401, 414 Adele (Adkins, A.), 119, 449 Adkins, A. (Adele), 119, 449 Adriaens, P. R., 367 Advokat, C. D., 193, 194, 217,
324, 407, 408, 474, 481, 512, 513, 518
Affatati, V., 379 Afifi, T. O., 478 Agras, S., 126 Agronin, M. E., 436 Aguilera, A., 210 Ahearn, W. H., 487 Ahern, D. C., 96 Ahern, G. L., 176 Ahlers, C. J., 367 Aiken, C. B., 217 Aiken, L. R., 82 Ainette, M. G., 331 Ajdacic-Gross, V., 239 Akhtar, S., 138 Akinbami, L. J., 263 Akins, C. K., 375 Alba, J., 302 Albala, I., 33 Al-Bedah, A. M., 43 Albert (Little), 123 Alcalar, N., 203 Alcántara, C., 239, 241 Alder, M., 195 Aldhous, P., 458 Ale, C. M., 467 Alegría, M., 17, 71 Alexander, J. F., 69 Alfano, C. A., 128 Alfano, L., 297 Algars, M., 364 Ali, M., 518 Ali, M. M., 230 Ali, S., 254, 260 Alicea, G., 81 Alisic, E., 154 Allan, C., 406 Allan, N. P., 136
Name Index Allan, R., 266 Allan, S., 284, 289, 293, 294, 302 Allderidge, P., 9 Allebeck, P., 412 Allen, D., 74 Allen, D. F., 321 Allen, W., 41, 428 Allison, R., 381 Alloway, T. P., 446 Almeida, J., 530 Aloe, A. M., 342 Alonzo, D., 232 Alonzo, T., 521 Alridge, J., 186 Altareb, B., 203 Alter, C., 21, 338 Althof, S. E., 355, 361, 364 Althouse, R., 15, 70, 412, 539 Alvarenga, M. S., 280, 281, 286 Alzheimer, A., 512 Amad, A., 438 Aman, M. G., 484 Ambresin, A., 301, 303 Ames, D., 508, 512 Amianto, F., 290, 302 Amore, M., 229, 437 Anbar, R. D., 274 an der Heiden, W., 392, 404 Anders, S. L., 269 Anderson, G., 192 Anderson, J., 424 Anderson, K. G., 443 Anderson, N., 156 Anderson, P. D., 137, 141, 142 Anderson, P. L., 130, 163 Andreasen, N. C., 393 Andreoli, S. B., 535 Andresen, J., 273 Andrews, G., 106 Andrews, J. A., 330 Andrews, V., 409 Anestis, J. C., 245 Anestis, M. D., 245 Angelou, M., 64 Angle, J., 304 Aniston, J., 119 Anna O., 258 Annunziato, R. A., 296 Antal, H., 91 Antony, M. M., 52, 53, 100,
125, 358 Apfelbaum, B., 356 Apostolova, L. G., 511, 520 Appelbaum, P. S., 33, 541 Apple, F., 302 Apter, A., 237 Arcelus, J., 292 Archer, D., 96, 129, 272, 342 Archer, D. F., 362, 366 Ardjmand, A., 174 Ardoin, S. P., 496 Arias, E., 235 Arias, I., 41
Arieti, S., 197, 385 Aring, C. D., 9 Aristotle, 8, 353, 418 Armitage, R., 212 Armour, C., 166 Armstrong, M. J., 523 Arndt, W. B., 543 Arnedt, J. T., 212 Arnold, S. M., 397 Aronow, E., 82 Arvanites, T. M., 535 Asberg, M., 234 Ash, R., 155 Ashraf, N., 252 Ashton, J. R., 231 Asimov, I., 142, 433 Asmar, M., 530 Asnis, G. M., 161 Assumpção, A. A., 367, 371, 374 Astbury, J., 184, 208, 209 Atack, J. R., 116 A-Tjak, J. L., 57, 410 Auguste D., 512 Aussprung, J., 268 Auxemery, Y., 434 Avila, J., 518 Avramopoulos, D., 397 Axelrod, M. I., 476 Ayalon, L, 522 Ayd, F. J., Jr., 189 Ayers, N., 16 Ayllon, T., 405 Ayoub, C. C., 250, 252 Aziz, R., 505 Azorin, J., 391
Babchishin, K. M., 372 Baca-Garcia, E., 227, 239 Bachelor, A., 101 Bacon, T., 410 Baer, L., 82, 86 Baer, T. E., 340 Bagby, E., 122 Bagge, C. L., 229 Bagnall, N., 509 Bai, Y., 187 Baig, M. R., 250 Bailey, R. L., 43 Baird, S. C., 435 Bakalar, N., 14 Baker, K., 173, 177 Baker, R., 136, 158 Bakoyiannis, I., 316, 495 Balassone, M., 416, 417 Baldessarini, R. J., 242 Baldinger, P., 192 Baldwin, D. S., 116, 135 Bales, D. L., 413 Balhara, Y. S., 339 Bancroft, J., 357 Bandelow, B., 135, 136 Bandura, A., 52, 53, 122, 123, 125 Barber, A., 18 Barber, R., 41 Barber, T., 41, 200 Barcott, B., 327 Bareggi, S. R., 142
Barker, K. K., 274 Barkus, E., 390 Barlow, D. H., 56, 101, 127,
136, 358 Barlow, M. R., 170, 171, 174 Barnes, A., 399 Barnes, C. A., 168 Barnes, D. H., 227, 239, 241 Barnes, G. E., 197 Barnes, T., 357 Barnes, T. R. E., 408 Baron-Cohen, S., 425 Barr, A. M., 323 Barrera, T. L., 133 Barron, E., 211 Barrowclough, C., 411, 415 Barry, L. M., 275 Bartels, S. J., 520 Bartholomew, R., 255 Bartol, A. M., 530, 532, 534, 542 Bartol, C. R., 530, 532, 534, 542 Barton, A., 11 Bartrop, R. W., 271 Bartz, J., 453 Basaraba, S., 522 Basoglu, M., 155, 158 Bass, C., 252 Basson, R., 359 Bateman, A. W., 439 Bates, G. W., 204 Batstra, L., 481, 482 Batten, S. V., 164 Baucom, B. R., 69 Baucom, D. H., 69, 70 Bauer, S., 21 Baum, A., 107, 268, 272 Bauman, M. L., 486 Baxter, L. R., Jr., 142 Beardslee,W. R., 70 Bearss, K., 488 Beasley, L. O., 478 Beatrice of Nazareth, 297 Bebbington, P. E., 392 Bebko, J. M., 494 Becher, T., 11 Beck, A. T., 54, 55, 56, 58, 94,
111, 112, 113, 135, 136, 202, 203, 204, 205, 211, 426, 428, 430, 436, 443, 445, 449, 451, 453, 454
Beck, J., 452 Becker, A. E., 286 Becker, J. V., 367 Becker, P. M., 274 Beckinsale, K., 302 Becvar, D. S., 70 Becvar, R. J., 70 Begeer, S., 485 Behrman, A., 186 Beidel, D. C., 128, 131 Beier, E. G., 206 Bekkouche, N. S., 265 Belendiuk, K. A., 311, 334,
335, 337 Belgeri, M. T., 504 Beljan, C., 133 Bell, A. G., 6
: Name INdexNI-2
Bundy, T., 543 Bunford, N., 2, 4 Burgess, J. L., 322 Burgholzer, J. A., 340 Burijon, B. N., 146 Burke, A., 511 Burns, G. L., 481 Burns, J. K., 387 Burns, T., 412, 414, 415, 417 Burton, V. S., 536 Busch, F. N., 109, 139, 198 Bush, G. W., 62 Bush, S. H., 510 Bushman, B. J., 437 Bussing, R., 482 Butcher, J. N., 82, 84, 86 Butler, T., 535 Byers, A. L., 162 Bylsma, L. M., 198
Caballero, B., 292 Cable, A., 368 Cachelin, F. M., 296 Cadet, J. L., 318 Cadge, W., 272 Cahill, L., 169 Cain, N. M., 453 Caldera, Y., 298 Caligor, E., 426, 428, 438, 451 Calkins, S. D., 74 Callahan, L. A., 530 Callanan, M. M., 98 Calmes, J., 547, 548 Calugi, S., 208 Cameron, D. J., 511 Campbell, A., 226 Campbell, D., 232 Campbell, J., 496 Campbell, S., 192 Campbell, W. K., 444, 445 Camus, A., 456 Canas, P. M., 516 Canat, S., 251 Canetta, S., 397 Canetto, S. S., 505 Cannon, J., 441 Capitán, L., 381 Capuzzi, D., 237 Carducci, B., 448 Carey, B., 18, 67, 238, 440 Carlson, L., 115 Carney, T., 298 Caro, I., 299 Caron, J., 245 Carpenter, K., 280, 282 Carr, S. N., 449 Carrey, J., 184 Carrobles, J. A., 357 Carroll, E. J., 83, 84 Carroll, K. M., 335, 337 Carroll, M. E., 332 Carroll, R. A., 363, 377, 378, 381 Carruthers, H. R., 185 Carter, S. C. (Jay Z), 334 Carvalho, J. P., 198, 366 Casey, P., 173 Cash, T. F., 295 Casimir, G. J., 455 Castillo, Y., 81
Bowers, T. G., 434 Bowman, E. S., 172 Boyd, B. A., 483, 487 Boyd, D., 470 Boyle, M., 457 Boyle, R., 396 Boysen, G. A., 170, 172 Brabender, V. M., 83 Braddock, A. E., 261 Bradford, J. M. W., 376 Bradley, M. M., 117 Bradley, S. J., 377 Brady, J. E., 327 Brainerd, C. J., 169 Brakoulias, V., 453 Brambrink, D. K., 119 Brand, B. L., 177 Brashears, M., 198 Bratskeir, K., 19 Brauhardt, A., 288 Braun, D. L., 297 Braxton, L. E., 86 Breitbart, W., 240 Bremner, J. D., 116, 134, 155, 159,
160, 167 Brendryen, H., 340 Brenot, P., 351, 353, 358, 362 Brent, D. A., 237 Breslau, J., 120 Bressi, C., 110 Breuer, J., 13, 258 Brewer, J., 115 Brewerton, T. D., 301, 304, 305 Bridler, R., 441 Briki, M., 388, 410 Briquet, P., 256 Brisch, R., 395, 396 Britt, R. R., 113 Broadus, C. C., Jr. (Snoop Dogg),
334 Brockmann, H., 191 Brook, J. S., 433 Brooks, A. C., 19 Brooks, G. R., 99, 275 Brooks, L., 265, 271 Brophy, M., 375 Brown, A., 257 Brown, A. S., 397 Brown, D., 436 Brown, G. K., 239, 242 Brown, G. W., 205 Brown, J. H., 230 Brown, R. J., 258 Brown, T. A., 95 Browning, C. J., 502 Brownley, K. A., 288 Bruch, H., 281, 289, 307, 439 Bruffaerts, R., 265 Brumberg, J. J., 297 Brunelin, J., 395 Bryant, R. A., 153 Brymer, C., 511 Bryner, J., 198 Buckingham, E. T., 478 Budney, A. J., 327, 333 Buffone, A., 63 Buhlmann, U., 144 Bullen, C., 320 Bunaciu, L., 135
Bisson, J. I., 165 Bitter, J. R., 69 Bivalacqua, T. J., 351, 363 Björgvinsson, T., 137 Björkenstam, C., 222 Black, D. W., 342, 393, 435 Black, M. C., 155, 156 Black, S. W., 203 Blackmore, D. E., 357 Blagov, P. S., 443 Blair, J., 435 Blais, M. A., 82, 86 Blanchard, E. B., 155, 275 Blanchard, J. J., 392 Blanken, I., 20 Blashfield, R. K., front endpaper Blass, R. B., 110 Blatt, S. J., 197 Bleiberg, K. L., 206, 207 Blinder, M., 533 Bliss, E. L., 173, 175 Blodgett, J. C., 338 Bloom, B. L., 404 Blow, F. C., 399 Blow, J., 296 Bluglass, K., 252 Blum, K., 332, 333 Bobbitt, J., 531 Bobbitt, L., 531 Bock, C., 443 Bodell, L. P., 302 Bodison, S. C., 483 Boeding, S., 70 Boets, B., 491 Boeve, B., 503 Bogdan, R., 489 Bokor, G., 137, 141, 142 Boleyn, A., 284 Bolgar, H., 22 Bolton, D., 336 Bonanno, G. A., 197, 272 Bonelli, R. M., 61 Bonetta, L., 340 Boone, K., 254, 260, 261 Boone, L., 281, 282, 286 Bor, W., 478 Borden, L. A., 337 Borge, F., 451 Borge, L., 404 Borges, S., 194 Borkovec, T. D., 112 Bornemann, T. H., 16 Bornstein, R. F., 84, 445, 450, 451 Borzekowski, D. L. G., 294 Bosco, D., 343 Bott, E., 262 Bouman, T. K., 262 Bouras, N., 496 Bourget, D., 367 Bourin, M., 133 Bourne, A., 168 Bourne, E. J., 118 Boutros, N. N., 387 Bowden, S. C., 89 Bowen, E. A., 415 Bowen, S., 337 Bower, B., 185 Bower, E. S., 505 Bower, G. H., 174
Bell, K., 275 Bell, M. D., 413 Belleville, G., 263 Bellows, G., 10 Belluck, P., 521 Belushi, J., 329 Bemporad, J., 197 Bender, D. S., 443, 445 Bender, E., 239 Benedek, E. P., 528 Beninger, R. J., 395 Benjamin, K., 457 Ben-Natan, M., 478 Bennett, M. D., 269 Bennett, M. P., 269 Benoit, C., 235 Berenson, K. R., 438 Beresin, E. V., 299 Berg, A., 481 Bergado-Acosta, J. R., 116 Bergeman, C. S., 272 Bergink, V., 394 Bergler, E., 360 Bergner, R. M., 2, 4 Berk, S. N., 140 Berkowitz, D. (Son of Sam),
531, 543 Berlim, M. T., 196 Berman, A. L., 236 Bernheim, H-M., 13, 257 Bernstein, D. P., 426 Bernstein, I. H., 78 Berra, Y., 91 Berrettini, W., 189 Berridge, M. J., 516 Berry, M. D., 349, 353, 357, 360,
361, 366 Berry, P. D., 349, 353, 357, 360,
361, 366 Berry, S. M., 195 Berthoud, H., 291 Bertozzi, S., 359 Bertsch, K., 435, 439 Berzofsky, M., 155 Best, L. A., 292 Beutler, L. E., 74, 98, 100, 246 Bewley, A., 144 Beyoncé (Knowles-Carter, B. G.),
184 Bharani, N., 108 Bhat, R. S., 510 Bhattacharya, R., 85 Bhavsar, V., 415 Bhutta, M. R., 86 Bianchi, K., 531 Bianchini, O., 408 Bieber, J., 119 Bienvenu, O. J., 465, 468, 481 Bierer, L. M., 160 Bigdeli, T. B., 215 Billings, J., 168 Bills, C. B., 233 Bina, R., 190 Binet, A., 89 Biran, J., 151 Birkeland, S. F., 426 Biron, M., 150 Birrell, P., 169 Bisaga, A., 338
Name INdex : NI-3
Davidson, L., 11, 101 Davidson, S., 25 Davis, C., 288 Davis, M., 153 Davis, R. E., 81 Davis, T. E., III., 467 Daw, J., 546 Day, E., 338, 339 Day, J. M., 61 Deahl, M. P., 165 DeAngelis, T., 209 Deas, D., 337 Deb, P., 17 de Beurs, D. P., 244 De Block, A., 367 DeBoer, E., 72 de Castro, S. M., 510 DeCusati, F., 297 De Genna, N. M., 455 Degortes, D., 282 Dehn, M. J., 78 Deitz, S. M., 31 De La Garza, R., II., 328 Delahanty, D. L., 165 de Leede-Smith, S., 390 De Leo, D., 245 de l’Etoile, S. K., 174 Delforterie, M. J., 294 Delinsky, S. S., 281 Dell, P. F., 175 De Matteo, D., 433 Demidenko, N., 208 Deming, A., 172 Dendy, C. A. Z., 482 Dennis, C., 190 Dennis, J. P., 239 DePaulo, B. M., 19, 457 Depp, J., 119 Derenne, J. L., 299 Derivois, D., 107 Dervic, K., 235, 236 de Sade (Marquis), 375 DeSalvo, A., 543 Descartes, R., 250 de Schipper, L. J., 254 Desmet, M., 197 de Sutter, P., 357 Devanand, D. P., 508 DeVeaugh-Geiss, J., 142 Devilly, G. J., 165 Devineni, T., 275 DeWitt, M. A., 509, 510 Dewitte, M., 359, 366 De Witte, N. A., 413 Dey, J. K., 143 Dhabhar, F. S., 263, 271 Dhejne, C., 381 Diamond, D., 445 Diana (Princess of Wales), 302 Dickens, B. M., 240 Dickerson, F. B., 387, 406, 508 Dickinson, T., 368 DiClemente, C. C., 338 Didden, R., 490, 492, 493,
496, 497 Didion, J., 360 Dienes, K. A., 198, 201 Dietz, P., 543 Di Florio, A., 394
Courchesne, E., 486 Couric, K., 286 Courtet, P., 215 Courtois, F., 357 Couturier, J., 285 Covell, N. H., 414 Covington, M. A., 388 Coyne, J. C., 198 Crabtree, S., 19 Craig, K. J., 116 Craig, T., 413 Crandall, C. S., 268 Craske, C. M., 127, 136 Craske, M. G., 108, 110 Crawford, C., 497 Creed, F. H., 256 Crighton, A. H., 250 Crits-Christoph, P., 338 Crombez, G., 359, 366 Cronin, E., 177 Crosby, A. E., 229 Cross, T. L., 237 Crouter, F., 541 Crow, S. J., 286, 301 Crow, T. J., 392 Crystal, S., 398 Cuddeback, G. S., 70, 415, 417 Cuijpers, P., 118, 135, 136, 205 Cukrowicz, K. C., 239 Cullen, A. E., 400 Culp, A. M., 236 Culver, J. L., 217 Cummings, J. L., 502, 511, 520 Cunha, M., 115 Cunningham, C. L., 331 Curlee, H., 305 Curley, A., 457 Currier, D., 234 Curtis, R. G., 456 Cutler, D. M., 237 Cutright, P., 234 Cutting, J., 389 Cynkar, A., 18 Cyrus, M., 119, 334
Dagan, M., 272 D'Agata, F., 290 Dahmer, J., 531, 543 Daigre, C., 454 Daine, K., 238 Daitch, C., 106 Dalai Lama (Dondrub, L.), 62 Daley, D. C., 337 Dallman, M. F., 390 Daly, M., 86 Daly, R., 547 Dana, R. H., 85, 86 Danes, C., 216 Danesh, J., 535 Daniels, C. W., 87 Daniolos, P., 478 Danquah, M. N-A., 183, 184 D’Arienzo, J. A., 275 Darke, S., 229 da Rosa, G., 503 Dasgupta, M., 511 da Silva, R. P., 353 Davey, M., 20, 238 David (King), 8
Clarkin, J. F., 426, 428, 438, 451 Clarkson, K., 302 Claudino, A. M., 305 Clausen, L., 300 Clay, R. A., 550 Cleare, A., 505 Cleckley, H. M., 22, 171 Clifford, T., 488 Clinton, A. B., 81 Clinton, W. (Bill), 32 Cloninger, C. F., 454 Coates, J., 482 Cobain, K., 222, 226, 229,
231, 331 Cocotas, A., 207 Coffey, C. E., 502, 504, 505 Coffey, M. J., 504 Coffey, S. F., 437 Cohen-Kettenis, P. T., 377 Cohen, J. A., 478 Cohen, N., 83 Cohen, S., 208, 272 Cohn, L., 283, 285 Colburn, D., 229, 231 Coleman, L., 533 Coleman, M., 329 Colijn, M. A., 508 Colletti, G., 176 Colli, A., 428, 430, 435, 439, 443,
445, 449, 451 Collings, S. C., 238 Collins, R. W., 477 Columba of Rieti, 297 Columbus, C., 55 Comas-Díaz, L., 72, 210 Combs, D. R., 408 Comer, J. S., 118, 157, 465, 468 Comer, R., 406 Cone, J. E., 157 Conner, K. R., 233 Conrad, N., 237 Constantino, J. N., 198 Conti, A. A., 250 Conwell, Y., 228 Cook, B. L., 72 Cook, C. H., 226 Cooley, M., 443 Coon, D., 393 Coons, P. M., 172 Cooper, J. L., 482 Cooper, M., 101 Cooper, R., 127, 405 Cooper, T. V., 296 Cooper, W. O., 238 Cooper, Z., 197, 299, 300,
302, 303 Copley, J., 49 Cordeau, D., 357 Corega, C., 286 Corey, G., 66, 68 Corrie, S., 98 Corsini, R. J., 98 Corter, A., 275 Corves, C., 392 Cosgrove, K. P., 332 Costa, E., 116 Costa, R., 120 Costantino, G., 84 Costin, C., 301, 304, 305
Castro, A., 228 Castroneves, H., 5 Catanesi, R., 160 Catherine of Siena, 297 Cauwels, J. M., 306 Cavallo, F., 520 Cayman, S., 350 Celani, D. P., 445 Cénat, J. M., 107 Centeno, D., 368 Cerel, J., 226 Cerezo, L. M. (Lea T.), 381 Cerletti, U., 192 Chacón, F., 157 Chamberlain, S. R., 116 Chambless, D. L., 98 Chan, A. L., 115 Chan, K. K. S., 101 Chandler, C., 481 Chandola, T., 266 Chandra, A., 350 Chang, K. D., 472 Chapman, M. D., 531 Charney, D. S., 116, 133, 134, 159 Chase, M., 209 Chassin, L., 331 Chaudhry, M., 89 Chavira, D. A., 455 Chekki, C., 239 Chemerinski, E., 424 Chen, C., 326 Chen, C-H., 215 Chen, L., 163 Chen, S., 187 Cheng, A. T. A., 237 Cherner, R. A., 358 Cherry, K., 14, 18, 81, 84, 85, 86,
122, 123, 124 Cherry, K. E., 155 Chi, S., 511 Chien, W. T., 410 Chiesa, A., 337 Chin-Chan, M., 514 Chiu, L. H., 109 Cho, S-H., 429 Chollet, J., 118 Chopik, W. J., 272 Christensen, A., 70 Christensen, B. S., 349, 352, 358 Christensen, J., 318 Christiansen, E., 238 Christodoulou, M., 294 Christophersen, E. R., 476, 477 Chrousos, G. P., 160 Chu, J. A., 170, 171 Chun, S., 389, 396, 407 Chung, P. H., 332 Chung, T., 330 Church, D., 161 Churchill, W., 202 Ciccone, M. (Madonna), 119 Ciraulo, D. A., 193, 194 Clapton, E., 334 Clark, D. A., 111, 113, 135, 136 Clark, R., 160 Clark, T. T., 330, 331 Clarke, D. E., front endpaper Clarke, J. C., 335 Clarke, M., 397
: Name INdexNI-4
Fittig, E., 289 Fitz, A., 139 Flaherty, E. G., 252 Flanagan, D. P., 89 Flavin, D. K., 229 Fleck, P., 30 Fletcher, R. J., 493 Flor, H., 119 Floyd, A., 272 Foa, E. B., 140, 141, 275 Fogley, R., 391 Fok, M. L., 422 Folkman, S., 150 Folsom, D. P., 399 Fonareva, I., 271 Fondas, N., 470 Foo, X. Y., 226 Forcano, L., 281 Ford, E., 540 Ford, J. M., 386 Ford, T., 296 Forester, J., 336 Foreyt, J. P., 293 Forgas, J. F., 185 Forgatch, M. S., 475 Forsén Mantilla, E., 282 Fortune, S. A., 236 Foster, J., 527, 531 Foster, J. D., 445 Fouassier, D., 520 Fowler, K. A., 443 Fowler, P. J., 478 Fowler, R. D., 16 Fox, D., 397 Fox, J. A., 434, 543 Fox, M. D., 196 Fox, M. J., 518 Frances, A. J., 95 Francis, A. J. P., 449 Frank, J. D., 7 Frank, R. G., 538 Franklin, A., 119 Franklin, B., 6 Franklin, M. E., 140, 141 Frasch, K., 11 Frazier, A. D., 237 Frederick V (King of Denmark), 443 Frederickson, J., 49 Freeman, J. L., 516 Freeman, W., 405 Freitag, F., 273 French, C., 302 Freud, J., 497 Freud, S., 13, 14, 16, 22, 23, 35,
44, 45, 46, 47, 49, 50, 61, 108, 109, 119, 139, 179, 196, 219, 232, 233, 239, 258, 398, 453, 550, 551
Frey, R., 390 Frick, P. J., 474 Fried, E. I., 187 Friedman, H. S., 272 Friedman, M., 266, 434 Friedrich, F., 400, 411 Friman, P. C., 476, 477 Fromberger, P., 374 Fromm-Reichmann, F., 398, 401 Frosch, W. A., 324
Everson, S. A., 272 Ewing, C. P., 533 Eyberg, S. M., 475
Fábrega, H., Jr., 41, 260 Fair, B., 272 Fairbank, J. A., 162 Fairburn, C. G., 282, 284, 290,
299, 300, 302, 303, 305 Faiz, O. D., 509 Faje, A. T., 282 Falco, M., 484 Faller, K. C., 373 Falzer, P. R., 538 Fang, A., 144, 145 Farber, B. A., 551 Farberow, N. L., 244, 245 Farde, L., 408 Fareed, A., 339 Farkas, M., 373 Farley, C., 329 Farmer, C. A., 484 Farmer, R. F., 430, 451 Faubion, S. S., 348 Faulkner, W., 187, 214 Faust, D., 96 Faust, J., 478 Fava, M., 451 Fawcett, J., 238, 356 Fay, B. P., 235 Fazel, S., 228, 234, 535 Federoff, J. P., 371, 374, 376 Feifer, S. G., 491 Feldman, M. D., 251, 252 Feldman, R. A., 414, 547 Feldman, R. S., 457 Feldman, S. R., 541 Felix, E., 467 Fenichel, M., 57 Fennig, S., 302 Fenty, R. R. (Rihanna), 119, 334 Ferman, T. J., 513 Fernandez, L., 81 Fernandez, R., 161 Fernholz, T., 548 Fernquist, R. M., 233, 234 Ferrari, R., 260 Feske, U., 455 Fiala, A., 530 Fichter, M. M., 305 Field, A. P., 122 Fields, J., 505 Fieve, R. R., 202 Figley, C. R., 154 Filip, M., 311, 316 Fine, C. G., 177 Fineberg, N. A., 142 Fink, D. S., 330 Fink, G., 262 Fink, M., 133, 192 Finkelhor, D., 478 Finnegan, L. P., 341 Fischer, B. A., 12 Fischer, S., 305 Fisher, C., 215 Fisher, M. A., 545 Fisher, P. L., 112 Fiske, A., 503
Durbin, A., 399 Düring, S., 395, 407 Durkheim, E., 233, 234, 235 Durkin, K. F., 373 Durkin, M. S., 495 Durso, S., 522, 524 Duval-Harvey, J., 482 Dvoskin, J. A., 535 Dygdon, J. A., 198, 201 Dyl, J., 287 Dysken, M. W., 518 Dziemian, A., 373
Easterbrooks, M. A., 478 Edelstein, B. A., 502 Edoka, I. P., 208 Eeles, E., 510 Efran, J. S., 140 Eftekhari, A., 163 Egawa, J., 486 Eggers, A. E., 192 Ehnvall, A., 232 Eich, T. S., 387 Eifert, G. H., 285, 303 Eikenaes, I., 448 Einstein, A., 42, 550 Eisold, K., 446 Eker, C., 215 Ekern, J., 280, 283, 284, 292 Ekman, P., 185 Eliot, G., 430 Ellenberger, H. F., 171, 258 Elliott, S. L., 353, 356, 363,
364, 366 Ellis, A., 54, 110, 111, 112, 113,
114, 130, 131 Ellis, C. C., 164 Ellis, C. E., 512 El-Mallakh, R. S., 215 Elson, K., 302 Elwood, C. E., 435 Emery, C., 111 Emig, D., 40 Eminem (Mathers, M. B., III ),
184, 334 Emmelkamp, P. G., 57 Emmelkamp, P. M., 130, 140 Emmons, K. K., 208 Enatescu, V., 190 Endrass, T., 142 Engel, J., 265 Engqvist, I., 394 Epstein, R., 215 Erikson, E., 139 Erlangsen, A., 239 Ernsberger, P., 293 Escobar, J. I., 161, 260 Espada, J. P., 341 Esposito-Smythers, C., 469 Estes, A., 487 Etaugh, C., 504, 505, 523 Etkin, A., 134 Ettinger, U., 430 Evans, G. W., 495 Evans, J., 299, 300 Evans, M., 190 Evans, R., 245 Evans, S. A., 538
DiGangi, J. A., 160 Dilts, S. L., 317, 318 Dilts, S. L., Jr., 317, 318 Dimidjian, S., 200 Dimsdale J. E., 256, 261 Di Narzo, A. F., 234 Dines, P., 505 Ding, Y., 189 Dingfelder, S. F., 13 DiPlacido, J., 272 Di Rosa, M., 520 DiSalvo, D., 28 Dix, D., 10, 11, 14 Dixon, L. B., 15 Doctor, R. M., 371 Dodes, L. M., 330 Dogra, T. D., 543 Dohrmann, R. J., 273 Dolak, K., 323 Dolan, E., 65 Dole, V. P., 339 Dolezsar, C. M., 267 Dollar, J. M., 74 Domino, M. E., 17 Dominus, S., 255 Donaldson, K., 539 Donato, I., 466 Dondrub, L. (Dahai Lama), 62 Donnan, S., 231 Dorahy, M. J., 171, 172, 174, 177 Dorsett, S., 171 Dossat, A. M., 291 Douglas, J., 543 Douglas, K. S., 538 Douglas, M., 213 Down, L., 493 Downey, L. A., 325 Doyle, M., 33 Dozier, C. L., 369 Draguns, J. G., 260 Drake, B., 412, 414, 415, 417 Drake, R. E., 413 Draper, B. M., 239, 241, 504, 505 Dray, J., 298 Dreisbach, S., 287 Drescher, J., 368 Drevets, W. C., 215 Drew, C. J., 480 Drouin, M., 368 Drummond, E., 529 Druss, B. G., 16 Dubovsky, A., 504, 505, 507 Dubovsky, S., 504, 505, 507 Dubowitz, T., 267 Duckworth, K., 411 Duenwald, M., 503 Dugas, M. J., 112 Duggan, M., 548 Duhig, M., 412 Dukart, J., 42 Duman, R. S., 191 Dunbar, F., 262 Duncan, B. L., 101 Dunham, L., 140 Dunn, J., 47 Dunner, D. L., 196 Dunsmoor, J. E., 126 DuPaul, G. J., 482
Name INdex : NI-5
Hancock, J, 457 Handel, G. F., 217 Hankin, B. L., 469 Hanna, D., 192 Hanson, R. K., 372 Hansson, L., 97, 413 Hanstede, M., 115 Hardin, S. B., 160 Hardman, M. L, 496 Hardy, G., 426 Hare, R. D., 431, 432 Harenski, C. L., 376 Hargittai, E., 470 Haring, M., 161 Haris, M., 516 Harklute, A., 57 Harlapur, M., 275 Harlow, H., 198 Haroules, B., 535 Harper, K. N., 397 Harrington, A., 398 Harrington, B. C., 290 Harris, E., 538 Harris, G., 238 Harris, G. T., 436 Harris, J. C., 495 Harris, T. O., 205 Harrison, E., 338 Hart, C., 312, 316, 317, 319, 320,
321, 322, 325, 328, 330, 337, 339, 340, 341, 492, 495
Hart, J., 137 Hartberg, C. B., 397 Hartford, D., 488 Hartmann, A. S., 144 Hartmann, U., 364 Hartney, E., 327 Harvey, P. D., 386 Hashimoto, K., 397 Hassija, C. M., 351 Hastings, R. P., 488 Hatcher, A. P., 370 Hathaway, A., 367 Hatton, D., 482 Hauss, R. B., 158 Hawken, E. R., 395 Hawkins, J. R., 260 Hawks, E., 135, 136 Hawton, K., 236 Hayaki, J., 284 Hayden, L. A., 365 Hayes, S. C., 56, 114, 205 Hayes-Skelton, S. A., 118 Haynes, S. G., 266 Hazlett, E. A., 429 He, Y., 503 Head, M. W., 516 Healey, J., 375 Heath, B., 434 Hedaya, R. J., 133 Heeramun-Aubeeluck, A., 8 Heffron, T. M., 263 Hegerl, U., 195 Heilbrun, K., 475 Heim, C. M., 158 Heiman, J. R., 356, 357, 358, 362 Heimberg, R. G., 127, 128,
130, 131
Grayson, J., 139, 140, 141 Green, E. K., 215 Green, M. J., 398 Green, S. A., 257 Green, S. M., 68 Greenberg, G., 93, 95 Greenfield, S. F., 340 Greening, L., 237 Greer, S., 266 Gregg, L., 337 Greinke, Z., 127 Grekin, P. M., 535 Griebel, G., 118 Grier, B. C., 472 Griffin, R. M., 320 Griffith, D. M., 26 Grigg, J. R., 231 Grill, J. D., 16 Grilo, C. M., 293, 305 Grimm, J. W, 332 Grisham, J., 141 Grob, G. N., 403 Groër, M. W., 158, 271 Grohol, J., 316 Gross, D. R., 237 Grossman, L. A., 10 Grossman, R., 443 Grover, S., 391 Grubin, D., 87 Grucza, R. A., 288 Gruttadaro, D., 464 Guarnaccia, P. J., 85, 108 Guevremont, D. C., 406 Guimón, J., 71 Guintivano, J., 190 Gunderson, J. G., 438, 441 Gündüz, A., 349 Güngörmüs, Z., 226 Guterman, J. T., 372 Gutheil, T. G., 451 Gutman, D. A., 26, 197
Haagen, J. G., 162 Haaken, J., 169 Haas, M. H., 391 Haberman, C., 290 Haddad, P. M., 408 Haddock, G., 411 Hadland, S. E., 340 Häfner, H., 391, 392, 404 Hagerman, R. J., 494 Hagihara, A., 230, 231 Haglund, K., 301 Hahn, L. J., 494 Haile, C. N., 319, 321, 322 Hale, J. B., 481 Haliburn, J., 238, 301 Hall, K., 358, 361, 363 Hall, L., 283, 285 Hallahan, D. P., 496 Hall-Flavin, D. K., 92 Hallquist, M. N., 259, 260 Halpern, L., 411 Halverson, J. L., 184 Hamdan, S., 224 Hamilton, L. D., 351 Hammen, C. L., 203 Hampel, P., 275
Girden, E. R., 30 Girón, M., 411 Gist, R., 165 Gitlin, L. N., 521 Gjini, K., 158 Glaser, D., 252 Glass, G. V., 99 Glasser, M., 17 Glauberman, N., 509 Glied, S., 538 Glina, S., 351, 352, 353, 356 Gloster, A. T., 126, 127, 134,
135, 136 Glover, N. G., 456 Glovin, D., 113 Goate, A. M., 515 Godley, M. D., 335 Gola, H., 158 Gold, J. M., 391 Gold, M. S., 321 Gold, S. N., 81 Golden, C. J., 491 Goldenberg, H., 66 Goldenberg, I., 66, 68, 69 Goldfinger, K., 79, 89, 92 Goldfried, M. R., 67 Goldiamond, I., 54 Goldin, P. R., 130 Goldstein, D. J., 187, 189, 192 Goldstein, I., 365 Goldstein, S., 480, 491 Goldston, D. B., 238, 239 Gómez-Gil, E., 378 Gonçalves, J. B., 61 Gone, J. P., 239, 241 Gonidakis, F., 286 González, H. M., 189, 210 Good, G. E., 99 Goodman, G., 439 Goodman, M., 366 Goodman, S., 506 Goodwin, C. J., 23 Goodwin, K. A., 23 Goodyer, I., 225 Gordon, D., 124 Gordon, O. M., 453 Gorenstein, C., 86 Gorenstein, D., front endpaper Gorman, D. A., 475 Goshen, C. E., 403 Gosling, S., 24 Goss, K., 284 Goto, S., 213 Gottesman, I. I., 393 Gouin, J-P., 269 Gozlan, O., 381 Graepel, T., 24 Graham, J. R., 85 Graham, R., 95 Grandin, T., 485 Granholm, E., 411 Granitz, P., 3 Granot, M., 359 Grant, J. E., 144 Gray, E., 318 Gray, H., 254 Gray, J. A., 134 Gray, N. A., 217
Frost, A., 469 Frost, D., 416 Frost, R. O., 139, 143 Fugl-Meyer, K. S., 358, 359, 366 Fukumoto, M., 391
Gabbard, G. O., 438 Gabriel, C., 439 Gacy, J. W., 543 Gadalla, T. M., 297 Gado, M., 533 Gahan, P., 177 Galanter, M., 339, 340 Galderisi, S., 388 Galea, S., 107, 157, 161 Gall, F. J., 422 Galling, B., 216 Gallo, L. C., 267 Galvez, J. F., 214 Gamble, A. L., 123 Gamwell, L., 357 Gao, K., 216 Garaerts, E., 169 Garatachea, N., 503 Garb, H. N., 92 Garcia, R., 107 Gard, D. E., 389, 391 Garey, J., 270 Garfield, J. B., 333 Garner, D. M., 287, 292, 300 Garrett, B. L., 542 Garrison, Z., 302 Gaudiano, B. A., 100 Gay, P., 14 Gaynor, S. T., 435 Gebhard, P. H., 375 Geddes, J. R., 216, 217, 407, 408 Geisel, T. S. (Dr. Seuss), 200 Gelder, M. G., 369 Gelernter, J., 332 Gelfand, D. M., 480 Gelfand, L., 141 Gelkopf, M., 7 Gentile, J. P., 176, 179 George, M. S., 291, 292, 393 George, V., 296, 297 George, W. H., 351 Gerard, N., 237 Gerlach, A. L., 127 Germanotta, S. (Lady Gaga), 6, 302 Gerrity, E., 158 Gershon, E. S., 215 Gerst-Emerson, K., 502 Gheorghiu, V. A., 274 Ghetti, S., 542 Giesbrecht, T., 175 Gifford, M., 314, 316 Giffords, G., 535 Gilbert, K., 267, 484 Gilbert, S., 295 Gilbert, S. C., 292 Gill, A. D., 232 Gill, D., 439 Gill, H. S., 335 Gill, R. E., 414, 415, 547 Gilman, S. E., 197 Ginsburg, G. S., 467 Giraldi, A., 349, 351
: Name INdexNI-6
Janssen, S. J., 3 Janus, C. L., 350, 371, 374 Janus, S. S., 350, 371, 374 Jay Z (Carter, S. C.), 334 Jefferson, D. J., 323 Jeng, A. T., 515 Jenike, M. A., 141 Jenner, B. (Caitlin), 379 Jenner, C. (Bruce), 379 Jensen, M. P., 274, 275 Jenson, W. R., 480 Jess, C., 507 Jessen, F., 518 Jeste, D. V., 505 Jhanjee, S., 337, 339 Jia, J., 517 Jiang, G-R., 173 Jiang, W., 188 Jiann, B-P., 351, 357, 358 Jibson, M. D., 428 Jimenez, D. E., 26 Jiron, C., 474 Joe, S., 241 Johansson, A., 381 Johansson, S., 119 John, E., 302 Johnson, D. P., 204, 209 Johnson, L. A., 405 Johnson, S., 399, 413 Johnson, V. E., 348, 353, 360, 362,
364, 366 Johnson, W. E., Jr., 269 Johnston, L. D., 310, 312, 319,
320, 321, 325, 326, 327 Jolie, A., 438 Jones, B. (Bill), 112 Jones, B. (Brian), 331 Jones, K. D. (Lil’ Kim), 334 Jones, M., 404 Jones, M. C., 331 Jones, R. T. (Ol’ Dirty Bastard),
331 Joplin, J., 329, 331 Jordan, K., 374 Joshi, S. V., 231, 246 Jovanovic, T., 464 Joy, J., 328 Joyce, A. S., 426, 428 Joyce, J., 6 Juan, W., 224 Juang, L., 210, 260, 400 Juckel, G., 389, 397 Judge, C., 377, 381 June, A., 80 Jung, C. G., 45, 47, 50
Kabacoff, R. I., 30 Kabat-Zinn, J., 274 Kaczynski, T. (Unabomber), 543 Kagan, J., 91, 152 Kahn, A. P., 356 Kaij, L., 332 Kalechstein, A. D., 328 Kalin, N. H., 146 Kalmbach, D. A., 357 Kambam, P., 528 Kamboukos, D., 325 Kandall, S. R., 341 Kang, H. S., 519, 520
Humphrey, J. A., 233 Humphreys, K. L., 480 Humphry, D., 240 Hundersmarck, S., 373 Hunsley, J., 99 Hunt, C., 106 Huntjens, R. J. C., 174 Hurd, N. M., 330, 340 Hurlbert, D. F., 357, 359 Hurst, C. S., 269 Huyck, M. H., 522 Hwang, H. S., 71 Hyde, J. S., 349, 350, 352, 354 Hyett, M., 187
Iacovino, J. M., 454 Iadarola, S., 488 Iadecola, C., 515 Iglesias, E. B., 330 Igwe, M. N., 168 Ihle, W., 290 Ilahan, D. P., 496 Ingham, J. G., 25 Ingram, R. E., 56 Inman, A. G., 72 Inouye, S. K., 510 Insel, T. R., 95 Iohan, M., 237 Isacsson, G., 195, 238, 471 Isasi, C. R., 290 Ishii, M., 515 Islam, M. M., 118 Isolan, L., 464 Isomaa, A-L., 301, 302, 304 Isomaa, R., 301, 302, 304 Ito, Y., 205 Ivarsson, B. R., 412 Ivins, B., 543 Iwadare Y., 30 Iwata, B. A., 369 Iza, M., 128
Jablensky, A., 399 Jabr, F., 142, 342, 343 Jackson, A., 529 Jackson, B. R., 272 Jackson, M., 331 Jackson, M. L., 187 Jackson, S. L., 26 Jacob, M., 140, 141 Jacobi, C., 289 Jacobs, D., 376 Jacobs, L., 60, 61 Jacobs, M., 14 Jacobson, G., 246 Jaffa, T., 283 Jaffe, S. L., 327 Jager, L. R., 98 Jäger, M., 11 James, A. C., 468 James, C. (Salt), 296 James, J., 6 James, R., 331 James, S. D., 315 James, W., 54, 168, 450, 455 Jamison, K. R., 214, 216, 217 Janca, A., 438 Janis, R. A., 333 Jansen, R., 189
Hoge, E. A., 115 Hogebrug, J., 11 Hogue, L., 413 Holden, R. R., 78 Holinger, P. C., 237 Holl, F., 252 Hollingworth, P., 511, 514 Hollon, S. D., 139, 205, 217 Holm-Denoma, J. M., 282, 286 Holmes, A., 118 Holmes, J., 531 Holmes, L., 185 Holmes, T., 268, 269 Holowka, D. W., 180 Holschuh, J., 132 Holt, G., 496 Holt, H., 98, 100 Holtom-Viesel, A., 289, 293,
294, 302 Hölzel, L., 205 Homan, E. A., 63 Homant, R. J., 543 Hong, J. S., 464 Hong, L. E., 397 Honts, C. R., 87 Hope, L., 541 Hopfer, C., 322 Hopko, D. R., 108, 120, 198 Hops, H., 330 Horney, K., 49, 139 Horowitz, J. A., 190 Horowitz, M. J., 443 Horton, M. A., 381 Horwitz, A. G., 71, 237 Horwitz, A. V., 180, 185 Horwitz, S., 71 Hoste, R. R., 293 Hou, Y., 190 Houghton, D., 446 Houle, J. N., 228 Houston, K. A., 542 Houston, W., 323, 331 Howell, E. F., 173, 176, 177 Howes, O. D., 398, 409 Howland, J., 313 Howland, R. H., 43, 195 Howlin, P., 485 Hoyer, M., 434 Hoza, B., 482 Hróbjartsson, A., 91 Hsiao, C., 400 Hsu, J., 215, 515 Hsu, M. C., 275 Hsu, W., 343 Hu, W., 265 Huang, C., 394 Huang, J-J., 438 Huang, Y., 296 Hucker, A., 57, 361, 362 Hucker, S. J., 374 Hudd, S., 290 Hudson, J. L., 109 Hugdahl, K., 265 Hughes, F., 531 Hughes, K., 90 Hughes, M., 531 Hughes, S., 514 Huh, J., 91 Huijding, J., 358
Heine, C., 502 Heir, T., 30 Hektner, J. M., 475 Hellhammer, D., 390 Hembree, E. A., 275 Hembree-Kigin, T. L., 474, 475 Hemingway, E., 184, 202, 221, 224 Hemmings, C., 496 Henderson, K., 302 Henderson, V., 173 Hendrix, J., 331 Hengartner, M., 429, 432, 438 Henggeler, S. W., 474, 475 Henn, F., 134 Henry VIII (King), 10, 284 Henry, G. W., 9 Henry, J., 141 Henry, P. E., 295 Herbenick, D., 350 Herbert, J. D., 449 Herman, N. J., 456 Hermes, E. A., 154 Hernandez, P., 535 Herne, M. A., 227 Herning, R. I., 327 Herpertz, S. C., 435, 439 Herrick, A. L., 353, 356 Hersen, M., 81 Hertz, M. F., 466 Herzig, H., 281 Herzog, T., 298 Heslet, L., 157, 373 Hess, A., 14 Heston, L. L., 501 Heylens, G., 378 Hickey, E. W., 543 Hickling, E. J., 155 Hicks, B. M., 331 Hicks, K., 272 Higgins, E. S., 291, 292, 393 Higgins, S. T., 310, 335 Hilbert, A., 293 Hildebrandt, S., 127 Hildebrandt, T., 297 Hillemeier, M. M., 482 Hiller, W., 144, 258, 261 Hinckley, J. W., Jr., 527, 528,
529, 530, 531 Hinduja, S., 466 Hinrichsen, G. A., 504 Hinton, D. E., 161 Hippocrates, 8, 11, 14, 35 Hirsch, C. R., 112 Hobbs, F. B., 523 Hodges, S., 454 Hodgson, R. J., 139 Hofer, H., 142 Hoff, P., 11 Hoffman, A. C., 320, 323 Hoffman, D., 485 Hoffman, J., 57 Hoffman, P. S., 329, 331 Hoffman, R. E., 396 Hofman, S. G., 101 Hogan, R. A., 125 Hogan, T. P., 78, 81, 84, 85,
88, 89 Hogarty, G. E., 411 Hoge, C. W., 154
Name INdex : NI-7
Landau, E., 21 Landgraff, C., 368 Landreth, G. L., 468 Landrigan, P. J., 485 Lane, C., 95 Lane, K. L., 91 Laney, C., 542 Lang, E. V., 274 Lang, F. U., 432 Lang, J., 15 Lang, P. J., 117 Långström, N., 371 Lanier, C., 227 Lanning, K. V., 373 Lantz, M. S., 108 Lapidus, K. B., 405 Larsen, A., 546 Laska, K. M., 101 Laskin, D. M., 273 Latzer, Y., 293 Lau, M. A., 189 Laumann, E. O., 349, 350, 355,
357, 358 Laursen, T. M., 387 Lavender, J. M., 290 Lavin, M., 372 Lawlor, A., 251 Lawlor, B. A., 494 Lawlor, P. G., 510 Lawrence, D. H., 6 Lawrence, P. J., 141 Lawrence, R., 529 Laws, D. R., 534 Lawson, W. B., 399 Lawton, E. M., 456 Lazar, S. G., 546 Lazarov, O., 518 Lazarus, A. A., 360 Lazarus, R. S., 150 Lazarus, S. A., 438, 439 Le, Q. A., 163 Lea, T., 339 Lea T. (Cerezo, L. M.), 381 Leahy, R. L., 118 Lebedeva, A., 503 Lebow, J., 293 Lebow, J. L., 208, 451 Leclerc, A., 298 LeCroy, C. W., 132 Ledger, H., 331 Ledoux, S., 330 Lee, C. M., 99 Lee, D. E., 226 Lee, E. B., 337 Lee, J., 516 Lee, S., 158 Lee, T., 366 Leek, J. T., 98 Leeman, R. F., 342 Leenaars, A. A., 233, 245 Leff, J., 67, 410 Le Grange, D., 293 Leiblum, S. R., 351, 360, 363, 366 Leichsenring, F., 449 Lekander, M., 271 Lemma, A., 198 Lemogne, C., 191 Lemos, N. P., 321 Lener, M. S., 397, 430
Kopelowicz, A., 406 Korda, J. B., 362 Kosinski, M., 24 Koskinen, S. M., 332 Koss, M. P., 155, 157, 373 Kosten, T. R., 322, 332, 333 Koukopoulos, A., 95 Koutra, K., 400 Kposowa, A. J., 233 Krack, P., 405 Kraemer, K. M., 115 Kraepelin, E., 11, 12, 93, 418 Kraines, S. H., 186 Kramer, J., 242 Kramer, U., 428 Krantz, S., 203 Kranzler, H. R., 332 Krapohl, D. J., 87 Krasnova, H., 129 Krebs, G., 145 Kreipe, R. E., 291, 293, 295, 299,
302, 303 Kring, A. M., 391 Krippner, S., 154 Kroemer, N. B., 291 Kroon Van Diest, A. M., 296 Krueger, R. B., 375 Krueger, R. G., 369 Krug, O. T., 63, 64 Ksir, C., 312, 316, 317, 319, 320,
321, 322, 325, 328, 330, 337, 339, 340, 341, 492, 495
Kubera, M., 192 Kuhn, R., 193 Kuhn, T. S., 38 Kuipers, E., 392 Kukla, L., 254 Kulka, R. A., 161 Kumaran, A. K., 351 Kumari, V., 435 Kunar, S. S., 399 Kunst, J., 50 Kunst, M. J. J., 160 Kurita, H., 208 Kuter, R., 171 Kuyper, L., 376 Kyaga, S., 214
Laan, E., 349, 357, 358, 361, 364, 365
Laborit, H., 406, 407 Ladwig, K., 275 Lady Gaga (Germanotta, S.), 6, 302 Laessle, R. G., 289 Lagnado, L., 508 Lahey, B. B., 473 Lahmann, C., 254, 260 Lai, C. Y., 203 Lai, M. H., 246 Lake, C. R., 403 Lake, N., 68 Lakhan, S. E., 43 Lamar, M., 494 Lambdin, B. H., 339 Lambert, M. J., 99, 101 Lamm, N., 298 Lampe, L., 448, 449 Lamprecht, F., 163 Lancioni, G. E., 519
Kiev, A., 451 Kikuchi, H., 167, 173 Kikuta, R., 4 Kikuta, T., 4 Kiluk, B. D., 337 Kim, D. R., 190 Kim, E. S., 272 Kim, J., 272 Kim, J. M., 476 Kim, S. M., 228, 230, 239 Kimball, A., 145 Kimhi, Y., 485 King, A. P., 115 King, L., 394 King, R. A., 233 Kingsberg, S. A., 357 Kingston, D. A., 367 Kinnally, W., 287 Kinon, B . J., 407 Kirakowski, J., 251 Kirkcaldy, B. D., 226 Kirmayer, L. J., 85 Kiume, S., 21 Kleber, H. D., 339 Klebold, D., 538 Kleespies, P. M., 228 Klein, C., 299 Klein, D. F., 133 Klein, M., 327 Klein, W. C., 507 Kleinman, A., 210, 260 Kleinplatz, P. J., 361, 363 Klerman, G., 206 Kline, N. S., 193 Klonsky, E. D., 225 Kluft, R. P., 175, 177 Kluger, J., 457 Knappich, M., 441 Knatz, S., 299, 301 Knecht, T., 375 Knekt, P., 49 Knight, R. A., 375 Knoll, J. L., 434, 546 Knott, L., 390 Knowles-Carter, B. G. (Beyoncé),
184 Knudson, R. M., 281 Koch, W. J., 161 Kochunov, P., 397 Kocsis, R. N., 543, 544 Koczor, C. A., 325 Koenen, K. C., 160 Koenig, H. G., 61 Koenigsberg, H. W., 426 Koetting, C., 252 Koetzle, D., 318 Koh, M., 168 Koh, Y. W., 208 Kohen, D. P., 175 Köhl, J., 360 Kohut, H., 47 Kok, R., 210 Kokish, R., 87 Kolakowski, M. (Victoria), 380 Kolakowski, V. (Michael), 380 Komaroff, A. L., 269 Konrath, S., 21 Koo, K. H., 259 Kooyman, I., 15, 415
Kangelaris, K. N., 272 Kanner, B., 109, 137, 140, 437,
445, 456 Kanner, L., 483, 484 Kantor, M., 435, 448, 449 Kantrowitz, B., 49, 172 Kapadia, A. S., 387 Kaplan, H. S., 348 Kaplan, M. S., 369 Karch, C. M., 515 Kashdan, T. B., 356 Kass, A. E., 303 Kassel, J. D., 331 Katz, R., 293 Kaufman, L., 243 Kaufman, S. B., 214 Kawas, C., 518 Kaye, W. H., 291 Kaysen, S., 438 Kazano, H., 10, 11, 475 Kazdin, A. E., 99, 435, 475 Keane, T. M., 162 Kearney, C. A., 463, 473, 483 Kedmey, D., 67, 410 Keefer, A., 522 Keel, P. K., 298 Keen, E., 63 Keeshin, B. R., 478 Kelleher, E., 226 Keller, W. R., 412 Kellett, S., 426 Kelley, M. L., 314 Kellner, C. H., 505 Kelly, M. A., 275 Kemp, C. G., 238 Kemp, D. R., 546 Kemper, K. J., 119, 273 Kendall, J., 482 Kendall-Tackett, K. A., 190 Kendler, K. S., 134, 291, 426 Kenedi, C., 251 Kennedy, D. B., 543 Kennedy, J. L., 387 Kerber, K., 188 Kerekes, N., 474 Kern, M. L., 272 Kernberg, O. F., 47, 445 Kerr, C. E., 115 Kerr, J. H., 292, 297 Kesha (Sebert, K. R.), 292, 302 Kessler, R. C., 7, 43, 93, 106, 107,
120, 128, 132, 133, 137, 154, 184, 189, 213
Kety, S. S., 393 Keuthen, N. J., 143 Kevorkian, J., 240 Keys, A., 281, 286 Keyser-Marcus, L., 331 Khan, A., 387, 391, 413, 415, 514 Khantzian, E. J., 330 Khatri, N., 57 Khoury, B., 115 Kibler, J. L., 271 Kibria, A. A., 10 Kidman, N., 119 Kiecolt-Glaser, J. K., 269, 271, 272 Kienast, T., 437 Kiernan, W., 497 Kiesler, D. J., 99
: Name INdexNI-8
Maslow, A. H., 58 Mason, S. A. (Sybil), 171, 172 Masters, W. H., 348, 353, 360,
362, 364, 366 Mathers, M. B., III (Eminem),
184, 334 Mathew, J., 33 Mathis, C. E. G., 294 Mathys, M., 504 Matsumoto, D., 71, 210, 260, 400 Matsunaga, H., 137 Mattay, V. S., 408 Maurice, W. L., 351 Mauthner, N. S., 190 Mayberg, H. S., 192, 196 Mayer, L. E. S., 302 Mayo, C., 296, 297 Maza, C., 71 McAnulty, R. D., 373 McArthur, G., 491 McBride, J. J., 274 McCabe, C., 142 McCabe, M. P., 57, 361, 362 McCaghy, C. H., 478 McCance-Katz, E. F., 328 McCarthy, B., 348, 360, 361,
363, 364 McCarthy, D. E., 331 McCarthy, E., 348, 360, 361,
363, 364 McClelland, S., 165 McCloud, A., 229 McClure, E. A., 333 McConnaughey, J., 507 McCormick, L., 298 McCrady, B. S., 314, 335 McCullough, L., 449, 451 McDermott, B. E., 251 McDermott, B. M., 283 McDonald, A., 482 McDonald, J. A., 71 McDowell, D., 325 McEachin, J. J., 487 McEvoy, P. M., 130 McFeeters, D., 228 McGlothlin, J. M., 244 McGoldrick, M., 347 McGrath, J., 33 McGrath, R. E., 83, 84 McGraw, P. (Dr. Phil), 545 McGuffin, P., 188, 189 McGuinness, T. M., 377 McGuire, P. A., 413 McGurk, S. R., 426 McHale, S. M., 69 McIlvaine, R., 163 McKay, D., 140, 141, 144, 467 McKenna, K., 273 McKenzie, G., 505 McKenzie, J. A., 496 McKenzie, N., 478 McKinley, J., 465 McLaughlin, K. A., 107 McLay, R. N., 14, 163 McLean, D., 399 McMahon, C. G., 364 McMahon, R. J., 474 McMain, S. F., 439
Malhi, G. S., 216, 217 Maller, R. G., 136 Malm, U. I., 412 Malone, D. A., 196 Malvo, L. B., 531, 543, 544 Mamarde, A., 168 Manchanda, S. C., 273 Mancini, A. D., 272 Mandal, A., 390 Mandrioli, R., 116 Manfredi, C., 109 Manji, H. K., 215 Mann, A. P., 282, 286 Mann, J. J., 234 Mann, M., 19 Mann, R. E., 372 Mantila, L., 502 Manton, A., 30 Manuel-Logan, R., 510 Marceaux, J. C., 343 Marchand, W. R., 115 Marchese, M., 516 Marcoux, L., 444 Marcus, L. M., 488 Marder, S. R., 408 Margo, J. L., 293 Maris, R. W., 227, 229, 230, 232,
233, 245 Mark, T. L., 547 Markota, M., 397 Markowitz, J. C., 206, 207 Marks, B., 497 Marks, I. M., 124, 144, 369 Marks, J. W., 262 Marlatt, G. A., 331, 340 Marmot, M. G., 266 Marques, F. de A., 287 Marsh, R., 142 Marshall, C., 449 Marshall, J. J., 364 Marshall, L. E., 373, 374, 375 Marshall, T., 259, 261 Marshall, W. L., 369, 371, 373,
374, 375, 376, 534 Marsiglia, F. F., 330 Marson, A. G., 261 Marston, W. M., 87 Martell, C. R., 198, 200 Martens, W. H. J., 435 Martin, A. J., 481 Martin, A. L., 364 Martin, C. V., 372 Martin, D. M., 192 Martin, L. A., 26 Martin, P., 503 Martin, P. L., 365 Martin, S. A., 349, 352 Martín-Blanco, A., 438 Martinez, D., 333 Martino, F., 437 Martins, M. V., 70 Martinsen, M., 292 Martlew, J., 261 Marty, M. A., 80 Mary of Oignies, 297 Mas-Expósito, L., 414 Mash, E. J., 467, 469, 471, 472,
473, 474, 476, 478, 480, 481
Liu, H., 435 Liu, X. V., 41 Liu, Y., 107 Lizarraga, L. E., 325 Ljungberg, F., 263 Llewellyn-Jones, D., 305 Loas, G., 450 Lobban, F., 411, 415 Lochman, J. E., 475 Lock, J., 285 Loewenthal, K., 61 Loftus, E. F., 169, 542 Lombardi, G., 357 Lombroso, C., 436 Long, J., 386 Loomer, H. P., 193 Lopater, S., 358 López, S. R., 85, 108 Lopez Molina, M. A., 186 LoPiccolo, J., 353, 357, 358, 360,
363, 364 Lorand, S., 198 Lorentzen, S., 50 Loughner, J. L., 534, 535 Loukusa, S., 486 Lovaas, O. I., 487 Lovato, D., 286, 302 Lovejoy, M., 295 Lovibond, P. F., 464 Loving, J. L., 83 Lu, F. G., 61 Lu, Z., 8 Lubitz, A., 232 Lublin, N., 243 Luborsky, E. B., 49 Luborsky, L. B., 100, 109 Lucas, G., 110 Lucka, I., 373 Ludwig, A. M., 214 Luhrmann, T. M., 62 Lund, I. O., 340 Lundberg, U., 265 Lundqvist, D., 124 Lundqvist, T., 323 Lustig, S. L., 17, 547 Lyman, B., 290 Lynn, S. J., 172 Lyons, M. J., 160 Lysaker, P. H., 391
Macauley, A., 304 MacDonald, W. L., 241 Mack, A., 328 Mackey, J., 517 Mackie, B., 237 MacKinnon, B., 530 MacLaren, V. V., 87 MacLean, J., 228 Macmillan, H. L., 252 MacNeill, L. P., 292 Madan, K., 273 Madden, N. E., 177 Madoff, B., 431 Madonna (Ciccone, M.), 119 Magee, C. L., 43 Magee, L., 130, 131 Magiati, I., 139 Mäkinen, M., 287
Lennon, J., 531 Lentz, R., 404 Lentz, V., 430 Lenze, E. J., 505 Leong, F. T. L., 71 Leong, G. B., 532 Lepp, A., 129 Lepping, P., 539 Lerna, A., 488 Lerner, A. G., 325 Lerner, J. S., 185 Lerner, U., 443 Lester, D., 234, 243, 245 Leung, G. M., 61 Leung, T. K., 61 Levi, F., 226 Levin, J., 434, 543 Levin, M. E., 56, 205 Levine, D. S., 133 Levine, M. P., 296 Levinson, D. F., 189 Levinson, H., 405 Levounis, P., 329, 340 Levy, R. A., 50 Levy, S., 224 Levy, T. B., 239, 241 Leweke, F. M., 397 Lewin, A. B., 468 Lewinsohn, P. M., 198, 200 Lewis, D., 216 Lewis, M., 287 Lewis, R. W., 348, 349, 352, 355,
356, 357, 362 Lewis, S. P., 225 Leyfer, O., 106 Li, G., 233, 327 Li, H., 395 Li, L., 159 Li, Q., 408 Li, R., 215, 518 Liberto, J., 335 Liébault, A-A., 13, 257 Lieberman, J. A., 95 Liebman, J. I., 542 Liera, S. J., 112 Light, M. T., 228 Lightdale, H. A., 335 Lil’ Kim (Jones, K. D.), 334 Lilenfeld, L. R. R., 286 Lillis, J., 56 Lin, H., 509 Lin, L., 297 Lincoln, A., 184, 187 Lindau, S. T., 350 Lindenmayer, J. P., 387, 391,
413, 415 Lindert, J., 30 Lindhiem, O., 90 Lindner, M., 201 Lindsay, J., 169 Lindsey, P., 519 Linehan, M. M., 438, 439,
440, 441 Link, S., 150 Lintzeris, N., 339 Litjens, R. W., 325 Litman, R. E., 245 Liu, A., 305
Name INdex : NI-9
Nauert, R., 163 Nawata, H., 378 Nazarian, M., 108 Neacsiu, A. D., 438, 441 Neale, J. M., 391 Nebuchadnezzar, 184 Neeleman, J., 241 Neff, B., 371 Negrini, A., 546 Neighbors, H. W., 26 Nelson, L., 518 Nelson, S. D., 164 Nelson, T. F., 313 Nelson-Gray, R. O., 430, 451 Nemecek, S., 260 Nemeroff, C. B ., 26, 197 Nenadic´-Šviglin, K., 229 Ness, L., 171, 173 Neumark-Sztainer, D. R., 293 Neville, C., 439 Newcomb, M. E., 91 Newman, E., 164 Newman, M. G., 112, 114 Newnham, E. A., 438 Neziroglu, F., 145 Nezlek, J. B., 205 Nezu, A. M., 273 Ng, J. H., 522 Ng, M. T., 61 Nguyen, A., 478 Nichols, M. P., 69 Nichols, W. C., 451 Nichols, W. E., 189 Nicholson, C., 377 Nickel, R., 257, 258, 260 Nietzsche, F., 388 Nijinsky, V., 214 Nillni, Y. I., 135 Nitschke, J., 375 Niv, N., 43 Nivoli, A. M. A., 217 Nixon, M. K., 473 Nochajski, T. H., 168, 169 Nock, M. K., 229, 236, 245,
469, 473 Noeker, M., 252 Noh, Y., 233 Nolen-Hoeksema, S., 204, 208 Noll-Hussong, M., 155 Nonacs, R. M., 394 Noonan, D., 145 Noonan, S., 115 Norcross, J. C., 50, 53, 56, 60, 61,
63, 67, 69, 72, 74, 99, 100, 101, 110, 198, 210, 551
Nord, M., 408 Nordal, K., 475, 547 North, C. S., 165, 257, 261 Northoff, G., 373 Norton, A., 390 Notaro, P. C., 81 Notaro, T., 272 Novak, B., 530 Nowak, D. E., 342 Nugent, A. C., 215 Nunes, B. P., 502 Nunes, K. L., 373 Nurnberger, J. I., 215
Morgan, C. D., 82 Morgan, C. M., 305 Morgan, J. F., 297 Morgan, L., 157 Morgan, M., 162 Morgan, P. L., 482 Mori, C., 400 Morissette, A., 302 Morris, T. L., 467 Morrison, A. P., 410 Morrison, B. J., 455 Morrison, J., 331 Morrissey, J. P., 415, 417, 536 Mort, J. R., 508 Mosca, N. W., 477 Moscone, G., 532, 533 Mosconi, L., 516 Mosconi, M. W., 486 Moscovitch, D. A., 129, 130 Moses, 184, 531 Moskowitz, E. S., 57 Moss, K., 289 Mossman, D., 530, 538 Mott, J. M., 162, 164 Moukheiber, A., 130 Mowrer, O. H., 123, 476 Mowrer, W. M., 476 Moyano, O., 179 Mozart, W. A., 175 Mucha, S. M., 250 Mueller, S. E., 68 Muhammad, J. A., 531, 543, 544 Mulder, R. T., 238 Mulhauser, G., 57 Mullen, P. E., 434 Müller, C. A., 338 Müller, J. L., 374 Müller, N., 394 Munsey, C., 464 Murayama, Y., 502, 504 Murdock, K. K., 207 Murphy, E., 323 Murphy, L., 57 Murphy, R., 290 Murphy, W. D., 371 Murray, D. E., 328 Murray, H. A., 82 Murray, K. E., 209 Murray, L. K., 478 Murray, R. M., 398, 409 Musa, R., 30 Musiat, P., 306 Musikantow, R., 13 Mustanski, B., 91
Nace, E. P., 311, 314 Naeem, F., 409 Nagy, T. F., 545 Naidoo, S., 433 Nair, G., 405 Nairn, S., 98 Najman, J. M., 205 Naninck, E. F. G., 208 Nardi, A. E., 135 Narrow, W. E., 61 Nash, J., 411, 508 Nathan, D., 172 Nation, D. A., 514, 519
Miller, S. G., 455 Miller, T. I., 99 Miller, T., 446 Miller, W. D., 71 Miller, W. R., 201 Millichap, J. G., 481 Millier, A., 388 Millon, T., 425, 426, 427, 429,
439, 444, 445, 448, 450, 452, 453
Mills, J. F., 538 Milner, A., 228 Milrod, C., 377, 378 Mineka, S., 124 Miner, I. D., 251 Minnes, P., 488 Minnes, S., 322 Mintem, G. C., 287 Minuchin, S., 69, 293 Minzenberg, M. J., 100 Miranda, J., 210 Miret, M., 246 Mirone, V., 355 Mishak, P. B., 89 Mishor, Z., 142 Mitchell, A., 292 Mitchell, A. E., 438 Mitchell, A. J., 97 Mitchell, B. D., 531, 532 Mitchell, J. E., 286, 301 Mitchell, J. T., 164, 165 Mitchener-Nissen, T., 87 Mitka, M., 157 Mittal, V. A., 428 Mittelman, M. S., 520 Mitterer, J. O., 393 Mkize, D. L., 433 M’Naghten, D., 529 Moberg, T., 235 Modlin, T., 274 Moffatt, F. W., 273 Mohatt, J., 468 Mohler, H., 116 Mokros, A., 375 Mola, J. R., 363 Moldavsky, D., 260 Möller, J., 268 Momtaz, B., 243 Mond, J., 297 Mongrain, M., 17 Moniz, A. E., 44 Moniz, E., 405 Monroe, M., 222, 231 Monroe, S. M., 23, 184 Monsell, S. E., 16 Monson, C. M., 154, 164 Montaldo, C., 434 Monteith, C., 329, 331 Montejo, A-L., 353, 356 Montejo, J. E., 481 Moon, J. R., 268 Moore, C. E., 107 Moore, E. A., 456 Moore, P. J., 152 Moorhouse, P. A., 517 Moreno, C., 471 Morey, L. C., 422, 456 Morgan, C. A., 542
McManus, D., 130 McManus, M. A., 367 McNally, R. J., 165, 169 McNaughton, N., 134 McNeil, C. B., 474, 475 McNeil, E. B., 137 McPherson, M., 198 McSweeney, S., 208 McTeague, L. M., 117 Meana, M., 357, 358, 363, 366 Medina, M., 518 Mednick, S. A., 26 Meehan, K. B., 445 Meersand, P., 90 Mehl, E., 394 Mehta, D., 190 Meichenbaum, D. H., 54, 275 Meijer, E. H., 87 Meinhard, N., 394 Meisch, R. A., 332 Meloy, J. R., 433 Meltzer, A. L., 267, 290 Meltzer, H. Y., 230 Melville, C. L., 343 Melville, J., 120 Mendes, E., 267 Menninger, K., 232 Merckelbach, H., 175 Mercolini, L., 116 Merenda, R. R., 172 Merikangas, K. R., 7, 106, 213,
469, 480 Merkl, A., 192 Merrick, E. S., 546 Merrick, J., 496 Merrill, J. E., 5 Merskey, H., 172 Mesmer, F. A., 12, 13 Messer, S. B., 445, 454 Messias, E., 14 Meston, C. M., 351 Metcalfe, N. H., 10 Metsälä, E., 508 Metzl, J. M., 372 Metzner, J. L., 535 Meyer, P., 457 Meyer, V., 139 Meystre, C., 428 Mian, N. D., 467 Michael, J., 405 Michal, M., 178, 179 Micheletta, J., 65 Midgley, N., 198 Miklowitz, D. J., 216, 217 Milk, H., 532, 533 Millan, M. J., 397, 407, 408 Miller, A. L., 402, 409 Miller, A., 79, 80 Miller, D. C., 491 Miller, D. N., 236, 237 Miller, F., 427 Miller, J. A., 534 Miller, J. B., 154 Miller, J. D., 444, 445 Miller, K. L., 478 Miller, M., 172 Miller, N. E., 123 Miller, P. M., 25
: Name INdexNI-10
Prosen, H., 197 Protopopescu, X., 159 Pruchno, R., 417 Prusiner, S. B., 516 Puhl, R. M., 293 Pulman, J., 261 Punamäki, R., 158 Purcell, S. M., 395 Purkis, H. M., 122 Putnam, F. W., 172
Quah, S., 400, 411 Quas, J. A., 81 Quayle, E., 369, 373 Queinec, R., 231 Quillian, L., 113 Qureshi, N. A., 43
Rabin, R. C., 225, 517 Rabinowitz, J., 407 Raboch, J., 357 Raboch, J., Jr., 357 Rachman, S., 139, 141, 369 Radcliffe, J. D., 107 Rader, D. (“BTK killer”), 543 Radford, B., 83 Radomsky, A., 141 Ragatz, L., 534 Ragland, J. D., 387 Rahe, R., 268, 269 Raj, V., 254, 260, 261 Rajkumar, R. P., 351 Ramasamy, R., 31 Rametti, G., 378 Ramey, C. T., 492 Ramey, S. L., 492 Ramirez, E., 16 Ramone, D-D., 331 Rampell, C., 414, 547 Ramsey, C. M., 26 Ramsland, K., 171 Ramstad, J., 336 Randolph, J. J., 349 Rao, N. P., 395 Rapee, R. M., 109, 130 Rapport, M. D., 480, 481, 482 Rashid, T., 64 Rasic, D., 26 Raskin, D. C., 87 Raskin, N. J., 59, 60 Ratcliffe, R., 466 Rathbone, C. J., 176 Rathbone, J., 375 Rauch, S. M., 163 Raveesh, B. N., 539 Raveneau, G., 298 Ravitz, P., 207 Raviv, S., 279, 282 Ravndal, E., 340 Raymond, K. B., 482 Rayner, R., 123 Raz, M., 405 Razali, S. M., 407 Ready, R., 89 Reagan, R., 527, 528, 531 Reamer, F. G., 57, 67 Reas, D. L., 286 Reavey, P., 169
Pickover, C. A., 6 Pierce, K., 486 Pieters, S., 332 Pietrzak, R. H., 157 Pigott, H. E., 195 Pike, K. M., 296, 299 Pilecki, B., 467 Pillay, B., 272 Pilo, C., 443 Pinals, D. A., 530, 535, 538 Pinel, P., 10, 14, 403 Pinkham, A. E., 391 Pinna, F., 418 Pinto, A., 453, 454 Pipe, R. T., 367 Piper, A., 172 Piper, W. E., 426, 428 Pirkl, J. J., 523 Pistone, R. A., 538 Pitillo, E. S., 172 Pizzagalli, D. A., 190, 191, 192 Planty, M., 464 Plath, S., 184, 214, 251 Plato, 8 Platt, R., 467 Plaud, J. J., 369 Plaza, I., 115 Pletcher, M. J., 327 Pocklington, A. J., 393 Poe, E. A., 2 Pole, N., 161 Polizzi, N. (Snooki), 302 Pollack, M. H., 135 Polo, A. J., 108, 128 Pomerantz, A. M., 79, 89, 92 Pompili, M., 228, 229 Pondé, M. P., 433 Pongan, É., 520 Ponniah, K., 139, 217 Pope, H. G., Jr., 167 Pope, K. S., 20, 98, 544, 545, 549,
550, 551 Porcerelli, J., 449 Poretz, M., 145 Posmontier, B., 394 Pössel, P., 203 Post, R. M., 214, 215, 217 Potkin, S. G., 386 Poulin, M. J., 63 Poulos, C. X., 331 Poulsen, S., 303 Powell, D., 494 Power, P., 413 Pratchett, L. C., 217 Pratley, R. E., 30 Preisler, J. J., 268 Prelock, P. A., 488 Presley, E., 329 Presnell, K., 280, 285 Preti, A., 235 Preuss, U. W., 189 Price, M., 327 Prinstein, M., 96 Pritchard, R., 449 Prochaska, J. O., 50, 53, 56, 60,
61, 63, 69, 72, 74, 99, 100, 110, 198, 210
Prochwicz, K., 9
Paris, J., 172, 436, 437, 445, 446, 472
Parish, B. S., 254, 256, 260 Park, A., 484 Park, J. E., 513 Park, M., 208 Parker, G., 187 Parker, S, 295 Parker, T. S., 368 Parrott, A. C., 325 Paslakis, G., 7 Pasteur, L., 142 Patchin, J. W., 466 Patel, S. R., 137 Patrick, C. J., 443 Patrick, D., 5 Patterson, D., 160 Patterson, G. R., 475 Patterson, P. H., 397 Paul, G. L., 100, 404 Paul, R., 484 Paulson, C. M., 154 Pavlov, I., 51 Paykel, E. S., 65, 197 Payne, A. F., 82 Pear, R., 17, 67, 547, 548 Pearl, R. L., 288 Pearlson, G. D., 386 Pearson, C., 155 Peel, R., 529 Pekkanen, J., 539 Pelavin, E., 66 Pelissolo, A., 130 Pena-Garijo, J., 453 Pendery, M. L., 340 Peng, T., 294 Pennebaker, J. W., 275 Perdeci, Z., 435 Perilla, J. L., 161 Perillo, A. D., 533, 534 Perlin, M. L., 540 Perls, F. (Fritz), 60, 61 Perrin, M., 154, 161 Perry, J. C., 452 Perry, T., 478 Pervanidou, P., 160 Pessoa, F., 130 Peteet, J. R., 61 Peterlin, B. L., 154 Petermann, F., 467 Peters, R. H., 415, 417 Petersen, J. L., 350 Petersen, L., 234, 398 Peterson, D., 515 Peterson, L., 498 Petrakis, I., 338 Petrie, K. J., 275 Petrovich, G. D., 291 Pfeffer, C. R., 236 Pfefferbaum, B., 164, 165 Pham, A. V., 482 Phillips, D. P., 227, 231 Phillips, K., 291 Phillips, K. A., 144 Phillips, M. L., 24, 190 Piatt, A., 510 Pickel, K. L., 542 Pickert, K., 115
Nussbaum, R. L., 512 Nyp, S. S., 209
O’Brien, C. P., 331, 332 O’Connor, K. M., 363, 364 Odlaug, B. L., 144 O’Donohue, W., 447 Oelschlager, J. R., 264 Offer, D., 237 Ogden, L. P., 415, 539 Ogle, C. M., 160, 161 O'Hara, M. W., 394 Ohman, A., 124 Ohring, R., 287 Oinas-Kukkonen, H., 502 Okada, T., 116 Okawa, J. B., 158 Oken, B. S., 271 Okpokoro, U., 400, 411 Oldham, J. M., 422 Ollendick, T. H., 131, 467 Olmsted, M. P., 305 Olness, K., 175 Olsen, M-K., 302 Olson, D., 293 Olugbala, F. K., 269 Omar, H., 441 Omori, Y., 400 O’Neill, H., 434 Ong, C., 143 Onwuteaka-Philipsen, B. D., 240 Oquendo, M. A., 235, 241 Orbach, I., 237 Ordemann, G. J., 389, 411 O’Riley, A. A., 239 Orleanu, P., 274 Ornstein, C., 552 Orri, M., 236, 237 Orsillo, S. M., 114 Oslin, D., 507 Ostrov, J. M., 474 O’Sullivan, L. F., 350 Ott, J., 381 Otto, R. K., 538 Ouellette, S. C., 272 Overton, D., 174 Owens, G. P., 164 Owens, M., 190 Ozden, A., 251
Pace, M., 550 Pace, T. W. W., 158 Pacik, P. T., 366 Paczynski, R. P., 321 Padwa, L., 92 Page, I. J., 371 Pager, D., 113 Pagliari, C., 67 Paice, R., 251 Paillard, T., 519 Paiva, M. J., 115 Palamar, J. J., 325 Palermo, G. B., 543, 544 Palijan, T. Z., 538 Palley, W., 115 Paltrow, G., 190 Pankevich, D. E., 285 Parham, W. D., 72
Name INdex : NI-11
Schererk, M., 327 Scheuerman, O., 252 Scheuffgen, K., 485 Schienle, A., 116, 117 Schildkraut, J. J., 214 Schiller, B., 520 Schilling, E. A., 246 Schmidt, A. F., 372 Schmidt, D., 532, 533 Schmidt, H. M., 364 Schmidt, U., 306 Schneider, K. J., 63, 64 Schneider, K. L., 228 Schnoll, S. H., 325 Schrag, M., 516 Schrank, J., 336, 529 Schreiber, F. R., 171 Schreier, H. A., 252 Schroeder, M. J., 320 Schuch, J. J., 208 Schuel, H., 327 Schulte, I. E., 467 Schultz, D. S., 83 Schultz, G., 205 Schultz, L. T., 108 Schulz, S., 289 Schumann, R., 214 Schumm, J. A., 161, 164 Schwartz, C. E., 152 Schwartz, M., 185 Schwartz, M. W., 291 Schwartz, N., 226 Schwartz, S., 102 Schwarz, E. C., 15 Schwarzbach, M., 65 Scognamiglio, C., 393 Scott, J. E., 164, 165 Scott, L. N., 437 Scott, W., 404 Seaward, B. L., 152 Sebert, K. R., 292 Sedghi, A., 466 Seedat, S., 137 Segal, D. L., 80, 81 Segal, R., 497 Segal, Z., 62 Seiden, R. H., 241 Seligman, M. E. P., 16, 19, 30, 64,
201, 202, 211 Selkoe, D. J., 513, 515 Selling, L. S., 8, 10 Sennott, S. L., 376 Sergeant, S., 17 Serretti, A., 337 Seto, M. C., 367, 371, 373, 375 Seuss, Dr. (Geisel, T. S.), 200 Shalev, A. Y., 165 Shanks, D. R., 169 Shapiro, E. R., 445 Shapiro, J. R., 302 Sharar, G., 197 Sharf, R. S., 47, 56, 69, 72, 98, 99,
100, 109 Sharmila, I., 223 Shaw, H., 32 Shaw, K., 284, 443 Shaw, R. J., 259, 260 Sheidow, A. J., 474, 475
Rudes, J., 372 Ruggero, C. J., 157 Rullo, J. E., 348 Rüsch, N., 65 Ruscio, A. M., 106, 128 Rusconi, E., 87 Rush, B., 10 Russell, B., 135 Russell, J. E. A., 115 Russo, F., 49 Russo, N. F., 154, 157 Ruth, T. E., 227 Rutledge, P., 446 Ruzek, J. I., 154, 163, 164 Ryder, W., 438
Saad, G., 457 Saba, L. M., 332 Sacks, O., 390 Sadeh, N., 437 Saedi, G. A., 21 Sagara, J., 205 Sakinofsky, I., 230 Salari, A., 116 Salekin, K. L., 538 Salfati, C. G., 543 Salinger, J. D., 424, 531 Salkovskis, P. M., 140, 141 Salzer, S., 110, 449 Samek, D. R., 332 Sames, C., 251 Samorodnitzky-Naveh, G., 145 Samos, L. F., 523 Sampasa-Kanyinga, H., 465 Sample, I., 214 Samuel, V. J., 482 San Nicolas, A. C., 321 Sanburn, J., 245 Sandler, I., 341 Sandler, M., 193 Sanftner, J. L., 283, 284 Sani, G., 95 Sansone, A., 355 Sansone, L. A., 422, 426, 427,
429, 433, 438, 443, 444, 448, 451, 453
Sansone, R. A., 422, 426, 427, 429, 433, 438, 443, 444, 448, 451, 453
Santa-Cruz, N., 17 Santiseban, D. A., 66 Sar, V., 171 Sareen, J., 71, 107, 108, 120, 128,
133, 154, 184, 213, 387, 454 Sarin, F., 389, 398 Sarver, N. W., 131 Satir, V., 69 Saul (King), 8, 184, 221 Saunders, J. B., 335 Sauvageau, A., 374 Savitz, J., 215 Scelfo, J., 474 Schadenberg, A., 240 Schafer, J. A., 14 Schattner, E., 197 Schatz, M. L., 477 Schatzberg, A., 541 Scheidt, C. E., 254
Rockwood, K., 517 Rodav, O., 224 Rodriguez, B. F., 106 Roelants, F., 274 Roelofs, K., 254 Roemer, L., 114, 125 Roepke, S., 441, 444, 445 Roesch, R., 217, 535 Roesler, T. A., 478 Rogers, C. R., 7, 58, 59, 60, 64,
110, 119 Rogers, J., 467 Rogers, K. M., 482 Rogers, R., 530 Rogler, L. H., 86 Roh, D., 408 Rohn, T. T., 494 Romanelli, R. J., 142 Romero-Martínez, A., 478 Roney, T., 441 Ronningstam, E., 444 Rook, K. S., 268, 272 Rooney, W., 259 Roosevelt, E., 205 Roosevelt, T., 529 Rorschach, H., 82, 102 Rose, T., 85 Rosell, D. R., 424, 429 Rosellini, A. J., 229 Rosen, E. F., 293 Rosen, L. R., 356 Rosen, R. C., 352, 353, 356 Rosenbaum, T. Y., 365, 366 Rosenberg, A., 130 Rosenberg, T., 550 Rosenbloom, S., 24 Rosenblum, G. D., 287 Rosenbluth, M., 430 Rosenhan, D. L., 65, 400 Rosenman, R., 266 Rosenthal, R., 29 Rosenthal, R. N., 329, 340 Rosenthal, T., 122, 123 Roskar, S., 227, 228 Rosky, J. W., 86, 87 Ross, C. A., 171, 173, 177 Ross, J., 536 Ross, S., 506 Rossi-Arnaud, C., 388 Rotenberg, K. J., 202 Rothbaum, B. O., 155, 162,
163, 164 Rothschild, A. J., 192 Rotter, M., 426, 540 Rowan, P., 290 Rowe, L., 438 Rowen, T. S., 366 Rowland, D. L., 355, 356, 361,
363, 364 Rowling, J. K., 214 Roy, A., 230, 234 Roy, A. K., 472 Roy-Byrne, P. P., 154 Rubin, D. C., 161 Rubin, D. M., 478 Rubinstein, S., 292 Rubio-Aurioles, E., 351, 363 Rudd, M. D., 242, 245
Recordon, N., 360 Redding, A. J., 54 Redick, R. W., 414 Redmond, D. E., 133, 135 Rees, C. S., 449 Reese, J., 433 Reeves, K., 119 Regal, C., 352 Regier, D. A., 94, 128, 189, front
endpaper Reich, J., 541 Reichenberg, A., 486 Reid, M., 306 Reid, M. J., 475 Reif, S., 340 Reinares, M., 217 Reinecke, A., 136 Reisch, T., 228 Reisner, A. D., 534 Reiss, S., 136 Reissing, E. D., 358 Reitan, R. M., 89 Rellini, A. H., 357 Remberk, B., 392 Remington, G., 388, 389, 395 Renaud, J., 236 Reston, A. C., 295 Rezai, A. R., 196 Reznikoff, M., 82 Rhéaume, C., 265 Rhebergen, D., 95 Rice, C. E., 484 Rice, M. E., 436 Rich, C. L., 238, 471 Richard, M., 302, 304 Richards, S. B., 31 Richardson, F. C., 275 Richardson, J. R., 516 Richlan, F., 491 Richtel, M., 20 Rieber, R. W., 171, 172 Ries, R. K., 230 Riesch, S. K., 236 Riggs, P., 311, 334, 335, 337 Rihanna (Fenty, R. R.), 119, 334 Riina, E. M., 69 Ringer, J., 304 Ringstrom, P. A., 49 Ringwood, S., 57 Ripoll, L. H., 449 Risch, N., 486 Ristow, A., 487 Ritter, K., 445 Ritter, M., 516 Ritter, M. R., 107, 128 Rivett, M., 98 Rizvi, S. L., 441 Robbins, E. S., 324 Robbins, J., 304 Robert, G., 49 Roberts, M., 90 Roberts, M. C., 498 Robertson, C. A., 375 Robinson, W. P., 457 Rocca, P., 391 Roche, B., 369, 373 Roche, T., 394 Rocks, T., 298
: Name INdexNI-12
Syrjala, K. L., 275 Szabo, M., 464 Szalavitz, M., 21, 129, 510, 519 Szasz, T., 4, 410 Szumilas, M., 165
Tabachnick, B. G., 550, 551 Tabet, N., 518 Tacón, A., 298 Taghva, A. S., 196 Takeuchi, H., 408 Tallis, F., 111 Tamminga, C. A., 397 Tang, B., 469 Tantam, D., 57 Tantillo, M., 283, 284 Tarasoff, T., 546 Tartaro, J., 154, 157 Tasca, G. A., 303 Tashakova, O., 299 Tashkin, D. P., 327 Taube-Schiff, M., 189 Taycan, O., 256 Taylor, B., 158 Taylor, C. B., 306 Taylor, L. E., 487 Taylor, M. J., 486 Taylor, R., 31 Taylor, S., 140 Taylor, S. E., 162, 495 Taylor, S. F., 389 Taylor, S. J., 489 Taylor, W. D., 504 Tellez, M., 52, 125 Tenback, D. E., 408 Ten Have, M., 16, 538 Ter Kuile, M. M., 365 Teri, L., 505 Thakker, J., 85 Thase, M. E., 193 Thetford, E. S., 186 Thevasagayam, M. S., 252 Thigpen, C. H., 22, 171 Thomas, J., 203, 538 Thomasson, E., 240 Thompson, D. F., 435, 436 Thompson, R. A., 297 Thompson, W., 507 Thornton, L. M., 291 Tiggemann, M., 287 Tilak, J., 328 Timberlake, J., 119 Tolan, P., 478 Tolmunen, T., 152 Tolstoy, L., 66 Tomita, A., 387 Tomlin, L., 150 Tondo, L., 403 Torgersen, S., 134, 438 Toro, J., 296, 297 Torres, A. R., 137 Torrey, E. F., 15, 397, 414, 415 Toteja, N., 472 Toth, S. L., 27 Touchette, E., 284 Touyz, S. W., 298 Towers, S., 434 Trapp, M., 266
Stegmayer, K., 391 Stein, C. H., 15, 70 Stein, D. J., 120, 128, 135, 142 Stein, J., 273 Stein, J. S., 331 Steiner, H., 290 Steinhausen, H. C., 302 Steinmetz, K., 376, 377, 378, 381 Stekel, W., 232, 375 Steketee, G., 139 Stene, L. E., 157 Stephens, R., 259 Stern, A., 439 Stern, M., 324 Sternberg, R. J., 489 Stevens, L. M., 190 Stevens, S., 449 Stevenson, R. W. D., 353, 356,
363, 364, 366 Stewart, K., 119 Stewart, R. E., 98 Stewart, T. M., 284, 296, 302, 304 Stice, E., 280, 283, 285, 302,
305, 469 Stillwell, D., 24 Stolberg, R. A., 245, 246 Stone, M. H., 375, 438 Stoppler, M., 185 Strachan, E., 536 Strang, J., 338, 339 Strassberg, D. S., 368 Stratemeier, M. W., 262 Straub, J., 470 Street, A. E., 157, 160 Streisand, B., 127 Strickland, B. R., 204 Strober, M., 291, 300, 301 Stroup, T. S., 407 Strümpfel, U., 64 Stuart, S., 260 Stuber, J. P., 4, 14 Štulhofer, A., 351, 353 Stunkard, A. J., 288 Sturmey, P., 490, 492, 493,
496, 497 Su, C-C., 351, 357, 358 Su, S., 265, 266 Sue, D. W., 85 Sugrue, D., 482 Sujan, A. C., 478 Suler, J., 96 Sullivan, E. L., 292 Sullivan, E. M., 231 Sullivan, H. S., 139 Sunderland, M., 448 Sundgot-Borgen, J., 292 Sungur, M. Z., 349 Suokas, J. T., 281, 282, 286 Suppes, T., 216 Sussman, S., 331 Svartberg, M., 449, 451 Svrakic, D. M., 454 Swain, J., 57 Swan, L. K., 101 Swanson, J. W., 532, 536 Swanson, S. A., 106 Swartz, M. S., 406, 412, 532, 536 Syed-Abdul, S., 294
Smart, E., 531, 532 Smart-Richman, L., 267 Smink, F. E., 288 Smith-Lovin, L., 198 Smith, A. N., 331 Smith, A., 129, 228 Smith, J., 272 Smith, M. L., 99 Smith, P. K., 368, 464 Smith, S. J., 330 Smith, T., 67 Smith, T. W., 19 Smolak, L., 296 Smyth, J. M., 275 Snoop Dogg (Broadus, C. C., Jr.),
334 Snyder, W. V., 60 So, J. K., 260 Sobczyk, A., 9 Sobell, L. C., 340 Sobell, M. B., 340 Socrates, 479 Solar, A., 413 Soliman, M., 413 Soloff, P. H., 438 Solomon, A., 199 Solter, D., 33 Solter, V., 387 Sommers-Flanagan, J., 80, 81 Sommers-Flanagan, R., 80, 81 Soole, R., 236 Soto, J. A., 107 Soukup, J. E., 513 Spada, M. M., 343 Span, P., 522 Spanton, T., 409 Spaulding, W., 411 Spence, J., 164 Sperry, L., 430, 433, 445, 451, 452 Spiegel, D., 172 Spiegler, M. D., 406 Spielberger, C. D., 152 Spirito, A., 242, 469 Spitalnick, J. S., 131 Spitzer, R. L., 138 Spitzer, R. L., 28, 38, 201, 250,
256, 309, 352, 361, 369, 436, 450, 463
Spivak, Z., 293 Springen, K., 49 Springman, R. E., 81 Stacciarini, J. M. R., 210 Stack, S., 226, 227, 233 Stahl, S. M., 195 Stahlberg, O., 475 Staller, K. M., 373 Stanislaus, A., 538 Stanley, B., 235 Stanley, I. H., 242 Starcevic, V., 143, 453 Stares, J., 6 Starr, L. R., 106 Starr, T. B., 291, 293, 295, 299,
302, 303 Steadman, H. J., 417, 530 Steele, H., 171 Steenkamp, M. M., 162 Steffens, D. C., 505
Sheldon, P., 65 Shenassa, E., 228 Shenk, D., 512, 513 Sher, L., 230, 541 Sheras, P., 69 Shergill, S. S., 390 Sherman, R. T., 297 Sherry, A., 454, 455 Shi, J., 81 Shinto, A. S., 397 Shiraishi, N., 389 Shiratori, Y., 186 Shnaider, P., 164 Shneidman, E. S., 222, 228, 229,
232, 236, 244, 246 Shriver, M., 511 Shu, H., 514 Shultz, J. M., 107 Siahpush, M., 266 Sibley, M. H, 481, 482 Sibrava, N. J., 107 Sicile-Kira, C., 483, 485, 487, 488 Sidorov, P. I., 10 Siegler I. C., 161 Siep, N., 281, 290 Siever, L. J., 424 Sifferlin, A., 21, 108, 185, 314,
446, 511 Sigerist, H. E., 9 Silbersweig, D. A., 389 Silk, K. R., 428 Silverman, J. M., 485 Silverman, S., 476 Simard, V., 109 Simmon, J., 145 Simon, R., 98 Simon, T., 89 Simonelli, C., 358 Simonton, D. K., 214 Simple, I., 83 Simpson, A., 302 Simpson, H. B., 142 Singh, A., 506 Singh, D., 377 Singh, G. K., 266 Singh, S. P., 394, 399 Singhal, A., 229 Singleton, C., 540 Sinkus, M. L., 215 Sinrod, B., 145 Sinton, M. M., 306 Sinyor, M., 430 Sipahi, L., 41 Sipe, T. A., 17, 547 Sirey, J. A., 522 Sitt, D., 96 Sizemore, C. C., 171, 172, 173 Sjolie, I. I., 261 Skelton, M., 402 Skodol, A. E., 422, 438 Skorga, P., 265 Slater, A., 287 Slater, M. D., 341 Sledge,W. H., 546 Sloan, D. M., 296 Slopen, N., 107 Slovenko, R., 530, 532 Sluhovsky, M., 9
Name INdex : NI-13
Williams, A. D., 343 Williams, C. L., 84 Williams, D., 120, 128 Williams, P., 426 Williams, P. G., 266, 272 Williams, R., 222, 229 Williams, S., 306 Williams, S. R., 467 Williams, T. I., 141 Williams, T. M., 186 Williams, W., 266 Williamson, D. A., 284, 296,
302, 304 Willick, M. S., 398 Wills, T. A., 331 Wilson, C., 30 Wilson, G. T., 299, 303, 304 Wilson, K. R., 91 Wilson, R. S., 281, 519 Wincze, J. P., 353, 356 Winehouse, A., 331, 334 Winfrey, O., 478 Winick, B. J., 538 Winslade, W. J., 536 Winslet, K., 302 Winstock, A. R., 339 Winter, E. C., 465, 468, 481 Wise, J., 417 Wise, R. A., 542 Wisner, K. L., 394 Wiste, A., 215 Witcomb, G. L., 292 Witherow, M. P., 351 Witkiewitz, K. A., 340 Wittayanukorn, S., 71 Witthöft, M., 144, 258, 261 Witty, M. C., 59 Wohltmann, J., 510 Wolberg, L. R., 48 Wolf, M. R., 168, 169 Wolfe, D. A., 467, 469, 471, 472,
473, 474, 476, 478, 480, 481 Wolff, S., 428 Wolfson, D., 89 Wolitzky, D. L., 49 Wolpe, J., 52, 124, 360 Wolrich, M. K., 143 Wolters, F. J., 8 Wonderlich, S. A., 302, 303 Wong, J. P. S., 237 Wong, M. M., 236 Wong, Y., 296 Woodall, A., 380 Woodside, D. B., 293 Wooldridge, T., 294 Woolf, V., 214 Worchel, S., 69 Worsdell, A. S., 369 Worthen, M., 153 Wortman, C. M., 505 Wright, J. J., 363, 364 Wright, L. W., Jr., 370, 543 Wright, S. (Steven), 179 Wright, S., 367 Writer, B. W., 162 Wroble, M. C., 107 Wu, G., 81 Wurst, F. M., 226
Watson, T. S., 491 Watt, T. T., 314 Waugh, J. L., 481 Weaver, M. F., 325 Weber, T., 552 Webster-Stratton, C., 475 Wechsler, H., 313 Weck, F., 261, 262 Wedding, D., 98, 545, 549,
550, 551 Weeks, D., 6 Wei, Y., 164 Weichman, J., 243 Weinberger, J., 101 Weiner, A., 368 Weiner, R., 156 Weinshenker, N., 287 Weinstein, Y., 169 Weishaar, M. E., 54, 55, 202, 204,
426, 428, 430, 436, 443, 445, 449, 451, 453, 454
Weisman, R. L., 233 Weiss, D. E., 145 Weiss, F., 332 Weiss, J. A., 494 Weiss, K. A., 82 Weissman, M. M., 189, 205, 206 Weissman, S. W., 18 Wells, A., 111, 112, 114 Wells, G. L., 542 Welsh, C. J., 335 Werth, J. L., Jr., 230, 240 Wertheimer, A., 235 Wesner, A. C., 136 Westen, D., 438 Westermeyer, J., 85 Westheimer, R. K., 358 Wexler, H. K., 416 Weyandt, L. L., 474, 481 Weyer, J., 9 Wheeler, B. W., 238 Wherry, J. N., 81 Whiffen, V. E., 208 Whilde, M. R., 454, 455 Whisman, M. A., 209 Whitaker, R., 12, 195, 402 White, A. H., 400 White, D., 532, 533 White, M., 449 White, M. P., 16 White, P., 83 Whitney, S. D., 236 Whitten, L., 327 Whitton, A., 141 Wickett, A., 240 Widiger, T. A., 443 Wiebking, C., 373 Wiederman, M. W., 356 Wierckx, K., 379 Wijsen, C., 376 Wiklund, G., 474 Wilde, O., 56, 175, 442 Wilens, T. E., 330 Wiley-Exley, E., 411 Wilhelm, S., 144, 145 Wilkes, T. C. R., 473 Wilkinson, P., 225, 315 Wilkinson, T., 3
Vater, A., 444, 445 Vaz, S., 86 Veale, D., 144 Vecina, M. L., 157 Veiga-Martínez, C., 409 Vela, R. M., 470, 471 Verdeli, H., 206 Verschuere, B., 87 Vetter, H. J., 388 Via, E., 142 Vialou, V., 191 Vickrey, B. G., 97 Victor, S. E., 225 Victoria (Queen of England), 184 Vieira, K. F., 43 Vierck, E., 485 Vignogna, L., 262 Vitaro, F., 342 Vitelli, R., 255 Vlieger, A. M., 274 Voelker, R., 155 Vogt, D. S., 164 Volavka, J., 538 Volfson, E., 507 Volkert, J., 506 Volkow, N. D., 333 Voltaire, 406 von Krafft-Ebing, R., 11, 12 von Münchhausen, F. (Baron), 250 Vos, J., 63, 64
Waddington, J. L., 397, 408 Wade, T. D., 287, 299, 305 Wain, H., 202 Waisbren, S. E., 494 Wakefield, A. J., 486 Wakefield, J. C., 95, 180, 185 Waldinger, M. D., 364 Wallace, G. L., 474 Waller, B., 65 Waller, G., 299, 300, 303, 439 Waller, S., 543 Wallin, L., 389, 398 Walsh, E., 15, 415 Walsh, K., 155 Walters, G. D., 332 Wambeam, R. A., 341 Wang, J., 269 Wang, L., 202 Wang, M., 173 Wang, P. S., 106, 107, 128,
133, 154 Wang, S. S., 192 Wang, Y., 86, 266 Warburton, W., 439 Ward, T., 85, 534 Warren, R., 62 Washburn, I. J., 330 Washton, A. M., 323 Wasserman, D., 237 Wasserman, I., 226, 227 Waters, R., 391 Watkins, E. R., 204 Watson, D., 84, 86 Watson, H. J., 299 Watson, J. B., 123 Watson, J. C., 63 Watson, P. J., 165
Trauer, J. M., 263 Travers, B. G., 486 Travis, C. B., 267, 290 Traynor, V., 511 Treadway, M. T., 190, 191, 192 Treffert, D. A., 485 Trevisan, L. A., 507 Triebwasser, J., 426 Trifilieff, P., 333 Tripoli, T. M., 359 True, W. R., 160 Trull, T. J., 96, 443 Tsai, J., 411 Tsai, J. L., 85 Tsai, J-Y., 351, 357, 358 Tsang, T. W., 480 Tsuang, M. T., 134, 332 Tuckey, M. R., 164, 165 Tuke, W., 10 Tune, L. E., 509, 510 Turchik, J. A., 351 Turkat, I. D., 425 Turkle, S., 207, 446 Turner, B. H., 437 Turner, E. H., 195 Turner, L. J., 17, 547 Turner, S. M., 164 Turney, K., 203 Turton, M. D., 291 Tusa, A. L., 340 Twain, M., 132 Tyrer, P., 443 Tyson, A. S., 154
Udesky, L., 188 Uliaszek, A. A., 451 Ulrich, R. S., 275 Ungar, W. J., 81 Unger, J. B., 330 Unützer, J., 208 Urben, S., 70 Urcuyo K. R., 272 Uroševic´, S., 331, 333 Ursano, R. J., 161 Useda, J. D., 426
Vaherkoski, U., 508 Vahia, I. V., 399 Vahia, V. N., 399 Valbak, K., 303 Valencia, M., 100 Valenstein, E. S., 405 Vall, E., 305 VanBergen, A., 170, 172 van der Kruijs, S. M., 174 van Deurzen, E., 63 van Duijl, M., 178 Van Durme, K., 292 van Geel, M., 236 van Gogh, V., 402 Van Lankveld, J., 359, 366 Van Male, L. M., 357 Van Orden, K. A., 244 Van Praag, H. M., 61 van Son, G. E., 301 Van Vonderen, K. E., 287 VanZuylen, H., 372 Vasquez, M. J. T., 20, 544, 545, 551
: Name INdexNI-14
Zhao, L. N., 511, 513, 514 Zheng, Y., 77 Zhou, J. N., 378 Zhou, X., 260 Zhou, Y., 503 Zhuo, J. N., 20 Zilboorg, G., 9 Zimbardo, P., 398 Zimmerman, M., 437 Zipursky, R. B., 414, 418 Zisser, A., 475 Zoellner, T., 438 Zoroya, G., 154 Zu, S., 56 Zucker, K. J., 371, 377, 379 Zuckerman, M., 197, 456 Zweben, J., 323
Yun, R. J., 47 Yusko, D., 221 Yusoff, M. M., 407 Yutzy, S. H., 254, 256, 260
Zadra, A., 49 Zajonc, R., 493 Zakzanis, K. K., 325 Zanarini, M. C., 438 Zannas, A., 506 Zarate, C. A., Jr., 215 Zazzaro, E., 412 Zerbe, K. J., 284, 286, 290, 293,
298, 300, 306 Zerwas, S., 302 Zeschel, E., 213 Zeta-Jones, C., 213
Yin, R. K., 22, 23 Yin, S., 71 Yontef, G., 60, 61 Yoo, Y., 343 Yoon, H-K., 192 Yoon, J. H., 337 Yoshida, K., 395 You, S., 227, 228 Young, C., 265 Young, D. M., 206 Young, J. E., 205 Young, K. S., 343 Young, L., 119, 273 Young, S. L., 408 Ystrom, E., 332 Yu, S., 323 Yu, Y., 292
Wurtzel, E., 38 Wyatt, W. G., 72 Wymbs, B. T., 474
Xu, H., 516
Yager, J., 300, 301 Yaghoubi-Doust, M., 478 Yakeley, J., 433 Yakushev, I. B., 10 Yalom, I. D., 58, 63 Yap, M. H., 65 Yates, A., 394, 531 Yeates, K. O., 491 Yeats, W. B., 283 Yehuda, R., 158, 160 Yewchuk, C., 485
SI-1
Subject Index Note: Page numbers followed by f, t, and b indicate figures, tables, and boxes, respectively.
ABAB design, 31 Abilify, 408 Abnormal psychology, definition of, 2 Above the Influence, 341 Absentmindedness, 175b Abuse. See Child abuse; Domestic violence;
Victimization Acceptance and Commitment Therapy (ACT),
56, 114, 205 for schizophrenia, 409–410 for substance use disorders, 337
Acculturation, 296 Accurate empathy, 60 Acetylcholine, in Alzheimer’s disease, 516 Acquired immunodeficiency syndrome
neurocognitive disorders and, 518 in substance abusers, 339
ACTH, in stress response, 152 Acute stress disorder, 152–166. See also
Stress disorders biological factors in, 158–160 childhood experiences and, 160 cultural factors in, 161 definition of, 153 genetic factors in, 160 personality factors in, 160 severity of trauma and, 161 social support and, 160–161 treatment of, 161–165
Adaptive functioning, in intellectual disability, 490 Addictive disorders
gambling disorder, 342–343 Internet gaming disorder, 343 sexual addiction, 366 substance use disorders, 309–344. See also
Substance use disorders Addyi, 363 Adjustment disorders, 159b Adolescents. See also Children
African American, discrimination against, 267f alcohol use by, 312, 313b, 336b antidepressants for, 238b, 470–471 antipsychotics for, 472 bipolar disorder in, 471–472 body dissatisfaction in, 287 bullying of, 464–465, 466b, 470 common problems of, 464–465, 466b depression in, 186, 469–471 disorders of, 463–499 disruptive mood dysregulation syndrome in,
186, 472, 472t eating disorders in, 265–306 in enmeshed families, 293, 300–301 neurodevelopmental disorders in, 477t,
479–482 recovery schools for, 336b sexual behavior of, 350b substance use disorders in, 312, 313b, 326f,
327, 336b suicide by, 230–231, 236–239, 237f
antidepressants and, 238b, 471
Adoption studies, of schizophrenia, 393 Adrenal glands, 40
in stress response, 152, 152f, 159–160 Adrenocorticotropic hormone (ACTH), in stress
response, 152 Affect, inappropriate, in schizophrenia, 389–391 Affective response inventories, 86 Affectual awareness, 363 Affordable Care Act (ACA), 17–18, 547 African Americans. See also Race/ethnicity
anxiety in, 107, 108t, 120, 128 attention-deficit/hyperactivity disorder in, 482 body image in, 295–296 borderline personality disorder in, 455 depression in, 210 eating disorders in, 295–296 panic disorder in, 133 psychophysiological disorders in, 266–267,
267f, 267t schizophrenia in, 399 substance use disorders in, 311, 311f suicide by, 227, 227f, 238–239, 241
Aftercare, 413 right to, 540
Aggression. See also Criminality; Violence in conduct disorder, 473–474 self-directed, in suicide, 232–233 Type A personality and, 266
Aging. See also Elderly disorders of, 501–525, 506b wellness approach to, 524
Agoraphobia, 120–122, 128t. See also Phobias cultural aspects of, 108t definition of, 120 diathesis-stress model for, 146 key features of, 122t panic attacks and, 122, 127, 133 panic disorder and, 127, 133 prevalence of, 108t, 120, 128t treatment of, 126–127
Agreeableness, 456 AIDS
neurocognitive disorders and, 518 in substance abusers, 339
Al-Anon, 340 Alateen, 340 Alcohol, 311–316, 319t
blood levels of, 312 cultural aspects of, 311, 311f, 313 gender differences in, 312 intoxication in, 310, 312 metabolism of, 312 physical effects of, 312
Alcohol dehydrogenase, 312 Alcohol use disorder, 312–316, 319t
in adolescents and college students, 5, 311, 312, 313b
in American Indians, 71, 311, 311f, 313 Antabuse for, 338 antisocial personality disorder and, 433 aversion therapy for, 335 binge drinking and, 5, 311, 313b, 315b clinical picture in, 314 cognitive-behavioral therapy for, 335–337
community treatment for, 340 cultural aspects of, 71, 311, 311f, 313,
340–341 delirium tremens in, 314 demographics of, 313 detoxification for, 337–338 drinking patterns in, 314 in elderly, 505–507 fetal alcohol syndrome and, 316 genetic factors in, 332 Korsakoff ’s syndrome and, 316 medical problems in, 314–316, 319t patterns of use in, 314 personal and social impact of, 314–316,
319t in pregnancy, 316, 341, 494–495 prevalence of, 313 psychodynamic therapy for, 335 recovery schools for, 336b relapse-prevention training for, 337 risks and consequences of, 319t suicide and, 229 tolerance in, 314 treatment of, 334–343 withdrawal in, 314, 338
Alcoholics Anonymous, 339–340 Alcoholism. See Alcohol use disorder Alexithymia, 290 Alogia, in schizophrenia, 391 Alprazolam
for generalized anxiety disorder, 116, 117t for panic disorder, 135
Alternate personalities, 170–171 fusion of, 177
Altruistic suicide, 233 Alzheimer’s disease, 501–502, 511–522
assessment in, 516–517 beta-amyloid protein in, 513, 514, 515 biochemistry of, 515–516 brain abnormalities in, 515, 515f causes of, 514–516 diagnosis of, 513–514, 515–517 early-onset, 511, 512f, 514 emotional support in
for caregivers, 519–520 for patients, 521b
family stress in, 519–520 genetic factors in, 514–515 hallucinations in, 390b historical perspective on, 512–513 key features of, 513t late-onset, 511, 512f, 514 neurofibrillary tangles in, 513–514 prevention of, 519 progression of, 513 senile plaques in, 513–514 treatment of, 518–519
behavioral, 519, 521b cognitive, 518–519 drug therapy in, 518 sociocultural approaches in, 520
Amenorrhea, in anorexia nervosa, 282 American Indians. See also Race/ethnicity
alcohol abuse by, 71, 313 depression in, 210 substance use disorders in, 311, 311f suicide by, 227, 227f, 239, 241
American Law Institute test, 529
: Subject IndexSI-2
compulsions and, 137–138, 138–139 definition of, 106 diathesis-stress model for, 146 free-floating, 106 moral, 108 neurotic, 108 obsessions and, 137 performance, 127
erectile disorder and, 353 poverty and, 107–108 realistic, 108 separation, 467–468, 468t
dependent personality disorder and, 450 social. See Social anxiety disorder social media and, 129 state (situation), 152 trait, 152 vs. fear, 106 worry and, 111–114, 111f
Anxiety disorders, 105–147 in children, 108–109, 465–469 definition of, 106 diathesis-stress model for, 146 in DSM-5, 93 in elderly, 505 generalized anxiety disorder, 106–119 obsessive-compulsive disorder, 137–145 panic disorder, 132–136 phobias, 110–127 prevalence of, 106, 108t, 128t sociocultural aspects of, 108t stress management program for, 147 types of, 106
Anxiety sensitivity, 135–136 Anxiolytics. See Antianxiety drugs Anxious personality disorders, 423f, 437t,
447–454 Apathy
in depression, 186 in schizophrenia, 391
Apnea, sleep, 264b Apolipoprotein E (ApoE), in Alzheimer’s disease,
514 Apps, mental health, 21 Aricept, 518 Aripiprazole, 408 Arousal
antisocial personality disorder and, 435 anxiety and, 112, 116–117, 117f diathesis-stress model and, 146 psychophysiological disorders and, 265 sleep disorders and, 264b stress and, 149–152, 151f
Artifact theory, of depression, 208 Artistic creativity, psychological abnormalities
and, 214b Asian Americans. See also Cultural factors; Race/
ethnicity panic disorder in, 133 substance use disorders in, 311, 311f suicide by, 227, 227f, 238–239
Asperger’s syndrome. See Autism spectrum disorder
Asphyxia, autoerotic, 374–375 Assertive community treatment, 412 Assertiveness training, for social anxiety disorder,
131 Assessment. See Clinical assessment Assisted suicide, 240b
Antabuse, 338 Antagonism, 458 Antagonists, narcotic, 338 Anterior cingulate cortex
in anxiety, 117, 117f in gender dysphoria, 378
Antiandrogens, for paraphilic disorders, 367 Antianxiety drugs, 42
abuse of, 316, 319t for generalized anxiety disorder, 116,
117–118, 117t for panic disorder, 135
Antibipolar drugs, 42, 215–217 Antibodies, 269 Antidepressants, 42
for bulimia nervosa, 303–304 for children and adolescents, 470–471
suicide and, 238b, 471 for conversion disorder, 260 for depression, 193–195, 193t for generalized anxiety disorder, 118 for illness anxiety disorder, 262 ineffectiveness of, 195 MAO inhibitors, 193, 193t mechanism of action of, 194 for obsessive-compulsive disorder, 141, 142 for panic disorder, 133, 135 for paraphilic disorders, 367 for premature ejaculation, 364 second-generation, 193, 193t, 194–195,
194f selective serotonin reuptake inhibitors, 193t,
194–195, 194f sexual dysfunction due to, 356, 362 for smoking cessation, 320b for social anxiety disorder, 130 for somatic symptom disorder, 260 suicide and, 238b, 471 tricyclic, 193–194, 193t types of, 193–195, 193t
Antigens, 269 Antipsychotics, 42, 395–397, 406–408
for anxiety, 118 atypical, 397, 407, 408 for children and adolescents, 472 conventional, 407 development of, 395–396, 406–407 effectiveness of, 407 for elderly, 508 extrapyramidal effects of, 407–408 mechanism of action of, 395–397 neuroleptic, 407 Parkinsonian symptoms due to, 395, 408 for schizotypal personality disorder, 430 side effects of, 395, 407–408 types of, 408t
Antisocial behavior. See also Criminality; Violence
of children and adolescents, 473–476, 473t in conduct disorder, 473, 473t of serial killers, 543b
Antisocial personality disorder, 423f, 431–436, 437t
conduct disorder and, 473 Anxiety
adjustment disorder with, 159b antisocial personality disorder and, 435 biology of, 116–119, 117f in children, 108–109, 465–469
American Psychiatric Association (APA), 529–530
American Psychological Association (APA), 93 code of ethics of, 544–546
Amnesia continuous, 167 dissociative, 166–169, 167–169, 167t.
See also Dissociative disorders child abuse and, 169b
generalized, 167 hypnotic, 174–175 localized, 167 selective, 167
Amnestic episode, 167 Amphetamines. See also Stimulant(s)
abuse of, 319t, 322–323 psychosis and, 395
Amygdala, 39, 39f age-related changes in, 515, 515f in anxiety, 117, 117f, 133–134, 134f in borderline personality disorder, 438 in depression, 191, 191f in memory, 515, 515f in obsessive-compulsive disorder, 142, 142f in panic reactions, 133–134, 134f in stress response, 159
Amytal, for dissociative disorders, 176 Anafranil, for obsessive-compulsive disorder,
141 Anal regressive personality, 453 Anal stage, 47, 139 Analog observation, 90–91 Analogue experiments, 30–31 Anandamide, 333 Androphilic gender dysphoria, 378–379 Anesthesia, memory under, 175b Anger, self-directed, in suicide, 232–233 Anhedonia
in depression, 186 in schizophrenia, 391
Anomic suicide, 233 Anomie, 233 Anorexia nervosa, 280–282
alexithymia and, 290 binge-eating/purging-type, 280 causes of, 289–298 clinical picture of, 281–282 cognitive factors in, 290 core pathology in, 290 cultural aspects of, 295–298 depression and, 290–291 ego deficiencies and, 289–290 family environment and, 289–290,
293–294, 300–301 integrated approach to, 306 key features of, 280t medical problems in, 282 multidimensional risk perspective on, 289 outcome in, 301–302 overlap with other eating disorders, 284f prevalence of, 280 pro-anorexia Web sites and, 280t progression of, 280–281 psychological abnormality in, 282 restricting-type, 280 reverse, 297 societal pressures and, 292–293 treatment of, 298–301 vs. bulimia nervosa, 286
Subject Index : SI-3
Blind design, 29–30 Blunted affect, in schizophrenia, 391 Bodily illusions, in schizotypal personality
disorder, 429 Bodily sensations
in fear, 117f misinterpretation of, 135
Body dissatisfaction, 287 Body dysmorphic disorder, 144–145 Body image
in body dysmorphic disorder, 144–145 cultural aspects of, 295–298 depression and, 208 in eating disorders, 280, 295–298 in men, 296–298 in muscle dysmorphobia, 297 societal pressures and, 292–293 trends in, 280
Body weight. See Weight Borderline personality disorder, 423f,
436–441, 437t causes of, 438–439 clinical picture of, 436–438 cultural aspects of, 454–455 eating disorders and, 439 gender differences in, 454–455 personal account of, 440b suicide in, 437, 438, 440b victimization and, 454–455
Brain age-related changes in, 515, 515f, 517 anatomy of, 39, 39f imaging studies of, 88, 88f structural abnormalities of
in autism spectrum disorder, 486 in bipolar disorder, 215 in schizophrenia, 397, 397f
Brain chemistry, 39–40. See also Neurotransmitters
Brain circuits. See also Neurotransmitters in anxiety, 117, 117f, 133–134 definition of, 117 in depression, 191–192, 191f in obsessive-compulsive disorder, 141–142,
142f Brain injuries
intellectual disability and, 495 neurocognitive disorders and, 517f, 518f
Brain scanning, 88, 88f Brain stimulation, 195–196, 195f Brain surgery, 42–44
historical perspective on, 8, 8f, 42–44 lobotomy in, 44, 405b right to refuse, 540
Brain waves, recording of, 88 Brief psychotic disorder, 386t Briquet’s syndrome, 256 Brodmann Area 25, in depression, 191–192,
191f, 196 Bulimia nervosa, 280, 282–288
alexithymia and, 290 in athletes, 292, 297 binge eating in, 284 biological factors in, 291–292 causes of, 289–298 clinical picture of, 282–284 cognitive factors in, 290 compensatory behaviors in, 282, 284–286 core pathology in, 290
Bed-wetting, 476, 477t Behavioral medicine, 273–275 Behavioral model, 50–54, 74t
assessment of, 53–54 cognitive-behavioral model and, 54 conditioning and, 51–52, 51f treatment in, 52–53
Behavioral therapy. See also Cognitive-behavioral therapy; Exposure and response prevention; Exposure therapy
dialectical, 439–441 in enuresis treatment, 476 marital, 208 for obsessive-compulsive disorder, 139–140
Bell-and-battery technique, 476 Bender Visual-Motor Gestalt Test, 89 Benzedrine, 322–323 Benzodiazepines, 116, 117–118, 117t
abuse of, 316, 319t for panic disorder, 135
Beta-amyloid precursor protein, 514 Beta-amyloid protein, 513, 514, 515 Bethlehem Hospital (Bedlam), 10 Bias
experimenter, 29 observer, 91 subject, 29
La Bicêtre (Paris), 10, 403 Big Five theory of personality, 456, 458 Binge drinking, 5, 311, 313b, 315b Binge-eating disorder, 280, 288
clinical picture in, 288 integrated approach to, 306 key features of, 288t overlap with other eating disorders, 284f treatment of, 305
Binge-eating/purging-type anorexia nervosa, 280
Biofeedback for generalized anxiety disorder, 118–119, 118f for psychophysiological disorders, 273
Biological challenge tests, 135, 136 Biological model, 39–44, 74t
assessment of, 44 brain anatomy and, 39, 39f brain chemistry and, 39–40 endocrine system and, 40 evolution and, 41 genetics and, 40–41 treatment and, 42–44 viral infections and, 41
Biometrics, 21 Biopsychosocial theories, 74 Biosocial theory, 438–439 Bipolar disorder, 211–219
biochemistry of, 214–215 causes of, 214–215, 218–219 in children and adolescents, 471–472 creativity and, 214b definition of, 184 genetic factors in, 215 hypomania in, 212 key features of, 189t, 212t mania in, 212 prevalence of, 189t, 213 rapid cycling in, 213 treatment of, 215–217 type I, 212, 212t type II, 212, 212t
Assisted-living facilities for Alzheimer’s patients, 520, 521 for elderly, 522–524
Asthma, 262–263 race/ethnicity and, 266–267, 267t
Asylums, 10–11 Athletes
bulimia nervosa in, 292, 297 neurocognitive disorders in, 517f
Ativan, for generalized anxiety disorder, 116 Atomoxetine, 181 Attention-deficit/hyperactivity disorder, 463,
464, 477t, 479–482 causes of, 481 cultural aspects of, 482 diagnosis of, 481 key features of, 480t
Attribution-helplessness theory, 201–202 Atypical antipsychotics, 407, 408. See also
Antipsychotics effectiveness of, 407 mechanism of action of, 397 side effects of, 407–408
Auditory hallucinations, in schizophrenia, 389, 390b, 409, 410b
Augmentative communication system, 488 Autism spectrum disorder, 477t, 483–488
causes of, 484–487 key features of, 483t savant skills in, 485b treatment of, 487–488
Autoerotic asphyxia, 374–375 Autogenetic mass murders, 434b Autogynephilic gender dysphoria, 379 Autoimmunity, in Alzheimer’s disease, 516 Automatic thoughts, in depression, 203 Autonomic nervous system, in stress response,
149–152, 151f, 158–159, 265 Avatars, in cybertherapy, 57b, 67 Aversion therapy
for fetishistic disorder, 369 for sexual sadism disorder, 376 for smoking, 320b for substance use disorders, 335
Avoidance theory, 112 Avoidant personality disorder, 423f, 437t,
447–449 Avolition
in depression, 186 in schizophrenia, 391
Axons, 39, 39f
Baby blues, 190b Back wards, 404 Backward masking, 429 Balance compulsions, 138 Barbiturates, abuse of, 316, 319t Basal ganglia, 39, 39f
in bipolar disorder, 215 in obsessive-compulsive disorder, 141–142
Basic irrational assumptions in anxiety, 111 in depression, 54–55
Battery, test, 89, 102 B-cells, 269 Beck Depression Inventory, 86 Bed nucleus of stria terminalis, in gender
dysphoria, 378 Bedlam, 10
: Subject IndexSI-4
professional and personal issues of, 550–552, 551b
professional boundaries for, 541 sexual misconduct of, 545
Clinical research, 20–33 adoption studies in, 393 bias in, 29, 91 case studies in, 22–23, 25t correlational method in, 23–27, 25t epidemiological studies in, 26 in evidence-based treatment, 98 experimental method in, 25t. See also
Experiment(s) Facebook and, 24 family pedigree studies in, 116, 188–189 genetic linkage studies in, 332, 394–395 hypotheses in, 22 limitations of, 31–32 longitudinal studies in, 26–27 multicultural, 71–72 occupational opportunities in, 18 retrospective analysis in, 226 statistical analysis in, 23t, 25, 99 therapy outcome studies in, 99, 99f twin studies in. See Twin studies
Clinical scientists, 2 Clinical tests, 81–91. See also Test(s) A Clockwork Orange, 376 Clomipramine, for obsessive-compulsive
disorder, 141 Clozapine (Clozaril), 408 Club drugs, 322, 325b Cluster suicides, 239 Cocaine, 319–322, 319t
antagonist drugs for, 338 in stimulant use disorder, 323
Code of ethics, 544–546 Codeine, abuse of, 317 Cognex, 518 Cognitive impairment
in elderly, 509–522 in schizophrenia, 388
Cognitive inventories, 86 Cognitive model, 53–54, 54–58, 74t
assessment of, 56–57 illogical thinking and, 54, 111 treatment and, 55–56
Cognitive therapy, 55–57 Acceptance and Commitment Therapy and,
114 for depression, 55–56, 204–205 for generalized anxiety disorder, 112–114 mindfulness-based, 114, 115b new-wave, 56–57 for obsessive-compulsive disorder, 141 rational-emotive, 113–114 self-instruction training in, 275, 363
Cognitive triad, in depression, 202–204 Cognitive-behavioral model, 54. See also under
Behavioral; Cognitive Cognitive-behavioral therapy. See also Behavioral
therapy for autism spectrum disorder, 487–488 for bulimia nervosa, 302–303 couple, 69–70 for depression, 204–205 new wave, 409–410 for obsessive-compulsive disorder, 141
bullying of, 464–465, 466b, 470 common problems of, 464–465, 466b conduct disorder in, 473–476, 473t depression in, 186, 463, 464, 469–471 disorders of, 463–499 disruptive mood dysregulation syndrome in,
186, 472, 472t encopresis in, 476–477 enuresis in, 476 factitious disorder imposed on, 250t,
251–252, 252b gender dysphoria in, 377–378 hypnotherapy for, 468 learning disorders in, 477t neurodevelopmental disorders in, 477t,
479–482 oppositional defiant disorder in, 473 specific learning disorders in, 491b suicide by, 235–236, 237f
Chlorpromazine, 407 Cholecystokinin, 291 Cholesterol, elevated, race/ethnicity and, 267,
267t Chromosomes, 40 Chronic illness. See Medical conditions Cialis, 365b Cigarette smoking. See Smoking Cingulate cortex, in depression, 191 Circadian rhythm sleep-wake disorder, 264b Circuits, neural, in anxiety, 133–134 Cirrhosis, 314–315 Civil commitment, 536–540
to least restrictive facility, 540 Clang, 388 Classical conditioning, 51–52, 51f
phobias and, 122 in substance use disorders, 331–332
Classification systems, 92–96. See also Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Cleaning compulsions, 138 Client reactivity, in assessment, 91 Client-centered therapy, 58–60, 110
for generalized anxiety disorder, 110 Clinical assessment, 77–91
assessment tools in, 78–91. See also Test(s) clinical observations in, 89–91 cultural factors in, 84, 85t, 86 definition of, 77 idiographic information in, 77 interview in, 79–81 mental status exam in, 80–81 neuroimaging in, 88, 88f reliability in, 78 standardization in, 78 validity in, 78–79
Clinical interviews, 79–81 Clinical observation, 89–91
analog, 90–91 naturalistic, 90–91 participant, 90 self-monitoring in, 91
Clinical practitioners, 2 Clinical psychologists, 18, 18t
ethical code for, 544–546 in jury selection, 541–542 mental health of, 550–552 prescription privileges for, 541
cultural aspects of, 295–298 depression and, 290–291 ego deficiencies and, 289–290 family environment and, 293–294, 300–301 integrated approach to, 306 key features of, 283t medical problems in, 286 multidimensional risk perspective on, 289 outcome in, 304–305 overlap with other eating disorders, 284f prevalence of, 283–824 societal pressures and, 292–293 treatment of, 302–304 vs. anorexia nervosa, 286
Bullying, 464–465, 466b, 470
Caffeine, 319 Calcium imbalance, in Alzheimer’s disease, 516 Cancer
personality factors in, 272 race/ethnicity and, 266–267, 267t
Cannabis, 319t, 326–328 Carbamazepine, for bipolar disorder, 216 Cardiac disease, 265
personality style and, 266, 272 Case managers, 414 Case studies, 22–23, 25t CAT scan, 88, 88f Catatonia, 391, 392f Catatonic depression, 187 Catharsis, 49 Caudate nuclei, in obsessive-compulsive
disorder, 141–142, 142f Cell phones, 548. See also Social networking/
social media; Texting anxiety and, 129 selfies and, 446
Centenarians, 503b Central gray matter, in panic disorder, 133–134,
134f Cerebellum, 39. See also Brain
in autism spectrum disorder, 486 Cerebrovascular accident, vascular
neurocognitive disorder and, 517 Cerebrum, 39, 39f Chat group therapy, 57b Checking compulsions, 138 Child abuse, 478b
dissociative disorders and, 169b, 173 Munchausen syndrome by proxy as, 250t,
251–252, 252b psychological, 478b repressed memories of, 169b sexual, 372–374, 478b suicide and, 228
Childhood experiences depression and, 196–197, 202 personality disorders and, 438–439, 454 sexual dysfunction and, 351, 357–358 stress disorders and, 160 suicide and, 228, 232
Children. See also Adolescents antipsychotics for, 472 anxiety in, 108–109, 466–469 attention-deficit/hyperactivity disorder in,
463, 464, 479–482, 480t autism spectrum disorder in, 483–488 bipolar disorder in, 471–472
Subject Index : SI-5
patterns of, 542–544 predictors of, 538 psychological profiling and, 542–544 serial killers and, 543b
Crisis houses, 413 Crisis intervention
for stress disorders, 164–165 for suicide, 243 texting in, 243
Critical incident stress debriefing, 164–165 Cross-Cutting Symptom Measure, 94
in DSM-5, 94 Cross-dressing, 370–371
vs. gender dysphoria, 371, 379 Cross-situational validity, 91 Crystal meth, 332 CT (computed tomography), 88, 88f Cultural factors, 3–5. See also Race/ethnicity
in agoraphobia, 108t in alcohol use disorder, 71, 313, 340–341 in anxiety, 107–108, 108t, 120, 128 in assessment, 84, 85t, 86 in attention-deficit/hyperactivity disorder, 482 in borderline personality disorder, 439,
454–455 in conduct disorder, 474–475 in conversion disorder, 259–260 in depression, 209–210 in diagnosis, 96–97 in eating disorders, 295–298 in generalized anxiety disorder, 108t in intellectual disability, 490 in IQ testing, 89, 490 in lying, 457b in narcissistic personality disorder, 445 in neurocognitive disorders, 522–523, 523f in obsessive-compulsive disorder, 108t in panic disorder, 108t, 133 in personality disorders, 454–455 in phobias, 108t, 120 in psychological abnormality, 3–5 in psychophysiological disorders, 266–267,
267f, 267t in schizophrenia, 399–400 in sexual dysfunction, 351, 357–358 in social anxiety disorder, 108t, 128 in somatic symptom disorder, 259–260 in specific phobias, 108t in stress disorders, 161 in substance use disorders, 71, 311, 311f,
340–341 in suicide, 227, 227f, 238–239, 241 in treatment, 72 in violence, 435t
Culturally diverse perspective, 71–72. See also Cultural factors
Culture. See also Sociocultural model acculturation and, 296 definition of, 3, 71 deviance and, 3
Culture-bound disorders anxiety as, 108 social anxiety disorder as, 128
Culture-sensitive therapy, 72, 210 for depression, 210
Cutting, 224–225, 225b in borderline personality disorder, 437
Cyberbullying, 465, 466b, 470
Conduct disorder, 473–476, 473t, 477t antisocial personality disorder and, 473 causes of, 473 cultural aspects of, 474–475 treatment of, 474–476
Confabulation, in Korsakoff ’s syndrome, 316 Confederate, 123 Confidentiality, 545–546
in cybertherapy, 549 Confounds, 27 Congenital hypothyroidism, 494 Conjoint family therapy, 69 Conscience, 46 Conscientiousness, 456 Contingency management, 335 Continuous amnesia, 167 Control, learned helplessness and, 200–202, 209 Control group, 27 Conversion disorder, 250, 253–254, 253t, 259t
behavioral view of, 258–259 causes of, 257–260 cognitive view of, 259 cultural factors in, 259–260 definition of, 253 key features of, 253t primary gain in, 258 psychodynamic view of, 258 secondary gain in, 258 treatment of, 260–261
Conversion therapy, 28b Coping Power Program, 475 Coping self-statements, 275 Coping style, repressive, 266 Coronary heart disease, 265 Corpus callosum, 39, 39f Correlation coefficient, 25 Correlational method, 23–27, 25t Cortex, cerebral, 39, 39f Corticosteroids, in stress response, 152, 152f,
158, 160, 271 Cortisol, 40
in depression, 190 in stress response, 152f, 158, 160, 271
Cost containment, 17–18, 546–548 Counseling psychologists, 18, 18t Counselors, 18, 18t. See also Clinical
psychologists Countertransference, 551b Counting compulsions, 138 Couple therapy, 69–70
behavioral, 208 for depression, 208 for sexual dysfunction, 360–361
Crack cocaine, 321 Crank, 322 Crashing, 321 C-reactive protein, in depression, 192 Creativity, psychological abnormality and, 214b Cretinism, 494 Creutzfeldt-Jakob disease, 516, 517 Crime victims, stress disorders in, 155–157 Criminal commitment, 528–529, 534–535 Criminality. See also Violence
antisocial personality disorder and, 433 hate crimes and, 435t mass murder and, 434b mental health care in prisons and, 416b modeling of, 435
for paranoid personality disorder, 426 for schizoid personality disorder, 428 for schizophrenia, 409–410 for schizotypal personality disorder, 430 for social anxiety disorder, 130–131
College students. See also Adolescents binge drinking by, 311, 313b, 315b stress scale for, 268t, 269
Combat veterans dissociative amnesia in, 167 stress disorders in, 149, 153–154, 162–164.
See also Posttraumatic stress disorder Commitment. See also Hospitalization;
Institutionalization civil, 536–540 criminal, 528–529, 534–535 emergency, 537–538
Common factors treatment approach, 101b Communication. See also Emotional expression
in families, 66 in social networks, 66
Communication disorders, in children, 491b Communication training, for autistic children,
488 Community integration, in intellectual disability,
495–497 Community Mental Health Act, 411 Community mental health centers, 412–413 Community treatment, 15, 70
assertive, 412 for autism spectrum disorder, 488 components of, 412–413 coordinated services in, 412–413 deinstitutionalization and, 15, 15f, 411–412 historical perspective on, 9–10, 15 inadequate, 414–417 in intellectual disability, 495–497 partial hospitalization in, 413 promise of, 417 right to, 540 for schizophrenia, 411–417 shortage of, 15 short-term hospitalization in, 413 for stress disorders, 164–165 for substance use disorders, 340 supervised residences in, 413, 488
Competence to form criminal intent, 528–533 to stand trial, 534–535
Compulsions, 137–138. See also Obsessive- compulsive disorder
Compulsive lying, 457b Computed tomography (CT), 88, 88f Concordance, 393 Concurrent validity, 78–79 Concussions, neurocognitive disorders and,
517f Conditioned stimulus/response, 52, 122 Conditioning, 51–52
classical, 51–52, 51f phobias and, 122
definition of, 51 in enuresis treatment, 476 operant, 51, 173
in token economy program, 404, 405–406
in substance use disorders, 331–332 Conditions of worth, 59, 110
: Subject IndexSI-6
Desire phase, of sexual response cycle, 348, 349f disorders of, 348–351, 349t
Detachment, 458 Determinism, 44 Detoxification, 337–338 Developmental coordination disorder, 491b Developmental stages, in Freudian theory, 46–47 Deviance, 3 Dextroamphetamine, 322–323 Diabetes mellitus, race/ethnicity and, 266, 267t Diagnosis, 92–96
classification systems for, 92–96. See also Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
clinical picture in, 92 cultural aspects of, 96–97 definition of, 92 errors in, 96–97 labeling and, 65, 97, 400
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 93–96
additional information in, 94 categorical information in, 93–94 criticisms of, 94–95 dimensional information in, 93, 94 key changes in, 95–96 personality disorders in, 455–456, 458–459 premenstrual dysphoric disorder in, 209b reliability and validity of, 94–95
Diagnostic overshadowing, 270b Dialectical behavior therapy, 439–441 Diathesis-stress model, 74
of anxiety disorders, 146 of schizophrenia, 393
Diazepam, for generalized anxiety disorder, 116 Dichotomous thinking, in suicide, 229 Diencephalon, in memory, 515, 515f Dietary supplements, 43b Directed masturbation training, 365 Disability income, 414 Disasters, stress disorders and, 155, 155t,
164–165 DISCERN network, 396 Disengaged families, 66 Disinhibition, 458 Displacement, 46t Disruptive mood dysregulation syndrome, 187,
472, 472t Dissociative disorders, 166–180
behavioral perspective on, 173–174 child abuse and, 169b, 173 definition of, 166 depersonalization-derealization disorder, 167,
177–179 dissociative amnesia, 166–169, 167t
child abuse and, 169b key features of, 167t
dissociative fugue, 168–169 dissociative identity disorder, 166–177, 167t
key features of, 167t subpersonalities in, 177
hypnotherapy, 176 key features of, 167t memory and, 166 overview of, 166–167 psychodynamic perspective on, 173 psychodynamic therapy for, 176 self-hypnosis in, 174–175 sodium amobarbital for, 176
causes of, 218–219 childhood experiences and, 196–197 in children, 463, 464, 469–471 classification of, 187, 188t cognitive perspective on, 200–205 cultural factors, 209–210 definition of, 183, 185b demographics of, 184 diagnosis of, 187 in disruptive mood dysregulation syndrome,
187 in DSM-5, 93–94 eating disorders and, 290–291 in elderly, 503–505 endogenous, 188 family-social perspective on, 205–208 genetic factors in, 188–189 hormones in, 190–191, 208 in immigrants, 200–205 immune system in, 192 key features of, 188t learned helplessness and, 200–202, 209 loss and, 196–197 in major depressive disorder, 187, 188t, 189t in major depressive episode, 187, 188t melancholic, 187 multicultural perspective on, 208–210 negative thinking in, 202–204 neurotransmitters in, 189, 234–235 nutraceuticals for, 43b in persistent depressive disorder, 187,
188t, 189t in premenstrual dysphoric disorder, 187, 209b prevalence of, 184 psychodynamic perspective on, 196–198 psychotic symptoms in, 187 reactive (exogenous), 188 recurrence of, 210 rewards and, 198 role disputes in, 206 rumination and, 209 in schizotypal disorder, 430 in seasonal affective disorder, 187, 191 sexual dysfunction and, 351 social support and, 205 stress and, 188, 192
in women, 208 suicide and, 186, 229–230, 239–241.
See also Suicide symptoms of, 184–187 treatment of
behavioral approaches in, 200 biological approaches in, 192–196 brain stimulation in, 195–196, 195f cognitive approaches in, 204–205 couple therapy in, 208 drug therapy in, 193–195, 193t. See also
Antidepressants electroconvulsive therapy in, 42, 192, 540 interpersonal psychotherapy in, 206–207 psychodynamic approaches in, 197–198 sociocultural approach in, 210
vs. sadness, 185b in women, 184, 208–209
Depressive disorders, 183 Derailment, 388 Derealization, 167, 177–179. See also Dissociative
disorders Desensitization, for phobias, 52–53, 124–125
Cybertherapy, 20, 21, 57b, 549, 550 avatars in, 57b, 67 ethical issues in, 549
Cyclothymic disorder, 189t, 213. See also Bipolar disorder
Cytokines, 271
D2 receptor gene, 332 Dancers, eating disorders in, 304b Danger, 4
maladaptive assumptions about, 111, 113b Dangerousness, determination of, 538 Dark sites, on Internet, 294b Dating skills programs, 497 Day care, for Alzheimer’s patients, 520 Day centers/hospitals, 413 Daytop Village, 340 Death
intentional. See Suicide most common causes of, 222t subintentional, 224
Death darers, 224 Death ignorers, 224 Death initiators, 224 Death instinct, 232 Death rates, in psychological abnormality,
222t Death seekers, 224 Debriefing, psychological, 164–165 Deep brain stimulation, 196 Defense mechanisms, 45, 46t
in obsessive-compulsive disorder, 139 Deinstitutionalization, 15, 15f, 411–412
community treatment and, 15 in intellectual disability, 495
Déjà vu, 175b Delayed ejaculation, 355–356, 355t
treatment of, 346 Delinquency, 474 Delirium, 509–510, 509t Delirium tremens, 314 Delusion(s)
in depression, 187 in elderly, 508–509 of grandeur, 388 mass, 9 of persecution, 388 of reference, 388 in schizophrenia, 388, 389, 409–410
Delusional disorder, 386t in elderly, 508–509
Dementia. See Alzheimer’s disease; Neurocognitive disorders
Demonology, 8–9 Dendrites, 39, 39f Denial, 46t Depakote, for bipolar disorder, 216 Dependence. See Substance use disorders Dependent personality disorder, 423f, 437t,
450–452, 458–459 Dependent variables, 27 Depersonalization-derealization disorder, 167,
177–179. See also Dissociative disorders Depression, 183–211
adjustment disorder with, 159b behavioral perspective on, 198–200 biological perspective on, 188–196 in bipolar disorder, 184, 211–219 brain circuits in, 191–192, 191f
Subject Index : SI-7
Empathy, accurate, 60 Empirically supported treatment, 98 Employee assistance programs, 546 Employment, supported, 413 Encephalitis, 495 Encopresis, 476–477, 477t Endocrine system, 40. See also Hormones
in depression, 190–191 in stress response, 151–152, 158–160, 271 in weight regulation, 291–292
Endogenous depression, 188 Endorphins, 317, 338 Enmeshed families, 66
eating disorders and, 293–294, 300–301 Enuresis, 476, 477t Epidemiologic Catchment Area Study, 26 Epidemiological studies, 26 Epinephrine. See also Neurotransmitters
in stress response, 151f, 152, 152f Erectile disorder, 351–354, 352t
treatment of, 363–364, 365b Ergot alkaloids, 323 Escitalopram, 194 Estrogen. See also Sex hormones
for Alzheimer’s disease, 518 sex drive and, 349 for sex reassignment, 379
E-therapy. See Cybertherapy Ethical issues, 544–546, 551b
in cybertherapy, 549 informed consent, 33 rights of study participants, 32–33
Ethnicity. See Race/ethnicity Ethyl alcohol, 311. See also Alcohol Eugenic sterilization, 12, 12t Euthanasia, 240b Everyday lying, 457 Evidence-based therapy, 98, 101b Evoked potentials, 172 Evolutionary factors
in phobias, 123–124 in psychological abnormality, 41
Excessive behaviors, 143–144 Excitement phase, of sexual response cycle, 348,
349, 349f, 351 disorders of, 351–354
Excoriation disorder, 143 Exelon, 518 Exhibitionistic disorder, 368, 371 Existential therapy, 63 Existentialism, 58, 61–63, 74t. See also
Humanistic-existential model Exogenous depression, 188 Exorcism, 8 Expectancy effects, in substance use disorders,
331 Experiment(s), 25t, 27–33
analogue, 30–31 bias in, 29, 91 blind, 29–30 confounds in, 27 control group in, 27 definition of, 27 design of, 28–31 double-blind, 30 experimental group in, 27–29 limitations of, 31–32 matched control participants in, 30 mixed, 30
cognitive factors in, 290 core pathology in, 290 cultural aspects of, 295–298 integrated approach to, 306 multidimensional risk perspective on, 289 overlap among, 284f overview of, 280 treatment of, 298–305
Eccentricity, 5, 6 Echolalia, 484 E-cigarettes, 320b Ecstasy, 323, 325b Educational services. See also under School
for children with autism, 488 for children with intellectual disability, 496
Effexor, 194 Ego, 45 Ego defense mechanisms, 45, 46t
in obsessive-compulsive disorder, 139 Ego deficiencies, in eating disorders, 289–290 Ego theory, 47 Egotistic suicide, 233 Eidetic images, 175b Ejaculation
delayed, 355–356, 364 premature, 354–355
Elderly anxiety disorders in, 505 cognitive impairment in, 509–522 delirium in, 509–510, 509t delusional disorder in, 508–509 demographic picture of, 506b depression in, 503–505 discrimination against, 522 life expectancy of, 506b living arrangements of, 520, 521b, 522–524 minority, 522 neurocognitive disorders in, 511–522.
See also Alzheimer’s disease; Neurocognitive disorders
“oldest-old,” 503b overmedication of, 508 psychological abnormality in, 501–525, 506b
age-related disorders and, 503 psychosis in, 508–509 schizophrenia in, 508–509 services for, 520, 521, 522–523 sexual behavior of, 350b social networking among, 510 stress in, 502–503 substance use disorders in, 505–508 suicide by, 237f, 239–241, 505
Electra complex, 258 Electroconvulsive therapy, 42, 192
right to refuse, 540 Electroencephalography (EEG), 88 Electromyography (EMG), in biofeedback,
118–119, 273 Electronic cigarettes, 320b Elimination disorders, in children, 476–477 E-mail therapy, 57b. See also Cybertherapy Emergency commitment, 537–538 Emotional Distress–Depression Scale, in
DSM-5, 94 Emotional expression
in conversion disorder, 259 in psychophysiological disorders, 275 in schizophrenia, 400, 411 in somatic symptom disorder, 259
state-dependent learning and, 174 stress and, 166 subpersonalities in, 170–171, 177 treatment of, 176–177
Distress, 3–4 Distrust, levels of, 426f Disulfiram, 338 Divorce, 70
depression and, 206, 208 suicide and, 227
Domestic violence learned helplessness and, 209 legal aspects of, 531b
Donepezil, 518 Dopamine. See also Neurotransmitters
antipsychotics and, 407 in attention-deficit/hyperactivity disorder, 481 cocaine and, 321 Ecstasy and, 323, 325b in obsessive-compulsive disorder, 141 in schizophrenia, 395–397 in substance use disorders, 332, 333
Dopamine antagonists, antipsychotics as, 395–397
Dopamine hypothesis, for schizophrenia, 395–397
Dopamine-2 receptor gene, 332 Double-blind experiments, 30 Doubling, 178 Down syndrome, 493–494 Downward drift theory, 387, 387f Dramatic personality disorders, 423f,
431–447, 437t Draw-a-Person Test, 83 Drawing tests, 83f, 84 Dreams, 49 Drinking games, on Internet, 315b Drug(s). See also specific drugs
definition of, 310 psychotropic, 15. See also Psychotropic drugs
Drug abuse. See Substance use disorders Dry-bed training, 476 DSM-5. See Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) DTs, 314 Dual-diagnosis patients, 413 Dualism, mind-body, 250 Duodenal ulcers, 262 Durham test, 529 Durham v. United States, 529 Dusky v. United States, 534 Duty to protect, 546 Dysfunction, 4 Dyslexia, 491b Dyssomnias, 264b Dysthymic syndrome, with persistent depressive
disorder, 187, 188t, 189t
Eating Disorder Inventory, 300t Eating disorders, 265–306
alexithymia in, 290 anorexia nervosa, 280–282. See also Anorexia
nervosa binge-eating disorder, 288. See also
Binge-eating disorder in borderline personality disorder, 439 bulimia nervosa, 282–288. See also Bulimia
nervosa causes of, 289–298
: Subject IndexSI-8
treatment of, 379–381 vs. cross-dressing, 371 vs. transvestic disorder, 371, 379
Gender-sensitive therapy, 72 Gene mapping, 41 General paresis, 11 Generalized amnesia, 167 Generalized anxiety disorder, 106–119, 128t.
See also Anxiety; Anxiety disorders biofeedback for, 118–119, 118f biological perspective on, 116–119 client-centered therapy for, 110 cognitive perspective on, 111–114 cultural factors in, 108t diathesis-stress model for, 146 drug therapy for, 116, 117–118, 117t humanistic perspective on, 110 key features of, 107t meditation for, 115b, 118 mindfulness-based cognitive therapy for,
114, 115b new-wave cognitive explanations for,
111–112 prevalence of, 108t, 128t psychodynamic perspective on, 108–110 psychodynamic therapy for, 109–110 rational-emotive therapy for, 113–114 relaxation training for, 118 sociocultural perspective on, 107–108, 108t
Genes, 40–41 Genetic factors
in Alzheimer’s disease, 514–515 in generalized anxiety disorder, 146 in intellectual disability, 493–494 in longevity, 503b in panic disorder, 134 in polygenic disorders, 395 in psychological abnormality, 40–41 in schizophrenia, 393–395, 393f in stress disorders, 160 in substance use disorders, 332
Genetic linkage studies of bipolar disorder, 215 of schizophrenia, 394–395 of substance use disorders, 332
Genetic mutations, 41 Genital stage, 47 Genito-pelvic pain/penetration disorder,
358–359, 358t treatment of, 365–366
Genuineness, 60 Geodon, 408 Geropsychology, 502–503. See also Elderly Gestalt therapy, 60–61 Gheel (Belgium), 9 Glands, 40, 151–152. See also Endocrine system;
Hormones Glove anesthesia, 254, 254f Glucagon-like peptide-1, 291–292 Glutamate
in Alzheimer’s disease, 516 in obsessive-compulsive disorder, 141, 142
Gray matter, in panic disorder, 134, 134f Greece, ancient, psychotherapeutic concepts and
treatment in, 8 Grief, 206. See also Loss
depression and, 186–197 Group homes, 413
for autistic adults, 488
preparedness and, 124 rationality of, 111, 113b vs. anxiety, 106 worry and, 111–114, 111f
Fear hierarchy, 52–53, 124 Female orgasmic disorder, 355t, 356–358
treatment of, 364–365 Female sexual interest/arousal disorder,
349–351, 349t treatment of, 363
Females. See Women Feminist therapy, 72 Fetal alcohol effect, 316 Fetal alcohol syndrome, 316, 494–495 Fetishistic disorder, 369–370 Fibanserin, 363 Field studies, 95 Fight-or-flight response, 151–152. See also Stress
response Five-factor model, of personality, 456, 458 Fixations, 46–47 Flashbacks, LSD, 325 Flat affect, in schizophrenia, 391 Flooding
for phobias, 125 for stress disorders, 162
Fluoxetine, 194 for obsessive-compulsive disorder, 141
fMRI (functional magnetic resonance imaging), 88
FOMO, 129 Forebrain, 39 Forensic psychology, 528. See also Legal issues Formal thought disorders, in schizophrenia, 388 Foster care, treatment, 475 Foucha v. Louisiana, 532 Fragile X syndrome, 494 Free association, 47, 109 Free-basing, 321 Frontotemporal neurocognitive disorder, 517, 517f Frotteuristic disorder, 372 Fugue, dissociative, 168–169. See also
Dissociative disorders Functional magnetic resonance imaging (fMRI),
88 Fusion, of subpersonalities, 177
GABA (gamma-aminobutyric acid) alcohol and, 311 in anxiety, 116–117, 117–118, 141 in obsessive-compulsive disorder, 141, 142
GABA-A receptors, 118 Galantamine, 518 Gamblers Anonymous, 343 Gambling disorder, 342–343, 342t Gaming, 548
Internet, 343 Gastric ulcers, 262 Gender. See Cultural factors; Women Gender dysphoria, 329, 376–381, 380b
causes of, 378 in children, 377–378 definition of, 347, 376 education about, 381 female-to-male, 378 male-to-female
androphilic, 378–379 autogynephilic, 379
patterns of, 378–379
natural, 30 quasi-experiments, 30 random assignment in, 29 reversal, 31 rights of participants, 32–33 single-subject, 31 variables in, 22, 27
Experimental group, 27–29 Experimenter bias, 29 Exposure and response prevention
for body dysmorphic disorder, 145 for bulimia nervosa, 302–303 for illness anxiety disorder, 262 for obsessive-compulsive disorder, 139–140
Exposure therapy for agoraphobia, 126–127 home-based, 126–127 for panic disorder, 135–136 for social anxiety disorder, 130 for specific phobias, 124–126 for stress disorders, 162 support groups for, 126–127
Expressed emotion, schizophrenia and. See Emotional expression
Extrapyramidal effects, 407–408 Extroversion, 456 Eye movement desensitization and reprocessing,
162–163 Eyewitness testimony, 542
Face validity, 78 Facebook, 548. See Social networking/social
media anxiety and, 129 as data source, 24
Factitious disorder, 250–252, 259t imposed on another, 250t, 251–252, 252b imposed on self, 250–251, 250t key features of, 250t
Family. See also Children; Parent(s) disengaged, 66 enmeshed, 66
eating disorders and, 293–294, 300–301 expressed emotion in, 400, 411
Family pedigree studies, 116 in depression, 188–189
Family psychoeducational programs, 411 Family stress
Alzheimer’s disease and, 519–520 schizophrenia and, 400–401
Family structure, 66 Family support groups, 411 Family systems theory, 66, 69 Family systems therapy, 69 Family therapy, 68–69
for anorexia nervosa, 300–301 conjoint, 69 for posttraumatic stress disorder, 164 for schizophrenia, 411 structural, 69
Family-social perspective, 62–70, 74t on depression, 205–208
Father. See Parent(s) Fear(s)
learned, 112–113 phobias and, 110–127 physical response to, 116–117, 117f, 149–152,
151f, 152f, 158–160. See also Stress response
Subject Index : SI-9
Hypothalamic-pituitary-adrenal (HPA) pathway, in stress response, 151–152, 152f, 159–160
Hypothalamus age-related changes in, 515, 515f in eating disorders, 291–292 lateral, 291 in memory, 515, 515f in panic disorder, 134, 134f in stress response, 151–152, 152f ventromedial, 291
Hypotheses, 22 Hypothyroidism, congenital, 494 Hypoxyphilia, 374–375 Hysterical disorders, 12–13, 257. See also
Conversion disorder; Somatic symptom disorder
Hysterical personality disorder, 441–443
Id, 45 Ideas of reference, 429 Idiographic data, 77, 98 Illness
mental. See Psychological abnormality physical. See Medical conditions
Illness anxiety disorder, 250, 259t, 261–262, 261t Illogical thinking
in anxiety, 111–114 in depression, 54, 202–204 in suicide, 229
Illusions, 390b Imagined loss, depression and, 196–197 Imaging, neurological, 88, 88f Imipramine, 193 Immigrants, depression in, 200–205 Immune system
in depression, 192 stress effects on, 269–272
Immunizations, autism spectrum disorder and, 486–487
Impotence, 351–354, 352t Impulsivity, 458
in borderline personality disorder, 437 in substance abusers, 331
In vivo desensitization, 124 Incidence, 26 Inclusion
in autism spectrum disorder, 488 in intellectual disability, 496
Independent variables, 27 Individual psychotherapy. See Interpersonal
psychotherapy Inflammation, stress and, 271 Influenza, schizophrenia and, 397 Informed consent, 33 Inhibited male orgasm, 355–356, 355t
treatment of, 364 Inkblot tests, 82, 82f
dissemination on Internet, 83 Insanity defense, 528–532 Insight therapy, for posttraumatic stress disorder,
162 Insomnia, 263, 264b Institutional Review Boards, 32–33 Institutionalization
back wards in, 404 civil commitment and, 536–540 criminal commitment and, 528–529, 534–535 of dangerous persons, 538 deinstitutionalization and, 15, 15f, 411–412
Home care, for Alzheimer’s patients, 519–520 Home-based support programs, for agoraphobia,
126–127 Homelessness, 415 Homosexuality, reparative therapy for, 28b Hopelessness
depression and, 201–202 health status and, 272 suicide and, 229
Hormones, 40, 151–152 in depression, 190–191, 208 sex
for Alzheimer’s disease, 518 for gender dysphoria, 379 sex drive and, 349, 363 for sex reassignment, 379, 381
stress, 151–152, 152f, 158–160, 271 in weight regulation, 291–292
Hospitalization. See also Institutionalization back wards in, 404 civil commitment and, 536–540 criminal commitment and, 528–529,
534–535 deinstitutionalization and, 15, 411–412 emergency commitment and, 537–538 historical perspective on, 10–14 milieu therapy in, 404–405, 413 partial, 413 for schizophrenia, 404–406 short-term, 15, 413 in state hospitals, 11 token economy in, 404, 405–406
Hostility, 458 heart disease and, 266
Hot lines, suicide, 243 Human Genome Project, 41 Human immunodeficiency virus infection
neurocognitive disorders and, 518 in substance abusers, 339
Human Sexual Inadequacy (Masters & Johnson), 360
Humanism, 58, 74t Humanistic-existential model, 58–64, 74t
assessment of, 63–64 client-centered therapy and, 58–60 existential therapy and, 63 Gestalt therapy and, 60–61 unconditional positive regard and, 59–60
Humors, 8 Huntington’s disease, 39, 518 Hyperactivity. See Attention-deficit/hyperactivity
disorder Hyperlearning, in schizophrenia, 396 Hypersexuality, 366, 367 Hypersomnolence disorder, 264b Hypertension, 265
race/ethnicity and, 266–267, 267t Hypnagogic hallucinations, 390b Hypnopompic hallucinations, 390b Hypnosis, 174–175
in children, 468 for psychophysiological disorders, 275
Hypnotic amnesia, 174–175 Hypnotic therapy, 176 Hypnotism, 12–13 Hypoactive sexual desire
male, 348–351, 349t, 363 Hypochondriasis. See Illness anxiety disorder Hypomania, 212
Group therapy, 67–68 for bulimia nervosa, 303 in chat rooms, 57b for posttraumatic stress disorder, 164
Guilty but mentally ill, 532 Guilty with diminished capacity, 532 Gustatory hallucinations, in schizophrenia,
389, 390b
Hair-pulling disorder, 143 Halfway houses, 413 Hallucinations
in depression, 187 mass, 9 in schizophrenia, 389, 390b, 409–410, 410b
Hallucinogens, 323–325 Hallucinosis, 310, 324 Happiness, 16–17, 19b
texting and, 207 Hardiness, 272 Hashish, 326 Hate crimes, 435t Head injuries
brain damage in, 495 neurocognitive disorders and, 517f, 518f
Headaches migraine, 263–265 tension, 263
Health insurance. See Insurance coverage Health problems. See Medical conditions Health promotion, 276
for elderly, 524 Heart disease, 265
personality style and, 266, 272 Hebephilic pedophilic disorder, 372 Helper T-cells, 269 Helplessness, learned, depression and,
200–202, 209 Heroin, 317, 319t. See also Opioid(s)
antagonist drugs for, 338 methadone maintenance for, 339
High blood pressure, 265 race/ethnicity and, 266–267, 267t
Hippocampus, 39 age-related changes in, 515, 515f, 517 in Alzheimer’s disease, 517 in depression, 191, 191f in memory, 515, 515f, 517 in stress disorders, 159
Hispanic Americans. See also Race/ethnicity anxiety in, 120, 128 attention-deficit/hyperactivity disorder in,
482 borderline personality disorder in, 455 depression in, 210 physical health of, 267, 267t psychophysiological disorders in, 267 schizophrenia in, 399 stress disorders in, 161 substance use disorders in, 311, 311f suicide by, 227, 227f, 238–239
Hispanic Health Paradox, 267 Histrionic personality disorder, 423f, 437t,
441–443 HIV infection
neurocognitive disorders and, 518 in substance abusers, 339
Hoarding disorder, 143 Holiday blues, 185b
: Subject IndexSI-10
guilty with diminished capacity, 532 insanity defense, 528–532 jury selection, 541 malpractice suits, 541 medical marijuana, 328 mental instability, 528–529 parity laws, 17–18 patients’ rights, 539–540 professional boundaries, 541 profiling, 542–544 psychology in law vs. law in psychology, 528 right to refuse treatment, 530 right to suicide, 240b right to treatment, 539–540 sex offender statutes, 533–534 third-party payment, 17–18
Lethality scale, 244 Leukotomy, prefrontal, 405b Levitra, 364 Lexapro, 194 Libido, 45 Lie detector tests, 86–87, 87b Life change units (LCUs), 268 Life expectancy, 506b Lithium, for bipolar disorder, 215–217 Lobotomy, 44, 405b Localized amnesia, 167 Locus ceruleus
age-related changes in, 515f in panic disorder, 133, 134f
Loneliness. See Social support Longitudinal studies, 26–27 Long-term care, for elderly, 520, 521b, 522–524 Loose associations, 388 Lorazepam, for generalized anxiety disorder, 116 Loss
depression and, 196–197, 232 grief and, 206 imagined, 196–197 suicide and, 232 symbolic, 196–197
LSD, 323–325 Lycanthropy, 9 Lying, 457b Lymphocytes, 192, 269, 271f Lysergic acid diethylamide (LSD), 323–325
Magnetic resonance imaging (MRI), 88, 88f Mainstreaming
in autism spectrum disorder, 488 in intellectual disability, 496
Major depressive disorder, 187, 188t, 189t. See also Depression
in children, 469–471 Major depressive episode, 187, 188t Major neurocognitive disorders, 511, 511t.
See also Neurocognitive disorders due to Alzheimer’s disease, 511, 512
Maladaptive assumptions in anxiety, 111 in depression, 54, 202–204
Male hypoactive sexual desire disorder, 349–351, 349t
treatment of, 363 Male orgasmic disorder, 354–356, 355t
treatment of, 364 Males
eating disorders in, 296–298 muscle dysmorphobia in, 297
for bulimia nervosa, 303 for depression, 206–207 for schizophrenia, 411
Interpersonal role disputes, depression and, 206 Interrater reliability, 78 Interviews, 79–81 Intolerance of uncertainty theory, 112 Intoxication, 310. See also Substance use
disorders alcohol, 310, 312 cannabis, 326 cocaine, 321 hallucinogen, 324 substance, 310
Ion transport, in bipolar disorder, 215 Iproniazid, 193 IQ. See Intelligence quotient (IQ) Irresistible impulse test, 529
Jackson v. Indiana, 535 Jail diversion, 535 Jamais vu, 175b Job training
for autistic persons, 488 for mentally ill persons, 413 for persons with intellectual disability, 497
Jury selection, 541 Juvenile delinquency, 474, 475 Juvenile training centers, 475
Kansas v. Hendricks, 534 Kinetic Family Drawing Test, 83f Korsakoff ’s syndrome, 316
La Bicêtre (Paris), 403 Labeling, 65, 97
in schizophrenia, 400 Language deficits
in autism spectrum disorder, 483–484, 488 in schizophrenia, 388
Language disorders, 491b Lanugo hair, 282 Latency stage, 47 Latent content, of dreams, 49 Lateral hypothalamus. See also Hypothalamus
in weight regulation, 291 Latinos. See Hispanic Americans Law. See Legal issues L-dopa, 395 Lead poisoning, 495
in Alzheimer’s disease, 516 Learned helplessness, depression and,
200–202, 209 Learning, 50–54. See also Behavioral model
conditioning in, 51–52, 122. See also Conditioning
modeling in, 50–51, 52f, 122–123, 124. See also Modeling
phobias and, 122–123 state-dependent, 174 stimulus generalization in, 123
Learning disorders, 477t, 491b Least restrictive facility, 540 Legal issues, 527–533
civil commitment, 536–540 competence to stand trial, 534–535 criminal commitment, 528–529, 534–535 eyewitness testimony, 542 guilty but mentally ill, 532
of elderly, 520, 521b, 522–524 emergency commitment and, 537–538 in intellectual disability, 495–496 of juvenile delinquents, 475 milieu therapy in, 404–405, 413 partial, 413 for schizophrenia, 404–406 short-term, 413 token economy in, 404, 405–406
Insulin coma therapy, 192 Insurance coverage
for mental health care, 17–18, 546–548 for nursing home care, 524
Integrative couple therapy, 69, 208. See also Couple therapy
Intellectual disability, 477t, 488–497 adaptive functioning in, 490 causes of, 493–495 community integration and, 495–496 in cretinism, 494 definition of, 489 deinstitutionalization for, 495–496 in Down syndrome, 493–494 in fragile X syndrome, 494 interventions for, 495–497 IQ in, 489–493, 490, 491 key features of, 489t in metabolic disorders, 494 mild, 491–492 moderate, 492 in phenylketonuria, 494 prenatal diagnosis of, 494 prenatal/birth-related factors in, 494–495 profound, 493 psychological abnormality and, 496 savant skills in, 485b severe, 493 sociocultural aspects of, 490 in Tay-Sachs disease, 494
Intellectualization, 46t Intelligence quotient (IQ), 89, 489–490
in intellectual disability, 489–493, 490, 491 Intelligence tests, 89, 489–490
commercialization of, 90b cultural aspects of, 490 misuse of, 90b reliability and validity of, 89
Intercourse, painful, 358–359, 358t treatment of, 365–366
Intermittent explosive disorder, 434b International Classification of Diseases (WHO),
93, 458 Internet
cyberbullying and, 465, 466b, 470 dark sites on, 294b drinking games on, 315b pro-anorexia sites on, 280t pro-suicide forums on, 237–238 psychopathology and, 548–550 social networking and. See Social networking/
social media suicide prevention and, 242–246 use by elderly, 510
Internet gaming disorder, 343 Internet therapy. See Cybertherapy Interpersonal deficits, depression and, 206 Interpersonal loss. See Grief; Loss Interpersonal psychotherapy, 15–16
for bipolar disorder, 217
Subject Index : SI-11
MOOGs, 548 Moral anxiety, 108 Moral treatment, 10–11 Morphine, 316–317, 319t. See also Opioid(s)
abuse of, 316–317, 319t Mortality. See also Death
most common causes of, 222t Mother. See also Family; Parent(s)
refrigerator, 485 schizophrenogenic, 398
Motivation, loss of in depression, 186 in schizophrenia, 391
Movement disorders, antipsychotic-induced, 407–408
MRI (magnetic resonance imaging), 88, 88f Multicultural perspective, 71–72. See also
Cultural factors Multicultural psychology, 17 Multidimensional risk perspective, on eating
disorders, 289 Multiple personality disorder, 166, 167, 167t,
170–177. See also Dissociative disorders key features of, 167t subpersonalities in, 170–171, 177
fusion of, 177 Munchausen syndrome, 250–251, 250t Munchausen syndrome by proxy, 250t,
251–252, 252b Muscle contraction headaches, 263 Muscle dysmorphobia, 297 Musical hallucinations, 390b Musical memory, 175b Musicians, psychological abnormalities in,
214b Mutations, 41 Mutual help groups, 68 Myocardial infarction, 265
Naloxone, 338 Nameda, 518 Narcissism, selfies and, 446 Narcissistic personality disorder, 423f, 437t,
444–447 Narcotic antagonists, 338 Narcotics, abuse of, 316–318, 319t. See also
Substance use disorders Narcotics Anonymous, 340 National Alliance for the Mentally Ill, 417 National Comorbidity Survey, 26 National Institute of Mental Health (NIMH), 95 National interest groups, for mentally ill, 417 Natural disasters, stress disorders and, 155, 155t,
164–165 Natural experiments, 30 Natural killer T-cells, 269 Naturalistic observation, 90–91 Negative affectivity, 458 Negative self-statements, 275 Negative thinking, in depression, 202–204 Neknomination, 315b Neologisms, in schizophrenia, 388 Nerve endings, 39, 39f Nervios, 108 Nervous system, in stress response, 151–152,
151f, 158–160, 265 Neural circuits. See also Neurotransmitters
in anxiety, 117, 117f, 133–134 definition of, 117
Meningitis, 495 Menstruation, in anorexia nervosa, 282 Mental competence
to form criminal intent, 528–533 to stand trial, 534–535
Mental health apps, 21 Mental health care. See Therapy Mental health promotion, 16–17, 276 Mental hospitals. See Hospitalization Mental illness. See Psychological abnormality Mental incompetence, 534–535 Mental retardation. See Intellectual disability Mental status exam, 80–81 Mentally disordered sex offenders, 533–534 Mentally ill chemical abusers (MICAs), 413 Mesmerism, 12–13 Meta-analysis, 99 Metabolic rate, 292 Metacognitive theory, of anxiety, 111–112 Meta-worries, 111–112 Methadone, 317, 339 Methamphetamine, 322–323 Methylphenidate, for attention-deficit/
hyperactivity disorder, 481–482 Metrazol, for depression, 192 Mexican Americans. See Hispanic Americans Middle Ages, psychotherapeutic concepts and
treatment in, 8–9 Migraine headaches, 264–265 Mild neurocognitive disorders, 511, 511t.
See also Neurocognitive disorders due to Alzheimer’s disease, 512
Milieu therapy, 404–405, 413 Military veterans
dissociative amnesia in, 167 stress disorders in, 149, 153–154, 162–164.
See also Posttraumatic stress disorder Mind-body dualism, 250 Mindfulness meditation, 56–57, 114, 115b, 274 Mindfulness-based cognitive therapy, 114, 115b Minnesota Multiphasic Personality Inventory
(MMPI), 84–86 Minor tranquilizers, 42 Minority groups. See Race/ethnicity Mixed experiments, 30 MMPI (Minnesota Multiphasic Personality
Inventory), 84–86 MMR vaccine, autism spectrum disorder and,
486–487 M’Naghten test, 529, 530 Mobile phones, 548. See also Social networking/
social media; Texting anxiety and, 129 selfies and, 446
Modeling, 51, 52f of antisocial behavior, 435 participant, 125 phobias and
in causation, 122–123 in treatment, 125
of suicide, 230–231, 237 video, 475
Models. See Psychological abnormality, models of Monoamine oxidase (MAO) inhibitors, 193,
193t. See also Antidepressants Mood changes, in suicide, 228–229 Mood disorders. See Bipolar disorder;
Depression Mood stabilizers, 42, 215–217
Malingering, 250, 259t Malnutrition, in alcohol abuse, 315–316 Malpractice suits, 541 Mammillary bodies, in memory, 515 Managed care, 17, 547 Mania
definition of, 183 symptoms of, 212
Manifest content, of dreams, 49 Mantra, 273 MAO inhibitors, 193, 193t. See also
Antidepressants Mapping, gene, 41 Marijuana, 319t, 326–328 Marital therapy, 69–70
behavioral, 208 for depression, 208 for sexual dysfunction, 360–361
Marriage. See also Divorce intellectual disability and, 497
Masochism, sexual, 374–375 Mass hysteria, via social media, 255 Mass madness, 9 Mass murder, 434b Massively Multiplayer Online Games (MOOGs),
548 Masturbation
delayed ejaculation and, 356 directed, 365
Masturbatory satiation, 369–370 Matched control subjects, 30 Mathematics, problems with, 491b MDMA (Ecstasy), 323, 325b Medical conditions
in anorexia nervosa, 282 assisted suicide in, 240b intellectual disability and, 494–495 prevention of, 276 psychological factors affecting, 259t, 262–275.
See also Psychophysiological disorders psychological treatment for, 273–275 psychosis in, 386t sexual dysfunction in, 357, 362 stress-related, 267–272. See also
Psychophysiological disorders suicide and, 228
Medical doctors, discrimination against patients with mental illness, 270b
Meditation, 56–57, 114, 115b, 118, 273–274 Melancholic depression, 187 Melatonin, in depression, 190–191 Memantine, 518 Memory, 166
under anesthesia, 175b biochemistry of, 516 brain structures in, 515, 515f, 517 impairment of. See also Amnesia
in dissociative disorders, 166 in head trauma, 517f, 518f in Korsakoff ’s syndrome, 316 in neurocognitive disorders, 513. See also
Alzheimer’s disease; Neurocognitive disorders
musical, 175b peculiarities of, 175b repressed, of child abuse, 169b verbal, 175b visual, 175b
Men. See Males
: Subject IndexSI-12
Operant conditioning, 51, 173 in substance use disorders, 331 in token economy program, 405–406
Opioid(s), 316–318 abuse of, 319t, 338–339, 340 antagonist drugs for, 338
Opioid use disorder, 317–318 Opium, 316, 319t Oppositional defiant disorder, 473 Oral contraceptives, insurance coverage for,
365b Oral stage, 47, 196 Orbitofrontal cortex, in obsessive-compulsive
disorder, 141–142, 142f Order compulsions, 138 Orgasm phase, of sexual response cycle, 348,
349f, 354 disorders of, 354–358
female, 355t, 356–358, 364–365 male, 354–356, 355t, 364
Orgasmic reorientation, 370 Outcome studies, therapeutic, 99 Outpatient therapy, 14, 15–16, 15f
current trends in, 15–16, 15f Overgeneralization, 54–55 Oxycodone (Oxy-Contin), abuse of, 317, 318f
Pain, sexual, 358–359, 358t treatment of, 365–366
Pain relievers, abuse of, 316, 317, 318f, 319t Panic attacks, 122
definition of, 132 key features of, 132 prevalence of, 132, 133
Panic disorder, 128t, 132–136. See also Anxiety disorders
agoraphobia and, 122, 127, 133 biological perspective on, 133–134 cognitive perspective on, 135–136 cultural aspects of, 108t, 133 definition of, 132 diathesis-stress model for, 146 in elderly, 505 key features of, 132t prevalence of, 108t, 128t, 133 treatment of, 127
Paradigms, 38 Paranoid personality disorder, 423f, 424,
425–426, 437t Paraphilic disorders, 367–376
causes of, 367 definition of, 347, 367 diagnosis of, 367 education about, 381 exhibitionistic disorder, 371 fetishistic disorder, 368–370 frotteuristic disorder, 372 key features of, 369t pedophilic disorder, 367, 372–374 sexual masochism disorder, 374–375 sexual sadism disorder, 375–376 transvestic disorder, 370–371 treatment of, 367 voyeuristic disorder, 372
Paraprofessionals, 243, 413 Parasomnias, 264b Parasuicide, 222 Parasympathetic nervous system, in stress
response, 151f, 152
Nonsteroidal antiinflammatory drugs, for Alzheimer’s disease, 518
Non-suicidal self-injury, 224–225, 225b Norepinephrine, 40. See also Neurotransmitters
in bipolar disorder, 214–215 in cocaine intoxication, 321 in depression, 189, 191, 194, 194f in panic disorder, 133–134 in stress response, 151f, 152, 152f, 158, 271
Normalization in intellectual disability, 495–496
Norms, 3 No-suicide contract, 244 Not guilty by reason of insanity, 528–529 NSAIDs, for Alzheimer’s disease, 518 Nursing homes, 520, 520b, 521, 521b,
522–524 overmedication in, 508
Nutraceuticals, 43b Nutritional problems, in alcohol abuse, 315–316 Nutritional therapy, 43b
Obamacare, 17–18, 547–548 Obesity, in binge-eating disorder, 288, 305 Object relations theory, 47, 197 Object relations therapy, 110
for paranoid personality disorder, 426 Observation. See Clinical observation Observer bias, 91 Observer drift, 91 Obsessive-compulsive disorder, 128t, 137–145.
See also Anxiety disorders behavioral perspective on, 139–140 biological perspective on, 141–142, 142f cognitive perspective on, 140–141 compulsions in, 137–138 cultural aspects of, 108t defense mechanisms in, 139 definition of, 137 diathesis-stress model for, 146 in elderly, 505 exposure and response prevention for, 139–
140 key features of, 138t neutralization in, 140–141 obsessions in, 137 obsessive-compulsive personality disorder
and, 453 prevalence of, 108t, 128t psychodynamic perspective on, 138–139 rituals in, 138 sexual dysfunction and, 351
Obsessive-compulsive personality disorder, 423f, 437t, 452–454
Obsessive-compulsive–related disorders, 106, 143–145
Occupational stress, 546 suicide and, 228
Occupational training for autistic persons, 488 for intellectual disability, 497 for mentally ill persons, 413
O’Connor vs. Donaldson, 539 Odd personality disorders, 423f, 424–430, 437t Olanzapine, 408 Olfactory hallucinations, in schizophrenia, 389,
390b Online counseling. See Cybertherapy Openness to experiences, 456
in depression, 191–192, 191f in obsessive-compulsive disorder, 142f,
151–152 Neurocognitive disorders, 502, 509, 511–522
age of onset of, 511, 512f, 514 in athletes, 517f causes of, 517–518 cultural factors in, 522–523, 523f definition of, 511 due to Alzheimer’s disease, 511. See also
Alzheimer’s disease due to Huntington’s disease, 518 due to prion disease, 517 frontotemporal, 517, 517f head trauma and, 517f major, 511, 511t mild, 511, 511t prevention of, 519 treatment of, 518–519 vascular, 517
Neurodevelopmental disorders, 479–498 attention-deficit/hyperactivity disorder, 477t,
479–482 autism spectrum disorder, 477t, 483–488 definition of, 479 intellectual disability in, 477t, 488–497
Neurofibrillary tangles, in Alzheimer’s disease, 513–514
Neuroimaging techniques, 88, 88f Neuroleptic drugs, 407. See also Antipsychotics Neurological tests, 88, 88f Neurons, 39, 39f Neuroprotective proteins, 217 Neuropsychological tests, 88–89 Neurosurgery. See Brain surgery Neurosyphilis, 11–12 Neurotic anxiety, 108 Neuroticism, 456 Neurotransmitters, 39–40, 40f
in Alzheimer’s disease, 516 in anxiety, 116–117, 117f in attention-deficit/hyperactivity disorder,
481 in bipolar disorder, 214–215 in cocaine intoxication, 321 in depression, 189–191, 194, 194f, 234–235 in Ecstasy intoxication, 325b in fear, 116–117, 117f in obsessive-compulsive disorder, 141–142 in pain processing, 317 in panic disorder, 133–134 in schizophrenia, 395–397 as second messengers, 217 in stress response, 151f, 152, 152f, 158, 271 in substance use disorders, 332–333 in suicide, 234–235
Neutralization, in obsessive-compulsive disorder, 140–141
New-wave cognitive explanations, for anxiety, 111–112
New-wave cognitive therapy, 56–57 for schizophrenia, 409–410
Nicotine, 320b Nicotine replacement products, 320b Nightmare disorder, 264b Nocturnal penile tumescence (NPT), 353 Nomophobia, 129 Nomothetic perspective, 22 Nondemand pleasuring, 361
Subject Index : SI-13
Postpartum psychosis, 190b, 394b, 531b Posttraumatic stress disorder, 152–166. See also
Stress disorders acute stress disorder and, 152–166 biological factors in, 158–160 childhood experiences and, 160 cultural factors in, 161 definition of, 153 genetic factors in, 160 key features of, 153t personality factors in, 160 severity of trauma and, 161 social support and, 160–161 symptoms of, 153 treatment of, 161–165 triggers of, 154–158
Poverty mental health and, 71, 71f psychophysiological disorders and, 266–267 schizophrenia and, 387, 387f, 399 stress and, 107–108
Poverty of speech, in schizophrenia, 391 Predictive validity, 78, 95 Prefrontal cortex
in anxiety, 117, 117f in borderline personality disorder, 438 in depression, 191, 191f in memory, 515, 515f
Prefrontal leukotomy, 405b Pregnancy
alcohol use in, 316, 494–495 postpartum depression and, 190b postpartum psychosis and, 190b, 394b,
531b viral infections in, schizophrenia and,
397–398 Premature ejaculation, 354–355, 355t
treatment for, 364 Premenstrual dysphoric disorder, 187, 209b Premenstrual syndrome, 209 Preparedness, phobias and, 124 Prescription drug misuse, 316, 319t. See also
Substance use disorders by elderly, 507–508
Prevalence, 26 Prevention, 16–17, 70 Primary gain, in conversion and somatic
symptom disorders, 258 Primary prevention, 70 Prion disease, neurocognitive disorder due
to, 517 Prisoners
psychological abnormality in, 535f therapy for, 416b
Private psychotherapy, 15–16 for bipolar disorder, 217 for bulimia nervosa, 303 for depression, 206–207 for schizophrenia, 411
Pro-anorexia Web sites, 280t Problems in living, 4, 7 Problem-solving seminars, 546 Problem-solving skills training, 475 Professional boundaries, 541 Professional opportunities, 18, 18t Profiling, 542–544 Projection, 46t Projective tests, 82–84 Prolactin, sex drive and, 349
dependent, 423f, 437t, 450–452 dramatic, 423f, 431–447, 437t five-factor model of, 456 histrionic, 423f, 437t, 441–443 key features of, 423f lying and, 457b mass murder and, 434b narcissistic, 423f, 437t, 444–447 obsessive-compulsive, 423f, 437t, 452–454 odd, 423f, 424–430, 437t overlap among, 422–424, 423f, 456–459 overview of, 421–424 paranoid, 423f, 424, 425–426, 437t schizoid, 423f, 424, 427–428, 437t schizophrenia and, 424 schizotypal, 423f, 424, 428–430, 437t in serial killers, 543b
Personality disorder trait specified, 458–459 Personality factors, in stress disorders, 160 Personality inventories, 84–86 Personality traits, 421
Big Five, 456, 458 Pervasive developmental disorder. See Autism
spectrum disorder Pessimism, in depression, 186 PET (positron emission tomography), 88, 88f Phallic stage, 47, 258 Phalloplasty, 381 Phenothiazines. See also Antipsychotics
development of, 395, 406–407 Phenylalanine, 494 Phenylketonuria (PKU), 494 Phobias, 110–127, 128t. See also Anxiety
disorders behavioral perspective on, 122–124 behavioral-evolutionary perspective on,
123–124 cultural aspects of, 108t, 120 definition of, 119 desensitization for, 52–53, 124–125 diathesis-stress model for, 146 flooding for, 125 key features of, 120t, 122t learning and, 122–123 modeling and
in causation, 122–123 in treatment, 125
preparedness and, 124 prevalence of, 108t, 128t school, 468 social. See Social anxiety disorder specific, 108t, 110, 120, 128t systematic desensitization for, 52–53 treatment of, 124–126
Phoenix House, 340 Physical illness. See Medical conditions Pick’s disease, 517 Pituitary gland, in stress response, 152, 152f PKU (phenylketonuria), 494 Placebo studies, 29 Placebo therapy, 29 Play therapy, 468 Pleasure principle, 45 Polygenic disorders, 395 Polygraph, 86–87, 87b Positive psychology, 16–17, 19b Positron emission tomography (PET), 88, 88f
in Alzheimer’s disease, 516–517 Postpartum depression, 190b
Parent(s). See also Family effective vs. ineffective, 289–290 with intellectual disability, 497 refrigerator, 485 schizophrenogenic, 398 worrying by, 470
Parent management training, 475 Parent training, for autism spectrum disorder,
488 Parent-child interaction therapy, 474–475 Parents Anonymous, 478b Parity laws, 17–18 Parkinsonian symptoms, antipsychotic-induced,
395, 408 Parkinson’s disease, 395, 518 Partial hospitalization, 413 Participant modeling, 125 Participant observation, 90 Pathological lying, 457b Patients’ rights, 539–540 Pause procedure, 364 Pedigree studies, 116 Pedohebephilic pedophilic disorder, 372 Pedophilic disorder, 367, 372–374 Peer review systems, 547 Penile prosthesis, in sex reassignment, 381 Penile tumescence, nocturnal, 353 Pennsylvania Hospital, 10 Pentobarbital, for dissociative disorders, 176 Percocet, abuse of, 317, 318f Performance anxiety, 127
delayed ejaculation and, 356 erectile dysfunction and, 353
Peripartum depression, 187, 190b Perseveration
of sameness, 484 in schizophrenia, 388
Persistent depressive disorder, 187, 188t, 189t Persistent sexuality disorder, 366 Personal psychotherapy. See Interpersonal
psychotherapy Personality, 421
alternate, 170–171 anal regressive, 453 definition of, 421 five-factor model of, 456, 458 immune function and, 271–272 psychophysiological disorders and, 266,
271–272 substance use disorders and, 330–331 Type A, 266 Type B, 266
Personality disorder(s), 421–460 alternative models of, 456–459 antisocial, 423f, 431–436, 437t anxious, 423f, 437t, 447–454 avoidant, 423f, 437t, 447–449 Big Five model and, 456, 458 borderline, 423f, 436–441, 437t categorical vs. dimensional approach to,
422–424, 456–459 childhood experiences and, 438–439,
454–455 classification of, 422–424, 423f, 437t, 455–459 clusters of, 422, 423f, 437t, 455–456 comorbidity in, 422 comparison of, 437t cultural factors in, 454–455 definition of, 421
: Subject IndexSI-14
Psychophysiological tests, 86–87, 87b Psychosis, 386
amphetamine, 395 community treatment for, 411–417 definition of, 386 in depression, 187 in elderly, 508–509 homelessness and, 415, 415f key features of, 386t in medical conditions, 386t postpartum, 190b, 394b, 531b schizophrenia as, 386. See also Schizophrenia substance use disorders and, 386t, 413 support groups for, 411, 417 treatment of, 401–418. See also Antipsychotics types of, 386t violent behavior in, 538
Psychosomatic disorders. See Psychophysiological disorders
Psychosurgery, 42–44 historical perspective on, 8, 8f, 42–44 lobotomy in, 42–44, 405b right to refuse, 540
Psychotherapy. See Therapy and specific approaches Psychoticism, 458 Psychotropic drugs, 15, 42. See also specific drugs
deinstitutionalization and, 15, 15f effectiveness of, 98–100, 99f overuse in elderly, 508 prescribing privileges for, 541 for prisoners, 416b with psychotherapy, 100 right to refuse, 540
Quasi-experiments, 30 Quetiapine, 408
Race/ethnicity. See also Cultural factors alcohol use disorder and, 311, 311f, 313 anxiety and, 107–108, 120, 128 assessment and, 84, 85t, 86 attention-deficit/hyperactivity disorder and,
482 depression and, 209–210 eating disorders and, 295–296 forensic psychology and, 535t hate crimes and, 435t legal issues and, 535t neurocognitive disorders and, 522–523, 523f phobias and, 120 psychophysiological disorders and,
266–267, 267f, 267t in social anxiety disorder, 128 stress disorders and, 161 suicide and, 227, 227f, 238–239
Random assignment, 29 Rap groups, for stress disorders, 164 Rape, 155–157, 156b Rapid cycling, in bipolar disorder, 213 Rapid ejaculation, 354–355, 355t
treatment for, 364 Rapid eye movement (REM) sleep, erections
during, 353 Rapid smoking, 320 Rapprochement movement, 100 Rational-emotive therapy, 113–114
for social anxiety disorder, 131 Rationalization, 46t Reaction formation, 46t
behavioral, 50–54, 74t biological, 37–44, 74t biopsychosocial, 74 cognitive, 54–58, 74t cognitive-behavioral, 54, 74t definition of, 38 family-social, 65–70, 74t humanistic-existential, 58–64, 74t multicultural, 74t psychodynamic, 45–50, 74t sociocultural, 64–73, 74t
national interest groups for, 417 overview of, 1–7 physical disorders and. See
Psychophysiological disorders physician discrimination and, 270 prevalence of, 93f prevention of, 16–17 in prison populations, 535f in psychologists, 440b, 550–552 societal costs of, 546–548 with somatic symptoms. See Somatic
symptoms, disorders featuring in substance use disorders, 386t suicide and, 229–230 as syndrome, 92–93 technology and, 548–550. See also Internet terminology for, 1, 3 treatment of, 5–16. See also Therapy violence and, 538. See also Violence vs. eccentricity, 5, 6
Psychological debriefing, for stress disorders, 164–165
Psychological factor affecting medical condition. See Psychophysiological disorders
Psychological profiling, 542–544 Psychologists. See also Clinical psychologists
types of, 18, 18t Psychology
abnormal, definition of, 2 forensic, 528. See also Legal issues multicultural, 17, 71–72. See also Cultural
factors; Multicultural perspective positive, 16–17, 19b
Psychomotor symptoms, in schizophrenia, 391 Psychoneuroimmunology, 269–272 Psychopharmacologist, 100 Psychophysiological disorders, 259t, 262–275
asthma, 262–263 biofeedback for, 273 biological factors in, 265 cognitive therapy for, 275 headaches, 263–265 heart disease, 265 hypertension, 265 immune response and, 269–272 insomnia, 263, 264b key features of, 262t new, 267–272 personality factors in, 266, 271–272 psychological factors in, 266 relaxation training for, 273 Social Adjustment Rating Scale and,
268–269, 268t sociocultural factors in, 266–267 support groups for, 275 symptoms in, 259t traditional, 262–267 ulcers, 262
Pronominal reversal, 484 Pro-suicide Web sites, 237–238 Proteins, neuroprotective, 217 Prozac, 194
for obsessive-compulsive disorder, 141 Pseudocommando mass murders, 434b Pseudohallucinations, 390b Pseudopatients, 65, 400 Psychedelic drugs, 323–325 Psychiatric social workers, 18, 18t Psychiatrists, 18, 18t, 541 Psychoanalysis, 13–14, 47–49. See also
Psychodynamic therapy Psychoanalytic theory, 13–14, 18, 44–50
assessment of, 49–50 Freudian, 45–47, 49–50 non-Freudian, 47
Psychodynamic model, 45–50, 74t assessment of, 49–50 ego theory and, 47 Freudian theory and, 45–47, 49–50 object relations theory and, 47 self theory and, 47 treatment and, 47–49
Psychodynamic therapy, 47–49 for generalized anxiety disorder, 109–110 relational, 49 short-term, 49, 110
Psychogenic perspective, 11, 12–14 Psychological abnormality
in anorexia nervosa, 282 assessment of, 77–91 in children and adolescents, 463–499 classification of, 92–96. See also Diagnostic
and Statistical Manual of Mental Disorders (DSM-5)
concepts of in Ancient Greece and Rome, 8 current trends in, 14–21 as illness vs. problems in living, 4, 7 in Middle Ages, 8–9 in 19th century, 10–11 in prehistoric times, 7–8 psychogenic, 11, 12–14 in Renaissance, 9–10 societal influences on, 3–5 somatogenic, 11–12 in 20th century, 11–14
creativity and, 214b criteria for, 4–5 cultural aspects of, 3–5. See also Cultural
factors culture-bound, 108 danger and, 4 deviance and, 3 diagnosis of, 92–97. See also Diagnosis diathesis-stress model of, 74, 146, 393 distress and, 3–4 dysfunction and, 4 in elderly, 501–525, 506b elusive nature of, 4–5 genetic factors in. See Genetic factors historical perspective on, 7–14 homelessness and, 415, 415f in intellectual disability, 496 key features of, 2–5 labeling and, 65, 97, 400 legal aspects of, 527–553 models of, 37–75
Subject Index : SI-15
Acceptance and Commitment Therapy in, 409–410
cognitive-behavioral therapy in, 409–410 community approach in, 411–417 drug therapy in, 406–408. See also
Antipsychotics family therapy in, 411 historical perspective on, 403–406 institutional, 404–406 milieu therapy in, 404–405, 413 in prison, 416b social therapy in, 411
Type I, 392 Type II, 392 violent behavior in, 538 viral infections and, 41, 397–398
Schizophrenia spectrum disorders, 386t, 424. See also Psychosis
Schizophreniform disorder, 386t Schizophrenogenic mother, 398 Schizotypal personality disorder, 423f, 424,
428–430, 437t School phobia, 468 School problems/placement
in attention-deficit/hyperactivity disorder, 479–482, 480t
in autism spectrum disorder, 488 in intellectual disability, 491–492, 496
School refusal, 468 School violence, bullying and, 465, 466b, 470 Schools, recovery, 336b Scientific method, 20. See also Experiment(s) Scream Zone, 121 Seasonal affective disorder, 191 Seasonal depression, 187 Second messengers, 217 Secondary gain, in conversion and somatic
symptom disorders, 258 Secondary prevention, 70 Second-generation antipsychotics.
See Atypical antipsychotics Sedative-hypnotic drugs, 117, 117t
abuse of, 316, 319t for elderly, 508
Sedative-hypnotic use disorder, 316, 319t Seizures, induced, for depression, 192 Selective amnesia, 167 Selective norepinephrine reuptake inhibitors, 194 Selective serotonin reuptake inhibitors
(SSRIs), 193t, 194–195, 194f. See also Antidepressants
Self theory, 47 Self-actualization, 58 Self-efficacy, 53 Self-help groups/programs, 68
for agoraphobia, 126–127 for gamblers, 434 home-based, for agoraphobia, 126–127 online, 57b for psychophysiological disorders, 275 for severe mental illness, 411, 417 for substance use disorders, 339–340
Self-hypnosis in dissociative disorders, 175 in psychophysiological disorders, 274
Self-injury, 224–225, 225b. See also Suicide in autism spectrum disorder, 484 in borderline personality disorder, 437 non-suicidal, 224–225, 225b
Rorschach test, 82, 82f dissemination on Internet, 83
Rosenthal effect, 29 Routines, 137, 137f. See also Compulsions Rumination, depression and, 204, 209
Sadism, sexual, 375–376 Sadness, 185b St. Vitus’ dance, 9 La Salpetrière, 10 Samaritans, 242 Savants, 485b Schizoaffective disorder, 386t Schizoid personality disorder, 423f, 424,
427–428, 437t Schizophrenia, 385–419
active phase in, 392 ambivalence in, 391 anhedonia in, 391 apathy in, 391 biochemical abnormalities in, 395–397 biological view of, 393–398 brain abnormalities in, 392, 397f catatonia in, 391, 392f causes of, 393–401 classification of, 392 clinical picture of, 387–391 cognitive view of, 398 computer models of, 396 course of, 386t, 391–392 cultural aspects of, 399–400 delusions in, 388, 389, 409–410 demographics of, 386–387 in developing countries, 399 diathesis-stress model of, 393 disordered thinking and speech in, 388 dopamine hypothesis for, 395–397 downward drift theory and, 387, 387f in elderly, 508–509 expressed emotion and, 400, 411 family dysfunction and, 400–401, 411 genetic factors in, 393–395, 393f hallucinations in, 389, 409–410, 410b heightened perceptions in, 389 homelessness and, 415, 415f hyperlearning in, 396 inappropriate affect in, 389–391 key features of, 386t living arrangements in, 413, 415f occupational training in, 413 overview of, 386–387 Parkinson’s disease and, 395 personality disorders and, 424 prevalence of, 386, 386t, 399 prodromal phase in, 391–392 psychodynamic view of, 398 schizotypal personality disorder and, 430 social labeling and, 400 social withdrawal in, 391 sociocultural view of, 399–401 socioeconomic status and, 387, 387f, 399 substance use disorders and, 413 suicide and, 229, 230 support groups for, 411, 417 symptoms of, 387–391
negative, 391 positive, 387–389 psychomotor, 391
treatment of, 401–417
Reactive depression, 188 Reactivity, client, in assessment, 91 Reading problems, 491b Realistic anxiety, 108 Reality principle, 45 Receptors, neurotransmitter, 40, 40f Recovery schools, 336b Refrigerator parents, 485 Regression, 46t Reimbursement issues, 17–18, 546–548 Relapse-prevention training
for pedophilic disorder, 374 for substance use disorders, 337
Relational aggression, in conduct disorder, 474 Relational psychoanalytic therapy, 49 Relaxation training, 118, 273
for psychophysiological disorders, 273 Reliability, 78 Religion
health status and, 272 psychological benefits of, 61, 62b suicide and, 226
REM sleep, erections during, 353 Reminyl, 518 Renaissance, psychotherapeutic concepts and
treatment in, 9–10 Reparative therapy, 28b Repressed childhood memories of abuse, 169b Repression, 45, 46t, 109
dissociative disorders and, 173 psychophysiological disorders and, 266
Research. See Clinical research Residency, 18 Residential crisis centers, 413 Residential settings
for elderly, 520, 521b, 522–524 in intellectual disability, 495–496 in schizophrenia, 413
Residential treatment. See also Hospitalization; Institutionalization
for substance use disorders, 340 Resilience, 272 Resistance, 48, 109 Response inventories, 86 Restricted affect, in schizophrenia, 391 Restricting-type anorexia nervosa, 280 Retardation. See Intellectual disability Retrospective analysis, of suicide, 226 Reversal design, 31 Reverse anorexia nervosa, 297 Revolving door syndrome, 412 Reward(s), 51
depression and, 198 Reward center, 333 Reward-deficiency syndrome, 333 Right to refuse therapy, 540 Right to therapy, 539–540 Risperidone (Risperdal), 408 Ritalin, for attention-deficit/hyperactivity
disorder, 481–482, 482 Rituals, compulsions and, 138 Rivastigmine, 518 Robinson v. California, 538–539 Role disputes, depression and, 206 Role playing, 61 Role transitions, depression and, 206 Roles, 65 Rome, ancient, psychotherapeutic concepts
and treatment in, 8
: Subject IndexSI-16
electronic cigarettes and, 320b nicotine dependence in, 320b rapid, 320b
Snap gauge, 353 Sobriety High, 336b Social Adjustment Rating Scale, 268–269, 268t Social anxiety disorder, 127–132, 128t.
See also Anxiety disorders avoidant personality disorder and, 448 causes of, 128–130 cultural aspects of, 108t, 128 definition of, 127 diathesis-stress model for, 146 key features of, 128t prevalence of, 108t, 128, 128t social skills training for, 131 treatment of, 130–131
Social contagion effect, in suicide, 230–231, 237–238
Social integration. See also Community treatment
in intellectual disability, 497 Social labeling, 65, 97
in schizophrenia, 400 Social networking/social media, 65, 548–550.
See also Internet among elderly, 510 anxiety and, 129 as data source, 24 growth of, 548, 548f Internet sites for, 20 mass hysteria and, 255 mental health effects of, 20 selfies and, 446 texting. See Texting
Social phobias. See Social anxiety disorder Social reciprocity, in autism spectrum disorder,
483 Social roles, 65 Social Security disability income, 414 Social skills inventories, 86 Social skills training, 131 Social support, 65
depression and, 205 immune function and, 272 stress disorders and, 160–161 stress management and, 272 suicide and, 228
Social therapy, for schizophrenia, 411 Social withdrawal
in schizoid personality disorder, 427 in schizophrenia, 391
Social workers, psychiatric, 18, 19t Societal labels. See Social labeling Societal roles, 65. See also under Role Sociocultural model, 64–73, 74t. See also
Cultural factors assessment of, 64–65 family structure/communication and, 66 multicultural perspective and, 71–72 social networks and, 65 social support and, 65 societal labels/roles and, 65 treatment and, 67–70
community treatment, 70 couple therapy, 69–70 culture-sensitive therapy, 72, 210 family therapy, 68–69
Sexual dysfunctions, 348–366. See also Paraphilic disorders
antidepressant-related, 355 classification of, 347 cultural factors in, 351 definition of, 347 disorders of desire, 348–351 disorders of excitement, 352–354 disorders of pain, 358–359, 358t education about, 381 marital therapy for, 360–361 medical conditions and, 357, 362 myths about, 381 orgasmic disorders
in females, 355t, 356–358, 364–365 in males, 354–356, 355t, 364
overview of, 347 in serial killers, 543b treatment of, 360–366. See also Sex therapy
Sexual function, throughout life cycle, 350b Sexual history, 361 Sexual intercourse, painful, 358–359, 358t
treatment of, 365–366 Sexual masochism disorder, 374–375 Sexual organs
female, 349f male, 354f
Sexual pain, 358–359, 358t treatment of, 365–366
Sexual reassignment surgery, 381 Sexual relations. See Sexual behavior Sexual response cycle, 348f, 380
desire phase of, 348, 348f, 349f, 354f disorders of, 348–351, 364
excitement phase of, 348, 348f, 351 disorders of, 352–354, 363–364
in female, 348f, 349f in male, 348f, 354f orgasm phase of, 348f, 349f, 354, 354f, 380
disorders of, 354–358, 364–365 Sexual sadism disorder, 375–376 Sexuality, throughout life cycle, 350b Shamans, 8 Sheltered workshops
for autistic persons, 488 in intellectual disability, 497 for mentally ill persons, 413
Short-term hospitalization, 15 Short-term psychodynamic therapy, 49, 110 Shuttle box experiment, in learned helplessness,
201, 201f Sildenafil, 363, 365b Single-subject experimental design, 31 Situation anxiety, 152 Skillful frustration, 60–61 Skin-picking disorder, 143 Skype, 57b, 549 Sleep
erections during, 353 REM, 353
Sleep apnea, 264b Sleep problems, 264b Sleep terrors, 264b Sleepwalking, 264b Smart phones, 548. See also Social networking/
social media; Texting selfies and, 446
Smoking
Self-instruction training, 275 for sexual dysfunction, 363
Self-monitoring, 91 Self-mutilation, 224–225, 225b Self-statements, 275 Self-stimulatory behavior, in autism spectrum
disorder, 484 Selfies, narcissism and, 446 Semihospitals, 413 Senile plaques, in Alzheimer’s disease,
513–514 Sensate focus, 361 Sentence-completion test, 82 Separation anxiety disorder, 467–468, 468t, 477t
dependent personality disorder and, 450 Separation insecurity, 459 September 11 attack, 157 Sequencing, genomic, 41 Serial killers, 543b Seroquel, 408 Serotonin, 40. See also Neurotransmitters
in antisocial personality disorder, 435 in bipolar disorder, 214–215 in borderline personality disorder, 438 in cocaine intoxication, 321 in depression, 189, 191, 194, 194f, 234–235 in eating disorders, 291 in Ecstasy intoxication, 325b in obsessive-compulsive disorder, 141, 142 premature ejaculation and, 355, 364 in schizophrenia, 397 in suicide, 234–235
Serotonin-norepinephrine reuptake inhibitors, 194
Sertraline, 194 Set point, in weight regulation, 292 Sex drive, 349 Sex hormones
for Alzheimer’s disease, 518 for gender dysphoria, 379 sex drive and, 349 for sex reassignment, 381
Sex offender statutes, 533–534 Sex therapy, 360–366
current trends in, 366 for disorders of desire, 363 for erectile disorder, 363–364 for female orgasmic disorder, 364–365 for female sexual interest/arousal disorder, 363 for male orgasmic disorder, 366 for premature ejaculation, 364
Sex-change surgery, 381 Sexting, 368 Sexual abuse, 367, 372–374, 478b
repressed memories of, 169b sexual dysfunction and, 351, 357 stress disorders and, 161
Sexual addiction, 366 Sexual arousal disorder. See Female sexual
interest/arousal disorder Sexual assault, 155–157, 156b Sexual behavior
client-therapist relationship and, 545 gender differences in, 357–358 in intellectual disability, 497 lifetime patterns of, 350b normal range of, 350b in paraphilic disorders, 367–376
Subject Index : SI-17
rap groups for, 164 severity of trauma and, 161 social support and, 160–161 susceptibility to, 152–153 symptoms of, 153 terrorism and, 157, 164–165 torture and, 158 treatment of, 161–165 triggers of, 154–158 victimization and, 155–157
Stress hormones, 151–152, 152, 152f, 271 Stress inoculation training, 275 Stress management, 146, 263f
workplace programs for, 546 Stress response, 149–152, 151–152
arousal and, 151–152 autonomic nervous system in, 151–152, 151f,
157–159 biochemistry of, 271 endocrine system in, 151–152, 152f, 271 neurotransmitters in, 159 psychophysiological disorders and, 271–272 sympathetic nervous system in, 151–152,
151f, 152f, 158–159 Stressors, 149–150 Stress-reduction seminars, 546 Stroke, vascular neurocognitive disorder and, 517 Structural family therapy, 69 Subject bias, 29 Subpersonalities, 170–171
fusion of, 177 Substance abuse personality, 330–331 Substance intoxication, 310 Substance use disorders, 309–344
abused substances in, 311 in adolescents, 326f, 327, 336b alcohol in, 311–316 amphetamines in, 319t, 322–323 antisocial personality disorder and, 433 barbiturates in, 316, 319t benzodiazepines in, 316, 319t biological view of, 332–333 cannabis in, 319t, 326–328 causes of, 330–334 club drugs in, 322, 325b cocaine in, 319–322, 319t, 323 cognitive-behavioral view of, 331–332 contingency management for, 335 cultural aspects of, 71, 311, 311f, 340–341 definition of, 310 depressants in, 311–318, 319t Ecstasy in, 325b in elderly, 505–508 expectancy effects in, 331 genetic factors in, 332 hallucinogens in, 323–325 hallucinosis in, 310 intoxication and, 310 key features of, 310t long-term problems in, 310–311 LSD in, 323–325 methamphetamine in, 323 neurotransmitters in, 332–333 nicotine in, 320b opioids in, 316–318, 319t overview of, 310–311 personality factors in, 330–331 polysubstance abuse in, 328–329
State hospitals, 11. See also Hospitalization for schizophrenics, 404–406
State schools, 495 State-dependent learning, 174 Statistical analysis, 99
in correlational studies, 25, 25t in experiments, 25
Sterilization, eugenic, 12, 12t Steroids, in stress response, 152, 152f, 158, 160,
271 Stimulant(s)
abuse of, 319–323, 319t for attention-deficit/hyperactivity disorder,
481–482, 482 Stimulant use disorder, 323 Stimulus, conditioned/unconditioned, 51–52,
122 Stimulus generalization, phobias and, 123 Stomach ulcers, 262 Stone Age, therapy in, 8 Stop-start procedure, 364 Strattera, 194 Stress
anxiety disorders and, 146–147 autism spectrum disorder and, 484, 485 in children and adolescents, 464–465, 464f,
466b conversion disorder and, 253–254 depression and, 188, 192
in women, 208 dissociative disorders and, 166–180. See also
Dissociative disorders in elderly, 502–503 family, 400–401
Alzheimer’s disease and, 519–520 immune response and, 269–272 personality style and, 266, 271–272 physical disorders and, 267–272. See also
Psychophysiological disorders physical response to. See Stress response poverty and, 107–108 racial discrimination and, 267f schizophrenia and, 393 Social Adjustment Rating Scale and,
268–269, 268t sources of, 107–108, 268–269, 268t substance use disorders and, 330 suicide and, 228, 236–237
Stress disorders, 149–181 acute stress disorder, 152–166 adjustment disorder, 159b biological factors in, 158–160. See also Stress
response childhood experiences and, 160 community mobilization for, 164–165 cultural aspects of, 161 debriefing for, 164–165 dissociative disorders and, 166 exposure therapy for, 162–164 family therapy for, 164 genetic factors in, 160 immune response in, 269–272 key features of, 153 natural disasters and, 155, 155t, 164–165 personality factors in, 160 psychological, 152–166 psychophysiological, 267–272. See also
Psychophysiological disorders
family-social therapy, 67–70 gender-sensitive therapy, 72 group therapy, 67–68
Socioeconomic status mental health and, 71, 71f psychophysiological disorders and, 266–267 schizophrenia and, 387, 387f, 399 stress and, 107–108
Sociopathic lying, 457 Sodium amobarbital, for dissociative disorders,
176 Sodium ion transport, in bipolar disorder, 215 Sodium pentobarbital, for dissociative disorders,
176 Software therapy programs, 57b Soldiers
dissociative amnesia in, 167 stress disorders in, 149, 153–154,
162–164. See also Posttraumatic stress disorder
Somatic hallucinations, in schizophrenia, 389, 390b
Somatic sensations, misinterpretation of, 135 Somatic symptom disorder, 250, 255–261, 259t
behavioral view of, 258–259 causes of, 257–260 cognitive view of, 259 cultural factors in, 259–260 key features of, 256t predominant pain pattern in, 256 psychodynamic view of, 258 somatization pattern in, 256–257 treatment of, 260–261
Somatic symptoms disorders featuring, 249–276
classification of, 250, 259t overview of, 249–250
in mass psychogenic illness, 255 Somatization disorder, 177–179 Somatoform disorders. See Somatic symptoms,
disorders featuring Somatogenic perspective, 11–12, 18, 38, 39–44.
See also Biological model Special education, 496 Specific learning disorders, 477t, 491b Specific phobias, 110, 120, 128t. See also Anxiety
disorders; Phobias cultural aspects of, 108t, 120
key features of, 120t, 122t diathesis-stress model for, 146 prevalence of, 108t, 128t
Spectator role delayed ejaculation and, 356 erectile disorder and, 353
Speech abnormalities in autism spectrum disorder, 483–484, 488 in schizophrenia, 388, 391
Speech disorder, 491b Spirituality
health status and, 272 psychological benefits of, 61, 62b suicide and, 226
Spousal abuse learned helplessness and, 209 legal aspects of, 531b
Stagefright. See Performance anxiety Standardization, test, 78 State anxiety, 152
: Subject IndexSI-18
Teacher preparedness, in special education, 496 Tease technique, 363 Technology. See also Internet; Social
networking/social media cell phones. See Cell phones effects on mental health, 20, 548–550 video games and, 548
Teenagers. See Adolescents Tegretol, for bipolar disorder, 216 Temporal lobe, in memory, 515, 515f Tension headaches, 263 Terrorism, stress disorders and, 157, 164–165 Tertiary prevention, 70 Test(s), 78–79, 81–91
battery of, 89, 102 biological challenge, 135, 136 dissemination on Internet, 83 drawing, 83f, 84 intelligence, 89, 90b, 489–490 lie detector, 86–87, 87b neuropsychological, 88–89 personality, 84–86 projective, 82–84 psychophysiological, 86–87, 87b reliability of, 78 response inventories, 86 Rorschach, 82, 82f, 83 sentence-completion, 82 standardization of, 78 Thematic Apperception, 82, 82f validity of, 78–79
cross-situational, 91 Testosterone. See also Sex hormones
paraphilic disorders and, 367 sex drive and, 349 for sex reassignment, 381
Test-retest reliability, 78 Tetrahydrocannabinol (THC), 326, 328 Texting, 548. See also Social networking/social
media anxiety and, 129 crisis, 243 effect on relationships, 207 sexting and, 368
Thalamus age-related changes in, 515f in memory, 515, 515f in obsessive-compulsive disorder, 142, 142f
Thanatos, 232 THC (tetrahydrocannabinol), 326, 328 Thematic Apperception Test, 82, 82f Theory of mind, 485–486 Therapeutic communities, for substance use
disorders, 340 Therapists. See Clinical psychologists Therapy, 5–16, 97–100, 101b. See also specific
therapeutic approaches in ancient Greece and Rome, 8 availability of, 17–18, 546–548 in biological model, 42–44 combined-modality approach in, 73–74, 100 common factors approach in, 101b culture-sensitive, 210 current trends in, 14–21 definition of, 5 deinstitutionalization and, 15, 15f with drug therapy, 100. See also Psychotropic
drugs
neurotransmitters in, 234–235 occupational stress and, 229 overview of, 221–225 parasuicide and, 222 patterns of, 226–227, 227f, 237f post-attempt treatment for, 242 postvention of, 231 prevalence of, 222, 226, 227f, 237f prevention of, 242–246 psychodynamic perspective on, 232–233 race/ethnicity and, 227, 227f religion and, 226 research methods for, 226 retrospective analysis of, 226 right to commit, 240b risk assessment for, 244 schizophrenia and, 229, 230 social isolation and, 228 sociocultural perspective on, 233–234 statistical analysis of, 226–227, 227f, 237f stress and, 228, 236–237 subintentional death and, 224 substance use disorders and, 229, 230 survivor studies of, 226 triggers of, 227–228 victimization and, 229 Web sites for, 237–238, 244
Suicide education programs, 246 Suicide hot lines, 243 Suicide prevention programs, 242–246
effectiveness of, 245–246 Superego, 46 Support groups, 68
for agoraphobia, 126–127 for families of schizophrenics, 441 for gamblers, 343 online, 57b for psychophysiological disorders, 275 for severe mental illness, 411, 417 for substance use disorders, 339–340
Supported employment, 413 Supportive nursing care, for anorexia nervosa,
298 Surgery. See Brain surgery Switching, 170 Sybil (Schreiber), 167, 171–172 Symbolic loss, depression and, 196–197 Sympathetic nervous system, in stress response,
151–152, 151f, 152f, 158–159 Synapses, 39, 39f Syndromes, 92–93 Synergistic effects, in polydrug abuse, 328–329 Synesthesia, 324 Syphilis, 11–12 Systematic desensitization, 52–53, 124–125
Tacrine, 518 Tactile hallucinations, in schizophrenia, 389,
390b Tadalafil, 363 Taijin kyofusho, 128 Tarantism, 9 Tarasoff v. Regents of the University of California,
546 Tardive dyskinesia, 408 Tau protein, 514, 515 Tay-Sachs disease, 494 T-cells, 269
in pregnancy, 316, 322, 341 prescription drug misuse in, 316, 318f, 319t,
507–508 prevalence of, 311, 311f prevention of, 341 psychodynamic view of, 330–331 psychological abnormalities in, 386t psychosis and, 386t, 413 recovery schools for, 336b reward-deficiency syndrome in, 333 sedative-hypnotic drugs in, 316, 319t sociocultural view of, 330 stimulants in, 319–323, 319t suicide and, 229, 230 synergistic effects in, 328–329 tolerance in, 310 treatment of, 334–343, 334f
antagonist drugs in, 338 aversion therapy in, 335 behavior therapy in, 335–337 biological therapy in, 337–339 cognitive-behavioral therapy in, 335–337 community programs in, 341 culture-sensitive programs in, 340–341 detoxification in, 337–338 drug-maintenance therapy in, 338–339 gender-sensitive programs in, 340–341 psychodynamic therapy in, 335 relapse-prevention training in, 337 residential programs in, 340 self-help groups in, 339–340
Suicidal behavior disorder, 222 Suicide, 221–247
by adolescents, 230–231, 236–239, 237f antidepressants and, 238b, 471
age and, 235–241, 237f altruistic, 233 anomic, 233 assisted, 240b biological view of, 234–235 in borderline personality disorder, 437,
438, 440b causes of, 232–235 by celebrities, 231 childhood experiences and, 228, 232 by children, 235–236, 237f cluster, 239 cognitive impairment in, 229 contagious, 230–231, 237 cultural factors in, 227, 227f, 238–239, 241 by death darers, 224 by death ignorers, 224 by death initiators, 224 by death seekers, 224 definition of, 222 demographics of, 226–227, 227f, 237f depression and, 229–230, 239–241 dichotomous thinking in, 229 egotistic, 233 by elderly, 237f, 239–241, 505 gender and, 226–227, 227f genetic factors in, 234 hopelessness and, 229 illness and, 228 mental disorders and, 229–230 methods of, 226–227 modeling of, 230–231, 237 mood changes in, 228–229
Subject Index : SI-19
Victimization borderline personality disorder and,
454–455 learned helplessness and, 200–202, 209 stress disorders and, 155–157 suicide and, 229
Video games, 548 Video modeling, 475 Violence. See also Aggression; Criminality
in antisocial personality disorder, 431–436 against children. See Child abuse civil commitment and, 538 in conduct disorder, 473–474, 473t, 477t criminal commitment and, 528–529, 534–535 cultural aspects of, 435t domestic
learned helplessness and, 200–202, 209 legal aspects of, 531b
duty to warn and, 546 mass murder and, 434b predictors of, 538 psychological abnormality and, 538 school, bullying and, 465, 466b, 470 serial killers and, 543b sexual assault, 155–157, 156b stress disorders and, 155–157 victims of. See Victimization
Viral infections, 41 Alzheimer’s disease and, 516 immunizations for, autism spectrum disorder
and, 486–487 intellectual disability and, 495 neurocognitive disorders and, 516
Virtual reality, in exposure therapy, 126 Virtual support groups, 57b Visual e-therapy, 57b Visual hallucinations, in schizophrenia, 389, 390b Visual memory, 175b Vitamin E, for Alzheimer’s disease, 518 Vocational opportunities
for autistic persons, 488 in intellectual disability, 497 for mentally ill persons, 413
Voyeuristic disorder, 372
War dissociative amnesia in, 167 stress disorders and, 149, 152, 153–154,
162–164. See also Posttraumatic stress disorder
Web sites. See Internet Weight
in anorexia nervosa, 298–301 regulation of, 291–292
Weight set point, 292 Wellness promotion, for elderly, 524 Werewolves, 9 White blood cells, 269 Withdrawal, 310
alcohol, 314 amphetamine, 323 barbiturate, 316, 319t biochemical factors in, 332–333 classical conditioning and, 332 cocaine, 323 detoxification and, 337–338 heroin, 317–318
Women. See also under Female; Gender
Trephination, 8, 8f, 42 Trevor Foundation, 244 Trevor Lifeline, 244 Trichotillomania, 143 Tricyclic antidepressants, 193–194, 193t.
See also Antidepressants Trisomy 21, 494 Trust, levels of, 426f Truth serum, for dissociative disorders, 176 Tube feeding, 298 Twelve-step programs, 339–340 Twin studies
concordance in, 393 of depression, 189 of eating disorders, 291 of schizophrenia, 393 of stress disorders, 160 of substance use disorders, 332
Twitter, 548–550. See Social networking/social media
Two-physician certificates (2-PCs), 538 Type A personality, 266 Type B personality, 266 Tyramine, MAO inhibitors and, 193
UCLA Loneliness Scale, 272 Ulcers, 262 Unconditional positive regard, 59–60, 110 Unconditional self-regard, 59–60 Unconditioned stimulus/response, 51–52, 122 Unconscious, 45 Uniformity myth, 99 Unipolar depression, 183–184. See also
Depression
Vaccines, autism spectrum disorder and, 486–487
Vacuum erection device, 364 Vaginismus, 358, 358t
treatment of, 365–366 Vagus nerve stimulation, 195, 195f Validity, 78–79
concurrent, 78–79 cross-situational, 91 face, 78 predictive, 78, 95
Valium, for generalized anxiety disorder, 116 Valproate, for bipolar disorder, 216 Vardenafil, 363 Variables, 20
dependent, 27 independent, 27
Vascular neurocognitive disorder, 517. See also Neurocognitive disorders
Venlafaxine, 194 Ventromedial hypothalamus. See also
Hypothalamus in weight regulation, 291
Ventromedial nucleus, in panic disorder, 133–134, 134f
Verbal compulsions, 138 Verbal memory, 175b Veterans
dissociative amnesia in, 167 stress disorders in, 149, 153–154, 162–164.
See also Posttraumatic stress disorder Veterans Outreach Centers, 164 Viagra, 363, 365b
economics of, 546–548 effectiveness of, 98–100, 99f evidence-based, 98, 101b feminist, 72 gender-sensitive, 72 insurance coverage for, 17–18, 546–548 in intellectual disability, 496 Internet and. See Cybertherapy in managed care, 17–18, 547 in Middle Ages, 9 moral, 10–11 multicultural, 72 in 19th century, 10–11 outcome studies for, 99, 99f outpatient, 14, 15–16, 15f for physical disorders, 273–275 placebo, 29 play, 468 in prehistoric times, 8 for prisoners, 416b private psychotherapy, 15–16 providers of, 18, 18t psychoanalytic, 13–14 in psychodynamic model, 47–49 for psychologists, 440b, 550–552 rapprochement movement and, 100 in Renaissance, 9–10 right to, 539–540 right to refuse, 540 in state hospitals, 11 surgical, 42–44
historical perspective on, 42–44 lobotomy in, 44, 405b right to refuse, 540
in 20th century, 11–14 uniformity myth and, 99
TheTruth.com, 341 Third-party payment, 17–18 Thought disorders. See also Illogical thinking
in schizophrenia, 388 The Three Faces of Eve, 22, 167, 171 Tip-of-the-tongue phenomenon, 175b Toilet training, Freudian view of, 139, 453 Token economy, 404, 405–406, 496 Tolerance, 310 Torture, stress disorders and, 158 Touching compulsions, 138 Trait anxiety, 152 Tranquilizers, minor, 42 Transcranial magnetic stimulation, 195–196,
195f Transference, 48, 109
countertransference and, 551b in dependent personality disorder, 451
Transgender experiences. See Gender dysphoria Transorbital lobotomy, 44, 405b Transsexualism. See Gender dysphoria Transvestic disorder, 370–371
vs. gender dysphoria, 371, 379 Trauma
brain intellectual disability and, 495 neurocognitive disorders and, 517f, 518f
psychological, 149–181 Treatment. See Therapy Treatment foster care, 475 Treatments for Adolescents with Depression
Study (TADS), 471
: Subject IndexSI-20
for generalized anxiety disorder, 116, 117t
for panic disorder, 135
York Retreat, 10
Zinc, in Alzheimer’s disease, 516 Ziprasidone, 408 Zoloft, 194 Zyprexa, 408
World Health Organization, International Classification of Diseases, 93, 458
World Trade Center attack, 157 Worrying, 111–114, 111f
by children, 464 by parents, 470
Wyatt v. Stickney, 539
X (Ecstasy), 325b Xanax
alcohol effects in, 312 depression in, 184, 208–209
postpartum, 190b oral contraceptives for, insurance coverage
for, 365b personality disorders in, 443, 454–455 pregnant. See Pregnancy substance use disorders in, 340–341 suicide by, 226–227, 227f
Working through, 49
Stone Age Mental disorders treated by trephination. p. 8 430–377B.C. Hippocrates cites brain as source of mental disorders. p. 8 500–1450 Middle Ages adopts demonological explanations and treatments. pp. 8–9 1547 Bethlehem Hospital in London converted into asylum. p. 10 1693 Witch-hunting trials peak in Salem, Massachusetts. p. 9 1773 First American hospital exclusively for mental patients opens in Williamsburg, Virginia. p. 10 1793 Phillipe Pinel frees asylum patients at LaBicêtre in Paris. p. 10 1812 Benjamin Rush writes first American textbook on psychiatry. p. 10 1842 Dorothea Dix begins campaign to reform mental hospitals in the United States. pp. 10–11 1865 Gregor Mendel publishes theories of genetics. p. 40 1879 German professor Wilhelm Wundt establishes first laboratory for experimental study of psychology. p. 22 1883 Emil Kraepelin publishes textbook on psychiatry, likening mental disorders to physical diseases. pp. 11, 93 1892 American Psychological Association founded. p. 18 1893 Sigmund Freud, with Josef Breuer, publishes first chapters of On the Psychical Mechanisms of Hysterical
Phenomena, launching psychoanalysis. pp. 13, 258 1896 Lightner Witmer establishes first psychological clinic in the U.S. at University of Pennsylvania. p. 13 1897 General paresis linked to physical cause, syphilis. pp. 11–12 1900 Freud publishes The Interpretation of Dreams. p. 49 1900 Morton Prince uses hypnosis to treat multiple personality disorder. p. 177 1901 Ivan Pavlov demonstrates classical conditioning. p. 51 1905 First intelligence test published. p. 89 1907 Alzheimer’s disease identified by Dr. Alois Alzheimer. p. 512 1908 Clifford Beers writes autobiography A Mind That Found Itself, launching Mental Hygiene Movement in the
United States. p. 404 1909 Freud makes his only visit to America and lectures at Clark University. pp. 13–14, 44–45 1913 Behaviorist John Watson argues that psychology should abandon study of consciousness. pp. 51, 123 1917 The U.S. Congress declares all nonmedical opioids illegal. p. 317 1921 Rorschach Test published. p. 82 1923 Freud publishes The Ego and the Id. p. 45 1929 EEG developed. p. 88 1935 Alcoholics Anonymous founded. p. 339 1935 First use of lobotomy for mental disorders. p. 405 1937 Marijuana made illegal in the United States. p. 327 1938 Electroconvulsive therapy introduced in Rome. p. 192 1938 B. F. Skinner proposes operant conditioning. p. 51 1939 The Wechsler-Bellevue Intelligence Scale published. p. 89 1943 LSD’s hallucinogenic effects discovered. pp. 323–324 1943 Minnesota Multiphasic Personality Test (MMPI) published. p. 84 1943 Jean-Paul Sartre’s existential book Being and Nothingness published. p. 58 1949 Lithium salts first used for bipolar disorder. p. 215 1951 Chlorpromazine, first antipsychotic drug, tested. p. 407 1951 Carl Rogers publishes Client-Centered Therapy. p. 59 1952 First edition of DSM published by the American Psychiatric Association. p. 93
Milestones in Abnormal Psychology Sc
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1952 Sex-change operation performed on Christine Jorgensen. p. 381 1955 The Los Angeles Suicide Prevention Center founded. p. 242 1956 Family systems theory and therapy launched. pp. 66, 68 1958 Joseph Wolpe develops desensitization. p. 52 1961 Thomas Szasz publishes The Myth of Mental Illness. p. 4 1962 Albert Ellis proposes rational-emotive therapy. pp. 54, 113 1963 The Community Mental Health Act helps trigger deinstitutionalization in the United States. p. 411 1963 Antianxiety drug Valium introduced in the United States. p. 117 1964 U.S. Surgeon General warns that smoking can be dangerous to human health. p. 320 1965 Norepinephrine and serotonin theories of depression proposed. p. 189 1967 Aaron Beck publishes cognitive theory and therapy for depression. pp. 202–205 1967 Methadone maintenance treatment begins. p. 339 1970 Masters and Johnson publish Human Sexual Inadequacy and launch sex therapy. p. 360 1972 CAT scan introduced. p. 88 1973 DSM stops listing homosexuality as a mental disorder. pp. 28, 368–369 1973 David Rosenhan conducts study On Being Sane in Insane Places. p. 65 1975 Endorphins—natural opioids—discovered in human brain. p. 317 1975 U.S. Supreme Court declares that patients in institutions have right to adequate treatment. p. 539 1981 MRI first used as diagnostic tool. p. 88 1982 John Hinckley found not guilty by reason of insanity of the attempted murder of President Reagan. p. 529 1987 Antidepressant Prozac approved in the United States. p. 194 1988 American Psychological Society founded. p. 22 1990 FDA approves first atypical antipsychotic drug, clozapine. p. 408 1994 DSM-IV published. p. 93 1995 APA task force begins search to identify empirically supported (evidence-based) treatments. p. 98 1997 PTSD patients are treated with virtual reality programs for first time. p. 163 1998 Viagra goes on sale in the United States, soon followed by Cialis and Levitra. pp. 363, 365 1999 Killing rampage at Columbine High School stirs public concern about dangerousness in children. p. 538 2000 DSM-IV-TR published. p. 93 2000 Scientists finish mapping (i.e., sequencing) the human genome. p. 41 2001 Around 1,600 mental health workers mobilize to help 57,000 victims of 9/11 terrorist attacks. pp. 157, 164–165 2002 New Mexico grants prescription privileges to specially trained psychologists. p. 541 2004 FDA orders black box warnings on all antidepressant drug containers. pp. 238–471 2006 U.S. Supreme Court upholds Oregon’s “Death with Dignity” Act, allowing doctors to assist suicides by
terminally ill individuals under certain conditions. pp. 239–240 2006 Andrea Yates, who drowned her five children while suffering from postpartum psychosis, is retried and
found not guilty by reason of insanity. pp. 394, 531 2011 The American Psychological Association declares its support for the legalization of same-sex marriages. p. 368–369 2012 Marijuana use (for any purpose) is made legal in Colorado and Washington. p. 328 2013 The White House announces 10-year “BRAIN Initiative” to map the activity of every neuron in the brain. p. 39 2013 DSM-5 published. p. 93 2014 The Affordable Care Act goes into effect, requiring all insurance plans to offer equal (“parity”) coverage for
mental and physical problems. pp. 17–18, 547–548 2015 A report uncovers American Psychological Association involvement in the development and practice of
“enhanced interrogation” techniques on suspected terrorists, triggering an APA membership vote banning psychologists from involvement in either enhanced or noncoercive national security interrogations. p. 546
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- Cover
- Front endpaper
- Half Title
- Title
- Copyright
- Dedication
- About the Author
- Contents in Brief
- Contents
- Preface
- CHAPTER: 1 Abnormal Psychology: Past and Present
- What Is Psychological Abnormality?
- Deviance
- Distress
- Dysfunction
- Danger
- The Elusive Nature of Abnormality
- What Is Treatment?
- How Was Abnormality Viewed and Treated in the Past?
- Ancient Views and Treatments
- Greek and Roman Views and Treatments
- Europe in the Middle Ages: Demonology Returns
- The Renaissance and the Rise of Asylums
- The Nineteenth Century: Reform and Moral Treatment
- The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives
- Current Trends
- How Are People with Severe Disturbances Cared for?
- How Are People with Less Severe Disturbances Treated?
- A Growing Emphasis on Preventing Disorders and Promoting Mental Health
- Multicultural Psychology
- The Increasing Influence of Insurance Coverage
- What Are Today’s Leading Theories and Professions?
- Technology and Mental Health
- What Do Clinical Researchers Do?
- The Case Study
- The Correlational Method
- The Experimental Method
- What Are the Limits of Clinical Investigation?
- Protecting Human Participants
- PUTTING IT TOGETHER: A WORK IN PROGRESS
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: Verbal Debuts
- PsychWatch: Marching to a Different Drummer: Eccentrics
- InfoCentral: Happiness
- MindTech: Mental Health Apps Explode in the Marketplace
- MindTech: A Researcher’s Paradise?
- MediaSpeak: Flawed Study, Gigantic Impact
- CHAPTER: 2 Models of Abnormality
- The Biological Model
- How Do Biological Theorists Explain Abnormal Behavior?
- Biological Treatments
- Assessing the Biological model
- The Psychodynamic Model
- How Did Freud Explain Normal and Abnormal Functioning?
- How Do Other Psychodynamic Explanations Differ from Freud’s?
- Psychodynamic Therapies
- Assessing the Psychodynamic Model
- The Behavioral Model
- How Do Behaviorists Explain Abnormal Functioning?
- Behavioral Therapies
- Assessing the Behavioral Model
- The Cognitive Model
- How Do Cognitive Theorists Explain Abnormal Functioning?
- Cognitive Therapies
- Assessing the Cognitive Model
- The Humanistic-Existential Model
- Rogers’ Humanistic Theory and Therapy
- Gestalt Theory and Therapy
- Spiritual Views and Interventions
- Existential Theories and Therapy
- Assessing the Humanistic-Existential Model
- The Sociocultural Model: Family-Social and Multicultural Perspectives
- How Do Family-Social Theorists Explain Abnormal Functioning?
- Family-Social Treatments
- How Do Multicultural Theorists Explain Abnormal Functioning?
- Multicultural Treatments
- Assessing the Sociocultural Model
- PUTTING IT TOGETHER: INTEGRATION OF THE MODELS
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Dietary Supplements: An Alternative Treatment
- PsychWatch: Cybertherapy: Surfing for Help
- MediaSpeak: Saving Minds Along with Souls
- MindTech: Have Your Avatar Call My Avatar
- CHAPTER: 3 Clinical Assessment, Diagnosis, and Treatment
- Clinical Assessment: How and Why Does the Client Behave Abnormally?
- Characteristics of Assessment Tools
- Clinical Interviews
- Clinical Tests
- Clinical Observations
- Diagnosis: Does the Client’s Syndrome Match a Known Disorder?
- Classification Systems
- DSM-5
- Is DSM-5 an Effective Classification System?
- Call for Change
- Can Diagnosis and Labeling Cause Harm?
- Treatment: How Might the Client Be Helped?
- Treatment Decisions
- The Effectiveness of Treatment
- PUTTING IT TOGETHER: ASSESSMENT AND DIAGNOSIS AT A CROSSROADS
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- MindTech: Psychology’s Wiki Leaks?
- PsychWatch: The Truth, the Whole Truth, and Nothing but the Truth
- MediaSpeak: Intelligence Tests Too? eBay and the Public Good
- InfoCentral: Common Factors in Therapy
- CHAPTER: 4 Anxiety, Obsessive-Compulsive, and Related Disorders
- Generalized Anxiety Disorder
- The Sociocultural Perspective: Societal and multicultural Factors
- The Psychodynamic Perspective
- The Humanistic Perspective
- The Cognitive Perspective
- The Biological Perspective
- Phobias
- Specific Phobias
- Agoraphobia
- What Causes Phobias?
- How Are Phobias Treated?
- Social Anxiety Disorder
- What Causes Social Anxiety Disorder?
- Treatments for Social Anxiety Disorder
- Panic Disorder
- The Biological Perspective
- The Cognitive Perspective
- Obsessive-Compulsive Disorder
- What Are the Features of Obsessions and Compulsions?
- The Psychodynamic Perspective
- The Behavioral Perspective
- The Cognitive Perspective
- The Biological Perspective
- Obsessive-Compulsive-Related Disorders
- PUTTING IT TOGETHER: DIATHESIS-STRESS IN ACTION
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: Fears, Shmears: The Odds Are Usually on Our Side
- InfoCentral: Mindfulness
- MediaSpeak: The Fear Business
- MindTech: Social Media Jitters
- CHAPTER: 5 Disorders of Trauma and Stress
- Stress and Arousal: The Fight-or-Flight Response
- Acute and Posttraumatic Stress Disorders
- What Triggers Acute and Posttraumatic Stress Disorders?
- Why Do People Develop Acute and Posttraumatic Stress Disorders?
- How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?
- Dissociative Disorders
- Dissociative Amnesia
- Dissociative Identity Disorder
- How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder?
- How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?
- Depersonalization-Derealization Disorder
- PUTTING IT TOGETHER: GETTING A HANDLE ON TRAUMA AND STRESS
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Sexual Assault
- PsychWatch: Adjustment Disorders: A Category of Compromise?
- MindTech: Virtual Reality Therapy: Better Than the Real Thing?
- PsychWatch: Repressed Childhood Memories or False Memory Syndrome?
- PsychWatch: Peculiarities of Memory
- CHAPTER: 6 Depressive and Bipolar Disorders
- Unipolar Depression: The Depressive Disorders
- How Common Is Unipolar Depression?
- What Are the Symptoms of Depression?
- Diagnosing Unipolar Depression
- Stress and Unipolar Depression
- The Biological Model of Unipolar Depression
- Psychological Models of Unipolar Depression
- The Sociocultural Model of Unipolar Depression
- Bipolar Disorders
- What Are the Symptoms of Mania?
- Diagnosing Bipolar Disorders
- What Causes Bipolar Disorders?
- What Are the Treatments for Bipolar Disorders?
- PUTTING IT TOGETHER: MAKING SENSE OF ALL THAT IS KNOWN
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Sadness
- PsychWatch: Sadness at the Happiest of Times
- MediaSpeak: Immigration and Depression in the 21st Century
- MindTech: Texting: A Relationship Buster?
- PsychWatch: Premenstrual Dysphoric Disorder: Déjá Vu All Over Again
- PsychWatch: Abnormality and Creativity: A Delicate Balance
- CHAPTER: 7 Suicide
- What Is Suicide?
- How Is Suicide Studied?
- Patterns and Statistics
- What Triggers a Suicide?
- Stressful Events and Situations
- Mood and Thought Changes
- Alcohol and Other Drug Use
- Mental Disorders
- Modeling: The Contagion of Suicide
- What Are the Underlying Causes of Suicide?
- The Psychodynamic View
- Durkheim’s Sociocultural View
- The Biological View
- Is Suicide Linked to Age?
- Children
- Adolescents
- The Elderly
- Treatment and Suicide
- What Treatments Are Used After Suicide Attempts?
- What Is Suicide Prevention?
- Do Suicide Prevention Programs Work?
- PUTTING IT TOGETHER: PSYCHOLOGICAL AND BIOLOGICAL INSIGHTS LAG BEHIND
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- MediaSpeak: Videos of Self-Injury Find an Audience
- PsychWatch: The Black Box Controversy: Do Antidepressants Cause Suicide?
- InfoCentral: The Right to Commit Suicide
- MindTech: Crisis Texting
- CHAPTER: 8 Disorders Featuring Somatic Symptoms
- Factitious Disorder
- Conversion Disorder and Somatic Symptom Disorder
- Conversion Disorder
- Somatic Symptom Disorder
- What Causes Conversion and Somatic Symptom Disorders?
- How Are Conversion and Somatic Symptom Disorders Treated?
- Illness Anxiety Disorder
- Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions
- Traditional Psychophysiological Disorders
- New Psychophysiological Disorders
- Psychological Treatments for Physical Disorders
- Relaxation Training
- Biofeedback
- Meditation
- Hypnosis
- Cognitive Interventions
- Support Groups and Emotion Expression
- Combination Approaches
- PUTTING IT TOGETHER: EXPANDING THE BOUNDARIES OF ABNORMAL PSYCHOLOGY
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: Munchausen Syndrome by Proxy
- MindTech: Can Social Media Spread “Mass Hysteria”?
- InfoCentral: Sleep and Sleep Disorders
- MediaSpeak: When Doctors Discriminate
- CHAPTER: 9 Eating Disorders
- Anorexia Nervosa
- The Clinical Picture
- Medical Problems
- Bulimia Nervosa
- Binges
- Compensatory Behaviors
- Bulimia Nervosa Versus Anorexia Nervosa
- Binge-Eating Disorder
- What Causes Eating Disorders?
- Psychodynamic Factors: Ego Deficiencies
- Cognitive Factors
- Depression
- Biological Factors
- Societal Pressures
- Family Environment
- Multicultural Factors: Racial and Ethnic Differences
- Multicultural Factors: Gender Differences
- How Are Eating Disorders Treated?
- Treatments for Anorexia Nervosa
- Treatments for Bulimia Nervosa
- Treatments for Binge-Eating Disorder
- PUTTING IT TOGETHER: A STANDARD FOR INTEGRATING PERSPECTIVES
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Body Dissatisfaction
- MindTech: Dark Sites of the Internet
- PsychWatch: The Sugar Plum Fairy
- CHAPTER: 10 Substance Use and Addictive Disorders
- Depressants
- Alcohol
- Sedative-Hypnotic Drugs
- Opioids
- Stimulants
- Cocaine
- Amphetamines
- Stimulant Use Disorder
- Hallucinogens, Cannabis, and Combinations of Substances
- Hallucinogens
- Cannabis
- Combinations of Substances
- What Causes Substance Use Disorders?
- Sociocultural Views
- Psychodynamic Views
- Cognitive-Behavioral Views
- Biological Views
- How Are Substance Use Disorders Treated?
- Psychodynamic Therapies
- Behavioral Therapies
- Cognitive-Behavioral Therapies
- Biological Treatments
- Sociocultural Therapies
- Other Addictive Disorders
- Gambling Disorder
- Internet Gaming Disorder: Awaiting Official Status
- PUTTING IT TOGETHER: NEW WRINKLES TO A FAMILIAR STORY
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: College Binge Drinking: An Extracurricular Crisis
- MindTech: Neknomination Goes Viral
- InfoCentral: Smoking, Tobacco, and Nicotine
- PsychWatch: Club Drugs: X Marks the (Wrong) Spot
- MediaSpeak: Enrolling at Sober High
- CHAPTER: 11 Disorders of Sex and Gender
- Sexual Dysfunctions
- Disorders of Desire
- Disorders of Excitement
- Disorders of Orgasm
- Disorders of Sexual Pain
- Treatments for Sexual Dysfunctions
- What Are the General Features of Sex Therapy?
- What Techniques Are Used to Treat Particular Dysfunctions?
- What Are the Current Trends in Sex Therapy?
- Paraphilic Disorders
- Fetishistic Disorder
- Transvestic Disorder
- Exhibitionistic Disorder
- Voyeuristic Disorder
- Frotteuristic Disorder
- Pedophilic Disorder
- Sexual Masochism Disorder
- Sexual Sadism Disorder
- Gender Dysphoria
- Explanations of Gender Dysphoria
- Treatments for Gender Dysphoria
- PUTTING IT TOGETHER: A PRIVATE TOPIC DRAWS PUBLIC ATTENTION
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Sex Throughout the Life Cycle
- PsychWatch: Sexism, Viagra, and the Pill
- MindTech: “Sexting”: Healthy or Pathological?
- MediaSpeak: A Different Kind of Judgment
- CHAPTER: 12 Schizophrenia
- The Clinical Picture of Schizophrenia
- What Are the Symptoms of Schizophrenia?
- What Is the Course of Schizophrenia?
- How Do Theorists Explain Schizophrenia?
- Biological Views
- Psychological Views
- Sociocultural Views
- How Are Schizophrenia and Other Severe Mental Disorders Treated?
- Institutional Care in the Past
- Institutional Care Takes a Turn for the Better
- Antipsychotic Drugs
- Psychotherapy
- The Community Approach
- PUTTING IT TOGETHER: AN IMPORTANT LESSON
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Hallucinations
- PsychWatch: Postpartum Psychosis: The Case of Andrea Yates
- MindTech: Can Computers Develop Schizophrenia?
- PsychWatch: Lobotomy: How Could It Happen?
- MindTech: Putting a Face on Auditory Hallucinations
- MediaSpeak: “Alternative” Mental Health Care
- CHAPTER: 13 Personality Disorders
- “Odd” Personality Disorders
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
- “Dramatic” Personality Disorders
- Antisocial Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
- “Anxious” Personality Disorders
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive-Compulsive Personality Disorder
- Multicultural Factors: Research Neglect
- Are There Better Ways to Classify Personality Disorders?
- The “Big Five” Theory of Personality and Personality Disorders
- “Personality Disorder—Trait Specified”: Another Dimensional Approach
- PUTTING IT TOGETHER: DISORDERS OF PERSONALITY—REDISCOVERED AND RECONSIDERED
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: Mass Murders: Where Does Such Violence Come From?
- MediaSpeak: The Patient as Therapist
- MindTech: Selfies: Narcissistic or Not?
- InfoCentral: Lying
- CHAPTER: 14 Disorders Common Among Children and Adolescents
- Childhood and Adolescence
- Childhood Anxiety Disorders
- Separation Anxiety Disorder
- Treatments for Childhood Anxiety Disorders
- Childhood Depressive and Bipolar Disorders
- Major Depressive Disorder
- Bipolar Disorder and Disruptive Mood Dysregulation Disorder
- Oppositional Defiant Disorder and Conduct Disorder
- What Are the Causes of Conduct Disorder?
- How Do Clinicians Treat Conduct Disorder?
- Elimination Disorders
- Enuresis
- Encopresis
- Neurodevelopmental Disorders
- Attention-Deficit/Hyperactivity Disorder
- Autism Spectrum Disorder
- Intellectual Disability
- PUTTING IT TOGETHER: CLINICIANS DISCOVER CHILDHOOD AND ADOLESCENCE
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- InfoCentral: Child and Adolescent Bullying
- MindTech: Parent Worries on the Rise
- PsychWatch: Child Abuse
- PsychWatch: A Special Kind of Talent
- PsychWatch: Reading and ‘Riting and ‘Rithmetic
- CHAPTER: 15 Disorders of Aging and Cognition
- Old Age and Stress
- Depression in Later Life
- Anxiety Disorders in Later Life
- Substance Misuse in Later Life
- Psychotic Disorders in Later Life
- Disorders of Cognition
- Delirium
- Alzheimer’s Disease and Other Neurocognitive Disorders
- Issues Affecting the Mental Health of the Elderly
- PUTTING IT TOGETHER: CLINICIANS DISCOVER THE ELDERLY
- CLINICAL CHOICES
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: The Oldest Old
- InfoCentral: The Aging Population
- MindTech: Remember to Tweet; Tweet to Remember
- MediaSpeak: Focusing on Emotions
- CHAPTER: 16 Law, Society, and the Mental Health Profession
- Law and Mental Health
- How Do Clinicians Influence the Criminal Justice System?
- How Do the Legislative and Judicial Systems Influence Mental Health Care?
- In What Other Ways Do the Clinical and Legal Fields Interact?
- What Ethical Principles Guide Mental Health Professionals?
- Mental Health, Business, and Economics
- Bringing Mental Health Services to the Workplace
- The Economics of Mental Health
- Technology and Mental Health
- The Person Within the Profession
- PUTTING IT TOGETHER: OPERATING WITHIN A LARGER SYSTEM
- KEY TERMS
- QUICK QUIZ
- LAUNCHPAD
- PsychWatch: Famous Insanity Defense Cases
- PsychWatch: Serial Murderers: Madness or Badness?
- MindTech: New Ethics for a Digital Age
- InfoCentral: Personal and Professional Issues
- Glossary
- A
- B
- C
- D
- E
- F
- G
- H
- I
- K
- L
- M
- N
- O
- P
- Q
- R
- S
- T
- U
- V
- W
- References
- Credits
- Name Index
- A
- B
- C
- D
- E
- F
- G
- H
- I
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- S
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- U
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- W
- X
- Y
- Z
- Subject Index
- A
- B
- C
- D
- E
- F
- G
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- M
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- W
- X
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- Back endpaper
- Inside Back Cover
- Back Cover
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- 2016-12-20T20:50:01+0000
- Preflight Ticket Signature
