DB5 - Chapter 5: Trauma

Gillianrich

FundamentalsofAbnormalPsychologyNinthEdition.c212.pdf

Home >Psychology homework help >DB5 - Chapter 5: Trauma

Fundamentals of Abnormal Psychology ninth edition

RONALD J. COMER

Princeton University

JONATHAN S. COMER

Florida International University

Senior Vice President, Content Strategy: Charles Linsmeier

Program Director, Social Sciences: Shani Fisher

Executive Program Manager: Matt Wright

Senior Development Editor: Mimi Melek

Assistant Editor: Un Hye Kim

Senior Marketing Manager: Clay Bolton

Marketing Assistant: Chelsea Simens

Director of Media Editorial & Assessment, Social Sciences: Noel Hohnstine

Media Editor: Stefani Wallace

Media Project Manager: Eve Conte

Director, Content Management Enhancement: Tracey Kuehn

Senior Managing Editor: Lisa Kinne

Senior Content Project Manager: Martha Emry

Senior Workflow Project Supervisor: Susan Wein

Photo Editor: Jennifer Atkins

Permissions Manager: Jennifer MacMillan

Permissions Associate: Michael McCarty

Director of Design, Content Management: Diana Blume

Design Services Manager: Natasha A.S. Wolfe

Cover Design: John Callahan

Text Design and Infographics: Charles Yuen

Layout Designer: Paul Lacy

Art Manager: Matthew McAdams

Composition: Lumina Datamatics, Inc.

Cover: Lucille Clerc/Illustration (USA) Inc.

Library of Congress Control Number: 2018951322

ISBN-13: 978-1-319-20580-5(mobi)

1 2 3 4 5 6 22 21 20 19 18

Worth Publishers

One New York Plaza

Suite 4500

New York, NY 10004-1562

www.macmillanlearning.com

http://www.macmillanlearning.com

With boundless love and appreciation, to Marlene Comer and Jami Furr, who fill our lives with love

and joy.

About the Authors

RONALD J. COMER has been a professor in Princeton University’s Department of Psychology

for the past 44 years, serving also as director of Clinical Psychology Studies and as chair of the

university’s Institutional Review Board. He has recently transitioned to emeritus status at the

university. He has received the President’s Award for Distinguished Teaching at Princeton,

where his various courses in abnormal psychology have been among the university’s most

popular.

Professor Comer is also Clinical Associate Professor of Family Medicine and Community

Health at Rutgers Robert Wood Johnson Medical School. He is 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 the textbooks Fundamentals of Abnormal Psychology (ninth edition),

Abnormal Psychology (tenth edition), Psychology Around Us (second edition), and Case Studies in

Abnormal Psychology (second edition), Professor Comer has published a range of journal articles

and produced numerous widely used educational video programs, including The Higher

Education Video Library Series, The Video Anthology for Abnormal Psychology, Video Segments in

Neuroscience, Introduction to Psychology Video Clipboard, and Developmental Psychology Video

Clipboard.

Professor Comer was an undergraduate at the University of Pennsylvania and a graduate

student at Clark University. He currently lives in Lawrenceville, New Jersey, with his wife

Marlene. From there he can keep a close eye on the often-frustrating Philadelphia sports teams

with whom he grew up.

JONATHAN S. COMER is a professor of psychology at Florida International University,

where he also directs the Mental Health Interventions and Technology (MINT) Program. He is -

President of the Society of Clinical Psychology (Division 12 of the American Psychological

Association) and a leader in the field of clinical child and adolescent psychology. The author of

130 scientific papers and chapters, he has received career awards from the American

Psychological Association, the Association for Psychological Science, and the Association for

Behavioral and Cognitive Therapies for his research on innovative treatment methods, childhood

anxiety and disruptive behaviors, and the impact of traumatic stress, disasters, and terrorism on

children. His current work also focuses on ties between psychopathology, neurocircuitry, and the

intergenerational transmission of psychological problems.

In addition to Fundamentals of Abnormal Psychology (ninth edition), Professor Comer has

authored Abnormal Psychology (tenth edition) and Childhood Disorders (second edition) and

edited The Oxford Handbook of Research Strategies for Clinical Psychology, among other books. He

serves as Associate Editor of the journal Behavior Therapy and is on the Board of Directors of the

Society of Clinical Child and Adolescent Psychology. He is a Fellow of the American

Psychological Association, the Society of Clinical Psychology, and the Society for Child and

Family Policy and Practice. He is also a practicing clinical psychologist.

Professor Comer was an undergraduate at the University of Rochester and a graduate student

at Temple University. He currently lives in South Florida with his wife Jami and their children

Delia and Emmett. He loves music—both playing and listening—and enjoys keeping an eye on

the often-frustrating Philadelphia sports teams that his father taught him to love/hate.

Brief Contents Abnormal Psychology in Science and Clinical Practice

1 Abnormal Psychology: Past and Present

2 Models of Abnormality

3 Clinical Assessment, Diagnosis, and Treatment

Problems of Anxiety and Mood

4 Anxiety, Obsessive-Compulsive, and Related Disorders

5 Disorders of Trauma and Stress

6 Depressive and Bipolar Disorders

7 Suicide

Problems of the Mind and Body

8 Disorders Featuring Somatic Symptoms

9 Eating Disorders

10 Substance Use and Addictive Disorders

11 Sexual Disorders and Gender Variations

Problems of Psychosis

12 Schizophrenia and Related Disorders

Life-Span Problems

13 Personality Disorders

14 Disorders Common Among Children and Adolescents

15 Disorders of Aging and Cognition

Conclusion

16 Law, Society, and the Mental Health Profession

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

Recent Decades and 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

Alternative Research Designs

What Are the Limits of Clinical Investigations?

Protecting Human Participants

Moving Forward

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Verbal Debuts

PSYCHWATCH Marching to a Different Drummer: Eccentrics

INFOCENTRAL Happiness

MINDTECH The Use and Misuse of Social Media

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 Cognitive-Behavioral Model

The Behavioral Dimension

The Cognitive Dimension

The Cognitive-Behavioral Interplay

Assessing the Cognitive-Behavioral 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

Integrating the Models: The Developmental Psychopathology Perspective

Key Terms

Quick Quiz

LaunchPad

... TRENDING TV Drug Ads Come Under Attack

INFOCENTRAL Mindfulness

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

What Lies Ahead for Clinical Assessment?

Key Terms

Quick Quiz

LaunchPad

MINDTECH Psychology’s WikiLeaks?

... TRENDING The Truth, the Whole Truth, and Nothing but the Truth

INFOCENTRAL DSM: The Bigger Picture

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-Behavioral 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-Behavioral Perspective

Obsessive-Compulsive Disorder

What Are the Features of Obsessions and Compulsions?

The Psychodynamic Perspective

The Cognitive-Behavioral Perspective

The Biological Perspective

Obsessive-Compulsive-Related Disorders

Integrating the Models: The Developmental Psychopathology Perspective

Key Terms

Quick Quiz

LaunchPad

... TRENDING Separation Anxiety Disorder, Not Just For Kids Anymore

INFOCENTRAL Fear

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

Getting a Handle on Trauma and Stress

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Sexual Assault

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

The Psychological Models of Unipolar Depression

The Sociocultural Model of Unipolar Depression

Integrating the Models: The Developmental Psychopathology Perspective

Bipolar Disorders

What Are the Symptoms of Mania?

Diagnosing Bipolar Disorders

What Causes Bipolar Disorders?

What Are the Treatments for Bipolar Disorders?

Making Sense of All That Is Known

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Sadness at the Happiest of Times

INFOCENTRAL Exercise and Dietary Supplements

MINDTECH Texting: A Relationship Buster?

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 Interpersonal 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?

Psychological and Biological Insights Lag Behind

Key Terms

Quick Quiz

LaunchPad

... TRENDING Internet Horrors

INFOCENTRAL The Right to Die by Suicide

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-Behavioral Interventions

Support Groups and Emotion Expression

Combination Approaches

Expanding the Boundaries of Abnormal Psychology

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Munchausen Syndrome by Proxy

MINDTECH Can Social Media Spread “Mass Hysteria”?

INFOCENTRAL Sleep and Sleep Disorders

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-Behavioral 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

Prevention of Eating Disorders: Wave of the Future

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Body Dissatisfaction

MINDTECH Dark Sites of the Internet

... TRENDING Shame on Body Shamers

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

The Developmental Psychopathology View

How Are Substance Use Disorders Treated?

Psychodynamic Therapies

Cognitive-Behavioral Therapies

Biological Treatments

Sociocultural Therapies

Other Addictive Disorders

Gambling Disorder

Internet Gaming Disorder: Awaiting Official Status

New Wrinkles to a Familiar Story

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH College Binge Drinking: An Extracurricular Crisis

... TRENDING The Opioid Crisis

INFOCENTRAL Smoking, Tobacco, and Nicotine

CHAPTER 11

Sexual Disorders and Gender Variations

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 Variations

Transgender Functioning

Gender Dysphoria

Personal Topics Draw Public Attention

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Sex Throughout the Life Cycle

PSYCHWATCH Sexism, Viagra, and the Pill

MINDTECH “Sexting”: Healthy or Pathological?

CHAPTER 12

Schizophrenia and Related Disorders

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

Developmental Psychopathology View

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

An Important Lesson

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Hallucinations

PSYCHWATCH Postpartum Psychosis: A Dangerous Syndrome

PSYCHWATCH Lobotomy: How Could It Happen?

MINDTECH Putting a Face on Auditory Hallucinations

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”: DSM-5’s Proposed Dimensional Approach

Rediscovered, Then Reconsidered

Key Terms

Quick Quiz

LaunchPad

... TRENDING Mass Murders: Where Does Such Violence Come From?

MINDTECH Selfies: Narcissistic or Not?

INFOCENTRAL The Dark Triad

CHAPTER 14

Disorders Common Among Children and Adolescents

Childhood and Adolescence

Childhood Anxiety Disorders

Separation Anxiety Disorder and Selective Mutism

Treatments for Childhood Anxiety Disorders

Depressive and Bipolar Disorders During Childhood

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

Clinicians Discover Childhood and Adolescence

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Child and Adolescent Bullying

PSYCHWATCH Child Abuse

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

Clinicians Discover the Elderly

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH The Oldest Old

INFOCENTRAL The Aging Population

MINDTECH Remember to Tweet; Tweet to Remember

... TRENDING Damaging the Brain: Football and CTE

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

Within a Larger System

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Famous Insanity Defense Cases

PSYCHWATCH Serial Murderers: Madness or Badness?

... TRENDING Doctor, Do No Harm

INFOCENTRAL Personal and Professional Issues

Glossary

References

Credits

Name Index

Subject Index

Preface Ron Comer

I thought it was cute when my 13-year-old son Jon sometimes sat in on my 400-student

Abnormal Psychology lectures at Princeton, interesting when he took his first psychology course

at the University of Rochester, amusing when his undergraduate abnormal psychology course

used my textbook, troubling when he autographed copies of the book for his classmates,

surprising when he decided to major in psychology, and very satisfying when he entered the

clinical psychology graduate program at Temple University. However, what Jon has

accomplished professionally from that point forward has been nothing short of mind-boggling to

me, and I am not easily mind-boggled.

He has become one of today’s most productive and influential researchers, a leader in the

clinical field, a magnificent teacher, and a deeply caring and wise clinician. Little of this has to do

with me and everything to do with his intellectual gifts and remarkable work ethic, and the giants

in the field who have mentored him over the years—particularly Dave Barlow, Phil Kendall,

Dante Cicchetti, Bill Pelham, Anne Marie Albano, and Mark Olfson. Nevertheless, I’ll take it.

At some point during Jon’s flourishing career at Boston University and now Florida

International University, an unstated question began to emerge: Should he join me as co-author

on my abnormal psychology textbooks Fundamentals of Abnormal Psychology and Abnormal

Psychology? I had never entertained the possibility of having a co-author during my 35 years of

writing these textbooks; and anyway, I believed Jon was too busy making his mark on the field,

receiving multiple career awards from the American Psychological Association and other

organizations, being elected President of the APA’s Society of Clinical Psychology, writing over

130 scientific papers, and the like. But, as the saying goes, “If you want to make God laugh, tell

Him your future plans.” Lo and behold, Jon and I are now co-authors of these books.

Ultimately, the decision to ask Jon to join me in this endeavor was a natural one. As textbook

authors grow older, publishers seek out possible co-authors (for reasons that shall go unstated in

order to protect my fragile ego and growing sense of mortality). It was clear to me that the ideal

co-author would have to be a highly accomplished researcher and writer who would complement

my particular areas of expertise and bring special knowledge in such areas as the developmental

psychopathology perspective, technology-driven and novel treatment interventions, cognitive-

behavioral approaches, brain circuitry, and more. And it was obvious that Jon was that person.

Moreover, Jon was receiving offers from various publishing companies to author their abnormal

psychology textbooks, and the notion of having a Comer textbook competing with another

Comer textbook was simply too much for me to bear (did I mention my fragile ego?). And, of

course, personally, the possibility of collaborating with someone whom I respect deeply and love

greatly was too alluring to pass up. Thus, with the current editions of Fundamentals of Abnormal

Psychology and Abnormal Psychology, Jon and I have begun a new journey, from which, we hope

and believe, readers will learn much and profit greatly.

Jon Comer

Roughly two decades ago, I entered the University of Rochester with the intention of studying

music. But I soon realized that, despite my continuing love of music, the study of clinical

psychology fascinated me most. Two pivotal undergraduate experiences brought the clinical field

to life for me and prompted me to realize that work in this area should eventually be at the center

of my professional life.

The first experience was taking a psychology course with (and later working in the laboratory

of) Dante Cicchetti, the contagiously passionate researcher and professor who introduced me to

developmental psychopathology—his “neurons-to-neighborhoods” perspective that focuses on

how dynamic interactions among psychological, biological, and sociocultural factors unfold

across time to produce both normal and abnormal human functioning. I was excited by the

power of this comprehensive perspective to explain individual differences, embrace interacting

causal factors, and meaningfully inform prevention and treatment interventions. To this day, the

developmental psychopathology perspective explicitly guides much of my research and thinking.

The second influential undergraduate experience was the power of a unique textbook. In the

fall of my sophomore year, I enrolled in an abnormal psychology course and found a familiar

name on the syllabus: “Comer”. . . as in “the required text for this course is Ronald Comer’s

Abnormal Psychology (Second Edition).” At the time I did not have a particularly deep

understanding of my father’s work. I knew he worked very hard writing this book and that a

great many colleges and universities had adopted it, but I had never sat down to read more than a

few paragraphs here or there. But now, his book, cover-to-cover, was on my list of required

readings.

As I read through the chapters for class, I became captivated by the book’s engaging writing

style, empathic descriptions of people with psychological disorders, blend of clinical research and

practice, and strategic incorporation of current events and popular culture. I was also struck by

how the book translated complex ideas into highly readable and easy to digest material. The book

managed to present clinical psychology as a vibrant and evolving science, with many of the

biggest answers still ahead. I was hooked; this was the field for me.

I recognize that it may seem like I was biased to be so favorably disposed toward this

particular textbook, given the family connection. However, I would actually suggest the opposite

—I was in my late teens at the time, and I must confess that I was not exactly looking to give my

father copious credit for much during those years.

Over the past 20 years, from my time as a young undergraduate to my current academic and

professional roles, I have been continually reminded that I am far from alone in my experiences

with this extraordinary text. Countless individuals, from college freshmen to many of the field’s

senior leaders, have approached me to tell me what a special experience they have had with my

father’s textbook—whether as a student, as an instructor, or (like myself) as both.

When the opportunity arose to join Fundamentals of Abnormal Psychology and Abnormal

Psychology as a co-author, it was a no-brainer for me. It has been a privilege to bring my particular

background and areas of expertise to help expand these already outstanding books. For example,

together my father and I have worked to incorporate the increasingly influential developmental

psychopathology perspective throughout the books, along with a contemporary emphasis on

biopsychosocial accounts of abnormality. As an instructor in psychology, I have always taken

seriously my role as an ambassador for this field, someone who can introduce a captivating field

to students, excite them about it, and provide them with insights that can influence their

continued intellectual and professional development. Co-authoring the new editions of

Fundamentals of Abnormal Psychology and Abnormal Psychology has provided me with a special

opportunity to expand this ambassadorship and to reach a greater number of students than I

could have previously imagined. I am very appreciative.

On a more personal note, the greatest joy of undertaking this project has been to do so under

the mentorship of my father, Ronald Comer—a peerless educator and writer who has helped

teach and cultivate so many individuals over the years. Working with him has given me a coveted

front row seat to learn from the “master” about how to best communicate the complexities of the

field and how to respectfully portray mental dysfunction and human suffering, all with his

unique blend of empathy, dignity, and humor. He has mentored me on this project—as he has

throughout so many experiences of my life—with great wisdom, common sense, patience,

selflessness, and love. This field has no shortage of individuals who feel fortunate to have been

touched by his inimitable gifts. But no one more so than me.

Ron & Jon Comer

Between Fundamentals of Abnormal Psychology and Abnormal Psychology, the current textbook

represents the nineteenth edition of one or the other of the books. This textbook journey has

been a labor of love, but also one in which each edition is accompanied by an enormous amount

of work and ridiculous pressure, not to mention countless sleepless nights. We mention these

labors not only because we are world-class whiners but also to emphasize that we approach each

edition as a totally new undertaking rather than as a superficial update of past editions. Our goal

is to make each edition fresh by approaching our content coverage and pedagogical offerings as if

we were writing a completely new book. As a result, each edition includes cutting-edge content

reflecting new developments in the field, as well as in the world around us, delivered to readers

via innovative and enlightening pedagogical techniques.

With this in mind, and with the addition of Jon’s areas of expertise, we have added much 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 students and instructors. The result is, we believe, a book that

will excite readers and speak to them and their times. We have tried to convey our passion for the

field of abnormal psychology, and we have built on the generous feedback of our colleagues in

this undertaking—the students and professors who have used this textbook over the years.

New and Expanded Features This edition of Fundamentals of Abnormal Psychology reflects the many changes that have

occurred over the past several years in the fields of abnormal psychology, education, and

publishing, and in the world. Accordingly, we have introduced a number of new features and

changes to the current edition.

•NEW• Developmental Psychopathology Perspective The developmental psychopathology

perspective is introduced and applied throughout the book (for example, pages 68–69, 135–136,

151–152, and 317–318). This cutting-edge perspective—the clinical field’s leading integrative

perspective—uses a developmental framework to bring together the explanations and treatments

of the various models, explaining how biological, psychological, and sociocultural factors may

intersect and interact at key points throughout the life span to help produce both normal and

abnormal functioning. Over the course of our discussions, readers will also come to appreciate

that developmental factors are typically at work in both adult and child psychopathology. They

will also come to recognize this perspective’s principles of prevention, resilience, equifinality, and

multifinality.

•NEW• Brain Circuitry Brain circuits are now at the center of the textbook’s biological

discussions of anxiety, posttraumatic stress, depressive, personality, and other disorders (for

example, pages 38, 111, 125, 132, 149, 180, and 316–317). Over the past decade, researchers

have made striking discoveries about brain circuits—networks of brain structures whose

interconnectivity produces distinct behaviors, cognitions, and emotions. We discuss the

particular kinds of brain circuit dysfunction that contribute to each of the psychological

disorders. At the same time, we clarify how genetic factors, neurotransmitter activity, brain

anatomy, and immune functioning interface with the operation of the brain circuits to produce

psychological dysfunction.

•NEW• The Cognitive-Behavioral Model: Merging the Behavioral and Cognitive

Perspectives We now merge behavioral and cognitive explanations and treatments into a

cohesive and nuanced cognitive-behavioral model, consistent with today’s most prominent point

of view. Previous editions presented behavioral and cognitive discussions separately to help

readers understand the important distinctions between behavior-focused and cognition-focused

principles and research. This edition’s more integrated presentations of the cognitive-behavioral

model enable readers to better appreciate why today’s cognitive-behavioral theorists and

practitioners include both behavioral and cognitive principles in their work and the

complementary and interactive nature of behavioral and cognitive principles.

In addition, in this edition of Fundamentals of Abnormal Psychology we further expand our

coverage of “new wave” cognitive-behavioral theories and therapies, including mindfulness-based

interventions and Acceptance and Commitment Therapy (ACT) (for example, pages 53–54, 110,

195, and 389).

•NEW• “Trending” Boxes Throughout this edition, we present Trending boxes in addition to

the PsychWatch boxes and MindTech boxes featured in previous editions. Whereas PsychWatch

boxes explore important topics in the field and MindTech boxes give special attention to

provocative technological issues, the Trending boxes focus on particularly hot topics that are

trending, or current, in abnormal psychology. New Trending boxes include the following:

Separation Anxiety Disorder, Not Just For Kids Anymore (Chapter 4)

Internet Horrors: Live-Streaming of Suicides (Chapter 7)

Shame on Body Shamers (Chapter 9)

The Opioid Crisis (Chapter 10)

Mass Murders: Where Does Such Violence Come From? (Chapter 13)

Damaging the Brain: CTE and Football (Chapter 15)

Doctor Do No Harm: Enhanced Interrogation (Chapter 16)

•NEW• Additional InfoCentrals Our previous edition introduced a feature called InfoCentrals

—numerous lively, full-page infographics on important topics in the field. Given the very

positive reader response to these stimulating visual data offerings, we have included them again in

this edition—updating all of them, substantially changing some, and adding a number of totally

new ones. Brand-new InfoCentrals include the following:

DSM: The Bigger Picture (Chapter 3)

Fear (Chapter 4)

Exercise and Dietary Supplements (Chapter 6)

The Dark Triad (Chapter 13, page 429)

•NEW• Additional and Expanded Topic Coverage Over the past several years, a number of

topics in abnormal psychology have received special attention. In this edition, we have provided

new or expanded sections on these topics, including the impact of changing health care laws (pages

18, 516); transgender issues (pages 356–360); PTSD and the #MeToo movement (page 145); social

media–based research (pages 31, 122); mass murders (page 408); resilience and the Parkland,

Florida, school shootings (page 151); terrorism and mental health (pages 145–146, 514); cognitive

processing therapy (page 154); prolonged exposure therapy (page 154); exercise and mental health

(page 182); the interpersonal theory of suicide (pages 223–224); the implicit association test for

suicidal risk (page 234); teenage eating habits (page 280); body shaming (page 288); motivational

interviewing (page 283); the opioid crisis (page 302); addiction to prescription pain relievers (pages

301–302); community naloxone treatments for drug overdoses (page 321); recreational cannabis laws

(pages 311–312); contingency management treatment (page 320); erotomanic delusions (page 370);

disorders among the offspring of older fathers (pages 205, 389); cognitive remediation for

schizophrenia (page 387); mental health courts (page 392); mentalization (pages 413–414); selective

mutism (pages 439–440); parent management training (page 446); joint attention (page 456);

biomarkers for Alzheimer’s disease (page 486); chronic traumatic encephalopathy (page 488);

outpatient civil commitment (pages 500, 504); and psychologists and enhanced interrogations (page

514).

•NEW• Additional Focus on Technology In this edition we have expanded the previous

edition’s focus on the psychological impact of technology and the use of new technology in

treatment. In text discussions, MindTech boxes, photographs, and figures throughout the book,

we examine many additional technology topics such as telemental health (pages 20, 517–518),

Internet social media–based research (page 31), videoconferencing and parent-management

training (page 446), and live streaming of suicides (page 216).

•NEW• Case Material Over the years, one of the hallmarks of Fundamentals of Abnormal

Psychology has been the inclusion of numerous and culturally diverse clinical examples that bring

theoretical and clinical issues to life. In our continuing quest for relevance to the reader and to

today’s world, we have replaced or revised many of the clinical examples in this edition (for

example, pages 349–350, 410, 415, and 423).

•NEW• Additional Critical Thought Questions Critical thought questions have long been a

stimulating feature of Fundamentals of Abnormal Psychology. These questions pop up within the

text narrative, asking students to pause at precisely the right moment and think critically about

the material they have just read. We have added a number of new such questions throughout this

edition.

•NEW• Additional “Hashtags” This edition retains a fun and thought-provoking feature that

has been very popular among students and professors over the years—reader-friendly Hashtags

(#), previously called Between the Lines. Hashtags consist of surprising facts, current events,

historical notes, interesting lists, and quotes that are strategically placed in the book’s margins.

Numerous new Hashtags have been added to this edition.

•NEW• Thorough Update In this edition we present the most current theories, research, and

events, and include more than 2,000 new references from the years 2017–2019, as well as

numerous new photos, tables, and figures.

•EXPANDED COVERAGE• Prevention and Mental Health Promotion In accord with the

clinical field’s growing emphasis on prevention, positive psychology, and psychological wellness,

we have increased the textbook’s attention to these important approaches (for example, pages 16,

70, and 492).

•EXPANDED COVERAGE• Multicultural Issues Consistent with the field’s continuing

appreciation of the impact of ethnicity, race, gender, gender identity, and other cultural factors

on psychological functioning, this edition further expands its coverage of the multicultural

perspective and includes additional multicultural material and research throughout the text (for

example, pages 66–67, 281–282, 427–428, and 453–454). 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.

Continuing Strengths As we noted earlier, in this edition we have also retained the themes, material, and techniques

that have worked successfully for and been embraced enthusiastically by past readers.

Breadth and Balance The field’s many theories, studies, disorders, and treatments 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 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. We

have tried therefore to write always with empathy and to impart this awareness to students.

Pervasive Coverage of Treatment Discussions of treatment are presented 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 we mentioned earlier, the textbook features hundreds of culturally diverse

clinical examples to bring theoretical and clinical issues to life.

DSM-5 This edition continues to include discussions of DSM-5 throughout the book,

highlighting the classification system’s flaws as well as its utility. In addition to weaving DSM-5

categories, criteria, and information into the narrative of each chapter, we regularly provide a

reader-friendly pedagogical feature called Dx Checklist to help students fully grasp DSM-5 and

related diagnostic tools (for example, pages 89–93, 102, 120, 187, and 248).

Margin Glossary Hundreds of key words are defined in the margins of pages on which the words

appear. In addition, a traditional glossary is featured at the back of the book.

Focus on Critical Thinking The textbook provides various tools for thinking critically about

abnormal psychology. As we mentioned earlier, for example, “critical thought” questions appear

at carefully selected locations within the text discussion, asking readers to stop and think critically

about the material they have just read.

Striking Photos and Stimulating Illustrations Once again, the textbook features a wide range of

truly stunning photographs, diagrams, graphs, and anatomical figures that bring to life the

discussions of various concepts, disorders, and treatments. The carefully chosen photos range

from historical to today’s world to pop culture. They do more than just illustrate topics: they

touch and move readers and enhance understanding.

Adaptability Chapters are self-contained, so they can be assigned in any order that makes sense

to the professor.

Supplements We are delighted by the enthusiastic responses of both professors and students to the

supplements that have accompanied Fundamentals of Abnormal Psychology over the years. This

edition offers those supplements once again, revised and enhanced, and adds a number of

exciting new ones.

For Professors Worth Video Collection for Abnormal Psychology 2.0 Produced and edited by Ronald J. Comer,

Princeton University, and Gregory P. Comer, Princeton Academic Resources. Faculty Guide included.

This incomparable video package offers more than 125 clips on different kinds of clinical events,

psychopathologies, and treatments. More than 50 new videos have been added to this edition on

current topics such as the national opioid crisis, the impact of body shaming, mindfulness-based

interventions, transgender issues, borderline personality disorder, dialectical behavior therapy, cell

phone addiction, gaming addiction, acceptance and commitment therapy, binge-eating disorder,

training police for mental health interventions, mental health courts, and CTE and football.

These cutting-edge videos are available on LaunchPad and on the Video Collection for Abnormal

Psychology 2.0 flash drive. The package is accompanied by a guide that fully describes each video

clip, so that professors can make informed decisions about the use of the segments in lectures.

Instructor’s Resource Manual by Jeffrey B. Henriques, University of Wisconsin–Madison and Laurie

A. Frost. This comprehensive guide, revised by an experienced instructor and a clinician, ties

together the ancillary package for professors and teaching assistants. The manual includes

detailed chapter outlines, lists of principal learning objectives, ideas for lectures, discussion

launchers, classroom activities, extra credit 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 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.

iClicker Classroom Response System This is a versatile polling system developed by educators

for educators that makes class time more efficient and interactive. iClicker allows you to ask

questions and instantly record your students’ responses, take attendance, and gauge students’

understanding and opinions. A set of iClicker Questions for each chapter is available online and

in LaunchPad.

Image Slides and Tables These slides, featuring all chapter photos, illustrations, and tables, can

be used as is or customized to fit a professor’s needs.

Chapter Figures and Photos This collection gives professors access to all of the photographs,

illustrations, and alt text from Fundamentals of Abnormal Psychology, Ninth Edition.

Assessment Tools Computerized Test Bank powered by Diploma, includes a full assortment of test items. Each

chapter features over 200 questions to test students at several levels of Bloom’s taxonomy. All the

questions are tagged to the outcomes recommended in the 2013 APA Guidelines for the

Undergraduate Psychology Major, Bloom’s level, the book page, the chapter section, and the

learning objective from the Instructor’s Resource Manual. The Diploma 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,

Ninth Edition.

For Students Case Studies In Abnormal Psychology, Second Edition, by Ethan E. Gorenstein, Behavioral

Medicine Program, New York–Presbyterian Columbia Hospital, and Ronald J. Comer, Princeton

University. This edition of our popular case study book provides 20 case histories, each going

beyond diagnoses to describe the individual’s history and symptoms, theories behind treatment, a

specific treatment plan, and the actual treatment conducted. The casebook also provides three

cases without diagnoses or treatment so that students can identify disorders and suggest

appropriate therapies. Wonderful case material for somatic symptom disorder, hoarding disorder,

and gender dysphoria has been added by Danae Hudson and Brooke Whisenhunt, professors at

Missouri State University.

with LearningCurve Quizzing—Multimedia to Support Teaching and

Learning Available at www.launchpadworks.com

A comprehensive Web resource for teaching and learning psychology, LaunchPad combines

Worth Publishers’ award-winning media with an innovative platform for easy navigation. For

students, it is the ultimate online study guide, with rich interactive tutorials, videos, an e-book,

and the LearningCurve adaptive quizzing system. For instructors, LaunchPad is a full-course

space where class documents can be posted, quizzes can be 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.

http://www.launchpadworks.com

LaunchPad to accompany Fundamentals of Abnormal Psychology, Ninth Edition, can be

previewed at www.launchpadworks.com. Fundamentals of Abnormal Psychology, Ninth Edition,

and LaunchPad can be ordered together with:

ISBN-10: 1-319-25126-9

ISBN-13: 978-1-319-25126-0

LaunchPad for Fundamentals of Abnormal Psychology, Ninth Edition, includes the following

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 game-like interface to engage students in a learning experience that is unique to each student. Each LearningCurve quiz is fully integrated with other resources in LaunchPad through the Personalized Study Plan, so students will be able to review the material 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 that of 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 Immersive Learning Activities by Taryn Myers, Virginia Wesleyan University. This edition polishes and streamlines Clinical Choices, the well-received interactive case studies available through LaunchPad, our online course-management system. Through an immersive mix of video, audio, and assessment, each of the 11 Clinical Choices case studies allows students to simulate the thought process of a clinician by identifying and evaluating a virtual “client’s” symptoms, gathering information about the client’s life situation and family history, determining a diagnosis, and formulating a treatment plan.

Abnormal Psychology Video Activities, by Ronald J. Comer, Princeton University; Jonathan S. Comer, Florida International University; and Taryn Myers, Virginia Wesleyan. These intriguing video cases run 3 to 7 minutes each and focus on people affected by disorders discussed in the text. Students first view a video case and then answer a series of thought- provoking questions.

Research Exercises in each chapter help stimulate critical thinking skills. Students are asked to consider real research, make connections among ideas, and analyze arguments and the evidence on which they are based.

Deep integration is available between LaunchPad products and Blackboard, Brightspace by Desire2Learn, 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 customization capability within their learning management system.

•NEW• Achieve Read & Practice with LearningCurve Quizzing—Achieve Read & Practice is

the marriage of Worth’s LearningCurve adaptive quizzing and our mobile, accessible e-book in

one easy-to-use and affordable product.

With Achieve Read & Practice, instructors can arrange and assign chapters and sections from

the e-book in any sequence they prefer, assign the readings to their class, and track student

performance.

Assignments come with LearningCurve quizzes offering individualized and adaptive question

sets, immediate feedback, and e-book references for correct and incorrect answers. If students

struggle with a particular topic, they are encouraged to reread the material and check their

understanding by answering a few short additional questions before being given the option to

quiz themselves again.

The Read & Practice Gradebook provides analytics for student performance individually and

for the whole class, by chapter, section, and topic, helping instructors prepare for class and one-

on-one discussions.

Fundamentals of Abnormal Psychology and Read & Practice can be ordered together with

ISBN-10: 1-319-25132-3

ISBN-13: 978-1-319-25132-1

The Loose-leaf Edition of Fundamentals of Abnormal Psychology and Read & Practice can be

ordered together with

ISBN-10: 1-319-25130-7

ISBN-13: 978-1-319-25130-7

Acknowledgments We are very grateful to the many people who have contributed to writing and producing this

book. We particularly thank Gregory Comer for his outstanding work on a range of text and

digital materials. In addition, we are indebted to Marlene Glissmann and Jean Erler for their fast,

furious, and fantastic work on the references.

We are 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: Seth A. Brown, University of Northern Iowa; Andrea Cartwright, Jefferson Community

& Technical College; Gisele Casanova, Purdue University Northwest; Lauren Dattilo, University

of South Carolina; Andrea Glenn, University of Alabama; Amanda Haliburton, Virginia

Polytechnic Institute and State University; Jacqueline Heath, Ohio State University; Robert

Hoople, Ivy Tech Community College of Indiana; Rick Ingram, The University of Kentucky;

Joni Jecklin, Heartland Community College; Kristin Juarez, Cochise College; Julia Kim-Cohen,

University of Illinois–Chicago; Terese Landry, Houston Community College; Vance Maloney,

Taylor University; Donna Marie McElroy, Atlantic Cape Community College; Jane-Marie

McKinney, Gordon State College; Alejandro Morales, California State Polytechnic University,

Pomona; Justin Peer, University of Michigan–Dearborn; Christopher Schulte, Coastal Carolina

Community College; Jerome Short, George Mason University; LaTishia Smith, Ivy Tech

Community College of Indiana; Caroline Stanley, Bridgewater State University; Helen Taylor,

Bellevue College; Sandra Terneus, Tennessee Tech University; Joseph Vielbig, Arizona Western

College; BJ Wallace, Albright College; Shannon Williams, Prince George’s Community College.

Earlier we 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 we

gratefully acknowledge their important contributions: Christopher Adams, Fitchburg State

University; Dave W. Alfano, Community College of Rhode Island; Jeffrey Armstrong,

Northampton Community College; Alisa Aston, University of North Florida; Kent G. Bailey,

Virginia Commonwealth University; Stephanie Baralecki, Chestnut Hill College; Sonja Barcus,

Rochester College; Wendy Bartkus, Albright College; Marna S. Barnett, Indiana University of

Pennsylvania; Jennifer Bennett, University of New Mexico; 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; Christine Browning, Victory University; Gregory M. Buchanan, Beloit

College; Jeffrey A. Buchanan, Minnesota State University, Mankato; Laura Burlingame-Lee,

Colorado State University; Loretta Butehorn, Boston College; Glenn M. Callaghan, San José

State University; E. Allen Campbell, University of St. Francis; Julie Carboni, San Jose Christian

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; Megan Davies, NOVA, Woodbridge

Campus; Pernella Deams, Grambling State University; Lauren Doninger, Gateway Community

College; Pernella Deams, Grambling State University; 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; Frederick Ernst, University of Texas, Pan American;

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,

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, James Madison University; James Hansell, University of Michigan;

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; Abby Hill, Trinity International University; Tony Hoffman,

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; Jessica Goodwin Jolly, Gloucester County College; 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; Craig Knapp, College of St. Joseph; Futoshi Kobayashi, Northern State University;

Alan G. Krasnoff, University of Missouri, St. Louis; Sally Kuhlenschmidt, Western Kentucky

University; 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;

Paul Lewis, Bethel College; 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; Gregory Mallis,

University of Indianapolis; 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; F. 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; Taryn Myers, Virginia Wesleyan

University; Sandy Naumann, Delaware Technical Community College; David Nelson, Sam

Houston State University; Hansjörg Neth, Rensselaer Polytechnic Institute; 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; Edward O’Brien, Marywood 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; Mary Pelton-Cooper, Northern Michigan University; 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; Ginger Pope, South Piedmont

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; Lisa Riley, Southwest Wisconsin Technical College; 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; Ty Schepis, Texas State University; Elizabeth Seebach, Saint Mary’s

University of Minnesota; George W. Shardlow, City College of San 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 & State University; Deborah Stipp, Ivy Tech Community College;

Joanne H. Stohs, California State University, Fullerton; Jaine Strauss, Macalester College;

Mitchell Sudolsky, University of Texas, Austin; John Suler, Rider University; Sandra Todaro,

Bossier Parish Community College; Terry Trepper, Purdue University Calumet; Thomas A.

Tutko, San José State University; Maggie VandeVelde, Grand Rapids Community College;

Arthur D. VanDeventer, Thomas Nelson 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.

We would also like to thank a group of talented professors who provided valuable feedback that

shaped the development of our exciting immersive learning activities, Clinical Choices: David

Berg, Community College of Philadelphia; Seth Brown, University of Northern Iowa; Julia

Buckner, Louisiana State University; Robin Campbell, Eastern Florida State University;

Christopher J. Dyszelski, Madison Area Technical College; Paul Deal, Missouri State University;

Urminda Firlan, Kalamazoo Valley Community College; Roy Fish, Zane State College; Julie

Hanauer, Suffolk County Community College; Stephanie Brooke Hindman, Greenville

Technical College; Sally Kuhlenschmidt, Western Kentucky University; Alejandro Morales,

California State Polytechnic University, Pomona; Erica Musser, Florida International University;

Garth Neufeld, Highline Community College; Kruti Patel, Ohio University; and Jeremy Pettit,

Florida International University.

A special thank you to the authors of the book’s supplements package for doing splendid jobs

with their respective supplements: Jeffrey B. Henriques, University of Wisconsin–Madison and

Laurie A. Frost (Instructor’s Resource Manual); Taryn Myers, Virginia Wesleyan University

(Clinical Choices); Joy Crawford, Green River Community College (Practice Quizzes). And thank

you to the contributors from previous editions: 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.

We also extend our deep appreciation to the core team of professionals at Worth Publishers and

W. H. Freeman and Company who have worked with us almost every day for the past year to

produce this edition: Un Hye Kim, assistant editor; Mimi Melek, senior development editor;

Martha Emry, senior content project manager; Paul Lacy, layout designer; and Jennifer Atkins,

photo editor and video researcher. It is accurate to say that these members of the core team were

our co-authors and co-teachers in this enterprise, and we are in their debt.

We also thank the following individuals, each of whom made significant contributions to the

writing and production of this textbook: Chuck Linsmeier, senior vice president, content

strategy; Matt Wright, executive program manager; Jennifer MacMillan, permissions manager;

Susan Wein, senior workflow project supervisor; Shani Fisher, program director, social sciences;

Tracey Kuehn, director of content management enhancement; Diana Blume, director of design;

Blake Logan, designer; John Callahan, cover designer; Natasha Wolfe, design services manager;

Matthew McAdams, art manager; Chuck Yuen, book and InfoCentral designer; Lucille Clerc,

cover and chapter-opener artist; Stefani Wallace, media editor; Noel Hohnstine, director of

media editorial & assessment, social sciences; Michael McCarty, permissions associate; Arthur

Johnson, text permissions researcher; Christine Buese, media permissions manager; Hillary

Newman, director of rights and permissions; Lisa Kinne, senior managing editor; Jean Erler,

copyeditor and references editor; William LaDue, proofreader; and Sherri Dietrich, indexer.

And, of course, not to be overlooked are the superb professionals at Worth Publishers who

continuously work with great passion, skill, and judgment to bring our books to the attention of

professors across the world: Kate Nurre, executive marketing manager; Clay Bolton, senior

marketing manager; Chelsea Simens, marketing assistant; Greg David, senior vice president,

Macmillan Learning sales; and the company’s wonderful sales representatives. Thank you so

much.

Two remaining notes. First, as you can imagine, we have found it more than a little exciting to

work together on this monumental project. But beyond our personal delight, we believe that our

co-authorship brings a valuable blend to the textbook. More than father and son, we are

psychology professors and clinicians at very different points in our lives and careers, with

different areas of expertise and accomplishment, and, at times, different sensibilities. Bridging

such differences in the writing of this book has enabled us to grow enormously—both

professionally and personally. We hope that our collaboration has, likewise, resulted in a special

textbook for our readers.

Finally, both in terms of our textbooks and more generally, we are very aware of just how

fortunate we are. We feel profoundly privileged to be able to work with so many interesting and

stimulating students during this important and exciting stage of their lives. Similarly, we are

grateful beyond words for our dear friends and for our extraordinary family, particularly our

magnificent wives Marlene and Jami (Marlene is also Jon’s mom); our wonderful son/brother,

Greg, and daughter-/sister-in-law, Emily; Jon’s loving parents-in-law, Jim and Mindy Furr; and

the lights of our lives, Delia (age 7) and Emmett (age 5).

Ronald J. Comer

Jonathan S. Comer

January, 2019

CHAPTER 1 Abnormal Psychology: Past and Present

TOPIC OVERVIEW

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: The Somatogenic and Psychogenic Perspectives

Recent Decades and 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 Alternative Research Designs What Are the Limits of Clinical Investigations? Protecting Human Participants

Moving Forward

Johanne 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 facing 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 remains all day in the cramped tent she shares with her daughters. 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 chosen 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 recognize 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 ranting 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 sometimes called psychopathology,

maladjustment, emotional disturbance, or mental illness (see PsychWatch). These terms have been

applied to the many problems that seem closely tied to the human brain or mind. Psychological

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.

PSYCHWATCH

Verbal Debuts

We use words like “abnormal” and “mental disorder” so often that it is easy to forget that there was a

time not that long ago when these terms did not exist. When did these and similar words (including slang terms) make

their debut in print as expressions of psychological dysfunction? The Oxford English Dictionary offers the following dates.

Why do actors who portray characters with psychological

disorders tend to receive more awards for their

performances?

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 abnormal psychology. As in any science, workers in this field, called clinical scientists,

gather information systematically 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.

abnormal psychology The scientific study of abnormal behavior undertaken to describe, predict, explain, and change abnormal patterns of functioning.

Deviance and abnormality This woman, like others from certain tribes in Myanmar (Burma), has permanently tattooed

her entire face with an elaborate pattern of black lines, a tradition that began centuries ago to repel invaders and discourage

kidnappings. In Western society, total facial disfigurement of this kind would break norms and might be considered

abnormal.

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, 2017, 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 conduct 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 key limitations.

Changing times Prior to this century, a woman’s love for race car driving might have been considered strange, perhaps even

abnormal. Then recently retired Danica Patrick (right) became one of America’s finest race car drivers. The size difference

between her first-place trophy at the 2008 Indy Japan 300 auto race and that of second-place male driver Hélio Castroneves

symbolizes just how far women have come in this sport.

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 functioning. Each society establishes norms—stated and unstated

rules for proper conduct. Behavior that breaks legal norms is considered to be criminal. Behavior,

thoughts, and emotions that break norms of psychological functioning are called abnormal.

norms A society’s stated and unstated rules for proper conduct.

Judgments about what constitutes 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.

culture A people’s common history, values, institutions, habits, skills, technology, and arts.

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 following 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

(Dube et al., 2018).

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

catastrophes and disasters, rape, child abuse, war, terminal illness, chronic pain (Compean &

Hamner, 2019; Scott et al., 2018). 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 abnormal. 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.”

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.

Context is key A couple dressed as Supergirl and Superman stop and point upward as they cross a street in New York City.

Their appearance and behavior might suggest psychological dysfunction were it not for the fact that they are attendees at a

2016 Comic-Con, one of the many popular conventions held across the country to showcase comic books, graphic novels,

and the like.

Should we conclude, then, that feelings of distress must always be present before a person’s

functioning can be considered abnormal? Not necessarily. Some people who function 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 honored to be chosen, loved

sending out warnings on the Internet, 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 interferes with daily functioning. 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

#TheirWords “I can calculate the motion of heavenly bodies but not the

madness of people.”

Sir Isaac Newton

perform well in their jobs and enjoy fulfilling relationships, would probably be considered simply

unusual.

Danger Perhaps the ultimate psychological dysfunction is behavior that becomes dangerous 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 functioning, research

suggests that it is actually the exception rather than the rule (Taylor, 2018; Bonnet et al., 2017).

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 typically raise as many questions as they answer.

Ultimately, 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,

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 (Martin & Chaney, 2018; Testa

& Cleveland, 2017). 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.

What behaviors fit the criteria of deviant, distressful,

dysfunctional, or dangerous but would not be considered

abnormal by most people?

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).

PSYCHWATCH

Marching to a Different Drummer: Eccentrics 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 removing 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 (Weeks, 2015; Newman, 2013; Weeks & James, 1995).

Researcher David Weeks (2015) studied 1,000 eccentrics and estimated that as many as 1 in 5,000 persons may be

“classic, full-time eccentrics.” Weeks pinpointed 15 characteristics common to the eccentrics in his study: nonconformity,

creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being different, high intelligence,

outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinions or company, mischievous sense

of humor, nonmarriage, eldest or only child, and poor spelling skills.

Eccentric, but not abnormal Tran Van Hay holds his hair—more than 20 feet in length—around his body, as if it

were a cobra. When he died in 2010, he had not had a haircut for 50 years and had washed his hair only a few times.

The Vietnamese man otherwise lived and worked as a respected and productive herbalist who cared for many people

in need. He just liked his hair on the long side—longer than any other person on earth.

Weeks suggests that eccentrics do not typically suffer from mental disorders. Whereas the unusual behavior of persons

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.

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 abnormality

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? Abnormal functioning is generally considered to be deviant, distressful, dysfunctional, and dangerous. Because

behavior must also be considered in the context in which it occurs, however, 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 psychological

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 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.

treatment A systematic procedure designed to change abnormal behavior into more normal behavior. Also called therapy.

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 treatment or therapy. Those terms are usually reserved for special,

systematic procedures for helping people overcome their psychological difficulties. According to a

pioneering clinical theorist, Jerome Frank, all forms of therapy have three essential features:

1. A sufferer who seeks relief from the healer.

2. A trained, socially accepted healer, whose expertise is accepted by the sufferer 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 seemingly straightforward definition, clinical treatment is surrounded by conflict

and, at times, confusion. 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.

Therapy … not At age 11, Ciro Ortiz set up a “therapy” office each week on a New York City subway platform. Calling

himself the Emotional Advice Kid, he talked to people of all ages with various kinds of psychological issues, charging 2

dollars for a five-minute session. Ciro’s advice may have been therapeutic for many persons, but it was not therapy. The

discussions lacked, for example, a “trained healer” and a series of systematic contacts between healer and sufferer.

SUMMING UP

WHAT IS TREATMENT? Therapy is a systematic process for helping people overcome their psychological difficulties. It typically requires a

patient, a therapist, 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 children and

adolescents in the United States display serious psychological disturbances and are in need of

clinical treatment (Williams et al., 2018; Kessler et al., 2015, 2012, 2009; Merikangas et al.,

2013). 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, resultant losses of employment, the threat of terrorism, or a decline in

religious, family, or other support systems (Elhai et al., 2017). But, as we shall see in the

following sections, every society, past and present, has witnessed psychological abnormality.

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 abnormal behavior as the work of

evil spirits. People in prehistoric societies apparently 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.

Expelling evil spirits The two holes in this skull recovered from ancient times indicate that the person underwent

trephination, possibly for the purpose of releasing evil spirits and curing mental dysfunction.

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 trephination, in which a stone instrument, or trephine, was used

to cut away a circular section of the skull (Verano, 2017; Wang, 2017). 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).

trephination An ancient operation in which a stone instrument was used to cut away a circular section of the skull to treat abnormal behavior.

Later societies also explained abnormal behavior by pointing to possession 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 feigned

madness to convince his enemies that he was visited by divine forces.

The treatment for abnormality in these

What demonological explanations or treatments, besides

exorcism, are still around today, and why do they persist?

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 civilizations

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

(Smith & Smith, 2016). An excess of yellow bile, for example, caused mania, a state of frenzied

activity; an excess of black bile was the source of melancholia, a condition marked by unshakable

sadness.

humors According to the Greeks and Romans, bodily chemicals that influence mental and physical functioning.

To treat psychological dysfunction, Hippocrates sought to correct the underlying physical

pathology. He believed, for instance, that the excess of black bile underlying melancholia could

be reduced by a quiet life, a diet of vegetables, temperance, 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.

“Just tell me about the new continent. I don’t give a damn what you’ve discovered about yourself.”

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.

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 scientific 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 abnormality, 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 (Ruys,

2017; Sluhovsky, 2017, 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 (Lanska, 2018; Corral-Corral & Corral-Corral, 2016). All were

convinced that they had been bitten and possessed by a wolf spider, now called a tarantula, and

they sought to cure their disorder 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.

Bewitched or bewildered? A great fear of witchcraft swept Europe beginning in the 1300s and extending through the

“enlightened” 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” repeatedly until she confesses to witchery.

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, 2017, 2011). If these techniques 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

#DoctorShakespeare Writing during the Renaissance, Shakespeare speculated on the

nature and causes of abnormal behavior in 20 of his 38 plays

and in many of his sonnets.

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 physician 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 continued to improve 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 (Goldstein, 2016; Aring, 1975, 1974). Many patients still live

in foster homes there, interacting with other residents, until they recover.

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 (Philo & Andrews, 2016; 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.

asylum A type of institution that first became popular in the sixteenth century to provide care for persons with mental disorders. Most asylums became virtual prisons.

#MythBuster Although it is popularly believed that a full moon is regularly

accompanied by significant increases in crime, strange and

abnormal behaviors, and admissions to mental hospitals,

decades of research have failed to support this notion.

(Chaput et al., 2016; Bakalar, 2013; McLay et al., 2006)

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.

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 (Arie, 2016; Selling, 1940).

The Nineteenth Century: Reform and Moral Treatment

As 1800 approached, the treatment of

people with mental disorders began to

improve once again. 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 (Sushma &

Tavaragi, 2016; Pelletier & Davidson, 2015). 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 successful. 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 (Rollin & Reynolds, 2018; Kibria & Metcalfe, 2016).

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.

moral treatment A nineteenth-century approach to treating people with mental dysfunction that emphasized moral guidance and humane and respectful treatment.

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 (Brown, 2018; Hopkins, 2014). For example, he

required that the hospital hire intelligent and sensitive attendants 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 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 horrors

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 mental disorders (Stamberg, 2017;

Kazano, 2012). 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.

state hospitals State-run public mental institutions in the United States.

Dance in a madhouse A popular feature of moral treatment was the “lunatic ball.” Hospital 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.

The Decline of Moral Treatment By the 1850s, a number of mental hospitals 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 treatment movement (Bartlett, 2017; Shepherd, 2016). One factor was the speed with

which the movement 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. Moreover, many of the patients entering public mental hospitals in the United States

in the late nineteenth century were poor foreign 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 they were becoming 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.

somatogenic perspective The view that abnormal functioning has physical causes. psychogenic perspective The view that the chief causes of abnormal functioning are psychological.

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

nineteenth century, 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 4, he developed the first modern system for classifying abnormal

behaviors, listing their physical causes and discussing their expected course (Kendler &

Engstrom, 2018; Hoff, 2015).

The more things change … Two patients lie on a table in their cage-like ward at a modern-day mental hospital in Bekasi,

Indonesia, while other patients live with a similar lack of privacy, activity, and sanitation in the wire-walled units behind

them. Despite the passage of Indonesia’s Mental Health Law in 2014, many patients still wind up living under conditions

reminiscent of those that existed in some state hospitals throughout the United States well into the twentieth century.

New biological discoveries also triggered the rise of the somatogenic perspective. One of the

most important discoveries was that an organic disease, syphilis, led to general paresis, an

irreversible disorder with both mental symptoms such as delusions of grandeur and physical ones

like paralysis (Kragh, 2017). In 1897, the German neurologist Richard von Krafft-Ebing (1840–

1902) injected matter from syphilis sores into patients suffering from general paresis and found

that none 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 disappointing results

throughout the first half of the twentieth century. Although many medical 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 the ability of

individuals 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.

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 two years.

Information from: Lombardo, 2017; Stern, 2016; Fischer, 2012; Whitaker, 2002.

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)

established 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 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 (Deeley, 2017; Ellis, 2015). 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 hypnosis. 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

scientists concluded that hysterical disorders were largely psychological in origin, and the

psychogenic perspective rose in popularity.

Hypnotism update Hypnotism, the procedure that opened the door for the psychogenic perspective, continues to influence

many areas of modern life, including 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, however, that hypnotic procedures are

as capable of creating false memories as they are of uncovering real memories.

Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer

#OddName Doctors who treated people with mental disorders in the 18th

century were called “mad-doctors.”

(1842–1925) of Vienna. Breuer, a physician, discovered that his patients sometimes awoke free

of hysterical symptoms after speaking candidly 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 Chapter 3, 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

processes are at the root of such functioning.

psychoanalysis Either the theory or the treatment of abnormal mental functioning that emphasizes unconscious psychological forces as the cause of psychopathology.

Freud also developed the technique of

psychoanalysis, a form of discussion in

which clinicians help troubled people gain

insight into their unconscious

psychological processes. He believed that

such insight, even without hypnotic procedures, would help the patients overcome their

psychological problems. Freud and his followers offered psychoanalytic 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.

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 evidence that Stone Age cultures used trephination 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 explanations of mental disorders.

Hippocrates believed that abnormal behavior was caused by an imbalance of the four bodily fluids, or humors.

In the Middle Ages, 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 continued to improve during

the early part of the Renaissance. Certain religious shrines became dedicated to the humane treatment of such

individuals. By the middle of the sixteenth century, however, persons with mental disorders were being warehoused

in asylums.

Care of those with mental disorders started to improve again in the nineteenth 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.

However, the moral treatment movement 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 perspective and the rise of the psychogenic

perspective. Sigmund Freud’s psychogenic approach, psychoanalysis, eventually gained wide acceptance and

influenced future generations of clinicians.

Recent Decades and Current Trends It would hardly be accurate to say that we now live in a period of great enlightenment 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, 31 percent consider such

disorders to be a sign of personal weakness, and 35 percent believe the disorders are caused by

sinful behavior (Roper, 2017; NMHA, 1999). Nevertheless, there have been major changes over

the past 60 years in the ways clinicians understand and treat abnormal functioning. 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.

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. Tens of

thousands of people with severe mental disorders are currently homeless.

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 dysfunction. 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.

psychotropic medications Drugs that mainly affect the brain and reduce many symptoms of mental dysfunction.

When given these drugs, many patients who had spent years in mental hospitals began to

show signs of improvement. Hospital 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 professionals 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 around 42,000 (Amadeo,

2017; Smith & Milazzo-Sayre, 2014). In addition, some 58,000 people receive treatment in

private psychiatric hospitals, care that is paid for by the patients themselves and/or their insurance

companies. On average, the private facilities offer more pleasant surroundings and more favorable

staff−patient ratios than the public ones.

deinstitutionalization The practice, begun in the 1960s, of releasing hundreds of thousands of patients from public mental hospitals.

FIGURE 1-1

The Impact of Deinstitutionalization

The number of patients (around 42,000) now hospitalized in public mental hospitals in the United States is a small fraction

of the number hospitalized in 1955. (Information from: Amadeo, 2017; Smith & Milazzo-Sayre, 2014; Torrey, 2001; Lang,

1999.)

Without question, 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 psychotherapy and

medication in community programs and residences (Stein et al., 2015).

Chapters 2 and 12 will look more closely at this current emphasis on community care for

people with severe psychological disturbances—a philosophy called the community 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 (NIMH, 2017; 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. Around 140,000 people with such disturbances are

homeless on any given day; another 440,000 are inmates of jails and prisons (Allison et al., 2017;

NAMI, 2016). 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, outpatient 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, almost all outpatient care took the form of private psychotherapy, in

which individuals meet with a self-employed therapist for counseling services. Since the 1950s,

most health insurance plans have expanded coverage to include private psychotherapy, so that it

is now also widely available to people of all incomes. Today, outpatient therapy is also offered in

a number of less expensive settings, such as community mental health centers, crisis intervention

centers, family service centers, and other social service agencies. Surveys suggest that around 60

percent of people with psychological disorders in the United States receive treatment in the

course of a year (APA, 2016).

private psychotherapy An arrangement in which a person directly pays a therapist for counseling services.

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 receiving 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).

Yet another change in outpatient care since the 1950s has been the development of programs

devoted exclusively to specific psychological problems. 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 concentration in a single area.

Why do you think it has taken psychologists so long to start

studying positive behaviors?

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 (Mendelson & Eaton, 2018). Rather than wait for psychological 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 number, offering great

promise as the ultimate form of intervention.

prevention Interventions aimed at deterring mental disorders before they can develop.

Positive psychology in action Often, positive psychology and multicultural psychology 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 programs have been further

energized in the past few decades by the

field of psychology’s ever-growing interest

in positive psychology (Yaden,

Eichstaedt, & Medaglia, 2018; Seligman & Fowler, 2011). Positive psychology is the study and

promotion of positive feelings such as optimism and happiness, positive traits like hard work and

wisdom, and group-directed virtues, including altruism and tolerance (see InfoCentral).

positive psychology The study and enhancement of positive feelings, traits, and abilities.

While researchers study and learn more about positive psychology in the laboratory, clinical

practitioners with this orientation are teaching people coping skills that may help to protect them

from stress and adversity and encouraging them to become more involved in personally

meaningful activities and relationships—thus helping to prevent mental disorders (Sergeant &

Mongrain, 2014).

INFOCENTRAL

HAPPINESS

Positive psychology is the study of positive feelings, traits, and abilities. A better understanding

of constructive functioning 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.

Multicultural Psychology We are, without question, a society of multiple cultures, races, and languages. Members of racial

and ethnic minority groups in the United States collectively make up 39 percent of the

population, a percentage that is expected to grow to more than 50 percent by the year 2044

(KFF, 2016; U.S. Census Bureau, 2015). This change is due in part to shifts in immigration

trends and also to higher birth rates among minority groups in the United States (NVSR, 2016,

2010).

In response to this growing diversity, an area of study called multicultural psychology has

emerged. 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 may differ psychologically (Alegría et al., 2018, 2016, 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.

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.

Preventing an even worse outcome Children attend activities at this psychological support and education center in

Damascus, Syria, in 2016. The center was set up, on the advice of mental health, medical, and education advisers, to help

prevent or at least minimize the psychological and physical problems being experienced by millions of Syrian children

caught up in the ongoing horrors of the country’s civil war.

The Increasing Influence of Insurance Coverage So many people now seek mental health services that insurance programs have changed their

coverage for these patients in recent decades (Iglehart, 2016). The dominant form of insurance

#FilmPsych

“My philosophy is if you worry, you suffer twice.” (Fantastic Beasts and Where to Find Them, 2016)

now consists of managed care programs—programs in which the insurance company determines

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 (Xiang et al., 2018; Bowers, Owen, & Heller,

2016).

managed care program Health care coverage in which the insurance company largely controls the nature, scope, and cost of medical or psychological services.

Managed care coverage for mental health treatment 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 standards 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 (Decker, 2016). 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 (Bowers et al., 2016).

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 physical

disorders. This places persons with psychological difficulties at a distinct disadvantage (McGuire,

2016). Thus, in 2008, the U.S. Congress passed a federal parity law that directed insurance

companies to provide equal coverage for mental and physical 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 designated

mental health care as 1 of 10 types of “essential health benefits” that must be provided by all

insurers. The changes in federal leadership brought about by the election of 2016 have led to

some changes in the ACA and may eventually result in its repeal. Currently, it is not clear how

such changes will affect the decade-long efforts to achieve mental health insurance parity.

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

“I suffer from short-term memory loss.” (Finding Dory, 2016)

“Fear of death is illogical.” (Star Trek Beyond, 2016)

“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 love the smell of napalm in the morning.” (Apocalypse Now, 1979)

“Snakes. Why’d it have to be snakes?” (Raiders of the Lost Ark, 1981)

“Are you talkin’ to me?” (Taxi Driver, 1976)

“Mother’s not herself today.” (Psycho, 1960)

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,

cognitive-behavioral, humanistic-existential,

sociocultural, and developmental

psychopathology schools of thought. At

present, no single viewpoint 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 psychological problems.

Before the 1950s, psychotherapy was offered only by psychiatrists, physicians 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 as well as a one-year internship in a mental health setting. Psychotherapy and

related services are also provided by counseling psychologists, educational and school psychologists,

psychiatric nurses, marriage therapists, family therapists, and—the largest group—clinical 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 specialties often use similar techniques.

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 49,000 $194,000 35%

Psychologists PhD, PsyD, Late 1940s 188,000 $73,000 67%

EdD

Social workers

MSW, DSW Early 1950s 649,000 $46,000 84%

Counselors Various Early 1950s 570,000 $45,000 71%

Information from: BLS, 2017, 2016; DPE, 2016; Salary.com, 2016; APA, 2015; Block, 2015; Pallardy, 2015.

A related development in the study and treatment of mental disorders since World War II has

been the growth of effective research. Clinical researchers have tried to determine which concepts

best explain and predict abnormal behavior, which treatments are most effective, and what kinds

of changes in clinical theory or practice may be required. Well-trained clinical researchers

conduct studies in universities, medical schools, laboratories, mental hospitals, mental health

centers, and other clinical settings throughout the world. Their work has produced important

discoveries and has changed many of our ideas about abnormal psychological functioning.

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.

Our digital world provides new triggers for abnormal behavior (Turkle, 2017, 2015; Cottle,

2016). 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. Similarly,

the Internet, texting, and social media have become convenient tools for those who wish to stalk

or bully others, express sexual exhibitionism, or pursue pedophilic desires. Likewise, some

clinicians believe that violent video games may contribute to the development of antisocial

behavior. And, in the opinion of many clinicians, constant texting, tweeting, and Internet

browsing may become an addictive behavior or may help lead to shorter attention spans.

“Looks like another case of someone over forty trying to understand Snapchat.”

A number of clinicians also worry that social networking can contribute to psychological

dysfunction in certain cases. On the positive side, research indicates that, on average, social media

users are particularly likely to maintain close relationships, receive social support, be trusting, and

lead active lives (Hu et al., 2017; ACOG, 2016). But, on the negative side, there is research

suggesting that social networking sites may increase peer pressure and social anxiety in some

adolescents (Hanna et al., 2017; Houston, 2016). The sites may, for example, cause some people

to develop fears that others in their network will exclude them socially. Similarly, such sites may

facilitate shy or socially anxious people’s withdrawal from valuable face-to-face relationships.

In addition, the face of clinical treatment is constantly changing in our fast-moving digital

world. For example, telemental health, the use of various technologies to deliver mental health

services without the therapist being physically present, is growing by leaps and bounds

(Carpenter et al., 2018; Comer et al., 2017). As you’ll see in Chapter 2, telemental health takes

such forms as long-distance therapy between clients and therapists using videoconferencing,

therapy offered by computer programs, and Internet-based support groups. And literally

#GenderShift

28% Percentage of psychologists in 1978 who were female

74% Percentage of current psychology graduate students who are female

(NCES, 2016; APA, 2015, 2014; Cynkar, 2007)

thousands of smartphone apps are devoted to relaxing people, cheering them up, giving them

feel-good advice, helping them track their shifting moods and thoughts, or otherwise improving

their psychological states.

telemental health The use of digital technologies to deliver mental health services without the therapist being physically present.

Similarly, countless Web sites offer

mental health information.

Unfortunately, along with this wealth of

online information comes an enormous

amount of misinformation about

psychological problems and their

treatments, offered by persons and sites

that are far from knowledgeable. And there are numerous antitreatment Web sites that try to

guide people away from seeking help for their psychological problems. In later chapters, for

example, you will read about pro-anorexia and pro-suicide Web sites and their dangerous

influences. Clearly, the impact of technological change presents difficult challenges for clinicians

and researchers alike.

SUMMING UP

RECENT DECADES AND CURRENT TRENDS In the 1950s, researchers discovered a number of new psychotropic medications. 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 also affected the mental health field.

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 challenges 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 psychological

functioning. They search for a general, or nomothetic, understanding of the nature, causes, and

treatments of abnormality. To gain such broad insights, clinical researchers, like scientists in

other fields, use the scientific method—that is, they collect and evaluate information through

careful observations. These observations in turn enable them to pinpoint and explain

relationships between variables.

scientific method The process of systematically gathering and evaluating information, through careful observations, to understand a phenomenon.

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. Together, these methods enable scientists 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.

hypothesis

A hunch or prediction that certain variables are related in certain ways.

The Case Study A case study is a detailed description of a person’s life and psychological problems. 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 (Tight, 2017). 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).

case study A detailed account of a person’s life and psychological problems.

The Genains One of the most celebrated case studies in abnormal psychology is a study of identical quadruplets dubbed the

“Genain” sisters by researchers (after the Greek term for “dire birth”). All of the sisters developed schizophrenia in their

twenties.

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 better understand or treat the person under

discussion. In addition, case studies may play nomothetic roles that go far beyond the individual

clinical case.

100

How Are Case Studies Helpful? Case studies are useful to researchers in many ways (Gerring, 2017; Tight, 2017). They can, for

example, be a source of new ideas about behavior and “open the way for discoveries” (Bolgar,

1965). Sigmund Freud’s theory of psychoanalysis was based mainly on the patients he saw in

private practice. In 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. Conversely,

case studies may serve to challenge a theory’s assumptions.

“I’m a social scientist, Michael. That means I can’t explain electricity or anything like that, but if you ever want to know about

people I’m your man.”

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. Investigators of disorders such as dissociative identity disorder, the

multiple personality pattern on display in The Three Faces of Eve, once relied entirely on case

studies for information.

101

Why do case studies and other anecdotal offerings influence

people so much, often more than systematic research does?

What Are the Limitations of Case Studies?

Case studies also have limitations

(Gerring, 2017; Tight, 2017). 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. Even if we agree that Little Hans developed a dread

of horses because he was terrified of castration and feared his father, how can we be confident

that other people’s phobias are rooted in the same kinds of causes? 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 detail

that makes case studies so interesting, but they do help investigators draw broad conclusions

about abnormality in the population at large. Thus most clinical investigators prefer these

methods over the case study.

Three features of the correlational and experimental methods enable clinical investigators to

gain general, or nomothetic, insights: (1) The researchers typically observe many individuals. (2)

The researchers apply procedures uniformly and can thus repeat, or replicate, their investigations.

(3) The researchers use statistical tests to analyze the results of their studies and determine whether

broad conclusions are justified.

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 (Salkind, 2017). 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?

correlation The degree to which events or characteristics vary along with each other.

102

correlational method A research procedure used to determine how much events or characteristics vary along with each other.

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 (Yang et al., 2017; Hammen, 2016). 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 negative correlation between depression and

activity level. The greater one’s depression, the lower the number of one’s activities.

Stress and depression At a 2016 prayer service in Flint, Michigan, a woman holds a sign that conveys the desperate

predicament faced by her and thousands of other victims in the wake of the city’s water contamination crisis. Studies find

that the stress produced by this and similar community catastrophes has been accompanied by depression and other

psychological symptoms in many residents (Goodnough & Atkinson, 2016).

103

#WEIRDParticipants Nearly 70 percent of psychology studies use college students as

participants. These participants are often described by the

acronym WEIRD, because they are overwhelmingly from

societies that are Western, Educated, Industrialized, Rich, and

Democratic (Robson, 2017; Henrich et al., 2010).

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 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 calculated 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 negative 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, studies of life

stress and depression have found

correlations as high as +.53 (Krishnan, 2017; Miller et al., 1976). Although hardly perfect, a

correlation of this magnitude is considered large in psychological research.

104

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 identical genes) display a higher correlation for some disorders

than do fraternal twins (whose genetic makeup is not identical).

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 (Salkind, 2017). 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 conclude that their findings

reflect a real correlation in the general population.

What Are the Merits of the Correlational Method? The correlational 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.

105

Can you think of other correlations in life that are

interpreted mistakenly as causal?

TABLE: 1-3 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

Although correlations allow researchers

to describe the relationship between two

variables, they do not explain the

relationship. 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

correlated 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) Depression and

life stress may each be caused by a third variable, such as financial problems (Yazdi et al., 2018;

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 behavior, 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 certain measures (such as

hospitalization) to help save lives.

Of course, in other instances, clinicians do need to know whether one variable causes another.

Do parents’ marital conflicts cause their children to be more anxious? Does job dissatisfaction

lead to feelings of depression? Will a given treatment help people to cope more effectively in life?

Questions about causality call for the experimental method.

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 (Leavy, 2017). The manipulated variable is called the

106

independent variable and the variable being observed is called the dependent variable.

experiment A research procedure in which a variable is manipulated and the effect of the manipulation on another variable 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 that is expected to change as the independent variable is manipulated.

To examine the experimental method more fully, let’s consider a question that is often asked

by clinicians (Priday et al., 2017): “Does a particular therapy relieve the symptoms of a particular

disorder?” Because this question is about a causal relationship, it can be answered only by an

experiment. That is, experimenters 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

variable, 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 (Salkind, 2017). 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 independent 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.

confound In an experiment, a variable other than the independent variable that is also acting on the dependent variable.

107

Is animal companionship an effective intervention? A ring-tailed lemur sits on the shoulder of an individual at Serengeti

Park near Hodenhagen, Germany. It’s part of a monthly program called “Psychiatric Animal Days” based on the premise

that animals—even lemurs—have a calming effect on people. More than 400 kinds of intervention are currently used for

psychological problems. An experimental design is needed to determine whether this or any other form of treatment causes

clients to improve.

For example, situational variables, such as the location of the therapy office (say, a quiet

country setting, as opposed to a busy city street) 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, factors 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 masked design

(Comer & Bry, 2018).

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 experimental 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.

control group In an experiment, a group of participants who are not exposed to the independent variable.

108

Why might sugar pills or other kinds of placebo treatments

help some people feel better?

To study the effectiveness of a particular therapy, for example, experimenters typically divide

participants 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 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,

experimenters try to provide all participants, both control and experimental, with experiences

that are identical in every way—except for the independent variable.

experimental group In an experiment, the participants who are exposed to the independent variable under investigation.

Random Assignment Researchers must also watch out for differences in the makeup of the experimental 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 assignment.

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 (Comer & Bry, 2018). Researchers

might, for example, assign people to groups by flipping a coin or picking names out of a hat.

random assignment A selection procedure that ensures that participants are randomly placed either in the control group or in the experimental group.

Masked Design A final confound problem is bias. Participants may bias an experiment’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 better 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 masked

design (previously termed a blind design) because the individuals are kept unaware of their

109

assigned group. In a therapy study, for example, control participants could be given a placebo

(Latin for “I shall please”), something 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.

masked design An experiment in which participants do not know whether they are in the experimental or the control condition. Previously called a blind design.

An experiment may also be confounded by experimenter bias—that is, experimenters 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 participants. 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 unaware 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 unaware in an experiment, it is best that both be

unaware—a research strategy called a double-masked design. In fact, most medication experiments

now use double-masked designs to test promising drugs (Kim et al., 2017).

110

#EthicallyChallenged Symptom-Exacerbation Studies In some studies, patients are

Flawed studies, gigantic impact Outside a court hearing in Beijing on conversion, or reparative, therapy, an LGBTQ activist

protests by pretending to inject a patient with a giant syringe. Conversion therapy, a now widely discredited psychological

treatment to help gay persons change their sexual orientation, was positively received in a number of clinical circles after its

development in the late 1990s. However, in 2012, Robert Spitzer, one of the world’s most respected psychiatric researchers,

offered a public apology to the gay community, saying that his and other influential research studies that had seemed to

support the effectiveness of conversion therapy were fatally flawed and morally wrong.

Alternative Research Designs Clinical scientists must often settle for research designs that are less than ideal. These alternative

designs are often called quasi-experimental designs, or mixed designs—designs that fail to

include key elements of a “pure” experiment or intermix elements of both experimental and

correlational studies (Leavy, 2017; Salkind, 2017). Such variations include the matched design,

natural experiment, analogue experiment, single-subject experiment, longitudinal study, and

epidemiological study.

quasi-experimental design A research design that fails to include key elements of a “pure” experiment and/or intermixes elements of both experimental and correlational studies. Also called a mixed design.

In matched designs, investigators do

not randomly assign participants to

111

given drugs to intensify their symptoms so that researchers may

learn more about the biology of their disorder.

Medication-Withdrawal Studies In some studies, researchers

prematurely stop medications for patients who have been

symptom-free for a while, hoping to learn more about when

patients can be taken off particular medications.

control and experimental groups, but

instead make use of groups that already

exist in the world at large. 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 children who do

not. To make this comparison as valid as possible, the researchers match the experimental

participants (abused children) with control participants (non-abused children) who are similar in

age, sex, race, number of children in the family, type of neighborhood, or other characteristics

(Jacobsen, 2016). When the data from studies using this kind of design 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 (Greger et al., 2016; Jaschek et al., 2016).

matched design A research design that matches the experimental participants with control participants who are similar on key characteristics.

In natural experiments, nature itself manipulates the independent variable, while 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 in fact quasi-experiments.

natural experiment An experiment in which nature, rather than an experimenter, manipulates an independent variable.

On December 26, 2004, an earthquake occurred beneath the Indian Ocean off the coast of

Sumatra, Indonesia. The earthquake triggered a series of massive tsunamis that flooded the

ocean’s coastal communities, killed more than 225,000 people, injured over half a million, 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 survivors and from control groups of people who lived in areas

not directly affected by the tsunamis. The disaster survivors scored significantly 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 (Adeback et al., 2018; Hussain et al.,

112

2016). Over the past several years, other natural experiments have focused on survivors of the

2010 Haitian earthquake, Japan’s massive earthquake in 2011, and the Northeast’s Superstorm

Sandy in 2012, as well as the devastating hurricanes in Houston, Florida, and Puerto Rico in

2017 and the raging wildfires that swept through parts of California in 2017 and 2018. These

studies have also revealed lingering psychological symptoms among survivors of those disasters

(Li et al., 2018; Usami et al., 2016).

Researchers often run analogue experiments. Here they induce laboratory participants to

behave in ways that seem to resemble real-life abnormal behavior and then conduct experiments

on the participants in the hope of shedding light on the real-life abnormality. For example, as

you’ll see in Chapter 6, investigator Martin Seligman, in a classic body of work, has produced

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.

analogue experiment A research method in which the experimenter produces abnormal-like behavior in laboratory participants and then conducts experiments on the participants.

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

113

perceptions and experiences. Thus, abnormal-like behavior produced in animal analogue experiments may differ from the

human abnormality under study.

Scientists often use a single-subject experimental design when they do not have the luxury of

experimenting on many participants (Comer & Bry, 2018; Lane et al., 2017). They may, for

example, be investigating a disorder so rare that few participants are available. In designs of this

kind, a single participant is observed both before and after the manipulation of an independent

variable.

single-subject experimental design A research method in which a single participant is observed and measured both before and after the manipulation of an independent variable.

For example, using a particular 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 intellectual 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.

Yet another alternative research design is the longitudinal study, in which investigators

observe the same individuals on many occasions over a long period of time (Bryman, 2016). In

several such studies, investigators have observed the progress over the years of normally

functioning children whose mothers or fathers suffered from schizophrenia (Hameed & Lewis,

2016; Rasic et al., 2014). The researchers have found, among other things, that the children of

the parents with the most severe cases of schizophrenia were particularly likely to develop a

psychological disorder and to commit crimes at later points in their development.

longitudinal study A study that observes the same participants on many occasions over a long period of time.

As with some of the other quasi-experiments, researchers cannot directly manipulate the

114

independent variable or randomly assign participants to conditions in a longitudinal study, and

so they cannot definitively pinpoint causes. However, because longitudinal studies report the

order of events, they do provide compelling clues about which events are more likely to be causes

and which are more likely to be consequences.

Life is a longitudinal study Photos of this same individual at different points in his life underscore the logic behind

longitudinal studies. Just as this person’s eyes, nose, and overall smile at the age of 5 seem to predict similar facial features at

the ages of 35 and 55, so too might an individual’s early temperament, sociability, or other psychological features sometimes

predict adult characteristics. In some longitudinal studies, clinical researchers have found that a number of children who

seem to be at particular risk for psychological disorders do indeed develop such disorders at later stages of their lives.

Finally, researchers may conduct epidemiological studies to reveal how often a problem, such

as a particular psychological disorder, occurs in a particular population. More specifically, they

determine the incidence and prevalence of the problem (Jacobsen, 2016). Incidence is the number

of new cases that emerge in a population 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.

epidemiological study A study that measures the incidence and prevalence of a problem, such as a disorder, in a given population.

Over the past 45 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 (Cottler et al., 2016; Ramsey et al., 2013). They have

interviewed more than 20,000 people in five cities to determine the prevalence of many

psychological disorders in the United States and the treatment programs used. Two other large-

scale epidemiological studies in the United States, the National Comorbidity Survey and the

115

National Comorbidity Survey Replication, have questioned almost 15,000 individuals (Kelly &

Mezuk, 2017; Kessler et al., 2014, 2012). Findings from these broad-population studies have

been further compared with epidemiological studies of specific populations, such as Hispanic

Americans and Asian Americans, or with epidemiological studies conducted in other countries, to

see how rates of mental disorders and treatment programs vary from population to population

and from country to country (Nobles et al., 2016).

Such epidemiological comparisons 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 Western countries

have higher rates of eating disorders than those in non-Western ones.

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 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 understanding 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 (see MindTech). In

fact, researchers’ primary obligation is to avoid harming the human participants 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 further scientific knowledge in a safe and respectful

116

Might outside restrictions on research interfere with

way (Leavy, 2017; Salkind, 2017). But there have been some notable exceptions to this over the

years, particularly three infamous studies conducted in the mid-twentieth century. 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.

A national disgrace In a 1997 White House ceremony, President Bill Clinton offers an official 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 participants 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.

Who, beyond researchers themselves,

117

necessary investigations and thus limit potential gains for

human beings? might directly watch over the rights and

safety of human participants? For the past

several 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 (Parker, 2016). The institution 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 jeopardy, 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 empowered by two agencies of the federal government—the

Office for Human Research Protections and the Food and Drug Administration.

Institutional Review Board (IRB) An ethics committee in a research facility that is empowered to protect the rights and safety of human research participants.

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:

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.

The participants have access to information about the study.

The participants’ privacy is protected by principles such as confidentiality or anonymity.

MINDTECH

118

Can an argument be made that ethical standards for studies

The Use and Misuse of Social Media

Over the past several years, more and more researchers have been turning to social networks for their studies. One

study, for example, demonstrates the power and potential of using social media data (Kosinski et al., 2016, 2013). In this

investigation, 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 participant’s likes could predict with some

accuracy his or her personality traits, level of happiness, use of addictive substances, and level of intelligence, among other

variables.

What a great resource, right? Not so fast. The study above did indeed ask subscribers whether they were willing to

participate. However, in a number of other such studies, social media users do not know that their posted data is being

examined and tested. Here, the researchers assert that because posted information is already publicly available, users need

not be informed that their data is under examination—a view that has produced enormous debate.

An area that has raised additional ethical concerns involves the direct and secret manipulation of social media users by

researchers—an approach illustrated in a study conducted by a team of researchers from both Facebook and academia

(Kramer et al., 2014). The investigators wanted to determine whether the content of news feeds on Facebook influences the

moods of its users. Without the users knowing it, the researchers reduced the number of positive news feed posts seen by

around 350,000 users and reduced the number of negative posts seen by another 350,000 users over a one-week period. As

a result, the moods of the former users became slightly (but significantly) more negative than those of the latter users, as

measured by the number of negative and positive words posted by the users themselves in their Facebook status updates

over the course of that same week.

This study immediately triggered a flood of criticism (Golder et al., 2017; Flick, 2016). One concern was that the users

in the study were unaware of and did not give consent for their participation. Critics holding this view were unimpressed

with the claim that signing on to Facebook’s lengthy and small-print user agreement represents a sufficient form of

informed consent for this or similar social media studies. Another concern was that, by inducing more negative moods, the

researchers in this study might have been feeding into the clinical depressions of some negative news feed users.

A core problem for all social media studies is

119

using the Internet and social media should be different from

those applied to other kinds of research?

that most social media sites do not really have

policies prohibiting researchers from studying

subscribers or subscriber profiles without clear

permission. While the technology-driven questions

of what’s public and what’s private are under debate, it is probably best that posters follow a new version of that most

sacred rule of consumerism—“poster beware.”

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 (Perrault & Nazione, 2016; Mathew &

McGrath, 2002).

It turns out that most such forms—the very forms deemed acceptable by IRBs—are too long

and/or 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 consent 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 the

studies (CISCRP, 2013).

120

Making a point The rights of animal subjects must also be considered. Here, with his body painted as a monkey, an activist

from the organization PETA (People for the Ethical Treatment of Animals) sits in a cage to protest the use of animals in

research at a medical science institute in India.

In short, the IRB system is flawed, much like the research undertakings it oversees. One

reason for this is that ethical principles are subtle notions that do not always translate into simple

121

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, most observers agree that the creation and work of IRBs have helped

improve the rights and safety of human research participants over the years.

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. In experiments, researchers manipulate

suspected causes to see whether expected effects will result. This method enables researchers to determine the causes

of various conditions or events.

Clinical scientists must often settle for alternative research designs that are less than ideal, called quasi-

experimental designs, or mixed designs. These include the matched design, natural experiment, analogue experiment,

single-subject experiment, longitudinal study, and epidemiological study.

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 during the planning stages and can require changes in the proposed study before granting approval for the

undertaking. Among the important participant rights that the IRB protects is the right of informed consent, an

acceptable risk/benefit balance, and privacy (confidentiality or anonymity).

122

#TheirWords “I became insane, with long intervals of horrible sanity.”

Edgar Allan Poe

Moving Forward 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 understand the roots of

our present views and treatments. In addition, a look backward helps us appreciate just how far

we have come.

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 unimpressed by the claims and

accomplishments of the others. Clinical practice is carried 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 history of this field is that our current understanding of

abnormal behavior represents a work in progress—with some of the most important insights,

investigations, and changes yet to come.

123

Chapter 1 Review

Key Terms

abnormal psychology

deviance

norms

culture

distress

dysfunction

danger

treatment

trephination

humors

asylum

moral treatment

state hospitals

somatogenic perspective

psychogenic perspective

psychoanalysis

psychotropic medications

deinstitutionalization

private psychotherapy

prevention

positive psychology

multicultural psychology

124

managed care program

telemental health

scientific method

hypothesis

case study

correlation

correlational method

experiment

independent variable

dependent variable

confound

control group

experimental group

random assignment

masked design

placebo therapy

quasi-experimental design

matched design

natural experiment

analogue experiment

single-subject experimental design

longitudinal study

epidemiological study

prevalence

Institutional Review Board (IRB)

125

informed consent

Quick Quiz

1. What features are common to abnormal psychological functioning? pp. 2–4

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 nineteenth century, and the twentieth century. pp. 8–12

4. Describe the role of hypnotism and hysterical disorders in the development of the psychogenic view. pp. 12–13

5. How did Sigmund Freud come to develop the theory and technique of psychoanalysis? p. 13

6. Describe the major changes that have occurred since the 1950s in the understanding and treatment of psychological abnormality. pp. 14–20

7. What are the advantages and disadvantages of the case study, correlational method, and experimental method? pp. 21–30

8. What techniques do researchers include in experiments to guard against the influence of confounds? pp. 25–27

9. Describe six alternative research designs often used by investigators. pp. 27–29

10. What are Institutional Review Boards, and what are their responsibilities and goals? pp. 30–32

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

126

127

CHAPTER 2 Models of Abnormality

TOPIC OVERVIEW

The Biological Model

128

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 Cognitive-Behavioral Model

The Behavioral Dimension The Cognitive Dimension The Cognitive-Behavioral Interplay Assessing the Cognitive-Behavioral 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

Integrating the Models: The Developmental Psychopathology Perspective

Philip 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

129

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 relationship 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 corroborated 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 subsequently 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 control.” 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 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 bitterness 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)

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,

130

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 perspectives 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 investigators 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.

model A set of assumptions and concepts that help scientists explain and interpret observations. Also called a paradigm.

Until relatively 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 culture. 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.

131

A fascinating subject The human brain increasingly has captured the attention not only of neuroscientists but also the

public at large. Here an eighth-grade student holds and examines a brain ever so carefully during a visit to the psychology

department at Indiana University.

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 biological model, which sees physical

processes as key to human behavior. In the middle are three 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 cognitive-behavioral model emphasizes

behavior, the ways in which it is learned, and 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

132

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 exclusively follow one perspective often scoff at the “naïve” interpretations, investigations,

and treatment efforts of the others. Yet none of the models is complete in itself. Each focuses

mainly on one aspect of human functioning, and none can explain all aspects of abnormality.

133

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 problems will be biological ones.

How Do Biological Theorists Explain Abnormal Behavior? Adopting a medical perspective, biological theorists view abnormal behavior as an illness brought

about by malfunctioning parts of the organism. Typically, they point to problems in brain

anatomy, brain chemistry, and/or brain circuitry as the cause of such behavior.

Brain Anatomy and Abnormal Behavior The brain is made up of approximately 86 billion nerve cells, called neurons, and thousands of

billions of support cells, called glia (from the Greek word for “glue”) (Jernigan & Stiles, 2017).

Within the brain large groups of neurons form distinct regions, or brain structures. Toward the

top of the brain, for example, is a cluster of structures, 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 structures help control important functions. The basal

ganglia, for example, plays a crucial role in planning and producing movement, and the

amygdala plays a key role in emotional memory. Clinical researchers have sometimes linked

particular psychological disorders to problems in specific structures of the brain. One such

disorder is Huntington’s disease, a disorder marked by involuntary body movements, violent

emotional outbursts, memory loss, suicidal thinking, and absurd beliefs. This disease has been

linked in part to a loss of cells in the basal ganglia and cortex.

neuron A nerve cell.

134

FIGURE 2-1

The Cerebrum

Some psychological disorders 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.

Brain Chemistry and Abnormal Behavior Biological researchers have also learned that psychological disorders can be related to problems in

the transmission 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 neuron’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). Each neuron has multiple dendrites and a single

axon. But that axon can be very long indeed, often extending all the way from one structure of

the brain to another.

135

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.

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 somehow 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 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 moving

information through the brain.

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 synaptic space to be received at receptors on the dendrites of neighboring neurons. receptor A site on a neuron that receives a neurotransmitter.

136

Researchers have identified dozens of neurotransmitters in the brain, and they have learned

that each neuron uses only certain kinds. Studies indicate that abnormal activity by certain

neurotransmitters is sometimes tied to mental disorders. Depression, for example, has been

linked in part to low activity of the neurotransmitters serotonin and norepinephrine. Perhaps low

serotonin activity is at play in 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, 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 depression.

hormones The chemicals released by endocrine glands into the bloodstream.

Brain Circuitry and Abnormal Behavior Over the past decade, researchers have increasingly focused on brain circuits as the key to

psychological disorders rather than on dysfunction within a single brain structure or by a single

brain chemical. A brain circuit is a network of particular brain structures that work together,

triggering each other into action to produce a distinct behavioral, cognitive, or emotional

reaction. How do the structures of a given circuit work together? The answer, as you might

anticipate by now, is through their neurons. The long axons of the neurons from one structure

bundle together and extend across the brain to communicate with the neurons of another

structure, setting up a fiber pathway between the structures. The structures and

neurotransmitters that make up a given brain circuit are, as you read above, important

individually, but research indicates that it is usually most informative to look at the operation of

the entire circuit, including its interconnecting fiber pathways, to fully understand human

functioning. Proper interconnectivity (communication) among the structures of a circuit tends to

result in healthy psychological functioning, whereas flawed interconnectivity may lead to

abnormal functioning.

brain circuit A network of particular brain structures that work together, triggering each other into action to produce a distinct kind of behavioral, cognitive, or emotional reaction.

137

#TheirWords

“Help! I’m being held prisoner by my heredity and

environment.”

Dennis Allen

One of the brain’s most important circuits is the “fear circuit.” As you will see in Chapter 4,

this circuit consists of a number of specific structures (including the amygdala and prefrontal

cortex) whose interconnecting fiber pathways enable the structures to trigger each other into

action and to produce our everyday fear reactions. Studies suggest that this circuit functions

improperly (that is, displays flawed interconnectivity) in people suffering from anxiety disorders

(Williams, 2017). Perhaps dysfunction by Philip Berman’s fear circuit is contributing to his

repeated concerns that things will go badly and that other people will have low opinions and

negative motives toward him, concerns that keep triggering his depression and anger.

Sources of Biological Abnormalities Why might the brain structures, neurotransmitters, or brain circuits of some people function

differently from the norm? As you will see throughout the textbook, a wide range of factors can

play a role—from prenatal events to brain injuries, viral infections, environmental experiences,

and stress. Two factors that have received particular attention in the biological model are genetics

and evolution.

GENETICS AND ABNORMAL BEHAVIOR

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 20,000 genes (Dunham, 2018).

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 inheritance also

can play a part in certain mental disorders.

genes Chromosome segments that control the characteristics and traits we inherit.

In most instances, several or more genes combine to help produce our actions and reactions,

both functional and dysfunctional. The precise contributions of various genes or gene

combinations to mental disorders have become clearer in recent years, thanks in part to the

completion of the Human Genome Project in 2000, a major undertaking in which scientists used

138

the tools of molecular biology to map, or sequence, all of the genes in the human body.

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 mutation, 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 his or her 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 (Ram, Liberman, & Feldman, 2018; Fábrega, 2010).

More than coincidence? Identical twins Mike and Bob Bryan, shown here returning a shot during a semifinal tennis match

at the 2016 China Open, have had storied careers. Ranked as the world’s top doubles tennis players, they have won multiple

Olympic medals representing the United States. Studies of twins suggest that some aspects of behavior and personality are

influenced by genetic factors. Many identical twins, like the Bryans, have similar tastes, behave similarly, and make similar

life choices. Some even develop similar abnormal behaviors.

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

139

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 and often more subtle 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 patterns.

The evolutionary perspective is controversial in the clinical field and has been rejected by

many theorists. Imprecise and at times impossible to research, scientists often find such

explanations unacceptable.

Biological Treatments Biological practitioners look for certain kinds of clues when they treat people who are behaving

abnormally. 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 dysfunction, 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, brain stimulation, and psychosurgery. Drug therapy is by

far the most common of these approaches.

In the 1950s, researchers discovered several effective psychotropic medications, 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 (see Trending). 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.

psychotropic medications Drugs that primarily affect the brain and reduce many symptoms of mental dysfunction.

140

What might the popularity of psychotropic drugs suggest

about coping styles and problem-solving skills in our

society?

Four major psychotropic drug groups

are used in therapy. Antianxiety drugs, also

called minor tranquilizers or anxiolytics,

help reduce tension and anxiety.

Antidepressant drugs help improve the

functioning of people with depression and certain other disorders. 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 that often accompany psychosis, a loss of contact with reality found

in schizophrenia and other disorders.

Psychotropic drugs, like all medications, reach the marketplace only after systematic research

and review. It takes an average of 12 years and hundreds of millions 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,

2018, 2016, 2014).

TRENDING

TV Drug Ads Come Under Attack

“Ask your doctor about Abilify.” “There is no need to suffer any longer.” Anyone who watches television or

browses the Internet is familiar with phrases such as these. They are at the heart of direct-to-consumer (DTC) drug

advertising—advertisements in which pharmaceutical companies appeal directly to consumers, coaxing them to ask their

physicians to prescribe particular drugs for them. The United States and New Zealand are the only developed countries in

the world that allow such advertising. Around 80 percent of American adults have seen these ads, and at least 30 percent

ask their doctors about the specific medications they see advertised (ProCon, 2016; Hausman, 2008). Half of today’s

leading DTC-advertised medications are psychotropic drugs such as antibipolar and antipsychotic drugs (Bulik, 2017; Sukel,

2016).

141

DTC ads have flooded the airwaves since 1997 when the U.S. Food and Drug Administration (FDA) relaxed its

restrictions for drug advertising on television, ruling that DTC ads must simply recommend that consumers speak with a

doctor about the drug, mention the drug’s important risks, and indicate where consumers can get further information

about it—often a Web site or phone number (Chesnes & Jin, 2016; FDA, 2016, 2015). Such ads have received relatively

little criticism over the past two decades, but this climate of tolerance is now changing. A number of consumer groups and

even the American Medical Association (AMA) are now calling for a ban on such advertising, saying that the ads often

contribute to economic hardships, patient misinformation, and less-than-optimal treatment (Kuzucan, Doshi, & Zito,

2017; AMA, 2015).

First, the economic concerns. Altogether, pharmaceutical companies spend $5.2 billion a year on American television

and some online advertising, an amount that keeps growing (Lazarus, 2017; Campbell, 2016). This leads to higher drug

prices, at a time when prescription drug costs and insurance premiums are already skyrocketing, increasing by close to 5

percent each year. Moreover, the DTC ads typically promote newer and more expensive drugs, inflating the demand for

such drugs even when older, generic, and cheaper drugs might be equally or more appropriate (Campbell, 2016; AMA,

2015).

DTC ads also may adversely affect patient awareness and clinical treatment (Aikin et al., 2017). Three-quarters of

surveyed doctors believe that most of the ads overemphasize a drug’s benefits while leaving out key negative information

(ProCon, 2016). Similarly, 80 percent of doctors believe DTC ads help patients better understand the benefits of a drug,

but only 40 percent of them believe that patients understand the possible risks of a drug after seeing the ad (Kiernicki &

Helme, 2017; FDA, 2016, 2015). Small wonder that many patients believe their mental or physical health will be put in

jeopardy if they do not take advertised drugs (Campbell, 2016).

Despite these problems, doctors often feel pressured to prescribe DTC-advertised drugs, even in cases in which the

drugs are not appropriate for patients (Brown, 2017; FDA, 2015). Over half of patient requests for such drugs are granted

by doctors. This has apparently contributed to an overuse of psychotropic and other drugs.

So why do DTC ads continue to rise in number? One reason is that this form of advertising has its supporters. The

FDA, for example, believes that the ads may indeed serve a public service, protecting consumers—although imperfectly—

by directly educating them about drugs that are available in the marketplace (FDA, 2016, 2015). Many doctors also believe

that DTC ads get patients more involved in their mental and physical health care, and a number report that they now have

better discussions with their patients about treatment options as a result of DTC advertising. Finally, not to be overlooked

142

#FDAApproval

1954 Thorazine (antipsychotic drug)

1955 Ritalin (ADHD drug)

1958 MAO inhibitors (antidepressant drugs)

1960 Librium (antianxiety drug)

1961 Elavil (antidepressant drug)

1963 Valium (antianxiety drug)

1970 Lithium (mood stabilizer/antibipolar drug)

1987 Prozac (antidepressant drug)

1998 Viagra (erectile disorder drug)

are the profits that DTC advertising helps generate for pharmaceutical companies. The average number of prescriptions

written for DTC-advertised new drugs are a whopping nine times greater than those written for new drugs that do not have

DTC ads (ProCon, 2016).

As the name implies, a second form of biological treatment, brain stimulation, refers to

interventions that directly or indirectly stimulate certain areas of the brain. The oldest (and most

controversial) such approach, used primarily on severely depressed people, 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 sessions, spaced two or three days apart, many patients

feel considerably less depressed. This treatment is used on tens of thousands of persons annually,

particularly those whose depression fails to respond to other treatments (Hermida et al., 2018).

brain stimulation Interventions that directly or indirectly stimulate the brain in order to bring about psychological improvement. electroconvulsive therapy (ECT) A biological treatment in which a brain seizure is triggered when an electric current passes through electrodes attached to the patient’s forehead.

As you will see in Chapter 6, several

other brain stimulation techniques have

increasingly been used over the past

decade, particularly in cases of depression.

In one, transcranial magnetic stimulation

(TMS), an electromagnetic coil is placed

on or above a person’s head, sending a

current into certain areas of his or her

brain. In another such technique, vagus

nerve stimulation (VNS), a pulse generator

is implanted in a person’s neck, helping to

stimulate his or her vagus nerve, a long

nerve that extends from the brain down

through the neck and on to the abdomen.

The stimulated vagus nerve then delivers electrical signals to the brain. In a third technique,

called deep brain stimulation, electrodes are implanted in specific areas of a person’s brain and

connected to a battery (“pacemaker”) in his or her chest. The pacemaker proceeds to power the

electrodes, sending a steady stream of low-voltage electricity to the targeted brain areas. As with

ECT, research suggests that each of these newer brain stimulation techniques is able to improve

143

#TheirWords “Mental illness is so much more complicated than any pill that

any mortal could invent.”

Elizabeth Wurtzel, Prozac Nation

the psychological functioning of many people whose depressive or related disorders have been

unresponsive to other forms of treatment (Bari et al., 2018; Luber et al., 2017).

A third kind of biological treatment is psychosurgery, brain surgery for mental disorders. It

has 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 notorious technique

developed in the late 1930s by a 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 (Bari et al., 2018). Even so, they are typically used only

after certain severe disorders have continued for years without responding to any other treatment.

It is worth noting that deep brain stimulation, one of the interventions described above, is also a

psychosurgery procedure inasmuch as it involves making small incisions in a person’s skull in

order to implant electrodes in a targeted brain area.

psychosurgery Brain surgery for mental disorders.

Assessing the Biological Model Today the biological model enjoys considerable respect. Biological research constantly 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 capable

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.

144

SUMMING UP

THE BIOLOGICAL MODEL Biological theorists look at biological factors to explain abnormal behavior, pointing in particular to problematic

brain structures, chemicals, and circuits. Such abnormalities are sometimes the result of genetic inheritance or normal

evolution. Biological therapists use chemical and physical methods to help people overcome their psychological

problems. The leading methods are drug therapy, brain stimulation, and psychosurgery.

145

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, psychological 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 experiences. Thus Philip’s hatred for his mother, his memories of

her as cruel and overbearing, the apparent 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.

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.

The psychodynamic model was first formulated by Viennese neurologist Sigmund Freud

(1856–1939) at the turn of the twentieth century. After studying hypnosis, Freud developed the

146

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.

id According to Freud, the psychological force that produces instinctual needs, drives, and impulses.

The Ego During our early years we come to recognize that our environment 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.

ego According to Freud, the psychological force that employs reason and operates in accordance with the reality principle.

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,

147

repression, prevents unacceptable 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).

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.

TABLE: 2-1 The Defense Never Rests Defense Mechanism

Operation Example

Repression Person avoids anxiety by simply not allowing painful or dangerous thoughts to become conscious.

An executive’s desire to run amok and attack his boss and colleagues at a board meeting is denied access to his awareness.

Denial Person simply refuses to acknowledge the existence of an external source of anxiety.

You are not prepared for tomorrow’s final exam, but you 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 his or her own unacceptable impulses, motives, or desires to other individuals.

The executive who repressed his destructive desires may project his anger onto his boss and claim that it is actually the boss who is hostile.

Rationalization Person creates a socially acceptable reason for an action that actually reflects unacceptable motives.

A student explains away poor grades by citing the importance of the “total experience” of going to college and claiming that too much emphasis on grades would actually interfere with a well-rounded education.

Displacement Person displaces hostility away from a dangerous object and onto a safer substitute.

After a perfect parking spot is taken by a person who cuts in front of your car, you release your pent-up anger by starting an argument with your roommate later.

Intellectualization Person represses emotional reactions in favor of overly logical response to a problem.

A woman who has been beaten and raped gives a detached, methodical description of the effects that such attacks may have on victims.

Regression Person retreats from an upsetting conflict to an early developmental stage in which no one is expected to behave maturely or responsibly.

A boy who cannot cope with the anger he feels toward his rejecting mother regresses to infantile behavior, soiling his clothes and no longer taking care of his basic needs.

The Superego The superego is the personality force that 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.

superego According to Freud, the psychological force that represents a person’s values and ideals.

According to Freud, these three parts of the personality—the id, the ego, and the superego—

148

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—suicide gestures, jealous rages,

job resignations, outbursts of temper, frequent arguments.

“I’m doing a lot better now that I’m back in denial.”

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 personal 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.

149

fixation According to Freud, a condition in which the id, ego, or superego do not mature properly and are frozen at an early stage of development.

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.

“Luke … I am your father.” This lightsaber 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.

How Do Other Psychodynamic Explanations Differ from Freud’s?

150

#FreudFacts

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 was nominated for the Nobel Prize in 12 different years, but never won.

(Grohol, 2015; Hess, 2009; Gay, 2006, 1999)

Personal and professional differences between Freud and his colleagues led to a split in the

Vienna Psychoanalytic 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.

Two of today’s most influential psychodynamic theories are self theory and object relations

theory. Self theorists emphasize the role of the self—the unified personality. They believe that the

basic human motive is to strengthen the wholeness of the self (Corey, 2017; Kohut, 2001, 1977).

Object relations theorists, on the other hand, 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 (Kernberg, 2018, 2005, 1997; Rankin,

2017).

Psychodynamic Therapies Psychodynamic therapies range from

Freudian psychoanalysis to modern

therapies based on self theory or object

relations theory. Psychodynamic

therapists seek to uncover past traumas

and the inner conflicts that have resulted

from them (Safran, Kriss, & Foley, 2019).

They try to help clients resolve, or settle,

those conflicts and to resume personal

development.

According to most psychodynamic therapists, therapists must subtly guide therapy discussions

so that the patients discover their underlying problems for themselves. 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

151

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:

Patient: So I started walking, and walking, and decided to go behind the museum and walk through [New York’s] Central Park. … 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. … . There is something 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 feeling 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.

(Wolberg, 2005, 1967, p. 662)

free association A psychodynamic technique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.

Therapist Interpretation Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative

conclusions, and sharing interpretations 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. … The worst thing would be that you wouldn’t like me. You wouldn’t speak to me friendly. . . you’d feel you

152

Why do you think most people try to interpret and make

sense of their own dreams? Are such interpretations of value?

can’t treat me and discharge me from treatment. …

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 … I went against her will and suffered an accident that changed my life, a fractured back. Her attitude was, “I told you so.”

(Wolberg, 2005, 1967, p. 662)

resistance An unconscious refusal to participate fully in therapy. transference According to psychodynamic theorists, the redirection toward the psychotherapist of feelings associated with important figures in a patient’s life, now or in the past.

Finally, many psychodynamic

therapists try to help patients interpret

their dreams (Altszyler et al., 2017) (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 correctly interpreted, can reveal

unconscious instincts, needs, and wishes. Freud identified two kinds of dream content—manifest

and latent. Manifest 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.

dream A series of ideas and images that form during sleep.

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

Schools, 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

153

Failing an examination 37 48

Being physically attacked 40 44

Being frozen with fright 32 44

Information from: Cherry, 2018; Robert & Zadra, 2014; Kantrowitz & Springen, 2004.

Catharsis Insight must be an emotional as well as an intellectual process. Psychodynamic therapists believe

that patients must experience catharsis, a reliving of past repressed feelings, if they are to settle

internal conflicts and overcome their problems.

catharsis The reliving of past repressed feelings in order to settle internal conflicts and overcome 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.

working through The psychoanalytic process of facing conflicts, reinterpreting feelings, and overcoming one’s problems.

Current Trends in Psychodynamic Therapy The past 40 years have witnessed significant changes in the way many psychodynamic therapists

conduct 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 psychodynamic therapies and

relational psychoanalytic therapy.

SHORT-TERM PSYCHODYNAMIC THERAPIES In several short versions of psychodynamic therapy, patients choose a single problem—a dynamic

focus—to work on, such as difficulty getting along with other people (Levenson, 2017). 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 (Town et al.,

2017).

154

What are some of the ways that Freud’s theories have

affected literature, film and television, philosophy, child

rearing, and education in Western society?

RELATIONAL PSYCHOANALYTIC THERAPY Whereas Freud believed that psychodynamic 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 psychoanalytic therapy argues that therapists are key figures in the lives of

patients—figures whose reactions and beliefs should be included in the therapy process (Corey,

2017). Thus, a key principle of relational therapy is that therapists should also disclose things

about themselves, particularly their own reactions to patients, and try to establish more equal

relationships with patients.

“Look! I’m having enough trouble right now without your bringing up the past.”

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.

155

Psychodynamic theorists have also helped us to understand that abnormal functioning may be

rooted in the same processes as normal functioning. Psychological conflict 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 systematically to treatment. They were also the first to demonstrate the

potential of psychological, as opposed to biological, treatment, 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 (Safran et al., 2019). Because processes 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 relatively limited research support over the years, and psychodynamic theorists rely

largely on evidence from individual case studies. Nevertheless, recent research evidence suggests

that long-term psychodynamic therapy may be helpful for many persons with long-term complex

disorders (Berman, 2017; Werbart et al., 2017), and 18 percent of today’s clinical psychologists

identify themselves as psychodynamic therapists (Prochaska & Norcross, 2018).

SUMMING UP

THE PSYCHODYNAMIC MODEL Psychodynamic theorists believe that an individual’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 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 psychodynamic approaches include short-term

psychodynamic therapies and relational psychoanalytic therapy.

156

The Cognitive-Behavioral Model The cognitive-behavioral model of abnormality focuses on the behaviors people display and the

thoughts they have. The model is also interested in the interplay between behaviors and thoughts

—how behavior affects thinking and how thinking affects behavior. In addition, the model is

concerned with the impact the behavior–cognition interplay often has on feelings and emotions.

Whereas the psychodynamic model had its beginnings in the clinical work of physicians, the

cognitive-behavioral model began in laboratories where psychology researchers had been studying

behaviors, the responses an organism makes to its environment, since the late 1800s. Such

researchers believed that behaviors can be external (going to work, say) or internal (having a

feeling), and they ran experiments on conditioning, simple forms of learning, in order to better

understand how behaviors are acquired. In these experiments, researchers would manipulate

stimuli and rewards, then observe how such manipulations affect the behaviors of animal and

human subjects.

conditioning A simple form of learning.

During the 1950s, a number of clinicians, frustrated with what they viewed as the vagueness

and slowness of the psychodynamic model, began to explain and treat psychological abnormality

by applying principles derived from those laboratory conditioning studies. Consistent with the

laboratory studies, the clinicians viewed severe human anxiety, depression, and the like as

maladaptive behaviors, and they focused their work on how such behaviors might be learned and

changed.

157

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.

158

A decade or so later, yet other clinicians came to believe that a focus on behaviors alone, while

moving in the right direction, was too simplistic, that behavioral conditioning principles failed to

account fully for the complexity of human functioning and dysfunction. They recognized that

human beings also engage in cognitive processes, such as anticipating or interpreting—ways of

thinking that until then had been largely ignored in the behavior-focused explanations and

therapies. These clinicians developed cognitive-behavioral theories of abnormality that took both

behaviors and cognitive processes into account, and cognitive-behavioral therapies that sought to

change both counterproductive behaviors and dysfunctional ways of thinking (Kodal et al., 2018;

Craske, 2017).

Some of today’s theorists and therapists still focus exclusively on the behavioral aspects of

abnormal functioning, while others focus only on cognitive processes. However, most clinicians

with such orientations include both behavioral and cognitive principles in their work. To best

appreciate the cognitive-behavioral model, let us look first at its behavioral dimension and then

its cognitive dimension.

The Behavioral Dimension Many learned behaviors help people to cope with daily challenges and to lead happy, productive

lives. However, abnormal behaviors also can be learned. Philip Berman, for example, might be

viewed as a man who has received improper training: he has learned behaviors that offend others

and get him into various kinds of trouble.

Theorists have identified several forms of conditioning, and each may produce abnormal

behavior as well as normal behavior. In classical conditioning, for example, people learn to

respond to one stimulus the same way they respond to another as a result of the two stimuli

repeatedly occurring together close in time. If, say, a physician wears a white lab coat whenever

she gives painful allergy shots to a little boy, the child may learn to fear not only injection

needles, but also white lab coats. Many phobias are acquired by classical conditioning, as you will

see in Chapter 4. In modeling, another form of conditioning, individuals learn responses simply

by observing other individuals and then repeating their behaviors. Phobias can also be acquired

by modeling. If a little girl observes her father become frightened whenever a dog crosses his

path, she herself may develop a phobic fear of dogs.

classical conditioning A process of learning by temporal association in which two events that repeatedly occur close together in time become fused in a person’s mind and produce the same response. modeling A process of learning in which an individual acquires responses by observing and imitating others.

159

In a third form of conditioning, operant conditioning, individuals learn to behave in certain

ways as a result of experiencing consequences of one kind or another—reinforcements (for

example, rewards) or punishments—whenever they perform the behavior (Skinner, 1958, 1957).

Research suggests that a number of abnormal behaviors may be acquired by operant conditioning

(Held-Poschardt et al, 2018; Calarco, 2016). Some children, for example, learn to display

extremely aggressive behaviors when their parents or peers consistently surrender to their threats

or demands or shower them with extra attention when they act out. In addition, a number of

people learn to abuse alcohol because initially such behaviors bring feelings of calm, comfort, or

pleasure.

operant conditioning A process of learning in which individuals come to behave in certain ways as a result of experiencing consequences of one kind or another whenever they perform the behavior.

Conditioning for entertainment and profit Animals can be taught a wide assortment of tricks by using the principles of

conditioning—but at what cost? Here an Asian elephant performs one called “the living statue” as she acknowledges the

crowd at a circus in Virginia. In recent years the public has become alarmed at the training procedures used on circus

animals, leading some circuses to remove elephants from their shows. This in turn has led to declining ticket sales and

contributed to the closing of several circuses, including the famous Ringling Brothers and Barnum & Bailey Circus.

In treatment, behavior-focused therapists seek to replace a person’s problematic behaviors

with more appropriate ones, applying the principles of operant conditioning, classical

160

conditioning, or modeling (Antony, 2019; Foa et al., 2018). When treating extremely aggressive

children, for example, the therapists may guide parents to change the reinforcers they have been

unintentionally providing for their children’s behaviors. The parents may be taught to

systematically reinforce polite and appropriate behaviors by their children by providing the

children with displays of extra attention or special privileges. In addition, the parents may be

taught to systematically punish highly aggressive behaviors by withdrawing attention and

withholding privileges in the aftermath of such behaviors (Cornacchio et al., 2017; Elkins et al.,

2017).

The Cognitive Dimension Philip Berman, like the rest of us, has cognitive abilities—special intellectual capacities 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 experiences, Philip may misinterpret them in

ways that lead to poor decisions, maladaptive responses, and painful emotions.

In the 1960s two clinicians, Albert Ellis (1962) and Aaron Beck (1967), proposed that we can

best explain and treat abnormal functioning, not only by looking at behaviors, but also by

focusing on cognitions. 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 the assumptions and thoughts are leading.

According to these and other cognition-focused 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, 2019; Ellis & Ellis, 2019). Philip Berman,

for example, often seems to assume that his past history has locked him into his present situation.

He believes that he was victimized by his parents and that he is now forever doomed by his past.

He approaches all new experiences and relationships with expectations of failure and disaster.

Illogical thinking processes are another source of abnormal functioning, according to cognition-

focused theorists. Beck has found that depressed people consistently think in illogical ways and

keep arriving at self-defeating conclusions (Beck & Weishaar, 2019). They may, for example,

overgeneralize—draw broad negative conclusions on the basis of single insignificant events. One

depressed student couldn’t remember the date of Columbus’ third voyage to America while she

was in history class. Overgeneralizing, she spent the rest of the day in despair over her wide-

ranging ignorance.

In treatment, cognition-focused

161

#TheirWords “We cannot solve our problems with the same thinking we

used when we created them.”

Albert Einstein

therapists use several strategies to help

people with psychological disorders adopt

new, more functional ways of thinking. In

an influential approach developed by

Beck, the therapists guide depressed

clients to identify and challenge any

negative thoughts, biased interpretations, and errors in logic that dominate their thinking and

contribute to their disorder. The therapists also guide the clients to try out new ways of thinking

in their daily lives. As you will see in Chapter 6, depressed people treated with Beck’s approach

improve much more than those who receive no treatment (Beck & Weishaar, 2019).

In the excerpt that follows, a Beck-like therapist guides a depressed 26-year-old graduate

student to see the link between her interpretations and her feelings and to begin questioning the

accuracy of those interpretations:

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?

162

#SocialDistress For most people, silence becomes awkward after about four

seconds (Pear, 2013).

Patient: That I can never be happy …

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)

The Cognitive-Behavioral Interplay As you read earlier, most of today’s cognitive-behavioral theorists and therapists interweave both

behavioral and cognitive elements in their explanations and treatments for psychological

disorders. Let’s look, for example, at the cognitive-behavioral approach to social anxiety disorder,

a problem that you will be reading more about in Chapter 4.

People with social anxiety disorder

have severe anxiety about social situations

in which they may face scrutiny by other

people. They worry that they will

function poorly in front of others and will

wind up feeling humiliated. Thus they may avoid speaking in public, reject social opportunities,

and limit their lives in numerous ways.

social anxiety disorder A psychological disorder in which people fear social situations.

Cognitive-behavioral theorists contend that people with this disorder hold a group of social

beliefs and expectations that consistently work against them (Hofmann, 2018; Thurston et al.,

2017; Heimberg et al., 2010). These include:

Holding unrealistically high social standards and so believing that they must perform perfectly in social situations.

Viewing themselves as unattractive social beings.

Viewing themselves as socially unskilled and inadequate.

Believing they are always in danger of behaving incompetently in social situations.

Believing that inept behaviors in social situations will inevitably lead to terrible consequences.

163

Overrun 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. In turn, say cognitive-

behavioral theorists, the individuals learn to regularly perform “avoidance” and “safety” behaviors

(Mesri et al., 2017; Moscovitch et al., 2013). Avoidance behaviors include, for example, talking

only to people they already know well at gatherings or parties, or avoiding social gatherings

altogether. Safety behaviors include wearing makeup to cover up blushing. Such behaviors are

reinforced by eliminating or reducing the individuals’ feelings of anxiety and the number of

unpleasant events they encounter.

To undo this cycle of problematic beliefs and behaviors, cognitive-behavioral therapists

combine several techniques, including exposure therapy, a behavior-focused intervention in

which fearful people are repeatedly exposed to the objects or situations they dread (Thurston et

al., 2017). In cases of social anxiety disorder, the therapists encourage clients to immerse

themselves in various dreaded social situations and to remain there until their fears subside.

Usually the exposure is gradual. Then, back in therapy, the clinicians and clients reexamine and

challenge the individuals’ maladaptive beliefs and expectations in light of the recent social

encounters.

exposure therapy A behavior-focused intervention in which fearful people are repeatedly exposed to the objects or situations they dread.

In the following discussion, a cognitive-behavioral therapist works with a socially anxious

client who fears he will be rejected if he speaks up at gatherings. The therapy discussion is taking

place after the man has 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 therapy 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 did you do the second part of the homework assignment?”

“The forcing myself to speak up and express myself?”

164

#TheirWords “The greatest discovery of my generation is that human beings

can alter their lives by altering their attitudes of mind.”

William James (1842–1910)

“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.”. . .

“And how did you feel after expressing yourself like that?”

“Remarkable! … I felt, uh, just remarkable—good, that is … . 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)

In cognitive-behavioral approaches of this kind, clients come to adopt more accurate social

beliefs, engage in more social situations, and experience less fear during, and in anticipation of,

social encounters. Avoidance and safety behaviors drop away while social approach behaviors are

reinforced by opening the door to the joy and enrichment of social encounters. Studies show that

such approaches do indeed help many individuals to overcome social anxiety disorder (Gregory

& Peters, 2017; Heimberg & Magee, 2014).

Assessing the Cognitive-Behavioral Model The cognitive-behavioral model has

become a powerful force in the clinical

field. Various cognitive and behavioral

theories have been proposed over the

years, and many treatment techniques

have been developed. As you can see in

Figure 2-3, nearly half of today’s clinical psychologists report that their approach is cognitive

and/or behavioral (Prochaska & Norcross, 2018).

165

FIGURE 2-3

Theoretical Orientations of Today’s Clinical Psychologists

In surveys, 22 percent of clinical psychologists labeled their approach as “eclectic,” 46 percent considered their model

“cognitive” and/or “behavioral,” and 18 percent called their orientation “psychodynamic.” (Information from: Prochaska &

Norcross, 2018.)

One reason for the appeal of the cognitive-behavioral model is that it can be tested in the

laboratory, whereas psychodynamic theories generally cannot. Many of the model’s basic

concepts—stimulus, response, reward, attitude, and interpretation—can be observed or, at least,

measured. Moreover, investigators have found that people with psychological disorders often

display the kinds of reactions, assumptions, and errors in thinking that cognitive-behavioral

theorists would predict (Kube et al., 2018).

Yet another reason for the popularity of this model is the impressive research performance of

cognitive-behavioral therapies. Both in the laboratory and real life, they have proved very helpful

to many people with anxiety disorders, depression, sexual dysfunction, intellectual disability, and

yet other problems (Reavell et al., 2018; Dobson & Dobson, 2017).

At the same time, the cognitive-behavioral model has drawbacks. First, although maladaptive

behaviors and disturbed cognitive processes are found in many forms of abnormality, their

precise role has yet to be determined. The problematic behaviors and cognitions seen in

psychologically troubled people could well be a result rather than a cause of their difficulties.

Second, although cognitive-behavioral therapies are clearly of help to many people, they do not

help everyone. Research indicates, in fact, that it is not always possible for clients to rid

166

#WanderingThoughts Your mind wanders almost one-half of the time on average

(Killingsworth, 2013; Killingsworth & Gilbert, 2010).

themselves fully of their negative thoughts and biased interpretations (Sharf, 2015).

In response to such limitations, a new group of therapies, sometimes called the new wave of

cognitive-behavioral therapies, has emerged in recent years. These new approaches, including the

increasingly 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

(Gonzalez-Fernandez et al., 2018; Hayes, 2016). The hope is that by recognizing 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.

“Don’t take that tone of thought with me.”

As you will see in Chapter 4, ACT and similar therapies often employ mindfulness-based

techniques to help clients achieve such acceptance. These techniques borrow heavily from a form

of meditation called mindfulness 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 nonjudgmental way (see InfoCentral). Research suggests that ACT and other

mindfulness-based approaches are often quite helpful in the treatment of anxiety and depression,

among other problems (Walsh, 2019; Gonzalez-Fernandez et al., 2018).

A final drawback of the cognitive-

behavioral model is that it is narrow in

certain ways. Although behavior and

167

cognition obviously are key dimensions in

life, they are still only two aspects of human functioning. 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.

INFOCENTRAL

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 depressive disorders, as well as a variety of other

psychological disorders.

168

SUMMING UP

THE COGNITIVE-BEHAVIORAL MODEL Proponents of the cognitive-behavioral model focus on maladaptive behaviors and cognitions to explain and treat

psychological disorders. Most such proponents include both the behavioral and cognitive dimensions in their work.

On the behavioral side, the proponents hold that three types of conditioning—classical conditioning, modeling,

and operant conditioning—account for behavior, whether normal or dysfunctional, and they treat people who display

169

problematic behaviors by replacing such behaviors with more appropriate ones, using techniques based on the

principles of conditioning. On the cognitive side, the model’s proponents point to cognitive problems, like

maladaptive assumptions and illogical thinking processes, to explain abnormal functioning; and they treat

dysfunctional people by helping them recognize, challenge, and change their problematic ways of thinking.

In addition to the traditional cognitive-behavioral approaches, a new wave of cognitive-behavioral therapies, such

as acceptance and commitment therapy (ACT), try to teach clients to be mindful of and accept many of their

problematic thoughts.

170

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 understood 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 their 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).

self-actualization The humanistic process by which people fulfill their potential for goodness and growth.

Existentialists agree that human beings must have an accurate awareness of themselves and live

meaningful—they say “authentic”—lives in order to be psychologically 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 supportive 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.

client-centered therapy The humanistic therapy developed by Carl Rogers in which clinicians try to help clients by conveying acceptance, accurate empathy, and genuineness.

171

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 (Schneider & Krug, 2017; Cooper, 2016).

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, 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 page 16).

Rogers’ Humanistic Theory and Therapy According to Carl Rogers, the road to dysfunction begins in infancy (Raskin, Rogers, & Witty,

2019; Rogers, 1987, 1951). We all have a basic need to receive positive 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.

172

Actualizing the self Humanists suggest that self-actualized people show concern for others, among other positive qualities.

Many work as volunteers. For example, as part of the Free Hugs Project, a worldwide campaign, volunteers offer hugs to

passersby who look like they could use a quick dose of comfort.

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 relationship 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 supportive climate in

which clients feel able to look at themselves honestly and acceptingly (Raskin et al., 2019). The

therapist must display three important qualities throughout the therapy—unconditional positive

regard (full and warm acceptance for 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

173

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, 2018,

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., 2019). 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 treatment.

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, 2018).

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,

2019). But unlike client-centered therapists, they try to achieve this goal by challenging and even

frustrating the clients, demanding that they stay in the here and now during therapy discussions,

and pushing them to embrace their real emotions.

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.

174

For example, gestalt therapists often use the technique of role playing, instructing 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. The gestalt version of 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.

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.

Approximately 1 percent of clinical psychologists and other kinds of clinicians describe

themselves as gestalt therapists (Prochaska & Norcross, 2018). Because they believe that

subjective experiences and self-awareness cannot be measured objectively, proponents of gestalt

therapy have not often performed controlled research on this approach (Yontef & Jacobs, 2019).

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. In the early 1900s, for example, Freud argued that religious

beliefs were defense mechanisms, “born from man’s need to make his helplessness tolerable”

175

What various explanations might account for the correlation

between spirituality and mental health?

(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 (APA, 2017, 2010).

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 individuals 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 (Kucharska,

2017; Steffen, Masters, & Baldwin, 2017). 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

(Barnett, 2018; McClintock, Lau, & Miller, 2016). Similarly, a number of religious institutions

offer counseling services to their members.

176

Spirituality and science 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.

Existential Theories and Therapy Like humanists, existentialists believe that psychological dysfunction 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 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 & Josselson, 2019;

Cooper, 2016). 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 being oppressive. He fails to appreciate his choices in life and his

own 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

177

their problems. Therapists try to help clients recognize their freedom so that they may choose a

different course and live with greater meaning (Yalom & Josselson, 2019; Schneider & Krug,

2017). 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.

existential therapy A therapy that encourages clients to accept responsibility for their lives and to live with greater meaning and value.

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 individuals by reducing them to

test measures. Not surprisingly, then, little controlled research has been devoted to the

effectiveness of this approach (Yalom & Josselson, 2019; Schneider & Krug, 2017). Nevertheless,

around 1 percent of today’s clinical psychologists use an approach that is primarily existential

(Prochaska & Norcross, 2018).

178

#CharitableActs

83% Percentage of adult Americans who make charitable contributions each year

32% Percentage of charitable donations contributed to religious organizations

68% Percentage of donations directed to education, human services, health, and the arts

27% Percentage of adult Americans who do volunteer work each year

(Information from: NPT, 2017; Gallup, 2013)

#TheirWords “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

Assessing the Humanistic-Existential Model The humanistic-existential model appeals to many people in and out of the clinical 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. Moreover, the

factors that they say are essential to effective functioning—self-acceptance, personal values,

personal meaning, and personal choice—are certainly lacking in many people with psychological

disturbances.

The optimistic tone of the humanistic-

existential model is also an attraction.

Such optimism meshes quite well with the

goals and principles of positive psychology

(see page 16) (Rashid & Seligman, 2019).

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

traditionally rejected the use of empirical research. This anti-research position is 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 & Vitali, 2018;

Schneider & Krug, 2017).

179

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 therapists, 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 treatment 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, recognize their freedom to choose a different

course, and choose to live with greater meaning.

180

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 environment? 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.

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 (Ruscio, 2015). 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 colleagues of Rosenhan,

presented themselves at various mental hospitals, falsely 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.

181

Moreover, the pseudopatients had a hard time convincing 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 addition, 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.” Overall, 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 others? Researchers have often found ties

between deficient social connections and psychological dysfunction (Teo et al., 2019; Hsiao,

Chang, & Gean, 2018). 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 communicate and

develop relationships in their everyday lives will, alternatively, find adequate social contacts

online, using social networking platforms like Facebook or Instagram. Although this may be true

for some such individuals, research suggests that people’s online relationships tend to parallel

their offline relationships. Several studies of college students, for example, have found that

students who are self-disclosing and have many friends on Facebook also are particularly social

offline, while those who reveal less about themselves and initiate fewer relationships on Facebook

are less willing to communicate with other people offline (Dunbar, 2016; Sheldon, 2008).

182

“We broke up, Stuart—don’t you read your e-mail?”

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

& Stanton, 2019). 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 operation and would actually increase their own and their family’s turmoil.

family systems theory A theory that views the family as a system of interacting parts whose interactions exhibit consistent patterns and unstated rules.

183

Today’s TV families Unlike television viewers during the twentieth century, when problem-free families ruled the airwaves,

today’s viewers prefer more complex and occasionally dysfunctional families, like the Johnsons, whose trials and tribulations,

including dealing with racial-cultural dilemmas, are on display in ABC’s popular series Black-ish.

Family systems theory holds that certain family systems are particularly likely to produce

abnormal functioning in individual members (Lindblom et al., 2017). 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. Some families display disengagement, which is marked by

very rigid boundaries between the members. Children from these families may find it hard to

function in a group or to give or request support.

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

184

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.

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. Therapists of any

orientation may work with clients in these various formats, applying the techniques and

principles of their preferred models (see MindTech). 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.

Creative group work Psychodrama, developed by psychiatrist Jacob Moreno in 1921, is one of the oldest forms of group

treatment. Its group members act out their emotions, past or present situations, social interactions, and the like—often in

185

creative ways and sometimes on a stage. Although not as widely conducted as conventional group therapy, this format is still

offered in a number of locations, such as this psychodrama group in Pignan, France.

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. 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, build social skills, strengthen feelings of self-worth,

and share useful information or advice (Brown, 2017). 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.

group therapy A therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.

Research suggests that group therapy is of help to many clients, often as helpful as individual

therapy (Mergl et al., 2018; Law et al., 2016). The group format also has been used for purposes

that are educational rather than therapeutic, such as “consciousness raising” and spiritual

inspiration.

MINDTECH

Have Your Avatar Call My Avatar

The sociocultural model holds that abnormal behavior is best understood and treated in a social context. Thus, as

part of the movement toward technology-enhanced interventions, a growing number of clinicians are particularly interested

in using avatars—three-dimensional graphical representations of the clients and/or other key persons in their lives—in their

treatment programs (Alderson-Day & Jones. 2018; Craig et al., 2018, 2016).

As you will see in Chapters 4 and 5, the use of 3D computer graphics to simulate real-world objects and situations,

called virtual reality therapy, has become a popular technique for treating people with phobias, traumatic memories, and

other disorders. In such cases, the technique enables clients to be exposed—through computer simulation—to the objects

and memories they dread, thus helping them to confront their fears head-on.

On the other hand, avatar therapy, one version of virtual reality therapy, seeks primarily to immerse clients in

digitalized social situations—situations in which they interact with avatars as a bridge toward social improvement.

In one form of avatar-centered therapy, users are guided by computer software programs to interact with on-screen

virtual therapist figures who ask questions such as “What kinds of things do you dislike about yourself?” The virtual

therapist may also nod sympathetically when the users offer self-criticisms and may reinforce certain user statements with

smiles or encouraging words (Rehm et al., 2016; Reamer, 2013).

186

Why might group therapy actually be more helpful to some

people with psychological problems than individual

therapy?

In another use of avatars, clients are guided by their real-life therapists to enter virtual environments on their

computers, acquire virtual bodies, and interact with animated figures who resemble their parents, bosses, friends, or

enemies—in situations that feel very real (Allen, Jameson, & Myers, 2017; Myers et al., 2016). In one highly publicized

case, for example, a woman with social anxiety and agoraphobia—a fear of leaving the house—was guided by her therapist

to adopt an avatar and enter into a virtual world of other avatars, a journey that eventually enabled her to venture outside

into the real world and into relationships with other persons (Smith, 2008).

Not surprisingly, given its social focus, avatar therapy is used most often to help individuals suffering from problems

such as social anxiety, loneliness, interpersonal deficits, and hallucinations that hinder normal interactions (Allen et al.,

2017; Falconer et al., 2017). These applications are often quite helpful according to research (Craig et al., 2018; Leff et al.,

2014, 2013).

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, unemployment,

or divorce) come together to help and support one another without the direct leadership of a

professional clinician (Bond, Wright, & Bacon, 2017). 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 (Ahmadi, 2016). In addition, an ever-growing number

of self-help chat groups have emerged on the Internet.

187

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

#ShiftingValues

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

(Information from: Pew Research Center, 2015, 2013; Harris Interactive, 2013)

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 & Stanton, 2019). 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 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.”

188

“You don’t know how frustrating it is for me, honey.” Bob seemed upset. …

Ginny gave him a hard stare … “I could use some support from you [too]. You think … I will do everything. … 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 therapy A therapy format in which the therapist meets with all members of a family and helps them to change in therapeutic ways.

Family therapists may follow any of the major theoretical models, but many of them adopt the

principles of family systems theory. Today 2 percent of all clinical psychologists, 4 percent of

counseling psychologists, and 14 percent of social workers identify themselves mainly as family

systems therapists (Prochaska & Norcross, 2018).

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. Thus, family systems

therapists often try to change the family power structure, the roles each person plays, and the

relationships between members. They may also try to help members recognize and change

harmful patterns of communication (Corey, 2017; Minuchin, 2007, 1987, 1974).

Family therapy is often helpful to individuals, although research has not yet clarified how

helpful (Goldenberg & Stanton, 2019). Some studies have found that as many as 65 percent of

individuals treated with family 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 (Lebow, 2017).

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., 2018, 2015, 2010; Lebow, 2017). A

couple approach may also be used when a child’s psychological problems are traced to problems

in the parents’ relationship.

couple therapy

189

A therapy format in which the therapist works with two people who share a long-term relationship. Also called marital therapy.

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 difficulty (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 (Epstein & Zheng, 2017). Therapists help spouses

recognize and change problem behaviors largely by teaching specific problem-solving and

communication skills. A broader, more sociocultural version, called integrative behavioral couple

therapy, further helps partners accept behaviors that they cannot change and embrace the whole

relationship nevertheless (Christensen & Doss, 2017). 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., 2016, 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, particularly those with severe

psychological difficulties, to receive treatment in familiar 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 disorders (Schroeder, 2018). A

number of other countries have launched such programs over the past several decades.

community mental health treatment A treatment approach that emphasizes community care.

190

Reaching out On a freezing night in 2012, New York City police officer Lawrence DiPrimo bought a pair of socks and

shoes for a homeless man he had come across, then knelt down and gently put them on the man’s feet. Unbeknownst to the

officer, his humane act was photographed by a passerby and was viewed online by millions of people. Although DiPrimo’s

behavior came from the heart, it reflected the key principles of community mental health, including reaching out to the

needy in the community with kindness and understanding, which may help prevent mental health problems.

As you read in Chapter 1, a key principle of community 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 (Mendelson & Eaton, 2018; Koh, 2017).

Community workers recognize three types of prevention, which they call primary, secondary, and

tertiary.

Primary prevention consists of efforts to improve community attitudes and policies. Its goal is

to prevent psychological disorders altogether. Community workers may, for example, consult

with a local school board, offer public workshops on stress reduction, or construct Web sites on

191

how to cope effectively.

Secondary prevention consists of identifying and treating 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 millions 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 (NIMH, 2017). One of the reasons for this

failure is lack of funding, an issue that you will read about in later chapters.

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 & Juang, 2016). We

are, without question, a society of multiple cultures. Indeed, by the year 2044, members of racial

and ethnic minority groups in the United States will collectively outnumber non-Hispanic white

Americans (Frey, 2018; U.S. Census Bureau, 2015).

192

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.”

Partly in response to this growing diversity, the multicultural, or culturally diverse,

perspective has emerged (Comas-Díaz, 2019). 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 differ psychologically (Alegría et al., 2018, 2016,

2014). 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.

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.

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,

193

American Indian, and Asian American groups) and groups such as economically disadvantaged

persons, LGBTQ individuals, and women (although women are not a minority group numbers-

wise). 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 (APA, 2018; Sareen

et al., 2011) (see Figure 2-4). Perhaps the pressures of poverty explain this relationship.

FIGURE 2-4

Poverty and Mental Health

Surveys in the United States find that people with low annual incomes (below $20,000) have a greater risk of experiencing

mental disorders than do those with higher incomes (above $70,000). For example, 10 percent of low-income people have

persistent symptoms of anxiety, compared with 6 percent of higher-income people. (Information from: APA, 2018; CDC,

2015; Sareen et al., 2011.)

Of course, membership in these various groups overlaps. Many members of minority groups,

for example, also live in poverty. The higher rates of crime, unemployment, 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 (APA,

2018; Joshi et al., 2016).

Multicultural researchers have also noted that the prejudice and discrimination faced by many

minority groups may contribute to various forms of abnormal functioning (Yoon, Coburn, &

194

Spence, 2018). Women in Western society receive diagnoses of anxiety disorders and of

depression at least twice as often as men (MHA, 2018). Similarly, African Americans, Hispanic

Americans, and American Indians are more likely than non-Hispanic white Americans to

experience serious psychological distress (APA, 2018; HHS, 2009). American Indians also have

exceptionally high alcoholism and suicide rates (AFSP, 2018; NSDUH, 2016). Although many

factors may combine to produce these differences, prejudice based on race and sexual orientation,

and the problems such prejudice poses, may contribute to abnormal patterns of tension,

unhappiness, and low self-esteem.

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 (Alegría et al., 2018, 2016,

2014).

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 pursue therapeutic activities and reach out to the

community.

195

A number of studies suggest that two features of treatment can increase a therapist’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-Díaz, 2019; Chu et al., 2016). 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 (Corey, 2017; Vasquez &

Vasquez, 2016).

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.

Culture-sensitive approaches typically include the following elements:

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 understanding 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.

196

#FamilyRestructuring

9% Percentage of U.S. children living with only one parent in 1960

27% Percentage of U.S. children living with only one parent today

(U.S. Census Bureau, 2016)

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 disorder, 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 functioning

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 abnormality 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 multicultural explanations

as operating in conjunction with the biological or psychological explanations. They agree that

family, social, and cultural factors may create a 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 this perspective may practice group,

family, or couple therapy, or community treatment.

The multicultural perspective, another sociocultural perspective, 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 pressures faced by members of that culture. Practitioners of this perspective

may provide culture-sensitive therapies.

197

198

#TheirWords “Even a minor event in the life of a child is an event of that

child’s world and thus a world event.”

Gaston Bachelard, French philosopher

Integrating the Models: The Developmental Psychopathology Perspective Today’s leading models vary widely (see Table 2-3), 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.

TABLE: 2-3 Comparing the Models

Despite all their differences, the conclusions and techniques of the various models are often

compatible. And, indeed, many clinicians now favor explanations of abnormal behavior that

consider more than one kind of cause at a time. These explanations state that abnormality results

from the interaction of genetic, biological, emotional, behavioral, cognitive, social, cultural, and

societal influences. In a similar quest for integration, many therapists now combine treatment

techniques from several models (Norcross & Beutler, 2019). In fact, 22 percent of today’s clinical

psychologists, 31 percent of counseling psychologists, and 26 percent of social workers describe

their approach as “eclectic” or “integrative” (Prochaska & Norcross, 2018). Studies confirm that

clinical problems often respond better to combined approaches than to any one therapy alone.

One of today’s most influential

integrative views is the developmental

psychopathology perspective. As its name

implies, this perspective uses a

developmental framework to understand

how variables and principles from the

various models may collectively account for human functioning—both adaptive and maladaptive

functioning (Halperin, 2017; Cicchetti, 2016). As such, the perspective pays particular attention

to the timing of influential variables. The emergence of particular events, experiences, or

199

biological factors—from neurons to neighborhoods—can continue to have enormous impact on

later functioning if they occur at vulnerable points in a person’s life. Moreover, the critical

question for developmental psychopathologists is not which single factor is the cause of an

individual’s current psychological problems, but rather when, how, in what context, and to what

degree the multiple factors in his or her life interact with one another. In Philip Berman’s case,

for example, when did his brother’s birth occur, what was going on in Philip’s life at that point in

time, how did his mother’s depression affect her parenting skills, did his childhood experiences

teach him how to cope effectively with stress, and were his social systems during childhood,

college, and adulthood supportive or did they intensify his difficulties?

developmental psychopathology A perspective that uses a developmental framework to understand how variables and principles from the various models may collectively account for human functioning.

What are the factors that developmental psychopathologists look at collectively when seeking

to understand a person’s abnormal functioning? As noted above, they draw from each of the

clinical field’s major models. They draw from the biological model, for example, by determining

how certain genetic and brain factors have set the stage for the individual’s important

environmental experiences (Barker, 2018; Halperin, 2017). They extract from the

psychodynamic model, by considering how earlier events in a person’s life—including parent–

child relationships—have stifled subsequent development (Moreno, 2018; Chambers, 2017).

They employ principles from the cognitive-behavioral model by determining how the

individual’s maladaptive behaviors have been reinforced over the years and how he or she has

interpreted and processed life experiences (Hankin et al., 2016). In addition, developmental

psychopathologists draw from the humanistic-existential model by considering the person’s

competencies, uniqueness, and resilience, even in the face of overwhelming life stress (Hornor,

2017; Burt et al., 2016). And finally, they embrace the sociocultural model’s emphasis on the

influence of social context and culture—both present and past—on the individual’s functioning

(Shulman & Scharf, 2018; Pianta, 2016).

The developmental psychopathology perspective contends that various developmental routes,

or pathways, can lead to dysfunction. In fact, two key principles—equifinality and multifinality—

are at the center of the perspective. According to the principle of equifinality, a number of

different developmental pathways can lead to the same psychological disorder. Consider, for

example, two teenage boys with conduct disorder, a disorder that you’ll be reading about in

Chapter 14. Both boys may display the characteristic symptoms of this disorder, such as stealing,

skipping school, lying, and breaking into cars. However, for one of the boys, factors such as

unfavorable genes, poor parenting, and a limited cognitive capacity for empathy may have

200

interacted to foster the development of conduct disorder. In contrast, the other boy with the

disorder may not have any genetic vulnerabilities, may have been raised by highly attentive

parents, and may actually demonstrate a high capacity for empathy. His serious conduct

problems may have resulted instead from the interaction of long-term feelings of depression, low

self-esteem, strong needs for peer approval, and affiliations with peers who typically engage in

delinquent activities.

equifinality The principle that a number of different developmental pathways can lead to the same psychological disorder.

High-flying equifinality The principle of equifinality—the notion that people can arrive at the same end point through

different developmental pathways—has been observed in the physical realm as well as the psychological realm. Consider

Neil Douglas and Robert Stirling, two men born to different parents, inheriting different genes, experiencing different

childhoods, and raised in different cities. When the two strangers took a plane flight in 2015, they each were flabbergasted

to see that the passenger seated next to them was their “spitting image”—same red hair and beard, head shape, eyes, teeth,

smile, and more. They immediately took this selfie, and the photo went viral.

According to the principle of multifinality (the flipside of equifinality), persons who have

experienced a number of similar developmental variables (for example, comparable biological

predispositions, family structures, schools, and neighborhoods) may nevertheless react to

comparable current situations in very different ways or have different clinical outcomes. Consider

two women who lose their jobs suddenly. Despite their similar developmental variables, one

woman may react to this loss with devastation and spiral toward depression, while the other may

201

view the job loss as an opportunity for reinvention and enthusiastically seek out a wide range of

new employment opportunities. Why this enormous difference in the reactions of the two

individuals? Perhaps their developmental histories or current circumstances do in fact differ in

undetected ways. The latter woman may, for example, have experienced uniquely challenging

events while growing up that fostered a strong sense of resilience, or she may currently have

greater financial savings to help her weather a period of unemployment.

multifinality The principle that persons with a similar developmental history may nevertheless react to similar current situations in very different ways.

Given their emphasis on timing and development to explain psychological disorders, it is not

surprising that developmental psychopathologists focus more on the timing of treatment than on

specific treatment techniques. For example, they tend to prioritize prevention and early

intervention for vulnerable persons over treatment for individuals who have already developed

severe disorders (Beelmann et al., 2018; Toth et al., 2016). Further, consistent with the

perspective’s special emphasis on context and sociocultural influences, developmental

psychopathologists echo the call of community mental health advocates for community-wide

interventions, commonly targeting entire schools or neighborhoods, as opposed to individual

treatment formats. Indeed, developmental psychopathologists often play prominent roles in

advocacy and social policy, seeking changes in societal factors that negatively influence

development, such as poverty, community violence, and social inequalities.

Given the rise of integrative perspectives and combination treatments, our examinations of

abnormal behavior throughout this book will take two directions. As various disorders are

presented, we will look at how today’s models explain and treat each disorder, and how well

those explanations and treatments are supported by research. Just as important, however, we will

also be observing how the explanations and treatments may build upon one another, and we will

examine current efforts toward integration of the models, including the efforts of developmental

psychopathologists.

SUMMING UP

INTEGRATING THE MODELS Many theorists now favor explanations for abnormal behavior that consider more than one kind of cause, and many

therapists combine treatment techniques from several models. An influential integrative view, the developmental

psychopathology perspective, uses a developmental framework to understand how variables and principles from the

various models may collectively account for human functioning—both adaptive and maladaptive functioning. Two

202

principles at the center of this perspective are equifinality and multifinality.

203

Chapter 2 Review

Key Terms

model

neuron

synapse

neurotransmitter

receptors

endocrine system

hormone

brain circuit

genes

psychotropic medication

brain stimulation

electroconvulsive therapy (ECT)

psychosurgery

unconscious

ego

ego defense mechanism

superego

fixation

object relations theory

free association

resistance

204

transference

dream

catharsis

working through

short-term psychodynamic therapies

relational psychoanalytic therapy

conditioning

classical conditioning

modeling

operant conditioning

social anxiety disorder

exposure therapy

self-actualization

client-centered therapy

gestalt therapy

existential therapy

family systems theory

group therapy

self-help group

family therapy

couple therapy

community mental health treatment

multicultural perspective

culture-sensitive therapy

gender-sensitive therapy

205

developmental psychopathology

equifinality

multifinality

Quick Quiz

1. What are brain structures, neurotransmitters, and brain circuits? Describe the biological treatments for psychological disorders. pp. 37–42

2. Identify the models associated with learned responses (p. 49), values (p. 55), responsibility (p. 58), spirituality (p. 58), underlying conflicts (p. 43), and maladaptive assumptions (p. 50).

3. Identify the treatments that use unconditional positive regard (p. 56), free association (p. 46), exposure (p. 52), mindfulness meditation (p. 53), and dream interpretation (p. 46).

4. What are the key principles of the psychodynamic (pp. 43–45), cognitive-behavioral (pp. 48–51), humanistic-existential (pp. 55–59), and sociocultural models (pp. 60–67)?

5. According to psychodynamic theorists, what roles do the id, ego, and superego play in the development of both normal and abnormal behavior? What are the key techniques used by psychodynamic therapists? pp. 43–48

6. What forms of conditioning do cognitive-behavioral practitioners focus on in their explanations and treatments of abnormal behaviors? What kinds of cognitive dysfunctions can contribute to abnormal behavior, and which treatment approaches are used to address such dysfunctions? pp. 49–52

7. How do humanistic theories and therapies differ from existential ones? pp. 55–59

8. How might social labels and roles, social connections, family factors, and culture relate to psychological functioning? pp. 60–62, 66–67

9. What are the key features of culture-sensitive therapy, group therapy, family therapy, couple therapy, and community treatment? How effective are these various approaches? pp. 62–67

10. What are the key principles of the developmental psychopathology perspective? How does this perspective integrate the variables and principles found in the various models

206

of psychological abnormality? pp. 68–70

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

207

CHAPTER 3 Clinical Assessment, Diagnosis, and Treatment

TOPIC OVERVIEW

208

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

What Lies Ahead for Clinical Assessment?

Franco 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 psychology build a general

understanding of abnormal functioning. Clinical practitioners 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. To help a client overcome problems, clinicians must fully

understand the client and his or her particular difficulties. To gather such individual

209

information, clinicians use the procedures of assessment and diagnosis. Then they are in a position

to offer treatment.

idiographic information Information about a particular individual, as opposed to a larger population.

210

How reliable and valid are the tests you take in school?

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 information from

résumés, interviews, references, and perhaps on-the-job observations.

assessment The process of collecting and interpreting relevant information about a client or research participant.

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.

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 followed 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 aggressiveness 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.

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 refers to the consistency of

211

What about the tests you see online? assessment measures. A good assessment

tool will always yield similar results in the

same situation (Blanchard et al., 2017).

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 (Tenke et al., 2017). The higher the correlation (see Chapter 1), the greater

the test’s reliability.

reliability A measure of the consistency of test or research results.

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. 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.

validity A measure of the accuracy of a test’s or study’s results.

212

Reliable assessment? Former National Basketball Association stars Magic Johnson, Shaquille O’Neal, Tracy McGrady,

Dikembe Mutombo, and George Gervin served as judges at the 2016 All-Star slam dunk contest. Assigning a relatively wide

range of scores after each dunk, they displayed low interrater reliability.

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 (Duan et al., 2018).

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 information 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.

213

Seeking the right stuff During China’s annual military recruitment period, young men sit in front of computers to undergo

a series of psychological tests. The tests are used by the country’s armed forces to help assess the psychological stability,

coping skills, intellect, and leadership potential of each enlistee.

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 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 those results 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 (Sommers-Flanagan & Sommers-Flanagan, 2017). 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.

214

Conducting the Interview The interview is often the first contact between client and clinician. Clinicians use it to collect

detailed information about the person’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 seeking 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 interpreted 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.”

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 (Sommers-Flanagan & Sommers-

Flanagan, 2017; Miller, 2015). Psychodynamic interviewers try to learn about the person’s needs

and memories of past events and relationships. Cognitive-behavioral interviewers try to identify

information about the stimuli that trigger responses, consequences of the responses, and/or

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

215

#EmploymentScreening Around 60 percent of companies use social networking sites to

help screen job candidates. Why? To see whether candidates

present themselves professionally (65%), are good fits for the

company’s culture (51%), are qualified (45%), and/or are well

rounded (35%) (CareerBuilder, 2017, 2012).

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 have been 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, judgment and insight, thought content and processes, mood, and appearance

(Palsetia et al., 2018; Sommers-Flanagan & Sommers-Flanagan, 2017). 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.

mental status exam A set of interview questions and observations designed to reveal the degree and nature of a client’s abnormal functioning.

Although most clinical interviews have both unstructured and structured portions (Lee et al.,

2017), many clinicians favor one kind over the other. Unstructured interviews typically appeal to

psychodynamic and humanistic clinicians, while structured formats are widely used by cognitive-

behavioral clinicians, who need to pinpoint behaviors or thinking processes that may underlie

abnormal function.

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, 2017). Individuals may intentionally mislead in order to present

themselves in a positive light or to avoid discussing embarrassing topics. Or people may be

unable to give an accurate report in their interviews. Individuals who suffer from depression, for

example, take a negative view of themselves and may describe themselves as poor workers or

216

#PopTerms Online disinhibition effect refers to the tendency of people to

show less restraint when on the Internet (Suler, 2016, 2004;

Sitt, 2013).

inadequate parents when that isn’t the case at all.

Interviewers too may make mistakes in

judgments that slant the information they

gather (Kiger, 2017; Groth-Marnat &

Wright, 2016). They usually rely too

heavily on first impressions, for example,

and give too much weight to unfavorable information about a client. Interviewer biases,

including gender, race, and age biases, may also influence the interviewers’ interpretations of

what a client says.

Interviews, particularly unstructured ones, may also lack reliability (Young, Bell, & Fristad,

2016). People respond differently to different interviewers, 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).

Because different clinicians can obtain different answers and draw different conclusions even

when they ask the same questions of the same person, some researchers 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 person’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. Web sites, for example, regularly 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 standardization. That is, they do not yield consistent, accurate information or reveal

where we stand in comparison with others.

clinical test A device for gathering information about a few aspects of a person’s psychological functioning from which broader information about the person can be inferred.

217

The art of assessment Clinicians often view works of art as informal projective tests in which artists reveal their conflicts

and mental stability. The sometimes bizarre cat portraits by early-twentieth-century artist Louis Wain, for example, have

been interpreted as reflections of the psychosis with which he struggled for many years.

More than 1,000 clinical tests are currently in use around the world (EBSCO, 2018).

Clinicians use six kinds most often: projective tests, personality inventories, response inventories,

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.

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 (Fournier, 2018). The

most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence-

completion tests, and drawings.

projective test A test consisting of ambiguous material that people interpret or respond to.

RORSCHACH TEST In 1911 Hermann Rorschach, a Swiss psychiatrist, experimented with the use of inkblots in his

218

Despite its limitations, just about everyone has heard of the

Rorschach. Why do you think it is so famous and popular?

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 Figure 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 psychological condition. People

diagnosed with schizophrenia, for example, tended to see images that differed from those

described by people experiencing depression.

FIGURE 3-1

An Inkblot Similar to Those Used in the Rorschach Test

Rorschach selected 10 inkblots and

published them in 1921 with instructions

for their use in assessment (see

MindTech). 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

219

projective tests of the twentieth century.

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 inkblot 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 (Choca & Rossini, 2018). 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?

MINDTECH

Psychology’s WikiLeaks?

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.

Since the initial Wikipedia posting, many psychologists have criticized the site’s actions, arguing that the Rorschach

test responses of patients who have previously seen the test on Wikipedia cannot be trusted (White, 2017). In support of

their concerns, one 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.

Still other critics point out that the free 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

220

disorders (White, 2017; Plante, 2016). These studies were conducted on first-time inkblot observers, not on people who

had already viewed the cards online.

Despite these criticisms, the number of online sites posting images of the Rorschach cards has increased steadily since

the first Wikipedia presentation (Plante, 2016). Why? One reason is that the whole controversy brought to light a fact that

relatively few had been aware of previously: The copyright for the test actually ran out in the 1990s in a number of

countries, including Switzerland and the United States (White, 2017; Adamowicz, 2016). According to copyright laws,

because more than 70 years have passed since the author’s death and/or because the test was first published before 1923, the

Rorschach images are in the public domain. This means that, legally, anyone can use or publicly display the cards. Of

course, this legal distinction does not put to rest the important ethical and professional concerns that surround this

controversy.

THEMATIC APPERCEPTION TEST The Thematic Apperception Test (TAT) is a pictorial projective test (Cramer, 2017; 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 feelings 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)

221

FIGURE 3-2

A Picture Similar to One Used in the Thematic Apperception Test

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 (Weiner & Greene, 2017).

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 (Weiner & Greene, 2017). 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 the 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.

WHAT ARE THE MERITS OF PROJECTIVE TESTS? Until the 1950s, projective tests were the most commonly used method for assessing personality.

In recent years, however, clinicians and researchers have relied on them largely to gain

222

“supplementary” insights. One reason for this shift is that practitioners who follow the newer

models have less use for the tests than psychodynamic clinicians do. Even more important, the

tests have not consistently shown much reliability or validity (Weiner & Greene, 2017; Mihura

et al., 2016).

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 (Bornstein, 2007).

Another validity problem is that projective tests are sometimes biased against minority ethnic

groups (see Table 3-1). For example, people are supposed to identify with the characters in the

TAT when they make up stories about them, yet no members of minority groups are represented

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., 2014, 2007).

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 lifestyle in homeland

May overlook client’s sense of loss and frustrations

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 assessor May experience little rapport with client, or may misinterpret client’s distrust as pathology

May be uncomfortable with dominant culture’s values (e.g., assertiveness, confrontation) and so find it difficult to apply clinician’s recommendations

May view client as unmotivated

May manifest stress in culture-bound ways (e.g., somatic symptoms such as stomachaches)

May misinterpret symptom patterns

May hold cultural beliefs that seem strange to dominant culture (e.g., belief in communication with the dead)

May misinterpret cultural responses as pathology (e.g., a delusion)

223

May be uncomfortable during assessment May overlook and feed into client’s discomfort

Mere cultural differences may seem to be pathological symptoms May be unknowledgeable or biased about ethnic-minority culture

May become tense and anxious May nonverbally convey own discomfort to ethnic-minority client

Information from: Borden, 2017; Franklin, 2017; Dana, 2015; Rose et al., 2011; Bhattacharya et al., 2010; Westermeyer,

2004, 2001, 1993; López & Guarnaccia, 2005, 2000; Kirmayer, 2003, 2002, 2001.

Drawing test Drawing tests are commonly used to assess the psychological functioning of children. As part of a therapy

program administered by UNICEF, this young Nigerian refugee draws an attack scene. The program is provided in Baga

Sola, a town in western Chad that welcomes people who have fled extremist groups in northeastern Nigeria.

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 feelings. 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.

personality inventory A test, designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that

224

people evaluate as either characteristic or uncharacteristic of them.

By far the most widely used personality inventory is the Minnesota Multiphasic Personality

Inventory (MMPI). 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 an alternative and

streamlined version of the inventory called the MMPI-2-Restructured Form and a special version

of the test for adolescents, the MMPI-A (Weiner & Greene, 2017; Handel, 2016).

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 deviant. 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 hopeless

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 customs and

an emotional shallowness (“My activities and interests are often criticized by others.”)

Masculinity−femininity Items that are thought to separate male and female respondents (“I

like to arrange flowers.”)

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.”)

225

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

(Weiner & Greene, 2017). 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 two weeks receive approximately the same scores (Graham,

2011, 2006).

Personality inventories also appear to have more validity, or accuracy, than projective tests

(McCord, 2018; Moultrie & Engel, 2017). 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 character, 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 limitations.

Responses that indicate a psychological disorder in one culture may be normal responses in

another (Weiner & Greene, 2017; 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, 1989).

226

“We’re going to run some tests: blood work, a cat-scan, and the S.A.T.’s.”

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 (Sleboda &

Sokolowska, 2017). 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.

response inventories Tests designed to measure a person’s responses in one specific area of functioning, such as affect, social skills, or cognitive processes.

Affective inventories measure the severity of such emotions as anxiety, depression, and anger.

In one of the most widely used affective inventories, the Beck Depression Inventory, people rate

their level of sadness and its effect on their functioning. For social skills inventories, used

227

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.

Both the number of response inventories and the number of clinicians who use them have

increased steadily in the past 35 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 (Englbrecht et al., 2017). 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 psychological problems. 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 physiological changes has since played a key

role in the assessment of certain psychological disorders.

psychophysiological test A test that measures physical responses (such as heart rate and muscle tension) as possible indicators of psychological problems.

One psychophysiological test is the polygraph, popularly known as a lie detector (Amsel, 2017;

Rosky, 2016, 2013). Electrodes attached to various parts of a 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

physiological 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, psychophysiological tests have their drawbacks (Elliott &

Völlm, 2016). Many require expensive equipment that must be carefully tuned and maintained.

In addition, psychophysiological measurements can be inaccurate and unreliable (see Trending).

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

228

responses, for example, often decrease during repeated testing.

TRENDING

The Truth, the Whole Truth, and Nothing but the Truth

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 they do not work as well as we would like (Ben-Shakhar & Bar, 2019;

Rosky, 2016, 2015, 2013). Research indicates that at least 1 out of 10 truths, or as many as 1 out of 4 truths, are, on

average, called lies in polygraph testing (Wen, 2016; Grubin, 2010; MacLaren, 2001). Imagine 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 (Balmer, 2018; Vogel & Baran, 2016). Nevertheless, the FBI

and other law enforcement agencies use them extensively in criminal investigations; parole boards and probation offices

routinely administer them to help decide whether to release convicted offenders; and their use may actually be on the

increase in public-sector hiring, such as for police officers (CDPS, 2018; Vicianova, 2015; Meijer & Verschuere, 2010).

Given the polygraph’s flawed performance, researchers have been looking for other ways to detect lies over the past 15

years. The most promising alternative seems to be brain scanning. Some MRI studies have found that when participants

deny clear truths, certain parts of their brain—particularly regions within the prefrontal, anterior cingulate, and parietal

cortex—become more active than when they are confirming such truths (Mongilio, 2017; Wood, 2016).

229

All the rage A security administrator conducts a polygraph exam in Bogota, Colombia. Despite evidence that these

tests are often invalid, they are widely used by businesses in Colombia, where deception by employees has become a

major problem.

In general, MRI studies have yielded better lie-detection rates than have polygraph studies, but the procedures and

degree of accuracy have varied from study to study. Moreover, like polygraph testing, scanning procedures can produce false

positives. That is, the brain regions under study may also become more active when an individual is experiencing intense

anxiety or related emotions. Thus some anxious truth-tellers may be viewed as lying in the MRI procedures.

These questions and limitations have been partly addressed in a study at the University of Pennsylvania (Langleben et

al., 2016). Participants were instructed to secretly write down one of six numbers and to then deny, while being evaluated

by a polygraph and later by an MRI, the correctness of each number. That is, in each session, they were lying about their

selected number and telling the truth about the other five numbers.

Although both tools were far from perfect in detecting the particular number that each participant was lying about, the

MRI conclusions were 24 percent more accurate than the polygraph conclusions. Moreover, the accuracy of lie detection

rose to 100 percent in cases in which the MRI and polygraph agreed on which number was being concealed, suggesting to

some theorists that the two techniques should be used jointly in real-life applications. We will not know for some time

whether MRI testing or combined MRI-polygraph testing will eventually gain traction in the judicial, law enforcement,

security, or employment realms. But the implications of the study already have some researchers quite excited—and some

ethicists very worried.

Neurological and Neuropsychological Tests Some problems in personality or behavior are caused primarily 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 abnormalities. Some procedures, such as

brain surgery, biopsy, and X ray, have been used for many years. More recently, scientists 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.

neurological test A test that directly measures brain structure or activity.

230

Family EEG As part of a study conducted at York University in Toronto, a mother and her 5-year-old autistic child play,

socialize, and share tasks while wearing nets containing EEG sensors. The electrodes attached to their scalps help measure

their brain waves, and these measurements are later compared to those derived from other mothers and their non-autistic

children during similar interactions.

Other neurological tests actually take “pictures” of brain structure or brain activity. These

tests, called neuroimaging, or brain scanning, techniques, include computerized axial

tomography (CT scan or CAT 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.

neuroimaging techniques Neurological tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain scanning.

231

(a) MRI

(b) MRI scan

(d) PET scan

Variations in scanning Above a doctor prepares a patient for an MRI procedure (a). Today’s most widely used

neuroimaging techniques each produce pictures of the living brain. A MRI scan (b) shows the image of a normal

functioning brain; a CT scan (c) reveals a mass of blood within the brain; and a PET scan (d) shows which areas of the brain

are active (those colored in red, orange, and yellow) when an individual is being stimulated.

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

232

functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer

than PET scan images, the fMRI has generated enormous enthusiasm among brain researchers

since it was first developed 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

(Daugherty et al., 2017). Brain damage is especially likely to affect visual perception, memory,

and visual-motor coordination, so neuropsychological tests focus particularly 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 onto 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 (Hamo,

Abramovitch, & Zohar, 2018; Reitan & Wolfson, 2005, 1996).

neuropsychological test A test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.

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 physical 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 different intelligence tests available. As you will see in

Chapter 14, intelligence tests play a key role in the diagnosis of intellectual disability and they

can also help clinicians identify other problems (Bram, 2017; Keyes et al., 2017).

intelligence test A test designed to measure a person’s intellectual ability. intelligence quotient (IQ) An overall score derived from intelligence tests.

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

233

How might IQ scores be misused by school officials,

parents, or other individuals? Why is society preoccupied

with these scores?

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 performance 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 performance (Groth-

Marnat & Wright, 2016). 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 background

(Shuttleworth-Edwards, 2016). 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 clients 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.

Naturalistic and Analog Observations Naturalistic clinical observations 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 (Moens et

al., 2018; Wang & Repetti, 2016). 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 phobic people approaching an

object they find frightening.

Although much can be learned from actually witnessing behavior, clinical observations have

234

#TheirWords “You can observe a lot just by watching.”

Yogi Berra, baseball great

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.

Observation plus Using a one-way mirror, a clinical observer views a client interacting with her child during a play session.

In addition, with the aid of a microphone and ear bug device, the clinician can coach the client and offer real-time parenting

suggestions, a procedure commonly known as parent−child interaction therapy (PCIT).

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 (Mahtani et al., 2018).

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.,

235

#EarlyBeginnings Because of his love for sketching inkblots all the time,

Hermann Rorschach’s young schoolmates gave him the

nickname Klex, a variant of the German Klecks, which means

“inkblot” (Cacioppo & Freberg, 2016; Schwartz, 1993).

2015). If schoolchildren are aware that someone special is watching them, for example, they may

change their usual classroom behavior, perhaps in the hope of creating a good impression.

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 inventories 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. 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.

Increasingly, people in treatment are recording such private experiences on smartphone apps as

they are occurring—observations that can be sent immediately to their therapists or collectively

reported in their treatment sessions (Sperry & Kwapil, 2017; Rickard et al., 2016).

Like all other clinical assessment

procedures, however, self-monitoring has

drawbacks (Schat et al., 2017; 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 gathering individual information about each client. They seek an

236

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 interviews, 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, or self-monitoring.

237

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 disturbance, a construction

sometimes known as a clinical picture (Sommers-Flanagan & Sommers-Flanagan, 2017). The

clinical picture also may be influenced to a degree by the clinician’s theoretical orientation

(Grohol, 2016; 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 breakup 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 (from the Greek word for “a discrimination”)—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.

diagnosis

238

#NervousBreakdown? 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. Some people use the term simply to connote

the onset of any psychological disorder (Hall-Flavin, 2016;

Padwa, 1996).

Why do you think many clinicians prefer the label “person

with schizophrenia” over “schizophrenic person”?

A determination that a person’s problems reflect a particular disorder.

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. If people display this

particular pattern of symptoms,

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.

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.

In 1883, Emil Kraepelin developed the

first modern 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 American Psychiatric Association (APA, 2013). The DSM is the most widely used

classification system in North America. The content of the DSM has been changed significantly

over time. The current edition, called DSM-5, was published in 2013. It features a number of

changes from the previous editions. Most other countries rely primarily on a system called the

International Classification of Diseases (ICD), developed by the World Health Organization,

which lists both medical and psychological disorders. The current edition of this system is called

ICD-10. A new edition, ICD-11, is scheduled to go into effect in 2022.

Although there are some differences between the disorders listed in the DSM and ICD and in

their descriptions of criteria for various disorders (the DSM’s descriptions are more detailed), the

numerical codes used by DSM-5 for all disorders match those used by the ICD-10—a matching

that produces uniformity when clinicians fill out insurance reimbursement forms.

239

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.

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: APA, 2017; Greenberg, 2011; Kessler et al., 2005.)

DSM-5 requires clinicians to provide both categorical and dimensional information as part of

a proper diagnosis. Categorical information refers to the name of the distinct 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 and

behavior.

Categorical Information First, the clinician must decide whether the person is displaying one of the hundreds of

240

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

from other key individuals (separation anxiety disorder).

DEPRESSIVE DISORDERS People with depressive disorders may experience 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

(premenstrual dysphoric disorder).

Although people may receive just one diagnosis from the DSM-5 list, they often receive more

than one. Franco would likely receive 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).

241

The power of labeling When looking at this late-nineteenth-century photograph of a baseball 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.

Dimensional Information In addition to deciding what disorder a client is displaying, diagnosticians assess the current

severity of the client’s disorder—that is, how extensive are the symptoms and how much do they

impair the client’s functioning? For each disorder, the framers of DSM-5 have suggested various

rating scales for evaluating the severity of the disorder (APA, 2013). Using a depression rating

scale, for example, Franco’s therapist might assign a severity rating of moderate to the young

man’s depression, meaning his symptoms are quite frequent and disabling but not as extreme and

incapacitating as those found in the most severe cases of depression. 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 information when making a diagnosis. They may, for

example, indicate special psychosocial problems the client has. Franco’s recent breakup with his

242

#TheirWords

“The boundary of psychiatry keeps expanding; the realm of

normal is shrinking. … As chairman of the DSM-IV Task

Force, I must take partial responsibility for diagnostic

inflation.”

Allen Frances, 2013 Chair of the DSM-IV Task Force

#BandPsychNames

Alcoholics Unanimous

Widespread Panic

Madness

Obsession

Bad Brains

Placebo

Fear Factory

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 diagnosis 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

corresponding 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

(Blashfield et al., 2014). 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

diagnosticians, 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 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

243

Mood Elevator

Neurosis

10,000 Maniacs

Grupo Mania

The Insane Clown Posse

Unsane

experienced clinicians and researchers.

They then developed a number of new

diagnostic criteria and categories,

expecting that the new criteria and

categories would be reliable. Although

some studies have indeed found enhanced

reliability in DSM-5, others have not

(Aggarwal, 2017; Wakefield, 2015).

Why are the reliability findings less than stellar? Critics point to faulty procedures used in the

development of DSM-5. They suggest, for example, that the framers failed to run a sufficient

number of field studies to test the merits of the new criteria and categories. In turn, DSM-5 may

have retained several of the reliability problems found in past editions of the DSM.

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 edition by conducting extensive

reviews of research and consulting with numerous clinical advisors. As a result, according to

several studies, its criteria and categories do appear to have stronger validity than those of the

earlier versions of the DSM, but other research clarifies that the manual’s validity is still less than

desirable (La Greca, Danzi, & Chan, 2017; Frances, 2016, 2015; Stinchfield et al., 2016).

Among other validity issues, some of DSM-5’s criteria and categories may reflect gender or racial

bias.

244

#TheirWords “I spent 13 years at NIMH really pushing on the neuroscience

and genetics of mental disorders, and when I look back on that

I realize that while I think I succeeded at getting lots of really

cool papers published by cool scientists at fairly large costs—I

think $20 billion—I don’t think we moved the needle in

reducing suicide, reducing hospitalizations, improving recovery

for the tens of millions of people who have mental illness. I

hold myself accountable for that.”

Tom Insel, 2017

Director of the National Institute of Mental Health (2002–

2015)

“Correct me if I’m wrong, but hasn’t the fine line between sanity and madness gotten finer?”

Actually, one important organization

has already concluded that the validity of

DSM-5 is lacking and is acting

accordingly. The National Institute of

Mental Health (NIMH), the world’s

largest funding agency for mental health

research, no longer gives financial support

to clinical studies that rely exclusively on

DSM-5 criteria. And, more generally, the

agency has developed its own

neuroscience-focused classification tool,

called the Research Domain Criteria

(RDoC), that it expects will eventually be the primary classification guide used by researchers

(NIMH, 2018).

Call for Change

245

The effort to produce DSM-5 took more than a decade. After years of preliminary work by a

DSM-5 task force and numerous work groups, whose goal was to develop a DSM that addressed

the limitations of previous DSM editions, the new diagnostic and classification system was

published in 2013. The categories and criteria of DSM-5 are featured throughout this textbook

(APA, 2013).

DSM-5 has raised concerns among many clinical practitioners and researchers (see

InfoCentral). In addition to the possible reliability and validity limitations described above,

critics worry that some of its changes in criteria and categories are ill-advised and can, on

occasion, lead to problems for clients. The DSM-5 changes that have raised the most concern

include the following:

It calls for a diagnosis of “major depressive disorder” for some recently bereaved people (see Chapter 6).

It adds a new category, “premenstrual dysphoric disorder” (see Chapter 6).

It adds a new category, “somatic symptom disorder,” that can be assigned to people who are overly anxious about serious medical problems (see Chapter 8).

It combines the patterns of substance dependence and substance abuse (patterns that may each require different treatments) into a single category, “substance use disorder” (see Chapter 10).

It groups the category “gambling disorder” as an addictive disorder alongside the substance use disorders (see Chapter 10).

It combines all forms of autism into a single category, “autism spectrum disorder,” thus eliminating the past category of “Asperger’s syndrome” (see Chapter 14).

It adds a new category, “mild neurocognitive disorder,” that could be misapplied to normal age-related forgetfulness (see Chapter 15).

INFOCENTRAL

DSM: THE BIGGER PICTURE

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the most widely used

classification system in North America. It is actually a work in progress. DSM-5, the 947-page

current edition, is but the latest version of this system, which has undergone many changes over

the past seven decades. The DSM also faces competition from other diagnostic systems around

246

the world.

247

#StigmaContinues

33% Percentage of Americans who would not seek counseling for fear of being labeled “mentally ill”

Can Diagnosis and Labeling Cause Harm? Even with trustworthy assessment data

and reliable and valid classification

categories, clinicians will sometimes arrive

248

51% Percentage of Americans who would hesitate to see a psychotherapist if a diagnosis were required

(Roper, 2017; Opinion Research Corporation, 2011, 2004)

Why are medical diagnoses usually valued, while the use of

psychological diagnoses is often criticized?

at a wrong conclusion (Norman et al.,

2017). Like all human beings, clinicians

are flawed information processors. Studies

show that they are 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 name just a few.

Given the limitations of assessment tools, assessors, and classification systems, it is small wonder

that studies sometimes uncover shocking errors in diagnosis, especially in hospitals (Liese & Reis,

2016; Schildkrout, 2016).

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 diagnostic labels can become self-fulfilling prophecies. When people

are diagnosed as mentally disturbed, they may be perceived that way and reacted to

correspondingly. If others expect them to take on a sick role, they may begin to consider

themselves sick as well and act that way. Furthermore, our society attaches a stigma to

abnormality (Corrigan et al., 2017). People labeled mentally ill may find it difficult to get a job,

especially a position of responsibility, or to be welcomed into social relationships. Once a label

has been applied, it may stick for a long time.

249

Fighting the stigma of labeling A clothing line called “Wear Your Label” offers garments that challenge the stigma of

psychiatric labeling by sparking conversations about mental health. The “Sad But Rad” T-shirt is a big seller. (A heads-up

reminder for people over 30: “rad” is a slang term for radical, cool, and/or wonderful.)

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 classification 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 on a diagnosis. The diagnosis is

chosen from a classification 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

that were found in past editions of the DSM. The reliability and validity of this revised diagnostic and classification

250

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.

251

#OpposingTrends 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)

Treatment: How Might the Client Be Helped? Over the course of 10 months, Franco was treated for depression and related symptoms. 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, although 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.

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 performance. 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 having fun with his friends. He found his mood on

the upswing as a result of these re-established 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 treatment decisions.

Their treatment plans typically reflect their theoretical orientations and how they have learned to

252

conduct therapy (Wedding & Corsini, 2019). As therapists apply a favored model in case after

case, they become more and more familiar with its principles 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 (Gyani et al., 2015; Beutler et al., 1995). However, not all of them actually read research

articles, so they cannot be directly influenced by them (Holt et al., 2015; Stewart & Chambless,

2007). In fact, according to surveys, therapists gather much of their information about the latest

developments in the field from colleagues, professional newsletters, workshops, conferences, Web

sites, books, and the like (Farrell & Shaw, 2018; 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

influential movement in North America, the United Kingdom, and elsewhere toward

empirically supported, or evidence-based, treatment (Wiltsey-Stirman & Comer, 2019; Stamm

et al., 2018). 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. The movement has gained

considerable momentum over the past few decades.

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.

253

How can people make wise decisions about therapists and

treatment approaches when they are seeking treatment?

Raising public awareness Believing that more public awareness about stress and psychological disorders will lead to better

assessment and treatment, Boston’s Logan International Airport displays an art exhibit of enormous posters, featuring

dozens of people—from ordinary to famous—who have experienced such disorders.

The Effectiveness of Treatment Altogether, more than 400 forms of therapy are currently practiced in the clinical field (Zarbo et

al., 2015). 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 surface, the question may seem simple. In fact, it is one of the

most difficult questions for clinical researchers to answer.

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 successful? The

second problem is how to measure improvement (Lambert, 2015, 2010). Should researchers give

equal weight to the reports of clients, friends, relatives, therapists, and teachers? Should they use

rating scales, inventories, therapy insights, observations, or some other measure?

Perhaps the biggest problem in

determining the effectiveness of treatment

is the variety and complexity of the

254

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, format, 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 (see Figure 3-4).

FIGURE 3-4

What Factors Contribute to Therapy Outcomes?

According to research, a client’s progress in therapy relates only partly to the specific strategies used by his or her therapist.

In fact, factors such as the client’s expectations, the client−therapist relationship, and concurrent events in the client’s life

may collectively have the most influence on the outcome of treatment. (Information from: De Nadai et al., 2017;

McClintock et al., 2017; Davidson & Chan, 2014; Norcross & Lambert, 2011; Cooper, 2008.)

Proper research procedures address some of these problems. By using control groups, random

assignment, matched research participants, and the like, clinicians can draw certain conclusions

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, 2017, 2015).

Despite these issues and 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 and compare the effects of various treatments. 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?

255

#MovieClinicians

Dr. Fletcher (Split, 2017)

Dr. Aurelius (The Hunger Games: Mockingjay, Part 2, 2015)

Dr. Banks (Side Effects, 2013)

Dr. Patel (The 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. Sobel (Analyze This, 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. Berger (Ordinary People, 1980)

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

assortment of therapies (Smith, Glass, &

Miller, 1980; Smith & Glass, 1977). The

reviewers 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. 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, 2015, 2010; Lambert et al., 1986). Their symptoms may become more

intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or

hopelessness, because of their inability to profit from therapy.

Are Particular Therapies Generally Effective? The studies you have read about so far have lumped all therapies together to consider their

general effectiveness. 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’ training, experience, theoretical

orientations, and personalities (Heppner et al., 2016; Kiesler, 1995, 1966).

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, 2018). A number of other studies have compared

particular therapies with one another and found that no one form of therapy generally stands out

256

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 (Yang & Zhang, 2017). 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.

rapprochement movement A movement to identify a set of common factors, or common strategies, that run through all successful therapies.

Are Particular Therapies Effective for Particular Problems? People with different disorders may respond differently to the various forms of therapy (Norcross

et al., 2017; Norcross & Beutler, 2014). In an oft-quoted statement, influential clinical theorist

Gordon Paul said a half-century 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 effective particular therapies are at treating particular

disorders, and they often have found sizable differences among the various therapies. Cognitive-

behavioral therapies, for example, appear to be the most effective of all in treating phobias

(Antony, 2019; Grohol, 2016), whereas drug therapy seems to be the single most effective

treatment for schizophrenia (Joshi et al., 2018; Andrade, 2016).

257

“Batman is getting more press than me.”

As you read previously, studies also show that some clinical problems may respond better to

combined approaches (Kamenov et al., 2017; Norcross & Beutler, 2014). 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 primarily 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. We will keep returning to this issue as we

examine the various disorders throughout the book.

psychopharmacologist A psychiatrist who primarily prescribes medications.

SUMMING UP

TREATMENT The treatment decisions of therapists may be influenced by assessment information, the diagnosis, the clinician’s

258

theoretical orientation and familiarity 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 effective than others for certain disorders. Some therapists currently advocate

empirically supported treatment—the active identification, promotion, and teaching of those interventions that have

received clear research support.

259

What Lies Ahead for Clinical Assessment? It is clear from this chapter that proper diagnoses and effective treatments rest on the shoulders of

accurate clinical assessment. Correspondingly, before the 1950s, assessment tools were a highly

regarded part of clinical practice. However, as research in the 1960s and 1970s began to reveal

that a number of the tools were inaccurate or inconsistent, many clinicians abandoned systematic

assessment. Today, respect for assessment is on the rise once again. One reason for this renewal of

interest is the drive by researchers for more rigorous tests to help them select appropriate

participants for clinical studies. Still another factor is the growing belief 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 has come increased research in this area.

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.

Ironically, just as 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, insurance parity and treatment coverage, including assessment coverage, for

people with psychological problems had been improving during the twenty-first century as a

result of federal parity laws and the Affordable Care Act (see page 18). However, with new

260

federal leadership and different health care priorities now unfolding, many experts fear that

clinical assessment will receive only limited insurance support in the future. Which forces will

ultimately have a stronger influence on clinical assessment—promising research or economic

pressure? Only time will tell.

261

Chapter 3 Review

Key Terms

idiographic information

assessment

standardization

reliability

validity

clinical interview

mental status exam

clinical test

projective test

Rorschach test

Thematic Apperception Test (TAT)

personality inventory

Minnesota Multiphasic Personality Inventory (MMPI)

response inventories

psychophysiological test

neurological test

EEG

neuroimaging techniques

CT scan

PET scan

MRI

fMRI

262

neuropsychological test

battery

intelligence test

intelligence quotient (IQ)

naturalistic observation

analog observation

self-monitoring

diagnosis

syndrome

classification system

DSM-5

categorical information

dimensional information

empirically supported treatment

therapy outcome study

rapprochement movement

common factors

psychopharmacologist

Quick Quiz

1. What forms of reliability and validity should clinical assessment tools display? pp. 74– 75

2. What are the strengths and weaknesses of structured and unstructured interviews? pp. 76–77

3. List and describe today’s leading projective tests. pp. 77–79

4. What are the key features of the MMPI? pp. 80–81

263

5. What are the strengths and weaknesses of projective tests (p. 79), personality inventories (pp. 81–82), and other kinds of clinical tests (pp. 82–86)?

6. How do clinicians determine whether psychological problems are linked to brain damage? pp. 84–85

7. Describe the ways in which clinicians may make observations of clients’ behaviors. pp. 86–87

8. What is the purpose of clinical diagnoses? p. 88

9. Describe DSM-5. What problems may accompany the use of classification systems and the process of clinical diagnosis? pp. 89–94

10. According to therapy outcome studies, how effective is therapy? pp. 96–98

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

264

CHAPTER 4 Anxiety, Obsessive- Compulsive, and Related Disorders

TOPIC OVERVIEW

265

Generalized Anxiety Disorder

The Sociocultural Perspective: Societal and Multicultural Factors The Psychodynamic Perspective The Humanistic Perspective The Cognitive-Behavioral 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-Behavioral Perspective

Obsessive-Compulsive Disorder

What Are the Features of Obsessions and Compulsions? The Psychodynamic Perspective The Cognitive-Behavioral Perspective The Biological Perspective Obsessive-Compulsive-Related Disorders

Integrating the Models: The Developmental Psychopathology Perspective

Tomas, 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, offending 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 immediately 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

266

If fear is so unpleasant, why do many people seek out the

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 designing 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 difficult 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 worried,” 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 increase, 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 worrying

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 turning 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.

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.

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.

Although everyday experiences of fear

267

feelings of fear brought about by amusement park rides,

scary movies, bungee jumping, and the like? and anxiety are not pleasant, they often

are useful. 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 disabling 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 (NAMI, 2017; Kessler et al., 2012, 2010, 2009). Around 37

percent of these individuals receive treatment (NIMH, 2017; Wang et al., 2005). Surveys suggest

that non-Hispanic white Americans are more likely than African, Hispanic, or Asian Americans

to develop an anxiety disorder during their life-time (NIMH, 2017; Hofmann & Hinton, 2014).

The cause of this racial-ethnic difference is not well understood.

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

(Baldwin, 2018; Greist, 2018). 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 (Chen et al., 2019; Salcedo, 2018).

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.

268

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) and lead to a

reduced quality of life. Nevertheless, many people with the disorder are able, although with some

difficulty, to carry on social relationships and job activities.

generalized anxiety disorder A disorder marked by persistent and excessive feelings of anxiety and worry about numerous events and activities.

TABLE: 4-1 Dx Checklist Generalized Anxiety Disorder

1. For 6 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.

Generalized anxiety disorder is common in Western society. Surveys suggest that as many as 4

percent of the U.S. population have the symptoms of this disorder in any given year, a rate that

holds across Canada, Britain, and other Western countries (NIMH, 2017; Watterson et al.,

2017; Kessler et al., 2012, 2010). Altogether, around 6 percent of all people develop generalized

anxiety disorder sometime during their lives. It may emerge at any age (see Trending). Women

diagnosed with this disorder outnumber men 2 to 1. Non-Hispanic white Americans are more

likely than members of minority groups to develop the disorder (Budhwani, Hearld, & Chavez-

Yenter, 2015). Around 43 percent of people who have generalized anxiety disorder receive

treatment for it (NIMH, 2017; Wang et al., 2005).

A variety of explanations and treatments have been proposed for this disorder. Let’s look at

the views and approaches offered by the sociocultural, psychodynamic, humanistic, cognitive-

behavioral, and biological models.

The Sociocultural Perspective: Societal and

269

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 dangerous. 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 (Comer

et al., 2016). For example, there are higher rates of generalized anxiety disorder and similar

syndromes among people who live in crime-ridden or hostile neighborhoods and among people

living near nuclear power plants, especially ones that have had radiation accidents in the past

(Cerdá et al., 2017; Rubens et al., 2018).

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 dangerous environments experience greater anxiety and have a higher

rate of generalized anxiety disorder than those who live in other settings.

One of the most powerful forms of societal stress is poverty. People without financial 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 (Vittana, 2018; West, 2016). As

270

sociocultural theorists would predict, such people also have a higher rate of generalized anxiety

disorder (Delgadillo et al., 2016). Across North America, the rate is almost twice as high among

people with low incomes as among those with higher incomes (Watterson et al., 2017; Sareen et

al., 2011). As wages decrease, the rate of generalized anxiety disorder steadily increases (see Table

4-2).

TABLE: 4-2 Looking at Demographics Prevalence of Anxiety Disorders and Obsessive-Compulsive Disorder (Compared with Rate in Total Population)

Female Low-Income Elderly

Generalized anxiety disorder Higher Higher Higher

Specific phobias Higher Higher Lower

Agoraphobia Higher Higher Higher

Social anxiety disorder Higher Higher Lower

Panic disorder Higher Higher Lower

Obsessive-compulsive disorder Same Higher Lower

Information from: Watterson et al., 2017; de Jonge et al., 2016; Remes et al., 2016; Polo et al., 2011; Sareen et al., 2011;

Hopko et al., 2008; Schultz et al., 2008.

It appears that race and ethnicity can affect the precise picture of generalized anxiety disorder

(NIMH, 2017). For example, researchers have noted that the disorder often takes on a pattern

called nervios (“nerves”), or ataques de nervios, for Hispanic individuals in both the United States

and Latin America (Vazquez et al., 2017). People with nervios experience enormous emotional

distress, so-called brain aches marked by poor concentration and nervousness, reactions like

irritability and tearfulness, and physical symptoms such as headaches, stomachaches, trembling,

and heat in the chest rising into the head.

Although poverty and various societal pressures may help create a climate in which

generalized anxiety disorder is more likely to develop, sociocultural 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-behavioral, and biological schools of thought have all tried to explain why and have

offered corresponding treatments.

TRENDING

Separation Anxiety Disorder, Not Just For Kids Anymore

271

Individuals with separation anxiety disorder feel extreme anxiety, often panic, whenever they are separated from

home or from key people in their lives. Jonah’s symptoms began when he was 4 years old:

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 for an overnight weekend there. He screamed, “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 you die?” He cried all the way to his grandparents’ house. At their

door, Jonah hugged his mother as though he would never let her go. During the next several months, Jonah became hysterical

every time his parents 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 Jonah’s

mother to come get the child. 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.

Like Jonah, children with separation anxiety disorder have great trouble traveling away from their family, and they

often refuse to visit friends’ houses, go on errands, or attend camp or school. Many cannot stay alone in a room and cling

to their parents 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, they may function quite normally. At the first hint of

separation, however, the dramatic pattern of symptoms may be set in motion.

Oh, that first day! The first day of kindergarten is overwhelming for this child and perhaps also for his mother. Such

reactions to the beginning of school are common. But for some individuals, separations from attachment figures

repeatedly bring on severe and disabling anxiety reactions that may impair their lives.

For years, clinicians believed that separation anxiety disorder is developed only by children or adolescents. But in 2013

DSM-5 determined that the disorder can also occur in adulthood, particularly after adults have experienced traumas such as

the death of a spouse or child, a relationship break-up, separation caused by military service, or the like (Gesi et al., 2017;

APA, 2013). Such individuals may become consumed with concern about the health, safety, or well-being of a significant

other—their spouse, a surviving child, or another important person in their life. They may constantly and excessively try to

be with the other individual, check on the other’s whereabouts, protect the other person, and restrict the person’s activities

272

#InsecureAdults? Children may cling to blankets or cuddly 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).

and travels. Their extreme anxiety and invasive demands cause them severe distress and can greatly damage their social and

occupational lives (Gesi et al., 2017).

Given this new perspective, DSM-5 now categorizes separation anxiety disorder as one kind of anxiety disorder rather

than as a unique childhood disorder (APA, 2013). It states that symptoms must persist for at least 6 months for adults to

receive a diagnosis, compared to 4 weeks for children. Applying DSM-5’s criteria, studies find that as many as 2 percent of

all adults have the disorder in addition to 4 percent of all children (Schneier et al., 2017; Baldwin et al., 2016).

This new categorization is controversial (Gesi et al., 2017). Although most clinicians agree that certain adults do indeed

manifest the loss-triggered symptoms described above, many of them believe that the adult syndrome may be qualitatively

different from the one displayed by Jonah and other such children. These critics believe that adults who now receive a

diagnosis of separation anxiety disorder may actually be suffering from another disorder, such as posttraumatic stress

disorder (see Chapter 5), or an extended case of bereavement (see Chapter 6). Researchers are currently trying to sort out

this controversy, but in the meantime the term “for children only” cannot be applied to this debilitating pattern.

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

43–45). However, some children have particularly high levels of 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, early developmental

experiences may produce an unusually

high level of anxiety in certain children.

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 his various id impulses are very

dangerous, and he may feel overwhelming anxiety whenever he has such impulses, setting the

stage for generalized anxiety disorder.

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

273

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, a classic investigation 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 (Parisette-Sparks & Kreitler, 2017; Wang, Wang, & Liu, 2016). 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 (Howard et al., 2016;

Manfredi et al., 2011).

“Since my mother was rarely home, I guess I blame my nanny.”

274

#FearFilmFranchises

1. Alien (7 films)

2. Saw (7 films)

3. Jaws (4 films)

4. Paranormal Activity (6 films)

5. Friday the 13th (12 films)

6. A Nightmare on Elm Street (9 films)

7. Scream (4 films)

8. The Conjuring (3 films)

9. Halloween (10 films)

10. The Exorcist (5 films)

(Information from: Thompson, 2016)

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 use these methods to help clients with generalized anxiety disorder

become less afraid of their id impulses and more successful in controlling them. Other

psychodynamic 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 (Mullin et al., 2017).

Controlled studies have typically found psychodynamic treatments to be of only modest help

to persons with generalized anxiety disorder (Craske, 2018). An exception 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 (Glasofer, 2017).

The Humanistic Perspective Humanistic theorists propose that generalized anxiety disorder, like other psychological 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.

275

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 critical 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 dysfunction.

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)

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.

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, 2018). In addition, researchers have found, at best, only limited support

for Rogers’ explanation of generalized anxiety disorder and other forms of abnormal behavior.

Nor have other humanistic theories and treatment received much research support.

276

Animated anxiety In the animated film Inside Out, a young girl’s five basic emotions (Fear, Joy, Sadness, Disgust, and

Anger) come to life and guide her every behavior. More than a few clinicians note that the emotional figure named Fear

(left) personifies the core symptoms of generalized anxiety disorder. Like people with this disorder, he is always looking for

potential catastrophes and evaluating possible dangers—a mindset that leads to continuous worrying and tension.

The Cognitive-Behavioral Perspective As you read in Chapter 2, followers of the cognitive-behavioral model suggest that psychological

disorders are often caused by problematic behaviors and dysfunctional ways of thinking. Thus,

their explanations and treatments focus on the nature of such behaviors and thoughts, how they

are acquired, and how they influence feelings and emotions. Although cognitive-behavioral

explanations and treatments center most often on both behavioral and cognitive dimensions of a

given disorder, sometimes they focus primarily on one of these dimensions; such is the case with

regard to generalized anxiety disorder, where many proponents of this model concentrate largely

on the cognitive dimension of the disorder.

Maladaptive Assumptions Initially, cognitive-behavioral theorists suggested that generalized 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 & Ellis, 2019; Ellis, 2016, 1962). Ellis called these basic

irrational assumptions, and he claimed that people with generalized anxiety disorder often hold

the following ones:

277

“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 concerned 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)

basic irrational assumptions The inaccurate and inappropriate beliefs held by people with various psychological problems, according to Albert Ellis.

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, 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, 2018;

Clark & Beck, 2012, 2010). Since the time of Ellis’ and Beck’s initial proposals, researchers have

repeatedly found that people with generalized anxiety disorder do indeed hold maladaptive

assumptions, particularly about dangerousness, and are, in turn, overattentive to potentially

threatening stimuli (Craske, 2018; Yiend, Goodwin, & Hirsch, 2017).

Newer Cognitive-Behavioral Explanations In recent years, several additional cognitive-behavioral explanations for generalized anxiety

disorder have emerged. Each of them builds on the work of Ellis and Beck and their emphasis on

danger.

The metacognitive theory, developed by the researcher Adrian Wells suggests that people with

generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying

(Capobianco, Morrison, & Wells, 2018; Wells, 2014, 2011, 2005). 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 (see Figure 4-1).

278

Why might many people believe, at least implicitly, that

worrying is useful—even necessary—for problems to work

out?

FIGURE 4-1

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, 2015, 2014; Tallis et al., 1994.)

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 (mentally 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 include concerns that they are “going crazy” with worry, making themselves ill with worry,

or 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,

279

that people who generally hold both positive and negative beliefs about worrying are particularly

prone to developing generalized anxiety disorder and that repeated metaworrying is a powerful

predictor of developing the disorder (Baldwin, 2018; Wells, 2014, 2011, 2005).

According to another more recent 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

(Koerner, Meija, & Kusec, 2017; Dugas et al., 2012, 2010, 2004). Think of when you meet

someone you’re attracted to and how you then feel prior to texting or calling this person for the

first time—or how you feel while you’re waiting for the individual to contact you for the first

time. The worry that you experience in such instances—the sense of unbearable uncertainty over

the possibility of an unacceptable negative outcome—is, according to this theory, how people

with generalized anxiety disorder feel all the time.

Proponents of this theory believe that people with generalized anxiety disorder keep worrying

and worrying in their efforts to find “correct” solutions for various situations 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, considerable 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 (Koerner et al., 2017; Dugas et al., 2012,

2004). Research also suggests that intolerance of uncertainty develops in early childhood and can

be passed on from parents to children (Osmanaǧaoǧlu et al., 2018; Sanchez et al., 2017, 2016).

280

#DelayedDiagnosis

It is estimated that 45 percent of clients in treatment for

generalized anxiety disorder had suffered from its symptoms for

2 or more years before being diagnosed correctly (Bandelow &

Michaelis, 2015).

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 Paranormal Activity movies. These six films are among the

most profitable ever made. In this scene from the first film, the lead character Katie tries to escape a supernatural presence in

her house.

Finally, a third relatively recent 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 (Baldwin, 2018; Borkovec, Alcaine, & Behar, 2004). In short, the

avoidance theory holds that people with generalized anxiety disorder worry repeatedly in order to

reduce or avoid uncomfortable states of bodily arousal. When, for example, they find themselves

in an uncomfortable job situation or social relationship, they implicitly choose to worry about

losing their job or losing a friend rather than having to stew in a state of intense negative arousal.

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 overwhelming, worry more than other people upon becoming aroused, and

successfully reduce their arousal whenever they worry (Owens et al., 2017; Hirsch et al., 2012).

Cognitive-Behavioral Therapies Two kinds of cognitive-behavioral 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 (Meichenbaum, 2017). In the other,

“new-wave” cognitive-behavioral therapists (see page 53) help clients understand the special role

that worrying may play in their disorder, modify their views about worrying, and change their

behavioral reactions to such unnerving concerns.

CHANGING MALADAPTIVE ASSUMPTIONS

Therapists using Ellis’ technique of

rational-emotive therapy point out the

irrational assumptions held by clients,

suggest more appropriate assumptions,

and assign homework that gives the

clients practice at challenging old

assumptions and applying new ones (Ellis & Ellis, 2019; Ellis, 2016). Studies suggest that this

281

and similar approaches bring at least modest relief to those suffering from generalized anxiety

(Clark, 2018; Kishita & Laidlaw, 2017). 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:

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 yourself. … 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 desperately 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)

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.

BREAKING DOWN WORRYING Alternatively, some of today’s new-wave cognitive-behavioral therapists specifically guide clients

with generalized anxiety disorder to recognize and change their dysfunctional use of worrying

(Craske & Bystritsky, 2017; Topper et al., 2017). 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

thus less arousing), try out more constructive ways of dealing with arousal, and worry less about

the fact that they worry so much. Research indicates that a concentrated focus on worrying is

282

#MostGoogledSymptoms

1. Infection symptoms

2. Measles symptoms

3. Gastritis symptoms

4. Anxiety symptoms

5. Heat stroke symptoms

(Drain, 2016)

indeed a helpful addition to the traditional cognitive-behavioral treatment for generalized anxiety

disorder.

Treating individuals with generalized anxiety disorder by helping them to recognize their

inclination to worry is similar to another cognitive-behavioral approach that has gained

popularity in recent years. The approach, mindfulness-based cognitive-behavioral therapy, which

you read about in Chapter 3, was brought into the mainstream by psychologist Steven Hayes and

his colleagues as part of their broader treatment approach called acceptance and commitment

therapy (Hayes, 2016). Here therapists help clients to become aware of their streams of thoughts,

including their worries, as they are occurring and to accept such thoughts as mere events of the

mind. By accepting their worries rather than trying to eliminate them, the clients are expected to

be less upset by them and less influenced by them in their behaviors and life decisions. This is

indeed what happens for many clients with generalized anxiety disorder when they receive this

and related forms of treatment (Hoge et al., 2018; Kishita & Laidlaw, 2017).

Mindfulness-based therapy has also been applied to a range of other psychological problems,

such as depression, posttraumatic stress disorder, personality disorders, and substance use

disorders, often with promising results (Segal, 2017; Hayes, 2016). As we observed in Chapter 2,

this cognitive-behavioral 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.

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

pedigree studies, in which researchers

determine how many and which relatives

of a person with a disorder have the same

disorder. If biological tendencies toward

generalized 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

283

disorder also (Havinga et al., 2017; 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.

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.

Biological Explanations In recent decades, important discoveries by brain researchers have offered clearer evidence that

generalized anxiety disorder is related to biological factors (Shinba, 2017). One of the first such

discoveries was made in the 1950s, when investigators 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, researchers were able to pinpoint the exact neurons in the brain to which

benzodiazepines travel (Mohler & Okada, 1977). Apparently certain neurons have receptors that

receive the benzodiazepines, just as a lock receives a key.

benzodiazepines The most common group of antianxiety drugs, which includes Valium and Xanax.

Do monkeys experience anxiety? Clinical researchers must be careful in interpreting the reactions of animal subjects. This

infant monkey was considered “fearful” after being separated from its mother. But perhaps it was feeling depressed or

experiencing arousal that does not correspond to either fear or depression.

284

Investigators then discovered that these benzodiazepine receptors ordinarily receive gamma-

aminobutyric acid (GABA), a common neurotransmitter in the brain (Müller et al., 2017). As

you read in Chapter 2, neurotransmitters are chemicals that carry messages from one neuron to

another. GABA carries inhibitory messages: when GABA is received at a receptor, it causes the

neuron to stop firing. Initially, researchers believed that GABA activity throughout the brain

must be deficient in people with generalized anxiety disorder (Salari, Bakhtiari, & Homberg,

2015; Bremner & Charney, 2010). However, research conducted in this century indicates that

the biological basis of generalized anxiety disorder is more complicated than the disturbed

activity of this single neurotransmitter.

gamma-aminobutyric acid (GABA) A neurotransmitter whose low activity in the brain’s fear circuit has been linked to anxiety.

Investigators now know that our everyday fear reactions—like most other emotional,

behavioral, and cognitive reactions—are tied to brain circuits, networks of brain structures that

work together, triggering each other into action. As you read in Chapter 2, in a given brain

circuit, the long axons of the neurons from one structure bundle together, extend across the

brain, and use neurotransmitters to communicate with the neurons of another structure—thus

setting up interconnecting fiber pathways between the structures (see pages 38–39). The

particular circuit that produces and manages fear reactions, often called the “fear circuit,”

includes such brain structures as the prefrontal cortex, anterior cingulate cortex, insula, and

amygdala, a small almond-shaped brain structure that usually starts the emotional ball rolling (see

Figure 4-2).

brain circuits Networks of brain structures that work together, triggering each other into action.

285

FIGURE 4-2

The Biology of Anxiety

The circuit in the brain that helps produce anxiety reactions includes structures such as the amygdala, prefrontal cortex,

anterior cingulate cortex, and insula (not visible from this view of the brain).

Studies reveal that the fear circuit is excessively active (that is, hyperactive) in people with

generalized anxiety disorder, producing experiences of fear and worry that are excessive in

number and duration (Weber-Goericke & Muehlhan, 2019; Williams, 2017). In turn, many

theorists have concluded that such fear circuit hyperactivity is responsible for the development of

the disorder (Mohlman et al., 2017; Duval et al., 2015). GABA is one of the important

neurotransmitters at work in this circuit (particularly in the amygdala), so low GABA activity

could indeed help produce excessive communications between the structures in this circuit and,

as initially suggested, contribute to the development of generalized anxiety disorder. At the same

time, improper functioning by various neurons, structures, interconnections, or other

neurotransmitters throughout the fear circuit can also lead to broad circuit hyperactivity and

contribute to the development of generalized anxiety disorder (Yao et al., 2017).

Drug Therapies After their discovery in the 1950s, benzodiazepines were marketed as sedative-hypnotic drugs—

286

Why are antianxiety drugs so popular in today’s world?

Does their popularity say something about our society?

drugs that calm people in low doses and help them fall asleep in higher doses. The

benzodiazepines seemed less addictive than previous sedative-hypnotic medications, such as

barbiturates, and they appeared to produce less tiredness. Thus, these newly discovered drugs

were quickly embraced by both doctors and patients, and many new ones were developed to help

alleviate anxiety (see Table 4-3).

sedative-hypnotic drugs Drugs that calm people at lower doses and help them fall asleep at higher doses.

TABLE: 4-3 Common Benzodiazepine Drugs Generic Name Trade Name

Alprazolam Xanax

Chlordiazepoxide Librium

Clonazepam Klonopin

Clorazepate Tranxene

Diazepam Valium

Estazolam ProSom

Lorazepam Ativan

Midazolam Versed

Oxazepam Serax

As you have read, researchers eventually learned that benzodiazepines reduce anxiety by

traveling to receptor sites in the brain circuit—particularly in the amygdala—that ordinarily

receive the neurotransmitter GABA. Apparently, when benzodiazepines bind to these neuron

receptor sites, they increase the ability of GABA itself to bind to the sites and to stop neurons

from firing, thus helping to improve the overall functioning of the fear circuit and, in turn,

reducing an individual’s excessive levels of anxiety (Bystritsky, 2018; Muller et al., 2017).

Studies indicate that as many as 60

percent of people with generalized anxiety

disorder experience at least some

improvement when they take

benzodiazepines, compared to 40 percent of similar individuals who take placebo drugs

(Bystritsky, 2018; Islam et al., 2014). However, clinicians have come to realize that these drugs

pose significant problems. First, the effects of the medications are short-lived. When they are

stopped, anxiety returns as strong as ever. Second, people who take benzodiazepines in large

doses for an extended time can become physically dependent on them. Third, the drugs can

287

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 (Bystritsky, 2018).

Thus over the past two decades, other kinds of drugs have become more widely prescribed for

people with generalized anxiety disorder. The treatment of choice is now antidepressant

medications, drugs that are usually used to lift the moods of depressed persons. Like

benzodiazepines, these drugs bring at least some relief to 60 percent of the people with

generalized anxiety disorder who take them (Bystritsky, 2018). As you will see in Chapter 6,

antidepressant drugs often increase the activity of the neurotransmitters serotonin and

norepinephrine. These two neurotransmitters are prominent in certain parts of the fear circuit

(LeDoux & Pine, 2016; Bukalo, Pinard, & Holmes, 2014). The antidepressant drugs may help

relieve anxiety by improving the functioning of the fear circuit in these areas.

Finally, antipsychotic medications, drugs commonly given to people with schizophrenia and

other forms of psychosis, are also helpful to some individuals with generalized anxiety disorder

(Bystritsky, 2018). These drugs may help relieve anxiety by altering the activity of dopamine, yet

another neurotransmitter of importance in certain parts of the fear circuit (Bukalo et al., 2014).

SUMMING UP

GENERALIZED ANXIETY DISORDER

People with generalized anxiety disorder experience excessive anxiety and worry about a wide range of events and

activities. According to the sociocultural view, societal dangers, economic stress, or related racial and cultural

pressures may create a climate in which cases of generalized anxiety disorder are more likely to develop.

In the original psychodynamic explanation, Freud said that generalized anxiety 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 overcome 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

themselves. He treated such individuals with client-centered therapy.

Cognitive-behavioral theorists believe that generalized anxiety disorder is caused by various maladaptive

assumptions and/or inaccurate beliefs about the power and value of worrying. Cognitive-behavioral therapists help

their clients change their maladaptive thinking and/or dysfunctional uses of worrying.

Biological theorists hold that generalized anxiety disorder results from a hyperactive fear circuit, a brain circuit

that includes the prefrontal cortex, anterior cingulate cortex, insula, and amygdala. Common biological treatments

288

are antidepressant drugs, benzodiazepines, and antipsychotic drugs.

289

Phobias A phobia is a persistent and unreasonable fear of a particular object, activity, or situation. People

with a phobia (from the Greek word for “fear”) 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.

phobia A persistent and unreasonable fear of a particular object, activity, or situation.

We all have our areas of special fear, and it is normal for some things to upset us more than

other things (see InfoCentral). 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.

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 in which escape

might be difficult if one were to become panicky or incapacitated.

INFOCENTRAL

FEAR

Fear is a normal part of life. Like all emotions, it can be good or bad. On the positive side, fear

can alert us to danger, help us behave constructively, and guide us to make wise decisions. Up to

a point it can be stimulating and even fun. On the negative side, fear can be excessive and

inappropriate and contribute to phobias and other anxiety disorders.

290

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:

291

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)

specific phobia A severe and persistent fear of a specific object or situation.

TABLE: 4-4 Dx Checklist Specific Phobia

1. Marked, persistent, and disproportionate fear of a particular object or situation; usually lasting at least 6 months.

2. Exposure to the object produces immediate fear.

3. Avoidance of the feared situation.

4. Significant distress or impairment.

Information from: APA 2013.

Each year as many as 10 percent of all people in the United States have the symptoms of a

specific phobia (McCabe, 2018; Bandelow & Michaelis, 2015; 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.

292

“I don’t know. I’m something of a technophobe.”

The impact of a specific phobia on a person’s life depends on what arouses the fear (McCabe,

2018). People whose phobias center on dogs, insects, or water will keep encountering the objects

they dread. Their efforts to avoid them must be elaborate and may greatly restrict their activities.

Urban residents with snake phobias have a much easier time. At most, 32 percent of people with

a specific phobia seek treatment (McCabe, 2018; NIMH, 2017). Most individuals with the

disorder try instead to avoid the objects they fear.

Agoraphobia People with agoraphobia are afraid of being in public places or situations in which escape might

be difficult or help unavailable, should they experience panic or become incapacitated (APA,

2013) (see Table 4-5). This is a pervasive and complex phobia. Around 1.7 percent of the

population experience agoraphobia in any given year; around 2.6 percent display it at some point

in their lives. The disorder also is twice as common among women as men and among poor

people as wealthy people (Bandelow & Michaelis, 2015; Kessler et al., 2012; Sareen et al., 2011).

Around 46 percent of those with agoraphobia receive treatment for it (NIMH, 2017).

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 panic-like or embarrassing symptoms were to occur.

TABLE: 4-5 Dx Checklist

293

TABLE: 4-5 Dx Checklist Agoraphobia

1. Pronounced, disproportionate, or 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 situations 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 6 months.

5. Significant distress or impairment.

Information from: APA, 2013.

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 transportation 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 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 (McCabe, 2018).

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. Those offered by cognitive-behavioral theorists

have received the most research support. Focusing primarily on the behavioral dimension of this

disorder, they believe that people with phobias first learn to fear certain objects, situations, or

events through conditioning (McCabe, 2018). Once the fears are acquired, the individuals avoid

the dreaded object or situation, permitting the fears to become all the more entrenched.

294

How Are Fears Learned? Many cognitive-behavioral theorists 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 the person then reacts similarly to both of them. If one event

triggers a fear response, the other may also.

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.

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 became caught between two

rocks. 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 apparently 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 associated with entrapment in

the child’s mind and came also to elicit a fear reaction. The newly acquired fear was a conditioned

response (CR).

295

US: Entrapment → R: Fear

CS: Running water → R: 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. Consider a young boy whose

mother is afraid of illness, doctors, and hospitals. If she frequently expresses those fears, before

long the boy himself may fear illness, doctors, and hospitals.

modeling A process of learning in which a person observes and then imitates others. Also, a therapy approach based on the same principle.

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? Cognitive-

behavioral theorists 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.

Phobias, not Although these young women cling tightly to each other, frozen with fear as they try to walk across a bridge,

they are not displaying abnormal fear or a phobia. A closer look reveals that the bridge, which stands 600 feet high and

spans 1000 feet, has a glass floor, the first of its kind in China. Almost all visitors to this new tourist destination initially

experience the same emotional reaction—overwhelming and near-paralyzing fear.

296

What concerns might today’s human-participant research

review boards raise about the study on Little Albert?

How Have Cognitive-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 cognitive-behavioral position that fears can be acquired

through modeling. In a pioneering study, for example, psychologists Albert Bandura and

Theodore Rosenthal (1966) 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 was turned on. After the unsuspecting participants had observed

several such episodes, they themselves had a fear reaction whenever they heard the buzzer.

Similarly, some studies on children with real-life fears and phobias have found that modeling

played a key role in the acquisition of such problems (Reynolds et al., 2017).

Although these studies support cognitive-behavioral explanations of phobias, other research

has called those explanations into question (McCabe, 2018). Several laboratory studies with

children and adults have failed to condition fear reactions. In addition, although many case

studies have traced 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 (McCabe, 2018; McNally, 2016). This idea is referred to as preparedness

297

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 severe

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)

preparedness A predisposition to develop certain fears.

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 (McNally, 2016; Ohman & Mineka, 2003).

BFF 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.

How Are Phobias Treated? Every theoretical model has its own approach to treating phobias, but the cognitive-behavioral

approach is more widely used and, according to research, more successful than the rest,

298

particularly for specific phobias. Here again, practitioners of the model focus primarily on the

behavioral dimension of phobias.

Treatments for Specific Phobias Specific phobias were among the first anxiety disorders to be treated successfully. The major

cognitive-behavioral approach to treating them is exposure treatment, an approach in which

people are exposed to the objects or situations they dread (McCabe & Swinson, 2017). There are

actually a number of different exposure techniques. Three of the oldest, and most famous, are

systematic desensitization, flooding, and modeling.

exposure treatment Treatment in which persons are exposed to the objects or situations they dread.

People treated by systematic desensitization, an exposure technique developed by Joseph

Wolpe (1987, 1969), learn to relax while gradually facing the objects or situations 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.

systematic desensitization An exposure treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.

The world of exposure At a treatment program in France, this man undergoes exposure therapy to help him overcome

299

acrophobia, a severe fear of heights. Wearing a virtual reality headset, he feels as if he is approaching a vast, deep canyon.

Virtual reality techniques have greatly expanded the kinds of exposure available to clients receiving treatment for various

anxiety disorders or OCD.

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

person 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 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 exposure 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.

flooding An exposure treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.

When flooding therapists guide clients in imagining feared objects or situations, they often

exaggerate the description so that the clients experience intense emotional 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 another exposure technique, modeling, it is the therapist who confronts the feared object or

300

situation while the fearful person observes (Bandura, 2011, 1977, 1971; Bandura et al., 1977).

The therapist acts as a model to demonstrate that the person’s fear is groundless. 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 encouraged to join in with the therapist.

Clinical researchers have repeatedly found that these and other exposure treatments help

people with specific phobias. Around 70 percent of phobic patients show significant

improvement after receiving exposure treatment (McCabe & Swinson, 2017; Ryan et al., 2017).

The key to greater success in all forms of exposure treatment appears to be actual contact with

the feared object or situation. That is, in vivo exposure tends to be more effective than covert

exposure. It is also worth noting that a growing number of cognitive-behavioral therapists are

using virtual reality—3D computer graphics that simulate real-world objects and situations—as

an exposure tool, and are having considerable success with this approach (Costa et al., 2018). As

you’ll see in Chapter 5, the exposures provided by this computer tool are so intense that they

often are as powerful as real-life exposures.

Recovering lost revenues Several amusement 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.

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

301

#WrongSuffix? In 2012, the Associated Press banned its reporters from using

the increasingly popular suffix “-phobia” when describing

much relief to sufferers as the highly successful treatments for specific phobias, but they do offer

considerable relief to many people.

Cognitive-behavioral therapists have again led the way, this time by developing a variety of

exposure approaches for agoraphobia (Gloster et al., 2017, 2015, 2014; Klan, Jasper, & Hiller,

2017). The therapists typically help clients to venture farther and farther from their homes and

to gradually enter outside places, one step at a time. Sometimes the clinicians use support,

reasoning, and coaxing to get clients to confront the outside world. They also use more precise

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 psychiatric 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 [treatment],

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 criterion 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 compensated 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

302

people who are intolerant of particular groups of individuals.

The news organization’s reason was that such uses of the suffix

—for example, “homophobia,” “xenophobia,” “Islamophobia,”

and “transphobia”—inaccurately ascribes a mental disability to

prejudiced people, suggesting a knowledge the reporters (and

society) do not have (Hess, 2016).

groups and home-based self-help

programs—to 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 treatments themselves.

Around 70 percent of agoraphobic clients who receive exposure treatment find it easier to

enter public places, and the improvement persists for years (Gloster et al., 2017, 2015, 2014;

Craske & Barlow, 2014). Unfortunately, these improvements are often partial rather than

complete, and as many as half of successfully treated clients have relapses, although these people

readily 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

(Craske, 2017). We shall take a closer look at this group when we investigate treatments for panic

disorder.

SUMMING UP

PHOBIAS A phobia is a severe, persistent, and unreasonable fear of a particular object, activity, or situation. The two main

categories of phobias are specific phobias and agoraphobia. Cognitive-behavioral theorists believe that phobias are

often learned from the environment through classical conditioning or modeling and maintained by avoidance

behaviors.

Specific phobias have been treated most successfully with exposure techniques, cognitive-behavioral approaches

in which people confront the objects they fear. The exposures may be gradual and relaxed (desensitization), intense

(flooding), or observed (modeling). Agoraphobia is also treated effectively by exposure therapy.

303

Why do so many professional performers seem prone to

performance anxiety? Might their repeated exposure to

audiences have a therapeutic effect?

Social Anxiety Disorder Many people are uncomfortable when interacting with others or talking or performing in front of

others. A number of entertainers and sports figures, from the singer Adele to the actor Johnny

Depp, have described episodes of significant 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 competently than they actually do (see MindTech).

social anxiety disorder A severe and persistent fear of social or performance situations in which embarrassment may occur.

TABLE: 4-6 Dx Checklist Social Anxiety Disorder

1. Pronounced, disproportionate, and repeated anxiety about social situation(s) in which the individual could be exposed to possible scrutiny by others; typically lasting 6 months or more.

2. Fear of being negatively evaluated by or offensive to others.

3. Exposure to the social situation almost always produces anxiety.

4. Avoidance of feared situations.

5. Significant distress or impairment.

Information from: APA, 2013.

Social anxiety disorder can interfere

greatly with one’s life (Schneier, 2017). 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 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 8 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

304

Table 4-7). Around 13 percent develop this disorder at some point in their lives (NIMH, 2017;

Bandelow & Michaelis, 2015; Kessler et al., 2012). Poor people are 50 percent more likely than

wealthier people to have social anxiety disorder (Sareen et al., 2011). Non-Hispanic white

Americans are more likely to experience this problem than African, Hispanic, or Asian Americans

(Hofmann & Hinton, 2014). It tends to begin in late childhood or adolescence and may

continue into adulthood (Schneier, 2017). Around 40 percent of individuals with social anxiety

disorder are currently in treatment (NIMH, 2017).

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 Receiving Clinical Treatment Currently

Generalized anxiety disorder

4.0% 2:1 0−35 years Elevated 43%

Specific phobia 10.0% 2:1 Variable Elevated 32%

Agoraphobia 1.7% 2:1 15−35 years Elevated 46%

Social anxiety disorder

8.0% 3:2 10−20 years Elevated 40%

Panic disorder 3.1% 5:2 15−35 years Elevated 59%

Obsessive- compulsive

disorder

1.0% −2.0%

1:1 4−25 years Elevated 40%

Information from: McCabe, 2018; Roy-Byrne, 2018; NIMH, 2017; Watterson et al., 2017; Remes et al., 2016; Roy-Byrne,

2016; Simpson, 2016; Bandelow & Michaelis, 2015; Phillips, 2015; Kessler et al., 2010, 2005, 1999, 1994; Ritter et al., 2010;

Wang et al., 2005.

305

Much harder than it looks World-renowned singer Adele performs in front of 60,000 people at a stadium in Melbourne,

Australia, during her “Adele Live 2017” concert tour. When the gifted artist mesmerizes her fans in such venues, it is hard

to believe that she has struggled for years with severe performance anxiety and related panic attacks, particularly when

singing before large crowds.

What Causes Social Anxiety Disorder? The leading explanation for social anxiety disorder has been proposed by cognitive-behavioral

theorists (Hofmann, 2018; Heimberg et al, 2010). The explanation features an interplay of both

cognitive and behavioral factors. As you read in Chapter 2, cognitive-behavioral theorists start

with the contention that people with this disorder hold a group of dysfunctional beliefs and

expectations regarding the social realm. These can include:

Holding unrealistically high social standards and so believing that they must perform perfectly in social situations.

Believing they are unattractive social beings.

Believing they are socially unskilled and inadequate.

Believing they are always in danger of behaving incompetently in social situations.

Believing that inept behaviors in social situations will inevitably lead to terrible consequences.

Believing they have no control over the feelings of anxiety that emerge in social situations.

306

Can you think of other negative feelings that might be

triggered by social networking?

Cognitive-behavioral theorists hold that, because of these beliefs, people with social anxiety

disorder keep anticipating that social disasters will occur, overestimate how poorly things go in

their social interactions, and dread most social situations (Hofmann, 2018; Gavric et al., 2017).

Moreover, they learn to perform “avoidance” and “safety” behaviors to help prevent or reduce

such disasters (Mesri et al., 2017). Avoidance behaviors include, for example, avoiding parties or

avoiding interactions with new coworkers or acquaintances. Safety behaviors include wearing

makeup to cover up blushing or gloves to hide shaking hands. Behaviors of this kind are

reinforced by reducing feelings of anxiety and the number of awkward encounters.

Researchers have found that people with social anxiety disorder do indeed manifest the beliefs,

expectations, interpretations, feelings, and behaviors listed above (Parsons et al., 2017; Thurston

et al., 2017). These dysfunctional cognitions and behaviors have been tied to factors such as

genetic predispositions, trait tendencies, biological abnormalities, traumatic childhood

experiences, and overprotective parent–child interactions (Young et al., 2019; Schneier, 2017).

MINDTECH

Social Media Jitters

In recent years, researchers have learned that the use of computers and mobile devices can unintentionally produce

various forms of anxiety, including social and generalized anxiety (Gao et al., 2018; Golbeck, 2016).

The biggest culprit here seems to be spending

too much time on social media such as Facebook,

Instagram, or Snapchat. Although frequenting

social network sites helps many people feel

supported and included (Hu et al., 2017), for others, the visits seem to produce significant insecurities and fears (Levula,

Harré, & Wilson, 2018). Surveys suggest, for example, that more than one-third of social networkers develop a fear that

others will post or use information or photos of them without their permission (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 their social network—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 greetings 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 (Eckler, Kalyango, & Paasch, 2017; Hanna et

al., 2017).

307

Of course, as noted earlier, 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

missing out”) (Wolniewicz et al., 2018).

Social networking is not the only digital source of anxiety. Studies show that excessive cell phone use often results in

high levels of anxiety and tension (Richardson, Hussain, & Griffiths, 2018; Lepp et al., 2014; Archer, 2013). 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. 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 (Dasgupta et al., 2017).

Treatments for Social Anxiety Disorder Only in recent decades have clinicians been able to treat social anxiety disorder successfully.

Their 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 conversations, 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 or by providing training in social skills, or both.

How Can Social Fears Be Reduced? Medication often helps alleviate social fears (Stein, 2018; Curtiss et al., 2017). Such fears are

reduced to some degree in 55 percent of patients who take either benzodiazepines or

antidepressant drugs, compared to 24 percent of similar patients who take placebo drugs. It

appears that these medications bring about relief by improving functioning in the brain’s fear

308

#TheirWords “There are two types of speakers. Those who get nervous and

those who are liars.”

Mark Twain

circuit, which tends to be hyperactive for people with social anxiety disorder, just as it is in cases

of generalized anxiety disorder (Schneier, 2017; Brühl et al., 2014).

At the same time, cognitive-behavioral therapy has proved to be at least as effective as

medication at reducing social fears, and people helped by this approach seem less likely to relapse

than those treated with medications alone (Gregory & Peters, 2017; Thurston et al., 2017). This

finding suggests to some clinicians that this form of therapy should always be featured in the

treatment of social fears, either alone or in combination with medication.

To undo the cycle of problematic social beliefs and behaviors described earlier, cognitive-

behavioral therapists combine both behavioral and cognitive techniques. On the behavioral side,

they conduct exposure therapy, the intervention so effective with phobias. The therapists

encourage clients to expose themselves to their dreaded social situations and to remain in these

situations as their fears subside. Usually the exposure is gradual, and it often includes homework

assignments. On the cognitive side, the clinicians and clients have systematic therapy discussions

in which the clients are guided to reexamine and challenge their maladaptive beliefs and

expectations, given the less-than-dire outcomes of their social exposures.

How Can Social Skills Be Improved? In social skills training, also conducted by cognitive-behavioral therapists, several techniques are

combined. The therapists usually model appropriate social behaviors for clients and encourage 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.

social skills training A therapy approach that helps people learn or improve social skills and assertiveness through role-playing and rehearsing of desirable behaviors.

Reinforcement from other people with

similar social difficulties is often more

powerful than reinforcement from a

therapist alone. Thus in social skills

training groups and assertiveness training

groups, members try out and rehearse new

social behaviors with other group members. Such groups also provide guidance on what is

socially appropriate. According to research, social skills training, in both individual and group

formats, has helped many people perform better in social situations (Probst et al., 2017; Beidel et

309

al., 2014).

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-behavioral theorists believe that the disorder is

particularly likely to develop among people who hold certain dysfunctional social beliefs and expectations and who

learn to perform corresponding avoidance and safety behaviors.

Therapists who treat social anxiety disorder try to reduce social fears by drug therapy and/or cognitive-behavioral

therapy (including exposure techniques). They may also try to improve social skills by social skills training.

310

#TheirWords “Neither a man nor a crowd nor a nation can be trusted to act

humanely or to think sanely under the influence of a great

fear.”

Bertrand Russell

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).

panic attacks Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.

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 surging 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)

Approximately one-third of all people have one or more panic attacks at some point in their

lives (Roy-Byrne, 2018). 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,

311

2013).

panic disorder An anxiety disorder marked by recurrent and unpredictable panic attacks.

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.

Around 3.1 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 (Roy-Byrne, 2018; Bandelow &

Michaelis, 2015; 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 (de Jonge et al., 2016).

Surveys indicate that 59 percent of those with this disorder in the United States are currently in

treatment (NIMH, 2017; Wang et al., 2005).

The prevalence of panic disorder is higher among non-Hispanic white Americans than among

racial-ethnic minority groups in the United States (Hofmann & Hinton, 2014). The actual

features of panic attacks may also differ among these groups (Barrera et al., 2010). For example,

Asian Americans appear more likely than non-Hispanic white Americans to experience dizziness,

unsteadiness, and choking, while African Americans seem less likely to have those particular

symptoms.

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 agoraphobia. That is, after experiencing multiple unpredictable panic

attacks, a person becomes increasingly fearful of having new attacks in public places.

The Biological Perspective Over the past half-century, researchers have learned that panic disorder has biological

underpinnings and can respond to biological treatments. Researchers began their journey in the

312

1960s, when they discovered that the symptoms of this disorder were sometimes alleviated by

antidepressant drugs, specifically those antidepressant drugs that increase the activity of the

neurotransmitter norepinephrine throughout the brain (Klein, 1964; Klein & Fink, 1962).

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 reduce its symptoms. Given that the

drugs were so helpful in eliminating panic attacks, the 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 irregular in people

who suffer from panic attacks. For example, the locus coeruleus is a brain area rich in neurons

that use norepinephrine, and serves as a kind of “on-off” switch for many norepinephrine-using

neurons throughout the brain (Hedaya, 2011). When this area is electrically stimulated in

monkeys, the monkeys have a panic-like reaction, suggesting that panic reactions may be related

to irregularities 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 disturb the activity of norepinephrine (Bourin

et al., 1995; Charney et al., 1990, 1987).

locus coeruleus A small area of the brain that seems to be active in the regulation of emotions. Many of its neurons use norepinephrine.

Based on these findings, biological theorists initially reasoned that panic attacks might be

caused by abnormal activity of norepinephrine in the locus coeruleus. However, once again, more

recent research suggests that the root of panic attacks is more complicated than a single

neurotransmitter or a single brain structure. It turns out that panic reactions are produced by a

brain circuit consisting of structures such as the amygdala, hippocampus, ventromedial nucleus of

the hypothalamus, central gray matter, and locus coeruleus (Roy-Byrne, 2018; Henn, 2013; Etkin,

2010) (see Figure 4-3). When a person confronts a frightening object or situation, the amygdala

is stimulated. In turn, the amygdala stimulates the other brain structures in the circuit,

temporarily setting into motion an “alarm and escape” response (increased heart rate, respiration,

blood pressure, and the like) that is very similar to a panic reaction (Gray & McNaughton,

1996). Most of today’s researchers believe that this circuit—often called the “panic circuit”—

tends to be hyperactive in people who suffer from panic disorder (Roy-Byrne, 2018).

313

FIGURE 4-3

The Biology of Panic

The circuit in the brain that helps produce panic reactions includes structures such as the amygdala, hippocampus,

ventromedial nucleus of the hypothalamus, central gray matter, and locus coeruleus.

Some of the brain structures and neurotransmitters in the panic circuit overlap with those in

the fear circuit discussed earlier; for example, the amygdala is a part of each circuit. However, the

panic circuit seems to be more extensive than the fear circuit, suggesting to some researchers that

panic responses are more complex reactions than fear responses (Roy-Byrne, 2018).

Why might some people have hyperactive panic circuits and be prone to the development of

panic disorder? One possibility is that a predisposition to develop such abnormalities is inherited.

Once again, if a genetic factor is at work, close relatives should have higher rates of panic disorder

than more distant relatives. Studies do find that among identical twins (twins who share all their

genes), if one twin has panic disorder, the other twin has the same disorder in 31 percent of cases

(Roy-Byrne, 2018; Tsuang et al., 2004; Kendler et al., 1995, 1993). Among fraternal twins (who

share only some of their genes), if one twin has panic disorder, the other twin has the same

disorder in, at most, only 11 percent of cases.

314

Drug Therapies Ever since researchers discovered in 1962 that certain antidepressant drugs could prevent or

reduce panic attacks, studies across the world have repeatedly confirmed this initial observation.

Various antidepressant drugs bring at least some improvement to more than two-thirds of

patients who have panic disorder, and the improvement can last indefinitely, as long as the drugs

are continued (Roy-Byrne, 2017; Cuijpers et al., 2014). These antidepressant drugs appear to

prevent or reduce panic attacks by increasing the activity of the neurotransmitters serotonin and

norepinephrine in the locus coeruleus and other parts of the panic circuit, thus helping to correct

the circuit’s tendency to be hyperactive (Gerez et al., 2016; Duval et al., 2015). Researchers have

also discovered that alprazolam (Xanax) and other powerful benzodiazepine drugs can be effective

in many cases of panic disorder, although they are used less often than antidepressants because of

their potential for producing physical dependence and other risks. These various antidepressant

drugs and benzodiazepines also seem to be helpful in cases of panic disorder accompanied by

agoraphobia.

The Cognitive-Behavioral Perspective Cognitive-behavioral theorists argue that biological factors are but one 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-behavioral treatments

are aimed at correcting such misinterpretations.

The Cognitive-Behavioral Explanation: Misinterpreting Bodily Sensations Cognitive-behavioral theorists believe that panic-prone people may be very sensitive to certain

bodily sensations; when they unexpectedly experience such sensations, they misinterpret them as

signs of a medical catastrophe (Craske, 2017; Gloster et al., 2017, 2014). 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

315

sensations by administering drugs or by instructing clinical research participants 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 (Leibold et al.,

2017).

biological challenge test A procedure used to produce panic in participants or clients by having them exercise vigorously or perform some other potentially panic-inducing task in the presence of a researcher or therapist.

Why might some people be prone to such misinterpretations? One possibility is that panic-

prone individuals actually experience more frequent or intense bodily sensations than other

people do. Indeed, 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 brain’s panic circuit—and, as you’ll recall, the

panic circuit is overactive in people with panic disorder (Lieberman et al., 2017). Another

possibility, supported by some research, is that panic-prone people have had more trauma-filled

events over the course of their lives than other persons, leading to higher expectations of

catastrophe (Asselmann et al., 2018; De Cort et al., 2017). Whatever the precise cause of such

misinterpretations may be, once they take hold, they increasingly guide behaviors and choices in

life. Panic-prone individuals may, for example, learn to display avoidance and safety behaviors

that help control their bodily sensations. They may repeatedly hold onto people or objects to

avoid feeling faint, or they may move slowly or sit still much of the time to avoid upsetting

increases in heart rate (Craske, 2017).

316

“It came out of nowhere” All Star Kevin Love tries to make a pass during this National Basketball Association game on

November 5, 2017. Later in the game, Love experienced a panic attack—his first ever—and had to leave for hospital tests

and evaluation. The Cleveland Cavaliers player has since written about the attack, “It came out of nowhere. … But it was

real—as real as a broken hand or a sprained ankle. Since that day, almost everything about the way I think about my mental

health has changed” (Ducharme, 2018).

Given such misinterpretations, it is not surprising 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 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 (Kim et al., 2017).

anxiety sensitivity A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful.

Cognitive-Behavioral Therapy Cognitive-behavioral therapists use a combination of techniques to correct people’s

misinterpretations of their bodily sensations (Craske, 2017). First, they educate clients about the

general nature of panic attacks, the actual causes of bodily sensations, and the tendency of the

clients to misinterpret their sensations. Next, they teach the clients to apply more accurate

interpretations during stressful situations, thus short-circuiting the panic sequence at an early

point. The therapists may also teach the clients ways 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.

317

“Weekends I like to be able to panic without having all the distractions.”

In addition, cognitive-behavioral therapists often use biological challenge procedures to

induce panic sensations, so that clients can apply their new interpretations and skills under

watchful supervision (Gloster et al., 2017, 2014). Individuals whose attacks typically are

triggered by a rapid heart rate, for example, may be instructed to jump up and down for several

minutes or to run up a flight of stairs. They can then practice interpreting the resulting

sensations appropriately, without dwelling on them.

According to research, cognitive-behavioral treatment often helps people with panic disorder

(Craske, 2017; Cuijpers et al., 2016). In studies across the world, at least two-thirds of

participants who receive this treatment have become free of panic, compared with only 13

percent of control participants. Cognitive-behavioral therapy has proved to be at least as helpful

as antidepressant drugs or benzodiazepines in the treatment of panic disorder, sometimes even

more so (Roy-Byrne & Craske, 2017). In view of the effectiveness of both cognitive-behavioral

therapy and drug treatments, many clinicians have tried, with some success, to combine them

(Choi, Lee, & Cho, 2017). Similarly, research suggests that cognitive-behavioral therapy, drug

therapy, or a combination of these approaches are helpful to those individuals who display both

panic disorder and agoraphobia (Craske, 2017; Roy-Byrne, 2017).

SUMMING UP

PANIC DISORDER

Panic attacks are periodic, discrete bouts of panic that occur suddenly. Sufferers of panic disorder experience panic

318

attacks repeatedly and unexpectedly and without apparent reason. Panic disorder may be accompanied by

agoraphobia in some cases, leading to two diagnoses.

Many biological theorists believe that panic disorder is caused by a hyperactive panic circuit, a brain circuit that

includes structures such as the amygdala, hippocampus, ventromedial nucleus of the hypothalamus, central gray

matter, and locus coeruleus. Biological therapists use certain antidepressant drugs or benzodiazepines to treat people

with this disorder.

Cognitive-behavioral theorists suggest that panic-prone people become preoccupied with some of their bodily

sensations and misinterpret them as signs of medical catastrophe. In turn, they have panic attacks, learn to display

avoidance and safety behaviors that help control their bodily sensations, and in some cases develop panic disorder.

Cognitive-behavioral therapists teach clients to interpret their physical sensations more accurately and to cope better

with anxiety.

319

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 4-4 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.

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.

FIGURE 4-4

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.)

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). Although obsessive-compulsive disorder is not

classified as an anxiety disorder in DSM-5, anxiety does play a major role in this pattern. The

320

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 obsessions or compulsions.

obsessive-compulsive disorder A disorder in which a person has recurrent obsessions, compulsions, or both.

TABLE: 4-9 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.

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 morning, 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 (Simpson, 2017; Kessler et

al., 2012). 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. The

disorder usually begins by childhood or young adulthood (Chou et al., 2017) and typically

persists for many years, although its symptoms and their severity may fluctuate over time. It is

estimated that 40 percent of people with obsessive-compulsive disorder seek treatment, many for

an extended period (Phillips, 2015; Patel et al., 2014).

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

321

excessive.

Certain basic themes run through the thoughts of most people troubled by obsessive thinking

(Schwartzman et al., 2017; Simpson, 2017). The most common theme appears to be dirt or

contamination. Other common ones are violence and aggression, orderliness, religion, and

sexuality. The prevalence of such themes may vary from culture to culture (McIngvale et al.,

2017). Religious obsessions, for example, seem to be more common in cultures or countries with

strict moral codes and religious values.

Compulsions are similar to obsessions in many ways. For example, although compulsive

behaviors are technically under voluntary control, the people who feel 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 happen 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 compulsions 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 compulsions 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 (clothing, 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:

322

Patient:

If I heard the word, like, something that had to do with germs or disease, 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)

Personal knowledge The HBO hit series Girls (2012–2017) followed the struggles of Hannah Horvath and her friends as

they navigated their twenties, “one mistake at a time.” The show’s creator and star, Lena Dunham, says that Hannah’s

difficulties often were inspired by her own real-life experiences, including her childhood battle with OCD and anxiety.

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, cognitive-behavioral, and

biological models.

The Psychodynamic Perspective 323

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 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 counterthoughts 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 development

(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 (Goodman, 2017; Busch et al., 2010).

When treating patients with obsessive-compulsive disorder, psychodynamic therapists try to

help the individuals uncover and overcome their underlying conflicts and defenses, using the

customary techniques of free association and therapist interpretation. Research has offered little

evidence, however, that a traditional psychodynamic approach is of much help (Goodman, 2017;

Fonagy, 2015). 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 Cognitive-Behavioral Perspective Cognitive-behavioral theorists begin their explanation of obsessive-compulsive disorder by

pointing out that everyone has repetitive, unwanted, and intrusive thoughts. Anyone 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 (Salkovskis et

al., 2017, 2003; 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

324

amends.

neutralizing A person’s attempt to eliminate unwanted thoughts by thinking or behaving in ways that put matters right internally, making up for the unacceptable thoughts.

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 (Goodman, 2017). Eventually the neutralizing 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.

“Gretel, I don’t like living in this culture of fear.”

In support of this explanation, studies have found that people with obsessive-compulsive

disorder have intrusive thoughts more often than other people, resort to more elaborate

neutralizing strategies, and experience reductions in anxiety after using neutralizing techniques

(Salkovskis et al., 2017, 2003; Jacob et al., 2014).

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

325

Have you ever tried an informal version of exposure and

response prevention in order to stop behaving in certain

ways?

of conduct and morality; (2) to believe that intrusive negative thoughts are equivalent to actions

and capable of causing harm, a point of view called thought-action fusion; and (3) to believe that

they should have perfect control over all of their thoughts and behaviors in life (Schwartzman et

al., 2017; Simpson, 2017).

Cognitive-behavioral therapists use a combination of techniques to treat clients with

obsessive-compulsive disorder. They begin by educating the clients, pointing out how

misinterpretations of unwanted thoughts, an excessive sense of responsibility, and neutralizing

acts have helped to produce and maintain their symptoms. The therapists then guide the clients

to identify and challenge their distorted cognitions. Increasingly, the clients come to appreciate

that their obsessive thoughts are inaccurate occurrences rather than valid and dangerous

cognitions for which they are responsible. Correspondingly, they recognize their compulsive acts

as unnecessary.

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.

With such gains in hand, the clients

become willing to subject themselves to

the rigors of a distinctly behavioral

technique called exposure and response

326

#LosingBattle People who try to avoid all contamination 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.

prevention (or exposure and ritual prevention). In this technique, the clients are repeatedly

exposed to objects or situations that produce anxiety, obsessive fears, and compulsive behaviors,

but they are told to resist performing the behaviors they usually feel so bound to perform.

Because people find it very difficult to resist such behaviors, the therapists may set an example

first.

exposure and response prevention A cognitive-behavioral technique used to treat 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 exposure and ritual prevention.

In recent years, therapists who conduct exposure and response prevention have often used

videoconferencing to go beyond the office and deliver specific instructions to clients directly in

their home settings where compulsions cause the most problems (Comer et al., 2017). At the

very least, a number of therapists compose exposure-and-response-prevention exercises that

clients must carry out in the form of homework (Gellatly et al., 2017; Franklin & Foa, 2014),

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 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 house.

Techniques of this kind often help

reduce the number and impact of

obsessions and compulsions (Lenhard et

al., 2017; Liu et al., 2017). Overall,

between 50 and 70 percent of clients with

obsessive-compulsive disorder have been

found to improve considerably with cognitive-behavioral therapy, improvements that often

327

continue indefinitely (Abramowitz, 2017). The effectiveness of this approach suggests that people

with the 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 Biological Perspective In recent years, researchers have uncovered direct evidence that biological factors play a key role

in obsessive-compulsive disorder. For example, some genetic studies have identified gene

abnormalities that characterize individuals with this disorder (Grünblatt et al., 2018). In

addition, using brain scan procedures, researchers have identified a brain circuit that helps

regulate our primitive impulses such as sexual desires, aggressive instincts, and needs to excrete

(Simpson, 2017; Parmar & Sarkar, 2016; Tang et al., 2016). The circuit, which brings such

impulses to our attention and leads us to act on or disregard them, includes brain structures such

as the orbitofrontal cortex (just above each eye), cingulate cortex, striatum (including the caudate

nucleus and putamen, two other structures at the back of the striatum), and thalamus (see Figure

4-5). Among the most important neurotransmitters at work in this circuit are serotonin,

glutamate, and dopamine (Gerez et al., 2016).

328

FIGURE 4-5

The Biology of Obsessive-Compulsive Disorder

The brain circuit that has been linked to obsessive-compulsive disorder includes structures such as the orbitofrontal cortex,

cingulate cortex, striatum, thalamus, and amygdala.

Studies indicate that this circuit, called the cortico-striato-thalamo-cortical circuit, is hyperactive

in people with obsessive-compulsive disorder, making it difficult for them to turn off or dismiss

their various impulses, needs, and related thoughts (Frydman et al., 2016). After most people use

the bathroom, for example, they have concerns about contamination and they act accordingly by

washing their hands. When they perform this behavior, their brain circuit calms their

contamination concerns and cleanliness needs. In contrast, because the cortico-striato-thalamo-

cortical circuit of people with obsessive-compulsive disorder is hyperactive, these individuals may

continue to experience contamination concerns and need to perform cleaning actions—again and

again and again.

As you just read, brain scan studies have provided evidence that the cortico-striato-thalamo-

cortical circuit is hyperactive in people with obsessive-compulsive disorder. In addition, medical

329

scientists have observed for years that obsessive-compulsive symptoms often arise or subside after

the orbitofrontal cortex, striatum, or other structures in the circuit are damaged by accident,

illness, or surgical procedures (Simpson, 2017; Hofer et al., 2013).

By far, the most widely used biological treatment for obsessive-compulsive disorder is

antidepressant drugs, particularly ones that specifically increase activity of the neurotransmitter

serotonin. Numerous studies have found that such drugs bring improvement to between 50 and

60 percent of those with obsessive-compulsive disorder. Their obsessions and compulsions do not

usually disappear totally, but on average they are cut almost in half (Simpson, 2017; Bareggi et

al., 2004; DeVeaugh-Geiss et al., 1992).

Given the effectiveness of serotonin-enhancing antidepressant drugs in treating obsessive-

compulsive disorder, theorists initially reasoned that the disorder must be caused primarily by

low serotonin activity throughout the entire brain. However, most of today’s researchers believe

instead that the drugs bring improvement by increasing the activity of serotonin within the

cortico-striato-thalamo-cortical circuit, thus helping to correct the circuit’s tendency to be

hyperactive. Consistent with this notion, studies have found that the structures in the circuit

interconnect more appropriately after individuals with obsessive-compulsive disorder respond

successfully to antidepressant treatment (Tang et al., 2016).

While many clients with obsessive-compulsive disorder receive either cognitive-behavioral

therapy or antidepressant drug therapy, a growing number are now being treated by a

combination of those interventions. 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 (Abramowitz, 2017).

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 hoarding, hair-pulling, skin-picking, and

appearance-checking. DSM-5 has created the group name obsessive-compulsive-related

disorders and these four patterns to that group: hoarding disorder, trichotillomania (hair-pulling

disorder), excoriation (skin-picking) disorder, and body dysmorphic disorder. Collectively, these

disorders are displayed by at least 5 percent of all people (Mataix-Cols & de la Cruz, 2017;

Phillips, 2016).

obsessive-compulsive-related disorders Disorders in which obsessive-like concerns drive people to repeatedly and excessively perform certain abnormal patterns of behavior.

330

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 clutter their lives

and living areas. This pattern causes the individuals significant distress and may greatly impair

their personal, social, or occupational functioning (Mathes et al., 2017). It is common for them

to wind up with numerous useless and valueless items, from junk mail to broken 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.

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 excessive accumulation of items.

People with trichotillomania, also known as hair-pulling disorder, repeatedly 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 (Grant et al., 2017). 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 (Alexander et al., 2017; Starcevic, 2015). 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.”

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.

331

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.

People with excoriation (skin-picking) disorder keep picking at their skin, resulting in

significant sores or wounds (APA, 2013). Like those with hair-pulling 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 & Chamberlain, 2017; Grant et al., 2015, 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

(Park & Koo, 2017; Torales, Barrios, & Villalba, 2017).

excoriation disorder A disorder in which people repeatedly pick at their skin, resulting in significant sores or wounds. Also called skin-picking disorder.

332

Cultural rituals Rituals do not necessarily reflect compulsions. Indeed, cultural and religious rituals often give meaning and

comfort to their practitioners. Here Buddhist monks splash water over themselves during their annual winter prayers at a

temple in Tokyo. This cleansing ritual is performed to pray for good luck.

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 A disorder in which individuals become preoccupied with the belief that they have certain defects or flaws in their physical appearance. Such defects or flaws are imagined or greatly exaggerated.

Body dysmorphic disorder is the obsessive-compulsive-related disorder that has received the

most study to date. Researchers have found that, most often, individuals 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 (Phillips, 2017, 2016). 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

333

#LookingGood 42 percent of facial plastic surgeons report that many of their

patients seek cosmetic procedures in order to look better in

selfies, Instagram, Snapchat, and Facebook Live, and other

social media (AAFPRS, 2017).

years. … She avoided cinemas, dances, shops, cafes, and private homes. … Her husband was not allowed to invite any friends

home; she constantly sought reassurance 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-

6). Many teenagers and young adults

worry about acne, for instance. The

concerns 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 (Bouman et al., 2017; Phillips, 2017). A large number are housebound, 80

percent have suicidal thoughts, and as many as 25 percent may attempt suicide at some point in

their lives (Phillips, 2016).

334

FIGURE 4-6

“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 percentages of people regularly think about and try to change the way they look.

(Information from: ASPS, 2017; Samorodnitzky-Naveh et al., 2007; Noonan, 2003; Kimball, 1993; Poretz & Sinrod,

1991; Weiss, 1991; Simmon, 1990.)

As with the other obsessive-compulsive-related disorders, 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. Similarly, clinicians typically treat

clients with this disorder by applying the kinds of treatment used with obsessive-compulsive

disorder, particularly antidepressant drugs and cognitive-behavioral therapy (Krebs et al., 2017;

Phillips, 2017, 2016).

In an early study, for example, 17 clients with this disorder were treated with exposure and

response prevention (Neziroglu et al., 2004, 1996). Over the course of 4 weeks, the clients were

repeatedly reminded of their perceived physical defects and, at the same time, prevented from

doing anything to help reduce their discomfort (such as checking their appearance). 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.

335

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.

SUMMING UP

OBSESSIVE-COMPULSIVE DISORDER People with obsessive-compulsive disorder are beset by obsessions, perform compulsions, or both. According to the

psychodynamic view, this disorder arises out of a battle between id impulses and ego defense mechanisms. In

contrast, cognitive-behavioral theorists believe that the 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-behavioral therapists first help clients correct their

misinterpretations of the unwanted thoughts, then conduct exposure and response prevention.

Biological researchers have tied obsessive-compulsive disorder to a hyperactive brain circuit featuring such brain

structures as the orbitofrontal cortex, cingulate cortex, striatum, and thalamus. Antidepressant drugs that raise

serotonin activity are a useful form of treatment. In addition to obsessive-compulsive disorder, DSM-5 lists a group of

obsessive-compulsive-related disorders, disorders in which obsessive-like concerns drive individuals to repeatedly and

excessively perform specific patterns of behavior that greatly disrupt their lives. This group consists of hoarding

disorder, trichotillomania, excoriation (skin-picking) disorder, and body dysmorphic disorder.

336

Integrating the Models: The Developmental Psychopathology Perspective While reading through this chapter, you may have noticed that certain findings and principles

from each of the models seem compatible, and you may have wondered whether the explanations

offered by the models could sometimes be combined to provide a fuller understanding of the

various anxiety, obsessive-compulsive, and obsessive-compulsive-related disorders. A number of

clinical theorists have asked the same question and have looked for ways to integrate the variables

cited by the models. As you read in Chapter 2, one of today’s most influential integrative views is

the developmental psychopathology perspective. This perspective focuses on the intersection and

context of important factors at key points of time throughout an individual’s life span (Moreno,

2018; Eme, 2017; Cicchetti, 2016).

What are the factors that developmental psychopathologists look at when seeking to

understand the development of anxiety-related disorders? Drawing from the biological model,

they have been interested in the growing number of studies that link particular genetic variations

to hyperactive fear circuits and, in turn, to inhibited—that is, fearful—temperaments in certain

infants and toddlers (Buzzell et al., 2017; Johnson et al., 2016; Fox et al., 2015). From the

earliest days of life, such children show a withdrawn, isolated, and cautious pattern known as

behavioral inhibition. They are wary of new objects, people, and environments, and always seem

on guard against potential threats. Research indicates that this inhibited temperament often

endures throughout a person’s life and places some individuals at heightened risk for the

development of anxiety-related disorders (Abulizi et al., 2017; Buzzell et al., 2017).

Drawing from the cognitive-behavioral and psychodynamic models, developmental

psychopathologists have also been interested in research findings that highlight the important

role of parenting styles (Moreno, 2018; Hankin et al., 2016). Investigations indicate that as

children grow, overprotective parenting—in which parents rush in too quickly to prevent or rescue

their children from experiencing distress—denies them opportunities to learn how to manage

distress by themselves and to build a strong sense of self-confidence. If children already have a

biological vulnerability and an inhibited temperament, exposure to overprotective parenting can

help promote repeated eruptions of anxiety, setting the stage for lifelong anxiety.

Finally, drawing from the sociocultural model, developmental psychopathologists have also

been interested in research showing that life stress, poverty, school difficulties, family

disharmony, peer pressure, and community danger can heighten the likelihood of developing

anxiety-related disorders. Indeed, a growing number of studies suggest that, in many cases, some

337

CLINICAL CHOICES 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.

such factors must be present for these disorders to emerge, in addition to any unfavorable

biological factors, temperament, or parenting experiences the individual may have (Eme, 2017;

Pianta, 2016).

While the developmental

psychopathology perspective helps us

appreciate that the principles of the

various models may often be combined to

better account for anxiety-related

disorders, it also highlights that the

models have not typically addressed

important questions about the

development of these disorders. Precisely

how and when, for example, do the variables from each of the models interact to produce the

disorders? A growing body of research suggests that the various key factors—from biological to

temperament to parenting to life events—may have greater or lesser impact at different points of

development (Moreno, 2018; Eme, 2017; Cicchetti, 2016). The early settling in of a fearful

temperament, for example, may place a lid on the later impact of positive life events. Conversely,

effective parenting may reduce the impact of an unfavorable biological predisposition or of later

negative life events. Clearly, in order for anxiety-related disorders to be more fully understood

and effectively treated, these important developmental issues need to be clarified.

SUMMING UP

INTEGRATING THE MODELS To explain anxiety-related disorders, proponents of the developmental psychopathology perspective examine how key

factors emerge and intersect at points throughout an individual’s life span. The factors of interest to them include

genetic factors, a hyperactive fear circuit in the brain, an inhibited temperament, parenting style, maladaptive

thinking, avoidance behaviors, life stress, and negative social factors.

338

Chapter 4 Review

Key Terms

fear

anxiety

generalized anxiety disorder

unconditional positive regard

client-centered therapy

basic irrational assumptions

metacognitive theory

rational-emotive therapy

mindfulness-based cognitive-behavioral therapy

family pedigree studies

benzodiazepines

gamma-aminobutyric acid (GABA)

brain circuit

fear circuit

sedative-hypnotic drugs

phobia

specific phobia

agoraphobia

classical conditioning

modeling

preparedness

exposure treatment

339

systematic desensitization

flooding

social anxiety disorder

social skills training

panic attacks

panic disorder

norepinephrine

locus coeruleus

panic circuit

biological challenge test

anxiety sensitivity

obsession

compulsion

obsessive-compulsive disorder

neutralizing

exposure and response prevention

cortico-striato-thalamo-cortical circuit

serotonin

obsessive-compulsive-related disorders

hoarding disorder

trichotillomania

excoriation disorder

body dysmorphic disorder

developmental psychopathology

behavioral inhibition

340

overprotective parenting

Quick Quiz

1. What are the key principles in the sociocultural, psychodynamic, humanistic, cognitive- behavioral, and biological explanations of generalized anxiety disorder? pp. 103–111

2. How effective have treatments been for generalized anxiety disorder? pp. 106–112

3. Define and compare specific phobias and agoraphobia. How do cognitive-behavioral theorists explain phobias? pp. 113–116

4. Describe the three exposure techniques used to treat specific phobias. pp. 117–118

5. What are the various components of social anxiety disorder, and how is this disorder treated? pp. 120–123

6. How do biological and cognitive-behavioral clinicians explain and treat panic disorder? pp. 124–127

7. Which factors do psychodynamic, cognitive-behavioral, and biological theorists believe are at work in obsessive-compulsive disorder? pp. 129–132

8. Describe and compare the effectiveness of exposure and response prevention and antidepressant medications as treatments for obsessive-compulsive disorder. pp. 131– 133

9. Describe the four obsessive-compulsive-related disorders. pp. 133–135

10. How do developmental psychopathology theorists integrate the findings and principles from the various models to explain anxiety, obsessive-compulsive, and obsessive- compulsive-related disorders? pp. 135–136

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

341

342

CHAPTER 5 Disorders of Trauma and Stress

TOPIC OVERVIEW

343

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

Getting a Handle on Trauma and Stress

Specialist 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 injured 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)

344

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 continue 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

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 (Blaxton & Bergeman, 2017; 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.

Different strokes for different folks Some people are exhilarated by the opportunity to chase bulls through the streets of

Pamplona, Spain, during the annual “running of the bulls.” 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.

When we view a stressor as threatening, a natural reaction is arousal and a sense of fear—a

response frequently discussed in Chapter 4. Stress reactions, and the sense of fear they produce,

are often at play in psychological disorders. People who experience a large number of stressful

345

events are particularly vulnerable to the onset of the anxiety disorders that you read about in

Chapter 4 (Furr et al., 2018). Similarly, increases in stress have been linked to the onset of

depression, schizophrenia, sexual dysfunctions, and other psychological problems.

Extraordinary stress and trauma play an even more central role in certain psychological

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 range of significant 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 disorders also triggered by traumatic events, in which the primary symptoms are severe

memory and orientation problems. These disorders 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.

346

Stress and Arousal: The Fight-or-Flight Response The features of arousal are set in motion by the brain structure called the hypothalamus. 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 activates two important systems—the autonomic nervous system

and the endocrine system. The autonomic nervous system (ANS) is the extensive network 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 brain–body pathways, or routes, by

which these systems produce arousal—the sympathetic nervous system pathway and the

hypothalamic-pituitary-adrenal pathway.

autonomic nervous system (ANS) The network of nerve fibers that connect 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.

347

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 parasympathetic division leads to an overall calming effect.

When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous

system, a group of ANS fibers that work to quicken our heartbeat and produce the other changes

that we come to experience as fear or anxiety. These nerves may stimulate the organs of the body

directly—for example, they may directly stimulate the heart and increase heart rate. The nerves

348

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 chemicals epinephrine (adrenaline) and norepinephrine (noradrenaline)

are released. You have already seen that these chemicals are important neurotransmitters when

they operate in the brain (see page 38). When released from the adrenal medulla, however, they

act as hormones and travel through the bloodstream to various organs and muscles, further

producing arousal.

sympathetic nervous system The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal.

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

reactions.

parasympathetic nervous system The nerve fibers of the autonomic nervous system that help return bodily processes to normal.

The second brain–body pathway by which arousal is 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 corticosteroids, including the hormone cortisol. These corticosteroids travel to

various body organs, where they further produce arousal reactions (Donohoue, 2017; Jacoby et

al., 2016).

hypothalamic-pituitary-adrenal (HPA) pathway One route by which the brain and body produce arousal. corticosteroids Hormones, including cortisol, released by the adrenal glands at times of stress.

349

FIGURE 5-2

The Endocrine System: The HPA Pathway

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.

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 endocrine functioning and so has a particular

way of experiencing arousal when he or she confronts stressors. Some people, for example, react

with relatively little tension even in the face of significant threats, while others react with

considerable tension even when they encounter minimal threats. People also differ in their sense

of which situations are threatening. Flying in an airplane may arouse terror in some people and

boredom in others.

350

351

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 physically 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, fear, and depression that are beyond anything we have ever known.

For most people, such reactions subside soon after the danger passes. For others, however, the

symptoms of arousal, 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, the

situations that cause acute stress disorder or posttraumatic stress disorder—combat, rape, an

earthquake, an airplane crash—would be traumatic for almost anyone (Chou et al., 2017).

If the symptoms begin within 4 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 traumatic event or months or years

afterward (see Table 5-1). In fact, 25 percent of people with PTSD do not develop a full clinical

syndrome until 6 months or more after their trauma (Sareen, 2018).

acute stress disorder A disorder in which a person experiences fear and related symptoms soon after a trauma but for less than a month. posttraumatic stress disorder (PTSD) A disorder in which a person experiences fear and related symptoms long after a traumatic event.

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

352

features of the event(s) or experiencing repeated negative emotions.

5. Person displays conspicuous changes in arousal or reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.

6. Person experiences significant distress or impairment, with symptoms lasting more than a month.

Information from: APA, 2013.

Studies indicate that at least half of all cases of acute stress disorder develop into posttraumatic

stress disorder (Bryant, 2018, 2017). Think back to Latrell, the soldier in Iraq whose case opened

this chapter. As you’ll recall, Latrell became overrun by arousal, anxiety, insomnia, worry, anger,

depression, irritability, intrusive thoughts, flashback memories, 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:

INCREASED AROUSAL, NEGATIVE EMOTIONS, AND GUILT People may feel excessively alert (hyperalertness), be easily startled, have trouble concentrating,

and develop sleep problems. They may display anxiety, anger, or depression, and feel extreme

guilt because they survived the traumatic event while others did not (Norman et al., 2018). Some

also feel guilty about what they may have had to do to survive.

REEXPERIENCING THE TRAUMATIC EVENT People may be battered by recurring thoughts, memories, dreams, or nightmares connected to

the event (Walton et al., 2017). 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 conversations.

REDUCED RESPONSIVENESS AND DISSOCIATION People with these disorders may feel detached from other people, be unresponsive to external

stimuli, and lose interest in activities that once brought enjoyment. Many endure symptoms of

dissociation, or psychological separation: that is, they feel dazed, have trouble remembering

things, experience depersonalization (feeling that their conscious state or body is unreal), or have a

sense of derealization (feeling that the environment is unreal or strange).

353

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)

Clinicians have come to appreciate that people who experience symptoms of dissociation and

unresponsiveness as part of their stress syndrome tend to be more impaired and distressed than

other sufferers (Hansen, Ross, & Armour, 2017). This pattern is particularly common among

PTSD victims whose traumas involved military combat, sexual abuse, or other forms of physical

abuse, especially repeated abuse or childhood abuse.

An acute or posttraumatic stress disorder can occur at any age, even in childhood (Furr et al.,

2018). Surveys indicate that 3.5 to 6 percent of people in North America have one of the stress

disorders in any given year; 7 to 12 percent suffer from one of them during their lifetimes

(Sareen, 2018; Kessler et al., 2012). Around half of these individuals seek treatment, but

relatively few do so when they first develop the disorder (NIMH, 2017; Wang et al., 2005).

Approximately 20 percent attempt suicide (Cunningham et al., 2019). People with these stress

disorders often develop other psychological disorders as well, such as depressive, anxiety, or

substance use disorders (Dworkin et al., 2018). They also have an increased risk of developing

physical ailments such as bronchitis, asthma, heart disease, and liver disease (Sareen, 2018; La

Greca, Comer, & Lai, 2016).

People with low incomes are twice as likely as people with higher incomes to experience stress

disorders (Sareen, 2018; Sareen et al., 2011). Women are more likely than men to develop one of

these disorders: around 20 percent of women who are exposed to a severe trauma may develop

one, compared with 8 percent of men (Perrin et al., 2014; Russo & Tartaro, 2008). Similarly,

Hispanic Americans, African Americans, and American Indians are more likely than non-

Hispanic white Americans to develop a stress disorder after confronting a severe trauma (Tull,

2017; Ghafoori et al., 2013). The reason for this racial-ethnic difference is not clear.

354

Lingering impact More than four decades after the Vietnam War, over a quarter million veterans of that war are still

suffering from PTSD. Until his death in 2016, one such veteran was King Charsa Bakari Kamau. He is seen here playing

the piano at a mall in Denver, Colorado, an avocation that he considered to be his best therapy.

What Triggers Acute and Posttraumatic Stress Disorders? Any traumatic event can trigger a stress disorder; however, some are particularly likely to do so

(Sareen, 2018). 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 psychological

symptoms after combat (Ruzek et al., 2011).

By the late 1970s, it became apparent that many Vietnam combat veterans were still

experiencing war-related psychological difficulties. We now know that as many as 29 percent of

all Vietnam veterans, male and female, suffered an acute or posttraumatic stress disorder, while

another 22 percent have had at least some stress symptoms (Hermes, Hoff, & Rosenheck, 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 (Gradus, 2017; Marmar et al., 2015).

A similar pattern has unfolded among the nearly 2.7 million veterans of the wars in

Afghanistan and Iraq (Stevelink et al., 2018; Vasterling et al., 2016; Ruzek et al., 2011). Around

355

20 percent of the individuals deployed to those wars have so far reported symptoms of PTSD.

Among those directly exposed to prolonged periods of combat-related stress, the percentage with

PTSD is higher still.

Disasters and Accidents Acute and posttraumatic stress disorders may also follow natural and accidental disasters such as

earthquakes, floods, tornadoes, fires, airplane crashes, and serious car accidents (see Table 5-2).

Researchers have found, for example, unusually high rates of PTSD among the survivors of

2005’s Hurricane Katrina, 2010’s BP Gulf Coast oil spill, and the devastating hurricanes that

struck Puerto Rico, Florida, and Texas in 2017 (Dickerson, 2017; Brown et al., 2016). 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 found that between 12 and

40 percent of people involved in traffic accidents—adult or child—may develop PTSD within a

year of the accident (Sareen, 2018; Noll-Hussong et al., 2013).

TABLE: 5-2 Worst Natural Disasters of the Past 110 Years Disaster Year Location Number Killed

Flood 1931 Huang 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 Saturia, Bangladesh 1,300

Information from: Statista, 2018; Infogalactic, 2016; USGS, 2011; Ash, 2001.

Victimization People who have been abused or victimized often have stress symptoms that linger. Research

suggests that over one-third of all victims of physical or sexual assault develop PTSD (Sareen,

2018; Koss et al., 2011). As many as half of all people directly exposed to terrorism or torture

may develop the disorder (Comer et al., 2018; Basoglu et al., 2001).

SEXUAL ASSAULT

356

A common form of victimization in our society today is sexual assault (see InfoCentral). 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

96,000 cases of rape or attempted rape are reported to the police each year (FBI, 2017). 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 71 percent of the victims are raped by acquaintances, intimates, or relatives (BJS,

2017, 2016, 2013).

rape Forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse between an adult and an underage person.

The power of disclosure These demonstrators participate in a #MeToo Survivors March in Los Angeles, California. As part

of the #MeToo movement, which began in 2017 after a series of high-profile revelations of sexual assault and harassment,

women around the world have spoken out about their sexual victimization experiences—a wave of disclosures that has raised

public awareness, provided support and empathy to millions of victims, and led to calls for change in our society’s laws,

workplace policies, and social norms. According to research, disclosure—in written or verbal form—often enhances a

person’s recovery from traumatic experiences and can help prevent the onset of PTSD.

The rates of rape differ among racial-ethnic groups. 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 non-Hispanic white American women, 15 percent of Hispanic

American women, and 12 percent of Asian American women (BJS, 2017; Black et al., 2011).

357

How might physicians, police, the courts, and other agents

better meet the psychological needs of rape victims?

The psychological impact of rape on a

victim is immediate and may last a long

time (Bates, 2017; Koss et al., 2015,

2011, 2008). Rape victims typically

experience enormous distress during the week after the assault. Stress continues to rise for the

next 3 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 anxiety, suspiciousness, depression, self-esteem problems,

self-blame, flashbacks, sleep problems, and sexual dysfunction (Bates, 2017; Remes et al., 2016).

Female victims of rape and other crimes also are much more likely than other women to suffer

serious long-term health problems (Bates, 2017; 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 (Mills, Hill, & Johnson, 2018; Ng et al., 2018).

Because these forms of abuse may occur over the long term and violate family trust, many victims

develop other symptoms and disorders as well.

INFOCENTRAL

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.

Approximately one-third of rape victims develop PTSD.

358

TERRORISM People who are victims of terrorism or who live under the threat of terrorism often experience

posttraumatic stress symptoms (Comer et al., 2018, 2016; Glad et al., 2017). Unfortunately, this

source of traumatic stress is on the rise in our society. The terrorist events of September 11,

2001, have left a lasting mark on the United States and the rest of the world. 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

359

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 PTSD (Comer et al., 2018; Ruggero

et al., 2013).

Je suis Charlie In 2015, terrorists conducted a three-day killing spree in Paris, including the murder of 12 employees of the

weekly satirical newspaper Charlie Hebdo. Using the slogan Je suis Charlie (“I am Charlie”), close to 4 million people joined

rallies around France, voicing their support for free speech and their resolve against terrorism. This terrorist attack, like

others, led to a significant rise in the rate of PTSD across France (Ben-Ezra et al., 2015).

Follow-up studies suggest that many such individuals continue to struggle with terrorism-

related stress reactions (Tucker et al., 2018; 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 2013 Boston Marathon bombing, the 2016 Bastille Day truck

attack in Nice, France, and the 2017 Ariana Grande concert bombing in Manchester, United

Kingdom, tell a similar story (Comer et al., 2018, 2014; Goodwin et al., 2017).

360

#CommonEvent More than 60% of adults have experienced a traumatic event at

least once in their lives (NCPTSD, 2016; Sidran Institute,

2016).

An ever-growing phenomenon in the United States and across the world are mass shootings—

sometimes in the name of terrorism, sometimes not—at schools and other public places, such as

the 2017 killings of 58 concertgoers in Las Vegas, Nevada, and the 2018 killings of 17

individuals at the Marjory Stoneman Douglas High School in Parkland, Florida (see page 408).

Here again, studies suggest that many survivors of these shootings develop shooting-related stress

disorders (Godlasky, 2018; Bekker, 2017).

TORTURE Torture refers to the use of “brutal, degrading, and disorienting strategies 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

(Dando, 2017). 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 decade.

torture The use of brutal, degrading, and disorienting strategies to reduce victims to a state of utter helplessness.

People from all walks of life are subjected to torture worldwide—from suspected terrorists to

student activists and members of religious, ethnic, and cultural minority groups. The techniques

used on them may include physical torture (beatings, waterboarding, electrocution), psychological

torture (threats of death, mock executions, 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.

It also appears that between 30 and 50 percent of torture victims develop PTSD (Ibrahim &

Hassan, 2017; 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. Anyone who experiences an

unusual trauma will be affected by it, but

only some people develop a stress disorder. To understand the development of these disorders

361

more fully, researchers have looked at biological factors, childhood experiences, personal styles, social

support systems, and the severity and nature of the traumas. Our discussions in this section will

center on PTSD because that is the stress disorder that is most researched.

Biological Factors Investigators have linked posttraumatic stress disorder to several biological factors. The ones that

have received the most attention are the brain–body stress pathways, the brain’s stress circuit, and

inherited predispositions.

THE BRAIN–BODY STRESS PATHWAYS As you’ll recall, when we are stressed, the brain’s hypothalamus activates two stress pathways

throughout the brain and body—the sympathetic nervous system pathway and the

hypothalamic-pituitary-adrenal (HPA) pathway (see pages 141–142). These pathways react to

stress by producing a general state of arousal, the former through nerve cell firing and the latter

through releasing hormones into the bloodstream.

While everyone reacts to traumatic events with increased arousal throughout these two

pathways, research suggests that people who develop PTSD react with especially heightened

arousal in the pathways (Dayan, Rauchs, & Guillery-Girard, 2017; Ross et al., 2017). There is

evidence that, even prior to confronting a severe trauma, such individuals’ pathways are overly

reactive to modest stressors, thus setting up a predisposition to develop PTSD. There is also

evidence that after confrontation with a severe trauma, those brain–body pathways become even

more overly reactive (Lehrner & Yehuda, 2018; Rasmusson & Shalev, 2014). Small wonder that

researchers have found abnormal activity of the hormone cortisol and the

neurotransmitter/hormone norepinephrine—major players in the two pathways—in the urine,

blood, and saliva of combat soldiers, rape victims, concentration camp survivors, and survivors of

other severe stresses (Tull et al., 2018; Gola et al., 2012). In short, once PTSD sets in, an

individual’s brain–body pathways are characterized by still greater overreactivity in the face of

stress, and this persistent overreactivity may lock in brain and body dysfunction and the

continuing symptoms of PTSD.

362

Candidates for dysfunction A stock trader reacts with exhaustion, worry, and disbelief after a particularly bad—stock-

plummeting—day. Business difficulties, such as the trader’s, are among the most common triggers of adjustment disorder, a

DSM-5 disorder characterized by excessive and extended feelings of anxiety, depressed mood, or antisocial behavior in

response to life stressors. The symptoms of an adjustment disorder are not as severe as those in PTSD or in anxiety

disorders, but they do cause individuals considerable stress and may interfere with their job, schoolwork, or social life.

363

Helpers at risk Emergency rescue workers and volunteers frantically carry a victim from the ruins of an earthquake in

Kathmandu, Nepal. Studies reveal that those who are called on to help people during disasters, accidents, and other life-

and-death situations may themselves be at high risk for developing acute and/or posttraumatic stress disorders (Luftman et

al., 2017).

THE BRAIN’S STRESS CIRCUIT Researchers believe that the chronic overreactivity of the two stress pathways may help bring

about dysfunction in a distinct brain circuit, sometimes called the brain’s stress circuit. As you

have seen in earlier chapters, emotional, behavioral, and cognitive reactions of various kinds are

tied to brain circuits—networks of brain structures that communicate and trigger each other into

action. Dysfunction in one such circuit, the stress circuit, apparently contributes to the

symptoms of PTSD. The brain’s stress circuit includes such structures as the amygdala, prefrontal

cortex, anterior cingulate cortex, insula, and hippocampus, among others (Sheynin & Liberzon,

2017; Pedersen, 2016). Given the close relationship between arousal, fear, and anxiety, it is not

surprising that several of the structures in this circuit are also parts of the brain’s fear and panic

circuits that help produce anxiety disorders. But in the case of PTSD, the problematic activity

and interconnections of these structures differ from those found in anxiety disorders.

INHERITED PREDISPOSITION Researchers also believe that certain individuals inherit a tendency for overly reactive brain–body

364

#TopStressors

1. Personal finances

2. Job pressure

3. The economy

4. Relationships

5. Health

(Information from: APA, 2015)

stress pathways and a dysfunctional brain stress circuit. In turn, such individuals may have a

susceptibility to PTSD. Genetic studies have located several genes that might be involved in this

inherited susceptibility (Sheerin et al., 2017; Young, 2017). Similarly, family pedigree research

supports the notion of an inherited susceptibility. Studies conducted on thousands of pairs of

twins who have served in the military find that if one twin develops posttraumatic 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).

In related work, researchers have

found that people suffering from PTSD

are more likely to transmit relevant

biological abnormalities to their children

(Cook et al., 2018; Yehuda et al., 2015).

In one study, for example, investigators

examined the cortisol levels of women

who had been pregnant during the

September 11, 2001, terrorist attack and

had developed PTSD in its aftermath

(Yehuda & Bierer, 2007). Not only did these women have higher-than-average cortisol levels, but

their babies born after the attacks also displayed higher cortisol levels, suggesting that the babies

inherited a predisposition to develop PTSD.

Childhood Experiences Other researchers agree that certain individuals have overly reactive stress pathways and a

dysfunctional stress circuit that predispose them to develop PTSD. However, they believe that

such a predisposition may be acquired during childhood rather than inherited at birth (Ross et

al., 2017). In support of this notion, a number of studies have found that young children who

are chronically neglected or abused or otherwise traumatized develop overly reactive stress

pathways and a dysfunctional brain stress circuit that carry into later life (Lee, Coe, & Ryff,

2017; Zannas & West, 2014). Apparently, their unfortunate childhood experiences actually play

a role in reprogramming their brain and body stress responses.

365

Do the vivid images children see regularly on the Web, on

TV, and in video games make them more vulnerable to later

developing psychological stress disorders or less vulnerable?

Children too In this famous and heart-wrenching photo, a bloodied and disoriented 5-year-old child named Omran

Daqneesh sits in an ambulance covered with dirt and dust after being pulled from the rubble of a building destroyed by an

airstrike in Aleppo, Syria. After confronting horrific traumas, especially repeated ones, children too may develop PTSD,

leading clinicians to worry greatly about the mental health of children caught in the middle of Syria’s civil war.

Consistent with these findings,

researchers have also found that certain

childhood experiences increase a person’s

risk for later PTSD. People whose

childhoods were marked by poverty

appear more likely to develop the disorder in the face of later trauma (Lee et al., 2017). So do

people whose childhoods included an assault, abuse, or a catastrophe; multiple traumas; parental

separation or divorce; or living with family members suffering from psychological disorders

(Carroll et al., 2017; Hyland et al., 2017).

Personal Styles Research suggests that people with certain personalities, attitudes, and coping styles are

particularly likely to develop posttraumatic stress disorder (Ning, Guan, & Liu, 2017). For

example, a classic study conducted after the monster 1989 storm, Hurricane Hugo, revealed that

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 negative events as beyond their control tend to develop more severe stress

366

#GenderDifference 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 (Sareen, 2018; USDVA, 2015; Street et

symptoms after sexual abuse 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 anything positive from unpleasant situations adjust more

poorly after traumatic events than other people (Kunst, 2011).

Conversely, it has been found that people with a resilient style of personality are less likely than

other individuals to develop PTSD after encountering traumatic events (Thompson et al., 2018;

Ross et al., 2017). The term “resilient” has been applied to people who adapt well and cope

effectively in the face of life adversity. Although there is evidence that genetic factors may help

determine one’s level of resilience, studies also find that young children who are regularly exposed

to manageable stress often develop heightened resilience, a gain that may continue throughout

childhood and adulthood. Not surprisingly, studies also find that the brain–body stress pathways

and brain stress circuits of resilient persons tend to operate better than those of other people

(Meng et al., 2018).

Social Support Systems People whose social and family support systems are weak are also more likely to develop

posttraumatic stress disorder after a traumatic event (Sareen, 2018). Rape victims who feel loved,

cared for, valued, and accepted by their friends and relatives recover from their ordeal more

successfully. So do those treated with dignity and respect by the criminal justice system

(AAMFT, 2018; Patterson, 2011). In contrast, clinical reports have suggested that poor social

support contributes to the development of PTSD in some combat veterans (Schumm et al.,

2014).

The Severity and Nature of the Trauma As you might expect, the severity and nature of the traumatic event a person encounters help

determine whether the individual will develop a stress disorder. Some events may override a

favorable biological foundation, nurturing childhood, positive attitudes, and/or social support

(Conrad et al., 2017). One early study examined 253 Vietnam War prisoners five years after their

release. Some 23 percent qualified for a clinical diagnosis of PTSD, though all had been

evaluated as well adjusted before their imprisonment (Ursano et al., 1981).

Generally, the more severe or

prolonged the trauma and the more direct

one’s exposure to it, the greater the

likelihood of developing a stress disorder

367

al., 2011).(Hyland et al., 2017; Ursano et al., 2003).

Mutilation, severe physical injury, or

sexual assault in particular seem to

increase the risk of stress disorders, as does witnessing the injury or death of other people. In

addition, people who experience intentionally inflicted traumas are more likely to develop a stress

disorder than persons who encounter unintentional traumas (Sareen, 2018).

There is also growing evidence that encounters with multiple or recurring traumas can lead to

a particularly severe pattern called complex PTSD (Hyland et al., 2017; Jakob et al., 2017).

Persons with complex PTSD experience virtually all of the symptoms mentioned throughout this

chapter along with profound disturbances in their emotional control, self-concept, and

relationships.

Putting the Factors Together Most of today’s stress theorists believe that the various factors we have been looking at work

together to help produce posttraumatic stress disorder (Ross et al., 2017). The developmental

psychopathology perspective, which has received considerable research support in the realm of

PTSD, provides one of the most influential explanations of how this might occur (Cicchetti,

2018, 2016; Meyer et al., 2017).

As you’ll recall from Chapters 2 and 4, theorists from this perspective focus on the intersection

and context of important variables at key points of time throughout an individual’s life span. In the

case of PTSD, they suggest that certain people have a biological predisposition—either inherited

or acquired—for overreactivity in their brain–body stress pathways (that is, the sympathetic

nervous system pathway and the hypothalamic-pituitary-adrenal pathway) and for dysfunction in

their brain’s stress circuit. This predisposition sets the stage for, but does not guarantee, the later

development of PTSD. If, however, these individuals encounter extreme stressors throughout

their childhood, their stress pathways may become still more overreactive and their brain’s stress

circuit may become more dysfunctional, and their risk of later developing PTSD may continue

to grow. This risk may increase still further if, over the course of their lives, the individuals

acquire poor coping mechanisms, develop problematic personal styles, and/or have weak social

supports. When they confront extraordinary traumas in life, such individuals will be particularly

vulnerable to the development of PTSD.

368

#StressfulOutcome

20% Percentage of people who report they have no one to support them during stress

29% Percentage of people who report feeling more stress this year than last year

41% Percentage of married people who say stress has caused them to yell at their spouse during the past month

(Information from: APA, 2017, 2015)

Empowerment and resilience One week after 17 students and teachers were killed in a 2018 mass shooting at Marjory

Stoneman Douglas High School in Parkland, Florida, thousands of nearby south Florida students streamed out of their

classrooms and staged this rally on the grounds of the stricken high school, demanding improvements in school safety and

stricter gun-control laws. A month later, more than a million students nationwide followed suit in the “National School

Walkout.” Beyond the validity and importance of these protests, clinical theorists believe that the qualities of empowerment

and resilience demonstrated by the students—particularly those who directly experienced the school shooting trauma—has

helped protect some of them from developing posttraumatic stress disorder.

It is important to note that in the

developmental psychopathology

perspective, the relationship between the

contributing factors is often a two-way

street. For example, while overreactive

stress pathways can contribute to poor

coping during childhood and beyond, it is

also the case that a childhood filled with

experiences of manageable stress can, as we

saw earlier, improve the functioning of

the stress pathways, facilitate better coping skills, and help build a resilient personal style, thus

reducing the risk of later developing PTSD (Southwick & Charney, 2012).

369

According to developmental psychopathologists, the timing of stressors and traumas over the

course of development has a profound influence on whether an individual will develop PTSD

(Moreno, 2018; Bremner, 2016). For example, extreme stressors in childhood disrupt and alter

newly developing brain–body stress pathways and brain stress circuits, increasing the likelihood

that those pathways and circuits will operate poorly over the course of life. Thus experiences of

intense stress early in life are particularly likely to set the stage for PTSD should an individual

eventually confront extraordinary traumas. At the same time, each stage of development ushers in

new psychological and biological challenges, so extreme stressors at any point across the life span

can increase a person’s vulnerability to PTSD.

The consequence of all this, according to the developmental psychopathology perspective, is

that one person born with, say, overreactive stress pathways may eventually develop PTSD when

confronted by an extraordinary trauma, whereas another person born with similar predisposing

stress pathways may not develop PTSD in the face of such trauma. It all depends on the

presence, timing, and intersections of the various factors we have been discussing. As you’ll recall

from Chapter 2, this is the principle of multifinality, the notion that persons with similar

beginnings may wind up at very different end points (Cicchetti, 2018, 2016). Conversely, two

persons—one born with overreactive stress pathways and the other with pathways that react to

stressors more appropriately—may both develop PTSD when eventually confronted by an

extraordinary trauma. In such cases, the person born with favorable stress pathways might

nonetheless come to develop overreactive pathways as a result of aversive childhood experiences,

inadequate social supports, and other such factors. This principle is known as equifinality, the

notion that different developmental pathways may lead to the same end point (Cicchetti, 2018,

2016).

370

End of a journey? Not necessarily, at least in the psychological realm. This small boat filled with migrants comes ashore at

Lesbos, a pastoral Greek island through which a half million refugees—mostly from Syria—have passed on their way to

countries throughout Europe. The rate of PTSD among refugees can be as high as 56 percent in some areas of the world,

particularly for those who were tortured in their homeland or whose travels were perilous. Thus a small team of clinicians in

Lesbos work full-time to help reduce the stress-related symptoms of refugees during their short stay on the island (Yaser et

al., 2016).

How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? Treatment can be very important for people who have been overwhelmed by traumatic events.

Overall, one-third of all cases of posttraumatic stress disorder improve within 12 months. The

remainder of cases may persist for years, and, indeed, one-third of people with PTSD do not

achieve normal functioning even after many years (Sareen, 2018; Byers et al., 2014).

Today’s treatment procedures for troubled survivors often vary from trauma to trauma. Was it

combat, an act of terrorism, sexual molestation, or a major accident? 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 (Rothbaum, 2017; Brown et al., 2016).

Programs for combat veterans who suffer from PTSD illustrate how these issues may be

addressed.

371

Treatment for Combat Veterans Therapists have used a variety of techniques to help reduce veterans’ posttraumatic symptoms.

Among the most common are antidepressant drug therapy, cognitive-behavioral therapy, couple or

family therapy, and group therapy. Commonly, the approaches are combined, as no one of them

successfully reduces all the symptoms (Rothbaum, 2017).

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.

ANTIDEPRESSANT DRUGS Antidepressant drugs are widely used for veterans with PTSD (Stein, 2017). Typically, these

medications are more helpful for the PTSD symptoms of increased arousal and negative

emotions, and less helpful for the recurrent negative memories, dissociations, and avoidance

behaviors that also characterize the disorder. Around half of PTSD patients who take

antidepressant drugs experience some symptom reductions. Other psychotropic drugs do not fare

as well in PTSD research and are prescribed less often (Stein, 2017).

COGNITIVE-BEHAVIORAL THERAPY

372

#SmellingStress

Stress is odorless. The bacteria that feed off of our sweat are

what give our bodies an odor during very stressful events.

#GenderImpact

51% Percentage of U.S. women who often lie awake at night due to stress

32% Percentage of U.S. men who often lie awake at night due to stress

(Information from: APA, 2017, 2015)

Cognitive-behavioral therapy has proved

to be of considerable help to many

veterans with PTSD, bringing significant

overall improvement to half or more of

those who receive such treatment (Rothbaum, 2017; Shou et al., 2017). On the cognitive side,

the therapists guide the veterans to examine and change the dysfunctional attitudes and styles of

interpretation they have developed as a result of their traumatic experiences. Over the course of

such examinations and efforts, often called cognitive processing therapy when applied in cases of

PTSD, the veterans learn to deal with difficult memories and feelings, come to accept what they

have done and experienced, become less judgmental of themselves, and begin to trust other

people once again (Holliday et al., 2017). Increasingly, a number of cognitive-behavioral

therapists are adding mindfulness-based techniques (see page 53) to further help the clients

become more accepting and less judgmental of their recurring thoughts, feelings, and memories.

Research indicates that such mindfulness techniques produce some additional improvements

(Rothbaum, 2017).

On the behavioral side, cognitive-

behavioral therapists typically apply

exposure techniques when treating

veterans with PTSD. These techniques

have been quite successful at reducing

specific symptoms and, in turn, bringing

about improvements in overall

adjustment (Cooper et al., 2017; Korte et

al., 2017). In fact, some studies indicate that exposure may be the single most helpful

intervention for people with PTSD (Haagen et al., 2015).

During exposure therapy, veterans with PTSD are guided to confront trauma-related—

usually combat-related—objects, events, and situations that continue to cause them extreme

upset and anxiety. Their exposures may be imagined or in vivo. Of course, it is technically

impossible, not to mention unethical, to expose veterans with PTSD to actual combat

experiences, so many of today’s exposure treatments rely on the vivid, multisensory images

produced by virtual reality procedures (Maples-Keller et al., 2017) (see MindTech).

Perhaps the most widely applied exposure technique in cases of PTSD is prolonged exposure

(Foa et al., 2018; Acierno et al., 2017). Here therapists direct clients to confront not only

trauma-related objects and situations but also their painful memories of traumatic experiences—

373

memories they have been actively avoiding (Mahoney, Karatzias, & Hutton, 2019). The clients

repeatedly recall and describe the memories in great detail for extended periods of time, holding

on to them until becoming less aroused, anxious, and upset by them. Here a therapist conducting

prolonged exposure typically offers instructions to a client with PTSD:

Up to this point … you have been making great progress and have been experiencing the decrease in anxiety that we expect to

see. Today we are going to do the exposure a little differently. … I will ask you to tell me … what the most distressing or upsetting

parts of this memory are for you now. And then … I will ask you to focus the revisiting and recounting on each of these “hot spots,”

one at a time. We will pick one to begin with and you will repeat that one part of the memory over and over just by itself, focusing

in closely and describing what happened in great detail, as if in slow motion, including what you felt, saw, heard, and thought.

We will repeat it as many times as necessary to “wear it out” or bring about a big decrease in your [discomfort] level. When that

part seems to have been sufficiently processed, we will move to the next one.

(Foa et al., 2007, pp. 100–101)

prolonged exposure A treatment approach in which clients confront not only trauma-related objects and situations but also their painful memories of traumatic experiences.

Over the course of prolonged exposure, the clients are expected to remember more and more

details of their traumas, experience less distress during such memories, become less fearful of the

memories, and indeed display fewer symptoms of PTSD. Research suggests that for clients who

can stay with such intense memory exercises (many cannot), prolonged exposure is even more

helpful than more gradual exposure interventions (Foa et al., 2018).

Another popular form of exposure therapy is eye movement desensitization and

reprocessing (EMDR), in which clients move their eyes in a rhythmic manner from side to side

while flooding their minds with images of the objects and situations they ordinarily try to avoid.

Although this approach has a number of skeptics, case studies and some controlled studies

suggest that the treatment can sometimes be helpful to people with PTSD (Rothbaum, 2017;

Shapiro & Forrest, 2016). Many theorists argue that it is the exposure feature of EMDR, rather

than the eye movement per se, that accounts for its success as a treatment (Lamprecht et al.,

2004).

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.

MINDTECH

374

Virtual Reality Therapy: Better than the Real Thing?

For years, exposure-based 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 development 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.

“Virtual” exposure An ex-soldier’s headset and video game–type controller take him back to a battle scene in Iraq.

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, Afghanistan, or other war zones. The

therapist controls the intensity of the horrifying sights, terrifying sounds, and awful smells of combat, triggering very real

feelings of fear or panic in the client. Exposures to these stimuli are applied by the therapist in either gradual steps or

abruptly.

Study after study has suggested that virtual reality therapy is extremely helpful for combat veterans with PTSD, more

so than covert exposure therapy (Maples-Keller et al., 2017). 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 becoming

common in the treatment of other anxiety disorders and phobias, including social anxiety disorder and fears of heights,

flying, and closed spaces (Bouchard et al., 2017).

COUPLE AND FAMILY THERAPY Veterans with PTSD may be further helped in couple therapy or family therapy formats

(Rothbaum, 2017; Vogt et al., 2017, 2011). The symptoms of PTSD are particularly apparent to

spouses and other family members, who may be directly affected by the client’s anxieties,

375

depressed mood, or angry outbursts (Freytes et al., 2017). With the help and support of their

family members, clients may come to examine their impact on others, learn to communicate

better, and improve their problem-solving skills (Sareen, 2018).

GROUP THERAPY In group therapy sessions, called rap groups when initiated during the 1980s, veterans meet with

others like themselves to share experiences and feelings (particularly guilt and rage), develop

insights, and give mutual support (Levi et al., 2017; 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 clinics, provide group treatment (Finley et al., 2017).

These agencies also offer individual therapy, counseling for spouses and children, family therapy,

and aid in seeking jobs, education, and benefits. Clinical reports suggest that such programs offer

a necessary, sometimes life-saving, treatment opportunity.

Psychological Debriefing People who are traumatized by disasters, victimization, or accidents profit from many of the same

treatments that are used to help survivors of combat (Rothbaum, 2017). 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. 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 (Tarquinio et al., 2016; Mitchell, 2003, 1983). The

clinicians then clarify to the victims that their reactions are normal responses to a terrible event,

offer stress management tips, and in some cases, refer the victims to professionals for long-term

counseling. 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.

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.

This intense approach has been applied in the aftermath of countless traumatic events

(Tarquinio et al., 2016; Pfefferbaum, Newman, & Nelson, 2014). Indeed, when a traumatic

incident affects numerous individuals, debriefing-trained counselors may come from far and wide

376

#TheirWords “Reality is the leading cause of stress among those in touch

with it.”

Lily Tomlin

to conduct debriefing sessions with the victims. Large mobilizations of this kind have offered free

emergency mental health services at the sites of disasters such as the 2001 World Trade Center

attack, the 2005 floods caused by Hurricane Katrina, and the mass killings of 49 persons at

Pulse, a gay nightclub in Orlando, Florida, in 2016 and of 58 individuals at a concert in Las

Vegas, Nevada, in 2017.

Over the years, personal testimonials

for rapid mobilization programs have

often been favorable (Healy & Tyrrell,

2013; Watson & Shalev, 2005).

However, research conducted over the

past decade has called into question the

effectiveness of this kind of intervention (Tarquinio et al., 2016; USDVA, 2016). In fact, some

clinicians believe that the early intervention programs may encourage victims to dwell too long

on the traumatic events they have experienced. And a number worry that early disaster

counseling may unintentionally “suggest” problems to certain victims, thus helping to produce

stress disorders (USDVA, 2016; McNally, 2004). Thus, although many mental health

professionals continue to believe in psychological debriefing programs, the current clinical

climate is moving away from the ready application of this approach.

SUMMING UP

ACUTE AND POSTTRAUMATIC STRESS DISORDERS When we appraise a stressor as threatening, we often experience a stress response consisting of arousal and a sense of

fear. The features of arousal are set in motion by the hypothalamus, a brain structure that activates two different

pathways—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 long after a traumatic event, including reexperiencing the traumatic event, avoiding related events, being

markedly less responsive than normal, and feeling guilt. Traumatic events may include combat experiences, disasters,

or episodes of victimization.

In attempting to explain why certain people develop a psychological stress disorder, researchers have focused on

biological factors (particularly, overly reactive brain–body stress pathways, a dysfunctional brain stress circuit, and an

inherited predisposition), childhood experiences, personal styles, social support systems, and the severity and nature

of traumatic events, as well as on how these factors may work together to produce such a disorder. Techniques used

to treat the stress disorders include antidepressant drugs, cognitive-behavioral therapy (including exposure

techniques), family therapy, and group therapy. Critical incident stress debriefing initially appeared helpful after

large-scale disasters; however, recent studies have raised questions about the usefulness of this intervention.

377

378

Dissociative Disorders As you have just read, a number of people with acute and posttraumatic stress disorders have

symptoms of dissociation along with their other symptoms. They may, for example, feel dazed,

have trouble remembering things, or have a sense of depersonalization or derealization.

Symptoms of this kind are also on display in dissociative disorders, another group of disorders

triggered by traumatic events. The memory difficulties and other dissociative symptoms found in

these disorders 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.

dissociative disorders Disorders marked by major changes in memory that do not have clear physical causes.

Managing without memory Andy Wray developed dissociative amnesia after witnessing several horrific deaths in his work

as a policeman. His disorder is marked by continuous forgetting. Every few days, many of his new memories disappear,

leaving him unable to recognize friends, relatives, and events in any detail. To help him get on with his life, he uses

countless notebooks and reminder cards like the ones he is looking at here.

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

379

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.

memory The faculty for recalling past events and past learning.

There are several kinds of dissociative disorders. People with dissociative 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 may not always

be aware of each other’s memories, thoughts, feelings, and behavior. 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, usually 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 triggered by a traumatic or upsetting event

(Odagaki, 2017).

dissociative amnesia A disorder marked by an inability to recall important personal events and information.

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

380

#FrequentlyForgotten

Online passwords

Where cell phone was left

Where keys were left

Where remote control was left

Phone numbers

Names

Dream content

Birthdays/anniversaries

Why do many people question the authenticity of people

who seem to lose their memories at times of severe stress?

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.

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

difficulties 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 upsetting 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,

381

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 interferes 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.

Studies suggest that at least 2 percent of all adults experience dissociative amnesia in a given

year (Loewenstein, 2018). 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 personal information, such as their name

and address (Guina et al., 2018; Bremner, 2016, 2002).

Childhood abuse, particularly child sexual abuse, can also trigger dissociative amnesia (Hébert

et al., 2018); indeed, in the 1990s there were many reports in which adults claimed to recall

long-forgotten experiences of childhood abuse (see PsychWatch). In addition, dissociative

amnesia may occur under more ordinary 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) (Guina et al., 2018).

382

An additional risk Three concertgoers desperately run for cover during the 2017 mass shooting at an outdoor country

music festival in Las Vegas, Nevada, a horrific incident that left 58 people dead and 546 injured. People who experience

severe threats to their health and safety—as in natural and human-produced disasters—are particularly vulnerable to

amnesia and other dissociative reactions. In the aftermath of mass shootings, for example, survivors may forget specific

details of their ordeal, personal information, or even their identities.

PSYCHWATCH

Repressed Childhood Memories or False Memory Syndrome?

Throughout the 1990s, reports of repressed childhood memory of abuse attracted much public attention.

Adults with this type of dissociative amnesia seemed to recover buried memories 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 dramatically in recent years, clinicians remain divided on this issue

(Andrews & Brewin, 2017; McNally, 2017). 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 (MacIntosh, Fletcher, & Collin-Vézina,

2016). Other clinicians—the majority—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

remembered all too well, not completely wiped from memory. They also point out that memory in general is often flawed.

Moreover, false memories of various kinds can be created in the laboratory by tapping into research participants’

imaginations (McNally, 2017; Volz et al., 2017).

If the alleged recovery of childhood memories is not what it appears to be, what is it? According to opponents of the

383

concept, it may be a powerful case of suggestibility (McNally, 2017; Loftus, 2003, 2001). These theorists hold that the

attention paid to the phenomenon by both clinicians and the public leads some therapists to make the diagnosis without

sufficient evidence. Moreover, certain therapists use special memory recovery techniques, including hypnosis and regression

therapy. Perhaps some clients respond to the techniques by unknowingly forming false memories of abuse (McNally, 2017;

McNally & Garaerts, 2009).

Of course, repressed memories of childhood sexual abuse do not emerge only in clinical settings. Some individuals

come forward on their own (MacIntosh et al., 2016). Opponents of the repressed memory concept explain these cases by

pointing to various books, Web sites, and television shows that seem to validate the phenomenon of repressed memories of

childhood abuse (Haaken & Reavey, 2010; Loftus, 1993). Still other opponents believe that some individuals are simply

more prone than others to experience false memories—either of childhood abuse or of other kinds of events (McNally,

2017; McNally et al., 2005).

Early recall These 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.

It is important to recognize that the theorists 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 clinicians have doubts about the scope of the problem of child sexual abuse.

Unfortunately, that problem is all too real and all too common.

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 episode 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

384

(Harrison et al., 2017; 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.

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.

On January 17, 1887, [the Reverend Ansel Bourne, of Greene, R.I.] drew 551 dollars 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 suspected, 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)

385

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 suffering from a dissociative fugue.

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 (Harrison et al.,

2017; Igwe, 2013). As these people recover their past, some forget the events of the fugue period.

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.

386

#AssessmentDelay People with dissociative identity disorder do not receive that

diagnosis until they have been in therapy for an average of

seven years (Foote, 2018).

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, although 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 session. Her

therapist wrote in his notes, “Her entire physical presence transformed itself suddenly and almost violently. Her face, previously

relaxed and even flat, became 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 personalities. 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

subpersonalities, or alternate

personalities, each with a unique set of

memories, behaviors, thoughts, and emotions (see Table 5-3 again). At any given time, one of

the subpersonalities takes center stage and dominates the person’s functioning. Usually one

387

Why might women be more likely than men to receive a

diagnosis of dissociative identity disorder?

subpersonality, called the primary, or host, personality, appears more often than the others.

dissociative identity disorder A dissociative disorder in which a person develops two or more distinct personalities. Also known as multiple personality disorder. subpersonalities The two or more distinct personalities found in individuals suffering with dissociative identity disorder. Also known as alternate personalities.

The transition from one subpersonality to another, called switching, is usually sudden and

may be dramatic. 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.

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 common than was once thought (Foote, 2018;

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) (Foote, 2018). 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 (Morton, 2018,

2017; Ellenberger, 1970). Generally, however, there are three kinds of relationships. In mutually

amnesic relationships, the subpersonalities have no awareness of one another. 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).

388

#MemoryMovies

Split (2017)

Finding Dory (2016)

The Bourne series (2012, 2007, 2004, 2002)

Total Recall (2012, 1990)

Black Swan (2010)

Shutter Island (2010)

The Hangover (2009)

Spider-Man 3 (2007)

Eternal Sunshine of the Spotless Mind (2004)

The Manchurian Candidate (2004, 1962)

Finding Nemo (2003)

Memento (2000)

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 (Foote, 2018; APA, 2000).

In fact, there have been cases in which

100 or more subpersonalities were

observed. Often the subpersonalities

emerge in groups of 2 or 3 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.

According 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 dissociation. In an

autobiography 20 years later, she revealed that altogether 22 subpersonalities 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 apparently never knew about her previous or

subsequent subpersonalities. She later overcame her disorder, achieving a single, stable identity,

and was known as Chris Sizemore for four decades until her death in 2016 (Weber, 2016;

Sizemore, 1991).

How Do Subpersonalities Differ? As in Chris Sizemore’s case, subpersonalities 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

389

What verdict is appropriate for accused criminals who

experience dissociative identity disorder and whose crimes

are committed by one of their subpersonalities?

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

attractive 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 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.)

“Would it surprise you to learn, Felix, that we’re already married?”

ABILITIES AND PREFERENCES

Although memories of abstract or

encyclopedic information are not usually

affected in dissociative amnesia, they are

often disturbed in dissociative identity

disorder. It is not uncommon for the

390

#TreatingSybil 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

disorder was in fact induced largely by hypnosis, sodium

pentothal, and therapist suggestion (Carey, 2017; Nathan,

2011; Rieber, 2002, 1999).

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 (Foote, 2018; 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 allergies (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 (Foote, 2018). 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

391

lapses throughout their lives or because

relatives and friends have observed their subpersonalities (Foote, 2018; Putnam, 2006, 2000).

The number of people diagnosed with dissociative identity disorder increased dramatically in

the 1980s and 1990s, only to decrease again in the twenty-first century (Foote, 2018; Paris,

2012). Notwithstanding this decline, thousands of cases have now been diagnosed in the United

States and Canada alone and some clinical theorists estimate that around 1 percent of the

population in the United States and other Western countries displays the disorder (Foote, 2018).

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 dissociative identity

disorder. Older explanations, such as that offered by psychodynamic theorists, have not received

much investigation (Merenda, 2008). However, newer viewpoints, which 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 dissociative 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

(see PsychWatch), but people with dissociative amnesia and dissociative identity disorder are

thought to repress their memories excessively (Snyder, 2018; 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 (Foote, 2018; 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 (Snyder, 2018; Howell, 2011). Psychodynamic theorists believe that this continuous

use of repression is motivated by traumatic childhood events, particularly abusive parenting

(Foote, 2018; Blass, 2015). 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

392

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.

Support for the psychodynamic explanation of dissociative identity disorder comes from a

variety of studies, largely case studies, which report such brutal childhood experiences as beatings,

cuttings, burnings with cigarettes, imprisonment in closets, rape, and extensive verbal abuse

(Foote, 2018; Ross & Ness, 2010). Yet some individuals with this disorder do not seem to have

experiences of abuse in their background (Ross, 2018). For example, Chris Sizemore, the subject

of The Three Faces of Eve, reported that her disorder first emerged during her preschool years

after she witnessed two deaths and a horrifying accident within a three-month period.

“I think I accidentally repressed my good memories.”

PSYCHWATCH

Peculiarities of Memory

Usually memory problems must interfere greatly with a person’s functioning 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 recognizing a scene that we happen upon for the first time. We feel sure we have been there before.

Jamais vu Sometimes we have the opposite experience: a situation or scene that is part of our daily life seems

393

Might it be possible to use the principles of state-dependent

learning to produce better results in school or at work?

suddenly 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 looking at it just once. The images may be memories of pictures, events, fantasies, or dreams.

Memory while under anesthesia Some surgical patients continue to understand language while they are under anesthesia and may later recall what was said by others during the surgical procedure.

Memory for music Even as a small child, Mozart could memorize and reproduce a piece of music after having heard it only once. In a similar vein, many musicians can mentally hear whole pieces of music, so they can rehearse anywhere, far from their instruments.

Visual memory Most people recall visual 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 memories that come to their minds are often puns or rhymes.

Memory for music Eight-year-old blind pianist Ying-Shan Tseng performs at a concert in South Africa. The young

artist can breeze through complex concertos by Tchaikovsky, Mozart, and others from memory—a skill beyond the

reach of most accomplished pianists.

State-Dependent Learning: A Cognitive-Behavioral View 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

394

initially observed in animals who learned

things during experiments while under

the influence of certain drugs (Radulovic et al., 2017; 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 (Xie & Zhang, 2018; Bower,

1981) (see Figure 5-3).

state-dependent learning Learning that becomes associated with the conditions under which it occurred, so that it is best remembered under the same conditions.

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.)

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

395

arousal, the person is more likely to recall the memories linked to it.

Although people remember certain events better in some arousal states than in others, most

can recall events under a variety of states. However, some theorists suggest, people who are prone

to develop dissociative disorders have state-to-memory links that are unusually rigid and narrow

(Miller, 2017; Barlow, 2011). Each of their thoughts, memories, and skills may be tied exclusively

to a particular state of arousal, so they recall a given event only when they experience 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 different groups of memories, thoughts, and abilities—that is,

different subpersonalities. This could explain why personality transitions in dissociative identity

disorder tend to be sudden and stress-related.

Sensory memories Sensory stimuli often trigger important memories. Thus some clinicians practice olfactotherapy, a method

that uses the smells and vibrations of essential oils to help elicit memories from clients.

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

396

#CulturalTies Some clinical theorists argue that dissociative identity disorder

is culture-bound (Kim et al., 2016; Boysen & VanBergen,

2013). While the prevalence of this disorder has grown 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.

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 (Foote, 2018; 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 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

(Brenner, 2018; 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

person’s past and identity, that person may undergo a dissociative fugue.

self-hypnosis The process of hypnotizing oneself, sometimes for the purpose of forgetting unpleasant events.

The self-hypnosis theory might also be

used to explain dissociative identity

disorder (Brenner, 2018; Wood, 2016).

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 (Lyons, 2015; Kohen & Olness, 2011). These theorists argue that some children who

experience abuse or other horrifying events manage to escape their threatening world by self-

hypnosis, mentally separating themselves from their bodies and fulfilling their wish to become

some other person or persons (Foote, 2018). 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).

How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?

397

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, Dillon, & Gillig, 2013). Psychodynamic therapists guide

patients to search their unconscious in the hope of bringing forgotten experiences back to

consciousness (Howell, 2011). The focus of psychodynamic therapy seems particularly well

suited to the needs of people with dissociative amnesia. After all, the patients need to recover lost

memories, and the general approach of psychodynamic therapists 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 therapy 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 (Brenner,

2018; Rathbone et al., 2014). Given the possibility that dissociative 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).

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.

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. 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

398

Identity Disorder? Unlike victims of dissociative amnesia, people with dissociative identity 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 personality (Ross, 2018; Bressert, 2017).

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 procedures often create false memories.

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 (Meganck, 2017; Howell, 2011).

As bonds are formed, therapists try to educate patients and help them to recognize fully the

nature of their disorder. Some therapists actually introduce the subpersonalities to one another,

by hypnosis, for example, or by having patients look at videos of their other personalities (Ross,

2018; Howell, 2011). 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

educate spouses and children about the disorder and to gather helpful information about the

patient (Kluft, 2001, 2000).

399

#TheirWords “I was trying to daydream, but my mind kept wandering.”

Steven Wright, comedian

RECOVERING MEMORIES To help patients recover the missing pieces of their past, therapists typically use the same

approaches applied in dissociative amnesia, including psychodynamic therapy, hypnotherapy,

and drug treatment (Brenner, 2018; Brand, Loewenstein, & Spiegel, 2014). 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 suffering the pain of

recollecting traumatic experiences (Chefetz, 2017).

INTEGRATING THE SUBPERSONALITIES The final goal of therapy is to merge the different 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

subpersonalities may see integration as a form of death (Howell, 2011; Kluft, 2001, 1991).

Therapists have used a range of approaches to help merge subpersonalities, including

psychodynamic, supportive, cognitive-behavioral, and drug therapies (Ross, 2018; Cronin et al.,

2014).

fusion The final merging of two or more subpersonalities in dissociative identity disorder.

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 (Ross, 2018; Brand 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 disorder

as a dissociative disorder, even though it is

not characterized by the memory

difficulties found in the other dissociative

disorders. Its central symptoms are persistent and recurrent episodes of depersonalization (the

sense that one’s own mental functioning or body are unreal or detached) and/or derealization (the

400

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 connected 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 therapist was really alive.

(Kluft, 1988, p. 580)

depersonalization-derealization disorder A dissociative disorder marked by the presence of persistent and recurrent episodes of depersonalization, derealization, or both.

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.

401

If you have ever experienced feelings of depersonalization or

derealization, how did you explain them at the time?

Religious dissociations As part of religious 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.

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 manner, 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

derealization reactions are fairly common (Simeon, 2017; 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 individuals 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 compensate for the distortion

402

#TheirWords “There are lots of people who mistake their imagination for

their memory.”

Josh Billings

and continue to function with reasonable effectiveness until the temporary episode eventually

ends.

The symptoms of depersonalization-

derealization disorder, in contrast, are

persistent or recurrent, cause considerable

distress, and may impair social

relationships and job performance

(Simeon, 2017; Gentile et al., 2014). The

disorder is experienced by around 2 percent of the population, most often adolescents and young

adults, hardly ever in people over 40. It usually comes on suddenly and may be triggered by

extreme fatigue, physical pain, intense stress, or recovery from substance abuse. Survivors of

traumatic 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 depersonalization-derealization disorder. Several different

forms of psychotherapy have been applied in cases of this disorder, but there have been almost no

studies that test the efficacy of these approaches (Simeon, 2017).

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 information 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, a person develops two or more distinct

subpersonalities.

Dissociative amnesia and dissociative identity disorder are not well understood. Among the processes that have

been cited to explain them are extreme repression, state-dependent learning, and self-hypnosis.

Dissociative amnesia may end on its own or may require treatment. Dissociative 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

403

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.

404

CLINICAL CHOICES 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.

Getting a Handle on Trauma and Stress The concepts of trauma and stress have been prominent in the field of abnormal psychology

since its early days when, for example, Sigmund Freud proposed that most forms of

psychopathology begin with traumatic losses or events. But why and how do trauma and stress

translate into psychopathology? The answer to that question has, in fact, eluded clinical theorists

and researchers—until recent times. Researchers now better understand the relationship between

trauma, stress, and psychological dysfunction—viewing it as a complex and unfolding interaction

of many variables, including biological factors, childhood experiences, personal styles, and social

supports. Similarly, clinicians are now developing more effective treatment programs for people

with acute and posttraumatic stress disorders—programs that combine biological, cognitive-

behavioral, family, and group interventions.

Insights and treatments for the dissociative disorders, the other group of trauma-triggered

disorders discussed in this chapter, have not moved as quickly. However, the field’s focus on

these disorders has surged during the past two decades—partly because of intense clinical interest

in the memory abnormalities on display in posttraumatic stress reactions and in physically rooted

disorders such as Alzheimer’s disease.

Amidst the rapid developments in the

realms of trauma and stress lies a

cautionary 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. 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.

405

406

Chapter 5 Review

Key Terms

stressor

hypothalamus

autonomic nervous system (ANS)

endocrine system

sympathetic nervous system

parasympathetic nervous system

hypothalamic-pituitary-adrenal (HPA) pathway

corticosteroids

acute stress disorder

posttraumatic stress disorder (PTSD)

rape

terrorism

torture

stress circuit

resilience

complex PTSD

developmental psychopathology

cognitive processing therapy

prolonged exposure

eye movement desensitization and reprocessing (EMDR)

psychological debriefing

dissociative disorders

407

memory

dissociative amnesia

amnestic episode

dissociative fugue

dissociative identity disorder

subpersonalities

iatrogenic

repression

state-dependent learning

self-hypnosis

hypnotic therapy

fusion

depersonalization-derealization disorder

Quick Quiz

1. What factors determine how people react to stressors in life? pp. 139–142

2. What factors help influence whether persons will develop acute and posttraumatic stress disorders after experiencing a traumatic event? How does the developmental psychopathology perspective integrate these factors to explain the onset of posttraumatic stress disorder? pp. 148–152

3. What treatment approaches have been used with people suffering from acute or posttraumatic stress disorder? pp. 153–156

4. List and describe the different dissociative disorders. pp. 157–169

5. What are the various patterns of dissociative amnesia? What is dissociative fugue? pp. 157–160

6. What are the different kinds of relationships that the subpersonalities may have in dissociative identity disorder? pp. 161–162

408

7. Describe the psychodynamic, state-dependent learning, and self-hypnosis explanations of dissociative amnesia and dissociative identity disorder. How well is each explanation supported by research? pp. 164–166

8. What approaches have been used to treat dissociative amnesia? p. 167

9. What are the key features of treatment for dissociative identity disorder? Is treatment successful? pp. 167–168

10. Define and describe depersonalization-derealization disorder. How well is this problem understood? pp. 168–169

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

409

CHAPTER 6 Depressive and Bipolar Disorders

TOPIC OVERVIEW

410

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 The Psychological Models of Unipolar Depression The Sociocultural Model of Unipolar Depression Integrating the Models: The Developmental Psychopathology Perspective

Bipolar Disorders

What Are the Symptoms of Mania? Diagnosing Bipolar Disorders What Causes Bipolar Disorders? What Are the Treatments for Bipolar Disorders?

Making Sense of All That Is Known

The 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 illness. 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 decaying 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 take to my pallet of blankets and coats positioned on the living room floor and 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 absences. 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 coming around.

411

(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 disorder above, 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.

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.

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 lifts. In contrast, those with bipolar disorders have periods of mania that alternate

with periods of depression.

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.

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 Bruce Springsteen and Beyoncé. Their

problems have been shared by millions.

412

413

Almost every day we have ups and downs in mood. How can

we distinguish the everyday blues from clinical depression?

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. All of us experience dejection from time to time, but only some experience a

depressive disorder. Depressive disorders bring severe and long-lasting psychological pain that

may intensify as time goes by. Those who suffer from such disorders 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 8 percent of adults in the United States suffer from a severe unipolar pattern of

depression in any given year, while as many as 5 percent suffer from mild forms (Krishnan, 2017;

Kessler et al., 2012, 2010). Around 20 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, France, and many other countries. Moreover, the rate of depression—mild or severe—

is higher among poor people than wealthier people (Wood, 2017; Sareen et al., 2011).

Women are at least twice as likely as men to have episodes of severe unipolar depression

(WHO, 2017). 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.

An episode of severe depression can occur at any point throughout the life span. The average

age of onset is 19 years, with the peak age being late adolescence or early adulthood (Weissman et

al., 2016). In any given year, the rate of severe depression is twice as high among adults under 65

years of age as among those 65 years and older (Krishnan, 2017).

414

Approximately 85 percent of people with unipolar depression, including severe depression,

recover within 6 months, some without treatment. More than half of those who recover from

severe depression have at least one other episode later in their lives (Coryell, 2018; Simon &

Ciechanowski, 2017).

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.

415

“Idk what peace feels like” A few months after this 2016 concert performance in New Orleans, the hugely successful rap

artist and actor Kid Cudi revealed on his Facebook page that he had entered an inpatient program to receive treatment for

depression and suicidal urges. He wrote to his fans, “My anxiety and depression have ruled my life for as long as I can

remember … Idk what peace feels like.” He returned to performing a month later.

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 some cases display anhedonia, an inability to experience any

pleasure at all. A number also experience anxiety, anger, or agitation (Chen et al., 2019). 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:

Nights I could handle. I fell asleep easily, and sleep allowed me to forget. But 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 opening my eyes, the

crying bouts would start and I’d sit alone for hours, weeping and mourning my losses.

(Williams, 2008, p. 9)

416

Motivational Symptoms Depressed people typically lose the desire to pursue 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; others 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 die by suicide (Holmes, 2018; Alridge, 2012).

Behavioral Symptoms Depressed people are usually less active and less productive. They spend more time alone and

may stay in bed for long periods. One man recalls, “My eyes would open at the crack of dawn,

but getting out of bed was impossible. I just stayed there, and stayed there, and stayed there some

more, virtually paralyzed, knowing that a day filled with misery awaited me.” Depressed people

may also move, and even speak, more slowly (Liu et al., 2019).

Cognitive Symptoms Depressed people hold extremely negative views of themselves. They consider themselves

inadequate, undesirable, inferior, perhaps even evil (Scheffers et al., 2019; Dinger et al., 2017).

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 (Lyness, 2016).

417

People with depression frequently complain that their intellectual ability is very poor (Beblo

et al., 2017). They feel confused, unable to remember things, easily distracted, and unable to

solve even the smallest problems. In laboratory studies, depressed people do perform somewhat,

but not extremely, more poorly than nondepressed people on tasks of memory, attention, and

reasoning (Baune et al., 2018; Bowler et al., 2018). It may be, however, that these difficulties

sometimes reflect motivational problems rather than cognitive ones.

Physical Symptoms People who are depressed frequently have such physical ailments as headaches, indigestion,

constipation, dizzy spells, and general pain (Taycan, Özdemi, & Erdogan, 2017). In fact, many

depressions are misdiagnosed as medical problems at first (Tse, González, & Jenkins, 2018).

Disturbances in appetite and sleep are particularly common (Chang et al., 2017). 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). 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.

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

418

2. No pattern of mania or hypomania

Persistent Depressive Disorder

1. Person experiences the symptoms of major or mild depression for at least 2 years.

2. During the 2-year period, symptoms not absent for more than 2 months at a time.

3. No history of mania or hypomania.

4. Significant distress or impairment.

Information from: APA, 2013.

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 additionally 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 excessive activity, peripartum if it occurs during pregnancy or

within four weeks of giving birth (see PsychWatch), or melancholic if the person is almost totally

unaffected by pleasurable events.

major depressive disorder A severe pattern of depression that is disabling and not caused by such factors as drugs or a general medical condition.

People whose unipolar depression is chronic receive a diagnosis of persistent depressive

disorder (see Table 6-1 again). Some people with this chronic disorder have repeated major

depressive episodes, a pattern technically called persistent depressive disorder with major depressive

episodes. Others have less severe and less disabling symptoms, a pattern technically called persistent

depressive disorder with dysthymic syndrome.

persistent depressive disorder A chronic form of unipolar depression marked by ongoing and repeated symptoms of either major or mild depression.

419

Lighting up depression This visitor to the Science Museum in London makes herself comfortable in the Light Lounge, a

white enclosure containing four light boxes, where people can relax on a sofa and experience “light therapy” to help beat the

winter blues and prevent seasonal recurrences of depression. Winter depression has been linked to the decrease in the

amount of light people are exposed to at that time of year and to an accompanying shift in secretions of the hormone

melatonin.

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. Many

clinicians believe that the category is sexist and “pathologizes” severe cases of premenstrual

syndrome (PMS), premenstrual discomforts that are common and normal among women.

premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation.

Yet another kind of depressive disorder, disruptive mood dysregulation disorder, is characterized

by a combination of persistent depressive symptoms and recurrent outbursts of severe temper.

This disorder emerges during mid-childhood or adolescence and so is discussed in Chapter 14.

Stress and Unipolar Depression Episodes of unipolar depression often seem to be triggered by stressful events in an individual’s

life (Krishnan, 2017; Shin et al., 2017). In fact, researchers have found that 80 percent of all

severe episodes occur within a month or two of a significant negative event (Hammen, 2016).

420

Why do you think stressful events or periods in life might

trigger depressed feelings and other negative emotions?

Stressful life events also precede other psychological disorders, but depressed people report more

such events than anybody else.

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 depression 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 produce mood

changes. Could unipolar depression itself have biological causes? Studies of genetic factors,

biochemical factors, brain circuits, and the immune system suggest that often it does.

Genetic Factors Three kinds of research—family pedigree, twin, and gene studies—suggest that some people

inherit a predisposition to unipolar depression. 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 inherited, the relatives should have a higher

rate of depression than the population at 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).

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 Receiving Treatment Currently

Major depressive disorder 8.0 2:1 18−29 Elevated 50

Persistent depressive disorder (with dysthymic

syndrome)

1.5−5.0 Between 3:2 and 2:1

10−25 Elevated 62

Bipolar I disorder 1.6 1:1 15−44 Elevated 49

Bipolar II disorder 1.0 1:1 15−44 Elevated 49

421

#WorldCount More than 300 million people suffer from depression

worldwide (WHO, 2017).

Cyclothymic disorder 0.4 1:1 15−25 Elevated Unknown

Information from: Bressert, 2018; Stovall, 2018; Krishnan, 2017; NIMH, 2017; WHO, 2017; Stovall, 2016; Weissman et al.,

2016; Kessler et al., 2012, 2010; Wang et al., 2005.

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 depressed persons. Twin studies

have supported this expectation. When an identical twin has unipolar depression, there is a 38

percent chance that the other twin has already had or will eventually have the same disorder. In

contrast, when a fraternal twin has unipolar depression, the other twin has only a 20 percent

chance of having the disorder (Krishnan, 2017; McGuffin et al., 1996).

Finally, today’s scientists have at their

disposal techniques from the field of

molecular 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, 3, 4, 6, 9, 10, 11, 12, 13, 14, 17, 18, 20, 21, 22, and X

(Naoi et al., 2018; Wang et al., 2018). 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 in certain regions of the brain is closely tied to

depression.

Biochemical Factors Low activity of two neurotransmitter chemicals, norepinephrine 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 norepinephrine 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 while the drugs were relieving depression,

they also were bringing about increases in norepinephrine and/or serotonin activity.

norepinephrine A neurotransmitter whose abnormal activity is linked to depression and panic disorder. serotonin A neurotransmitter whose abnormal activity is linked to depression, obsessive-compulsive disorder, and eating disorders.

422

For years it was thought that low activity of either norepinephrine or serotonin directly

produce depression, but theorists now believe that their relationship to depression is more

complicated (Krishnan, 2017). Research indicates that interactions between serotonin and

norepinephrine activity, or between them and other kinds of neurotransmitters in the brain, are

more influential than the operation of any one neurotransmitter alone. In addition, as you will

read shortly, a number of studies suggest that the activity of these neurotransmitters may either

reflect or help produce dysfunction of a depression-related circuit in the brain, dysfunction that

may itself be a key to the development of depression.

Biological researchers have also learned that another group of chemicals—the body’s hormones

—are linked to depression. As you read in Chapter 5, whenever we confront stressors in life, our

brain triggers two stress pathways of the brain and body into action. One of those pathways, the

hypothalamic-pituitary-adrenal (HPA) pathway, ultimately brings about the release of hormones

at various locations throughout the body, and those hormones spur assorted body organs into

action, causing us to temporarily experience a heightened state of arousal (see page 142). You

may recall that the HPA pathway of people with posttraumatic stress disorder and certain anxiety

disorders consistently overreacts when those individuals confront stressors. Research indicates that

the HPA pathway of people with depression is also overly reactive in the face of stress, causing

excessive releases of cortisol and related hormones at times of stress (Geerlings & Gerritsen,

2017). This relationship is not all that surprising, given that stressful events so often seem to

trigger depression. Once again, it is possible that the HPA overreactivity and heightened

hormone activity found in depressed people either reflects or helps produce dysfunction in a

depression-related circuit in the brain, the biological focus that we turn to next.

PSYCHWATCH

Sadness at the Happiest of Times

Women usually expect the birth of a child to be a happy experience. But for at least 10 percent of new

mothers, the weeks and months after childbirth bring clinical depression (Kendig et al., 2017; Ko et al., 2017). Peripartum

depression, 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 syndromes 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, rattled emotions, and other stresses that accompany the

arrival of a new baby, they may have crying spells, fatigue, anxiety, insomnia, and sadness (Lewis et al., 2018; Enatescu et

al., 2014). These symptoms usually disappear within days or weeks (Viguera, 2016).

In postpartum depression, however, depressive symptoms continue and may last up to a year or more. The symptoms

423

include extreme sadness, despair, tearfulness, insomnia, anxiety, intrusive thoughts, compulsions, panic attacks, feelings of

inability to cope, and suicidal thoughts (Shi et al., 2018). The mother–infant relationship and the psychological and

physical health of the child may suffer as a result (Jacques et al., 2019; Weissman, 2018). Women who have an episode of

postpartum depression have a 25 to 50 percent chance of developing it again with a subsequent birth (Kendig et al., 2017).

Fending off postpartum depression Spin instructor Anouk Malavoy works out at a quads gym with her baby.

Malavoy has written columns for the Toronto Star about the role exercise can play in helping some women prevent or

combat postpartum depression.

Many clinicians believe that the hormonal changes accompanying childbirth 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 particularly influenced by these dramatic hormone changes (Viguera, 2016; Mehta et al., 2014). Other

theorists suggest that some women may have a genetic predisposition to postpartum depression (McEvoy, 2017). A woman

with a family history of mood disorders appears to be at high risk, even if she herself has not previously had a mood

disorder (Kendig et al., 2017; Viguera, 2016).

At the same time, psychological and sociocultural factors may play important roles in the disorder. The birth of a baby

brings enormous psychological and social change. A woman typically faces changes in her marital 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

(Viguera, 2016; Kendall-Tackett, 2010). Mothers whose infants are sick or temperamentally “difficult” may be under yet

additional pressure (Badr, 2018).

Fortunately, treatment can make a big difference for most women with postpartum depression. Self-help support

groups have proved extremely helpful for many women who have or who are at risk for postpartum depression (Ashford et

al., 2017; Viguera, 2017). In addition, many respond well to the same approaches that are applied to other forms of

depression—antidepressant medications, cognitive-behavioral therapy, interpersonal psychotherapy, or a combination of

these approaches (Viguera, 2017; Kim et al., 2014).

However, many women who would benefit from treatment do not seek help because they feel ashamed about being sad

424

at a time that is supposed to be joyous, and they are concerned about being judged harshly (Bina & Glasser, 2017; Kendig

et al., 2017). For them, and for the spouses and family members close to them, a large dose of education 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.

Brain Circuits As you have read in previous chapters, biological researchers have determined 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 or

behavioral reaction. A brain circuit whose dysfunction contributes to unipolar depression has

begun to emerge (Schmitgen et al., 2019; Newman et al., 2017). An array of brain-imaging

studies point to several brain structures that are likely members of this depression-related brain

circuit, including the prefrontal cortex, hippocampus, amygdala, and subgenual cingulate (also called

Brodmann Area 25), among other structures (see Figure 6-1). You may notice that several of the

structures in this circuit are also members of the brain circuits that contribute to certain anxiety

disorders and PTSD. However, the subgenual cingulate, a subregion of the brain’s anterior

cingulate cortex, is distinctly part of the depression-related circuit. Indeed, some theorists believe

that dysfunction by this particular structure may be the single most important contributor to

depression.

425

FIGURE 6-1

The Biology of Depression

Researchers believe that the brain circuit involved in unipolar depression includes the prefrontal cortex, hippocampus,

amygdala, and subgenual cingulate, among other structures.

Unlike some of the other brain circuits we have discussed, dysfunctions of this depression-

related brain circuit cannot be characterized in general terms, as, for example, a “hyperactive” or

“underactive” circuit. But there are many indications that the circuit does operate abnormally in

persons with depression. Research suggests, for example, that among depressed people, activity

and blood flow are unusually low in certain parts and unusually high in other parts of the

prefrontal cortex; the hippocampus is undersized and its production of new neurons is low;

activity and blood flow are high in the amygdala; the subgenual cingulate is particularly small

and active; and communication between these various structures, called interconnectivity, is often

problematic (Walsh et al., 2019; Newman et al., 2017; Pizzagalli, 2017).

Studies indicate that under usual circumstances the neurotransmitters serotonin and

norepinephrine are both plentiful and active in this brain circuit. It appears, however, that,

426

among depressed people, the activity of serotonin and norepinephrine in this circuit is distinctly

lower than among other people (Avraham et al., 2017; James et al., 2017). This is not surprising,

considering all the research that we observed earlier linking depression to generally low activity

by these neurotransmitters. The abnormal activity of these neurotransmitters in this brain circuit

might be the result of dysfunction within or between the circuit’s various structures, or,

alternatively, the cause of such circuit dysfunction. At this point researchers do not know which

is the case.

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 slower 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

(see pages 256–257). There is a growing belief among some researchers that immune system

dysregulation of this kind helps produce depression (Anderson, 2018; Faugere et al., 2018).

What Are the Biological Treatments for Unipolar Depression? Usually biological treatment means antidepressant drugs or popular alternatives such as herbal

supplements (see InfoCentral), but for people whose depression does not respond to medications,

psychotherapy, or the like, it sometimes means brain stimulation.

427

“This next one is a sad little blues tune about love and pain that I wrote before I started taking Celexa.”

INFOCENTRAL

EXERCISE AND DIETARY SUPPLEMENTS

“Complementary and Alternative Medicine (CAM)” is the popular term for interventions that

fall outside of conventional Western treatments. Two of the most common CAM interventions

are physical exercise and dietary supplements (also known as nutraceuticals). Depression is the

psychological problem for which these approaches are used most often, and research indicates

that each can indeed help improve the moods of modestly or moderately depressed people,

particularly when integrated with psychotherapy or medication, rather than applied alone (Jabr,

2017; Remick et al., 2017; Schuch et al., 2017).

428

ANTIDEPRESSANT DRUGS Two kinds of drugs discovered in the 1950s reduce the symptoms of depression: monoamine

oxidase (MAO) inhibitors and tricyclics. Over the years, these drugs have been joined by a third

group, the second-generation antidepressants (see Table 6-3).

TABLE: 6-3 Some Drugs That Reduce Unipolar Depression Monoamine Oxidase Inhibitors Tricyclics Second-Generation Antidepressants

Generic Name Trade Name Generic Name Trade Name Generic Name Trade Name

429

Iscarboxazid Marplan Imipramine Tofranil Trazodone Desyrel

Phenelzine Nardil Amitriptyline Elavil Fluoxetine Prozac

Tranylcypromine Parnate Doxepin Sinequan; Silenor Sertraline Zoloft

Selegiline Eldepryl Trimipramine Surmontil Paroxetine Paxil

Desipramine Norpramin Venlafaxine Effexor

Nortriptyline Aventil; Pamelor Bupropion Wellbutrin

Protriptyline Vivactil Citalopram Celexa

Clomipramine Anafranil Escitalopram Lexapro

Amoxapine Asendin Duloxetine Cymbalta

Mirtazapine Remeron Desvenlafaxine Pristiq

Atomoxetine Strattera

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, Saunders, & Kline, 1957).

What this and several related drugs had in common biochemically was that they slowed the

body’s production of the enzyme monoamine oxidase (MAO). Thus they were called MAO

inhibitors.

MAO inhibitor An antidepressant drug that prevents the action of the enzyme monoamine oxidase.

Normally, brain supplies of the enzyme MAO break down, or degrade, the neurotransmitters

serotonin and norepinephrine. MAO inhibitors block MAO from carrying out this activity and

thereby stop the destruction of serotonin and norepinephrine (Naoi et al., 2018). The result is a

rise in the activity levels of these neurotransmitters, and, in turn, a reduction of depressive

symptoms. Approximately half of depressed patients who take MAO inhibitors are helped by

them (Hirsch & Birnbaum, 2017; Ciraulo et al., 2011). There is, however, a potential danger

with regard to these drugs. When people who take MAO inhibitors eat foods containing 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 antidepressants because they all share a three-ring molecular structure.

430

tricyclic An antidepressant drug such as imipramine that has three rings in its molecular structure.

In hundreds of studies, depressed patients taking tricyclics have improved significantly more

than similar patients taking placebos, although the drugs must be taken for at least 10 days before

such improvements take hold (Hirsch & Birnbaum, 2017). Around 50 to 60 percent of patients

who take tricyclics are helped by them (Simon & Ciechanowski, 2017). If, however, recovered

individuals stop taking the drugs immediately after obtaining relief, they run a high risk of

relapsing. As many as half of recovered patients who discontinue the drugs in this way relapse

within a year (Jarrett & Vittengl, 2016). As a result, most clinicians now keep patients on

antidepressant drugs for at least five months after being free of depressive symptoms, an

extension called “continuation therapy” or “maintenance therapy.” Research indicates that this

approach decreases the individuals’ chances of relapse (Jarrett & Vittengl, 2016).

Most researchers have concluded that one of the ways in which tricyclics are able to reduce

depression is by acting on the neurotransmitter “reuptake” mechanisms of key neurons (Hirsch &

Birnbaum, 2017). Remember from Chapter 2 that brain messages are carried from a “sending”

neuron across the synaptic space to a receiving neuron by a neurotransmitter, the chemical

released from the end 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 limit how long the neurotransmitter remains in the synaptic space and to prevent it

from overstimulating the receiving neuron. Unfortunately, reuptake does not always progress

properly. In particular, the reuptake mechanisms for depressed people are too vigorous in neurons

that use either serotonin or norepinephrine—cutting off the activity of those neurotransmitters

in their synaptic spaces too soon, preventing messages from reaching the receiving neurons, and

helping to produce the symptoms of their disorder. Tricyclics inhibit (that is, block) this overly

vigorous reuptake process, allowing serotonin and norepinephrine to remain in their synapses

longer, thus increasing their stimulation of receiving neurons (see Figure 6-2).

431

FIGURE 6-2

Reuptake and Antidepressants

(Left) Soon after a neuron releases neurotransmitters such as norepinephrine or serotonin into its synaptic space, it activates

a pumplike reuptake mechanism to reabsorb excess neurotransmitters. 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 antidepressant drugs block the reuptake process, enabling norepinephrine or serotonin to remain in the synapse

longer and bind to the receiving neuron.

Recent studies suggest that, for many depressed people, once these reuptake processes are

corrected, serotonin and norepinephrine activity becomes smoother and more appropriate

throughout their depression-related brain circuit (Rolls, 2017). Correspondingly, the

interconnections between the structures in that circuit become more orderly and functional

(James et al., 2017). With such biological corrections in place, depression subsides for many

patients.

432

Flower power Hypericum perforatum, known as Saint-John’s-wort, is a low, wild-growing shrub, not an antidepressant drug.

It is currently among the hottest-selling products in health stores, with studies indicating that it can be quite helpful in cases

of mild or moderate depression.

A third group of effective antidepressant drugs, structurally different from the MAO

inhibitors and tricyclics, has been developed over the past three decades. Most of these second-

generation antidepressants are called selective serotonin reuptake inhibitors (SSRIs) because

they increase serotonin activity specifically, without affecting norepinephrine or other

neurotransmitters. The SSRIs include fluoxetine (trade name Prozac), sertraline (Zoloft), and

escitalopram (Lexapro). Other second-generation antidepressants are selective norepinephrine

reuptake inhibitors (such as atomoxetine, or Strattera), which increase norepinephrine activity

only, and serotonin-norepinephrine reuptake inhibitors (such as venlafaxine, or Effexor), which

increase both serotonin and norepinephrine activity.

selective serotonin reuptake inhibitors (SSRIs) A group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters.

In effectiveness and speed of action, the second-generation antidepressant drugs are on a par

with the tricyclics, yet their sales have skyrocketed (Hirsch & Birnbaum, 2017; Simon, 2017).

Because they primarily affect one or at most two neurotransmitters, they do not produce as many

undesired effects as MAO inhibitors or tricyclics. At the same time, these relatively newer

antidepressants can produce significant side effects of their own. Some people gain weight, feel

drowsy, or have a reduced sex drive, for example (Simon & Ciechanowski, 2017).

433

If antidepressant drugs are effective, why do many people

seek out herbal supplements, such as Saint-John’s-wort or

melatonin, for depression?

As popular as the antidepressants are,

it is important to recognize that they do

not work for everyone. As you have read,

even the most successful of them fails to

help at least 40 percent of clients with

depression. In fact, a number of recent reviews have raised the strong possibility that the failure

rate is higher still (Deacon & Spielmans, 2017; Turner et al., 2008). 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 (Rush, 2018). 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: ELECTROCONVULSIVE THERAPY As you read in Chapter 2, a different form of biological treatment, brain stimulation, refers to

interventions that directly or indirectly stimulate certain areas of the brain. The oldest—and

most controversial—such approach is electroconvulsive therapy (ECT). It is used primarily on

severely depressed people. In recent years, three additional kinds of brain stimulation have been

developed for the treatment of depressive disorders—vagus nerve stimulation, transcranial

magnetic stimulation, and deep brain stimulation.

brain stimulation Biological treatments that directly or indirectly stimulate certain areas of the brain.

Clinicians and patients alike vary greatly in their opinions of electroconvulsive therapy

(ECT). Some consider it a safe biological approach with minimal risks; others believe it to be an

extreme measure that can cause troublesome memory loss and even neurological damage. Despite

434

the heat of this controversy, ECT is used frequently, largely because it can be a very effective and

fast-acting intervention for unipolar depression.

electroconvulsive therapy (ECT) A treatment for depression in which electrodes attached to a patient’s head send an electrical current through the brain, causing a convulsion.

In an ECT 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 15 to 70 seconds (Kellner, 2018). After 6 to 12 such treatments, spaced over 2 to 4

weeks, most patients feel less depressed (van Dierman et al., 2018).

ECT today The techniques for administering ECT have changed significantly since the treatment’s early days. Today,

patients are given drugs to help them sleep, muscle relaxants to prevent severe jerks of the body and broken bones, and

oxygen to guard against brain damage.

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. 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

435

#MedicalBonding

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

(Caruso et al., 2017; NCI, 2017; Williams & Nieuwsma,

2018; Udesky, 2014; Kerber et al., 2011)

new techniques so often are. Its effectiveness with severe depression in particular became

apparent (Rothschild, 2017). In the early years of ECT, broken bones and dislocations of the jaw

or shoulders sometimes resulted from patients’ severe convulsions. Today’s practitioners avoid

these problems by giving patients strong muscle relaxants to minimize convulsions. They also use

anesthetics (barbiturates) to put patients to sleep during the procedure, reducing their terror.

Patients who receive ECT typically have difficulty remembering some events, most often

events that took place immediately before and after their treatments (Kellner, 2018; Martin et al.,

2015). In most cases, this memory loss clears up within a few months (Bodnar et al., 2016), 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 difficult to

determine why it works so well (Wang et al., 2018). Studies find that between 50 and 80 percent

of ECT patients improve (Kellner, 2018; Perugi et al., 2011). The approach is particularly

effective when patients follow up the initial cluster of sessions with continuation, or

maintenance, therapy—either ongoing antidepressant medications or periodic ECT sessions

(Kellner, 2018). ECT also seems to be quite effective in severe cases of depression that include

delusions (Rothschild, 2017).

OTHER FORMS OF BRAIN STIMULATION Over the past decade, three additional kinds of brain stimulation 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 suspected that they might be

able to stimulate the brain by electrically

stimulating the vagus nerve. They were

hoping to mimic the positive effects of

ECT without producing the undesired

effects or trauma associated with ECT. Their efforts gave birth to a new treatment for depression

—vagus nerve stimulation.

436

vagus nerve stimulation A treatment for depression in which an implanted pulse generator sends regular electrical signals to a person’s vagus nerve; the nerve then stimulates the brain.

As you read in Chapter 2, 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. The pulse generator is typically programmed to

provide 30 seconds of stimulation to the vagus nerve (and, in turn, the brain) every five minutes.

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 signals to the brain. This stimulation of the brain helps reduce depression in many patients.

Research has found that vagus nerve stimulation can bring significant relief (Aaronson et al.,

2017). In fact, studies find that a substantial number of severely depressed people who have not

437

responded to any other form of treatment may improve significantly when treated with this

procedure (Holtzheimer, 2018; Howland, 2014).

Transcranial magnetic stimulation (TMS) is another technique that is being 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 are underactive. TMS appears to increase neuron activity in

that structure, and, in turn, may improve functioning throughout the rest of the brain’s

depression-related circuit (Holtzheimer, 2017). A number of studies have found that the

procedure reduces depression when it is administered daily for 4 to 6 weeks (Iimori et al., 2019;

van den Noort, 2018).

transcranial magnetic stimulation (TMS) A treatment in which an electromagnetic coil, which is placed on or above a patient’s head, sends a current into the individual’s brain.

As you have read, around a decade ago, researchers linked depression to high activity in the

subgenual cingulate, a key member of the depression-related brain circuit. 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 the subgenual cingulate. The electrodes were

connected to a battery, or “pacemaker,” that was implanted in the patient’s chest (for men) or

stomach (for women). The pacemaker powered the electrodes, sending a steady stream of low-

voltage electricity to the brain structure. Mayberg’s expectation was that this repeated stimulation

would reduce activity in the structure to a normal level and help “recalibrate” the depression-

related brain circuit.

deep brain stimulation (DBS) A treatment for depression in which a pacemaker powers electrodes that have been implanted in subgenual cingulate, thus stimulating that brain area

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). Subsequent research with

other severely depressed individuals has also yielded promising findings (Holtzheimer, 2018;

Riva-Posse et al., 2018). Understandably, this work has produced considerable enthusiasm in the

clinical field, but it is important to recognize that research on DBS is still in its early stages.

438

Stimulating the brain In this version of transcranial magnetic stimulation, a woman wears headgear that contains an

electromagnetic coil. The coil sends currents into and stimulates her brain.

The Psychological Models of Unipolar Depression The psychological models that have been most widely applied to unipolar depression are the

psychodynamic and cognitive-behavioral models. The psychodynamic model has not been

strongly supported by research, but the cognitive-behavioral model has received considerable

support and has gained a large following.

The Psychodynamic Model Sigmund Freud (1917) and his student Karl Abraham (1916, 1911) developed the first

psychodynamic explanation and treatment for depression. Their emphasis on dependence and

loss continues to influence today’s psychodynamic clinicians.

PSYCHODYNAMIC EXPLANATIONS Freud and Abraham began by noting the similarity between clinical depression and grief in

people who lose loved ones: constant weeping, loss of appetite, difficulty sleeping, loss of pleasure

439

#ControversialChange

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.

in life, and general withdrawal. According to the theorists, a series of unconscious processes is set

in motion when a loved one dies. Unable to accept the loss, mourners at first regress to the oral

stage of development, the period of total dependency when infants cannot 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, called introjection, is temporary. However, for some—particularly those whose

various dependency needs were improperly met during infancy and early childhood—grief

worsens over time, and they develop clinical depression (Gipps, 2017; Bemporad, 1992).

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.

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.

Although many psychodynamic theorists have parted company with Freud and Abraham’s

theory of depression, it continues to influence current psychodynamic thinking (Gabbard &

DeJean, 2018; Gipps, 2017). For example, object relations theorists (the psychodynamic theorists

who emphasize relationships) propose that depression results when people’s relationships—

especially their early relationships—leave them feeling unsafe, insecure, and dependent on others.

The following description by the therapist of a depressed middle-aged woman illustrates the

psychodynamic concepts of dependence, loss of a loved one, symbolic loss, and introjection:

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 compliance. Before her marriage she had difficulty in

440

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. … Nothing 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 (Cheong et al., 2017; Krishnan,

2017). When, for example, a diagnostic survey was administered to thousands of adults in one

study, the individuals whose fathers had died during their childhood scored higher on depression

(Jacobs & Bovasso, 2009). Related research supports the psychodynamic idea that people whose

childhood needs were poorly met are particularly likely to become depressed after experiencing

loss (Conradi et al., 2018; Paterniti et al., 2017). At the same time, research does not indicate

that loss or problematic early relationships are 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 (Hammen, 2016; Sandler et al., 2008). 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.

441

Early loss The young daughter of a female police officer killed during the September 11, 2001, terrorist attack on the

World Trade Center in New York City, 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 likelihood of experiencing depression as adults.

WHAT ARE THE PSYCHODYNAMIC TREATMENTS FOR UNIPOLAR DEPRESSION? Because they believe 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 them

through (Ribeiro, Ribeiro, & von Doellinger, 2018; Busch et al., 2004). Using the arsenal of

basic psychodynamic procedures, they encourage the depressed client to associate freely during

therapy; suggest interpretations of the client’s associations, dreams, and displays of resistance and

transference; and help the person review past events and feelings. Free association, for example,

442

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 case reports of such successes as this, researchers have found that long-term

psychodynamic therapy is only occasionally helpful in cases of unipolar depression (Prochaska &

Norcross, 2018). Two features of the approach may help limit its effectiveness. First, depressed

clients may be too passive and feel too weary to join fully in 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 the longer-term approaches, especially when they are

combined with psychotropic medications (Goodyer et al., 2017; Fonagy, 2015).

The Cognitive-Behavioral Model As with other kinds of psychological disorders, cognitive-behavioral theories contend that

unipolar depression results from a combination of problematic behaviors and dysfunctional ways

of thinking. These theories fall into three groups: explanations that focus mostly on the

behavioral realm, those that give primary attention to negative thinking, and ones that feature a

complex interplay between cognitive and behavioral factors.

443

When the applause stops The reduction in rewards brought about by retirement may place athletes and other high

achievers at risk for depression unless they find new sources of gratification. Standing in front of photos of his great

moments as an NFL quarterback, Terry Bradshaw waves to a crowd of 71,000 fans at the 50th Super Bowl. Bradshaw, now

a successful football analyst on FOX NFL Sunday, has struggled with depression throughout much of his adult life, but he

went through particularly intense episodes in the years following his 1984 retirement from the game.

THE BEHAVIORAL DIMENSION Clinical researcher Peter Lewinsohn was one of the first theorists to link depression to significant

changes in the number of rewards and punishments people receive in their lives (Lewinsohn et

al., 1990, 1984). He suggested that the positive rewards in life dwindle for some people, leading

them to perform fewer and fewer constructive 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.

444

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, researchers 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 nondepressed participants, but when their rewards

begin to increase, their mood improves as well (Chan et al., 2017; Nyström et al., 2017).

Similarly, other investigations have found a strong relationship between positive life events and

feelings of life satisfaction and happiness (He et al., 2019; Sotgiu, 2016).

Lewinsohn and other theorists have further proposed that social rewards are particularly

important in the downward spiral of depression (Werner-Seidler et al., 2017; Martell et al.,

2013). 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 (see MindTech). Although depressed people are sometimes the victims of social

circumstances, it may also be that their dark mood and flat behaviors help produce a decline in

social rewards (Hodgetts et al., 2017; Hammen, 2016).

NEGATIVE THINKING Aaron Beck believes that negative thinking lies at the heart of depression (Beck & Weishaar,

2019; Beck, 2016, 2002, 1967). According to Beck, maladaptive attitudes, a cognitive triad, errors

in thinking, and automatic thoughts combine to produce unipolar depression.

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 own experiences and the judgments of the people around them. 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,

445

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 out to me so clearly.

(Fieve, 1975)

cognitive triad The three forms of negative thinking that Aaron Beck theorizes lead people to feel depressed. The triad consists of a negative view of one’s experiences, oneself, and the future.

MINDTECH

Texting: A Relationship Buster?

Texting has now become the leading way that most people communicate with others (Coyne, Padilla-Walker, &

Holmgren, 2018; Burke, 2016; Pew Research Center, 2015). The average 18- to 24-year-old, for example, sends and

receives a total of 128 texts each day. In fact, surveys suggest that people often fail to fully attend to their current activities

in order to juggle their text conversations. Some clinicians worry that excessive texting 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 (2017, 2015, 2013) has concluded that communicating primarily

via text does indeed affect relationships negatively. 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

446

Can you think of ways in which texting might sometimes be

helpful to relationships and communications?

#TheirWords

“No one can make you feel inferior without your consent.”

Eleanor Roosevelt

confrontations. Her participants said that texting saves valuable time over face-to-face conversations, but, Turkle concludes,

“People who feel they are too busy to have conversations in person are not making the important emotional connections

they otherwise 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 constantly

keep up with ongoing text conversations, interrupting 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 happiness. Rather, it

seems to be the exclusive and excessive use of it that

is the problem. Although half of all young adults

say that text conversations are just as meaningful as other avenues of communication (Burke, 2016), it just may be that

truly important discussions are better served by in-person, or at least phone, conversations.

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 situation 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

difficult for me. … Things will never change.”

447

Many studies have produced evidence in support of Beck’s explanation (Krishnan, 2017).

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 (Brouwer et al., 2019;

Beck, 2016). A number of studies have found the cognitive triad at work in depressed people

(Oltean et al., 2018). And still others have supported Beck’s claims about errors of logic (Özdel

et al., 2014).

Finally, research has supported Beck’s notion that automatic thoughts are tied to depression

(Riley, Lee, & Safren, 2017; Wang et al., 2016). In several classic studies, for example,

nondepressed participants who were tricked into reading negative automatic-thought-like

statements about themselves became 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

depression later in life than people who avoid such ruminations (Liu et al., 2017; Watkins &

Nolen-Hoeksema, 2014).

LEARNED HELPLESSNESS: A COGNITIVE-BEHAVIORAL INTERPLAY According to psychologist Martin Seligman (1975), feelings of helplessness are at the center of

depression. Since the mid-1960s Seligman has been developing the learned helplessness theory

of depression (Maier & Seligman, 2016). 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. Feelings of

helplessness fill this account of a young woman’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 recent

stresses (starting school again, friction with her boyfriend) had left her feeling 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 unattractive. 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.

448

(Spitzer et al., 1983, pp. 122–123)

learned helplessness The perception, based on past experiences, that one has no control over the reinforcements in one’s life.

Seligman’s theory first began to take shape when he was working with laboratory 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 activity, they simply “lay down and

quietly whined” and accepted the shock.

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.

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

449

#DarkestColor

In Western society, black is often the color of choice in

describing depression. British Prime Minister Winston

Churchill called his recurrent episodes a “black dog always

waiting to bare its teeth.” American novelist Ernest

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 depression, and he

proposed that people in fact become depressed after developing 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 symptoms. When, for example, human participants are

exposed to uncontrollable negative events, they later score higher than other individuals on a

depressive mood scale. Similarly, helplessness-trained animal subjects lose interest in sexual and

social activities—a common symptom of human depression (Smith et al., 2017; Zhou et al.,

2017).

The learned helplessness explanation of depression has been revised somewhat over the past

several decades. According to one modified version of the theory, the attribution-helplessness

theory, when people view events as beyond their control, they ask themselves why this is so

(Rubenstein et al., 2016; 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 know what got into me—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

supported the relationship between styles of attribution, helplessness, and depression (O’Sullivan

et al., 2018; 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

450

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.”

Can you think of other uses, advantages, and disadvantages

that might result from the growing use of mood-tracking

apps?

further produce a sense of hopelessness in a

person (Liu et al., 2015; Abramson et al.,

2002, 1989). By taking this factor into

consideration, clinicians are often able to

predict depression with still greater precision.

Although the learned helplessness theory of unipolar depression has been very influential, it

too has imperfections. For example, 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 (Kim et al., 2017). In addition, the attributional feature of the

theory raises difficult questions. What about the dogs and rats who learn helplessness? Can

animals make attributions, even implicitly?

COGNITIVE-BEHAVIORAL THERAPY Cognitive-behavioral therapists combine behavioral and cognitive techniques to help clients

suffering from depression. On the behavioral side, they seek to get the clients moving again—to

engage in and enjoy more activities. On the cognitive side, they guide the clients to think in

more adaptive, less negative ways. A variety of approaches have been developed to help bring

about these changes. Two of the leading ones are behavioral activation and Beck’s cognitive

therapy.

In behavioral activation, therapists work systematically to increase the number of

constructive and rewarding activities and events in a client’s life. The approach builds on the

work of Peter Lewinsohn, the theorist who, as you’ll recall, ties mood to the rewards one

experiences in life. There are three key components to the approach. The therapists (1)

reintroduce depressed clients to pleasurable events and activities, (2) consistently reward

nondepressive behaviors and withhold rewards for depressive behaviors, and (3) help clients

improve their social skills (Martin & Oliver, 2018; Moshier & Otto, 2017).

behavioral activation A therapy for depression in which the therapist works systematically to increase the number of constructive and pleasurable activities and events in a client’s life.

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

451

have shown that adding positive activities to a person’s life can indeed lead to a better mood.

Second, while reintroducing pleasurable events into a client’s life, the therapist makes sure that

the person’s various behaviors are reinforced correctly. Behavioral activation theorists argue that

when people become depressed, their negative behaviors—crying, ruminating, complaining, or

self-depreciation—keep others at a distance, reducing chances for rewarding experiences and

interactions (Hammen, 2016). To change this pattern, therapists guide clients to monitor their

negative behaviors and to try new, more positive ones (Farchione, Boswell, & Willner, 2017;

Martell et al., 2010). Dozens of smartphone apps are now available to help clients accurately

record the negative and positive activities they perform in life and the mood changes that result,

making behavioral activation a more precise approach than it once was (Dahne et al., 2017;

Huguet et al., 2016). Finally, behavior activation therapists train clients in effective social skills

(Farmer & Chapman, 2015). In group therapy programs, for example, members may work

together to improve eye contact, facial expression, posture, and other behaviors that send social

messages.

Behavioral activation techniques seem to be of only limited help when they are the sole

feature of treatment, particularly if the severity of depression is more than modest (Chan et al.,

2017; Dimidjian et al., 2014). But when they are combined with cognitive techniques, they are,

as you’ll see next, often quite helpful (Moshier & Otto, 2017).

To help depressed clients overcome their negative thinking, Aaron Beck has developed a

treatment approach that he calls cognitive therapy. He uses this label because the approach

focuses largely on guiding clients to recognize and change negative cognitive processes that he

believes underlie depression (Beck & Weishaar, 2019; Beck, 2016). However, as you will note,

the approach also includes several behavioral techniques such as those we have just examined.

The approach follows four phases and usually requires fewer than 20 sessions.

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 psychological disorders.

452

Reintroducing pleasure Following the principles of behavioral activation, depressed patients at the Zhongshan Mental

Hospital in China are encouraged to weed a garden. Behavioral activation therapists systematically guide clients to increase

the number of pleasurable activities in their lives, particularly activities that brought them joy (in this case, gardening) prior

to their disorders.

PHASE 1: Increasing activities and elevating mood Using behavioral techniques to set the stage for the cognitive dimensions of 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.

453

“Let’s try focusing on your posts that do receive comments.”

PHASE 2: Challenging automatic thoughts Once people are more active and feeling some emotional relief, 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. Here again, clients may

use smartphone apps to accurately identify and document such thoughts as they arise in their

daily lives (Huguet et al., 2016). The 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, the therapists show them how

illogical 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 maladaptive attitudes that set the stage for their depression in

454

#TheirWords

“Don’t cry because it’s over, smile because it happened.”

Dr. Seuss

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)

Over the past several decades, numerous studies have shown that 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 (Forand et al., 2018; Young et

al., 2014). Around 50 to 60 percent show significant improvement in or elimination of their

symptoms.

It is worth noting that a growing

number of today’s cognitive-behavioral

therapists do not agree with the

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), use mindfulness training and other cognitive-behavioral techniques to help

depressed clients 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 may better work around those

455

Why might problems in the social arena—for example,

social loss, social ties, and social rewards—be particularly

tied to depression?

thoughts as they navigate their way through life. Research suggests that approaches of this kind

are particularly useful as ongoing procedures that help prevent recurrences of depression once

individuals recover from an episode (Segal, 2017; Twohig & Levin, 2017).

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 (Krishnan, 2017). Once again, there are two

kinds of sociocultural views—the family-social perspective and the multicultural perspective.

The Family-Social Perspective Earlier you read that some cognitive-behavioral theorists believe that a decline in social rewards is

particularly important in the development of depression. This view is also consistent with the

family-social perspective.

The connection between declining

social rewards and depression is a two-way

street (Hammen, 2016). On the one

hand, researchers have found that

depressed people often display weak social

skills and communicate poorly. They seek repeated reassurances from others, and they typically

speak more slowly and quietly than nondepressed people, pause longer between words, and take

longer to respond to others. Such social deficits make other people uncomfortable and may cause

them to avoid the depressed individuals. As a result, the social contacts and rewards of depressed

people decrease, and, as they participate in fewer and fewer social interactions, their social skills

deteriorate still further.

Consistent with these findings, depression has been tied repeatedly to the unavailability of

social support such as that found in a happy marriage (Cao et al., 2017; Krishnan, 2017).

Research indicates that people in troubled marriages are 25 times more likely to have a depressive

disorder than people in untroubled marriages (Keitner, 2017). In some cases, the spouse’s

depression may contribute to marital discord or divorce, but often the interpersonal conflicts and

low social support found in troubled relationships seem to lead to depression (Williams &

Nieuwsma, 2018).

456

Social exclusion, depression, and the brain In a widely used research design called cyberball, a participant lies in an fMRI

scanner and is told (falsely) that he or she is playing a game of cyber catch with two players in other rooms. As the other

players increasingly exclude the participant from the three-way catch, the fMRI records what parts of his or her brain are

being affected. As shown in these brain scans, subregions of the anterior cingulate cortex (left) and the prefrontal cortex

(right), key structures in the depression-related brain circuit, become active during this lab-induced social exclusion, just as

they do in cases of clinical depression.

Researchers have also found that people whose lives are characterized by weak social supports,

isolation, and lack of intimacy are particularly likely to become depressed and to remain

depressed longer than other people (Liang et al., 2019; Levula et al., 2018; Werner-Seidler et al.,

2017). For example, 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).

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 psychotherapy and couple therapy.

INTERPERSONAL PSYCHOTHERAPY Developed by clinical researchers Gerald Klerman and Myrna Weissman, interpersonal

psychotherapy (IPT) holds that any of four interpersonal problem areas may lead to depression

and must be addressed: interpersonal loss, interpersonal role dispute, interpersonal role

transition, and interpersonal deficits (Swartz, 2018, 2017; Pu et al., 2017). Over the course of

around 20 sessions, IPT therapists address these areas.

457

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.

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 explore 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 whatever 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.

Is laughter the best medicine? A man laughs during a session of laughter therapy in a public plaza in South America. He is

458

#SeriousOversight

Family physicians, internists, and pediatricians fail to detect

depression in at least 50 percent of their depressed patients

(Lyness, 2016; Mitchell et al., 2011).

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.

Finally, some depressed people display

interpersonal deficits, such as extreme

shyness or social awkwardness, that

prevent them from having intimate

relationships. IPT therapists may help

such clients recognize 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:

Client:

(After a long pause with eyes downcast, a sad facial expression, 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-behavioral therapy (Zhou et al., 2017). 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 struggling with social conflicts or

459

#WaningConfidants

Intimate social contact has been declining 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 common response

to the same question is 2 or less (GSS, 2016; Bryner, 2011;

McPherson et al., 2006).

undergoing changes in their careers or social roles (Ravitz, Watson, & Grigoriadis, 2013).

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

(Keitner, 2017). In fact, as many as half

of all depressed clients may be in a

dysfunctional relationship. Thus it is not

surprising that 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.

couple therapy A therapy format in which the therapist works with two people who share a long-term relationship.

Therapists who offer integrative behavioral couples therapy combine cognitive-behavioral and

sociocultural techniques to teach couples specific communication and problem-solving skills,

guide them to recognize that their problematic interactions often reflect basic differences between

them, and steer them to become more accepting and supportive of each other (see Chapter 2).

When the depressed person’s spousal relationship is filled with conflict, this approach and similar

ones may be as effective as—or even more effective than—individual cognitive-behavioral

therapy, interpersonal psychotherapy, or drug therapy in helping to reduce depression (Keitner,

2017; Lebow et al., 2012).

The Multicultural Perspective Two kinds of relationships have captured the interest of multicultural theorists: (1) links between

gender and depression, and (2) ties between cultural and ethnic background and depression. In the

case of gender, a strong relationship has been found, but a clear explanation for that relationship

has yet to emerge. The clinical field is still sorting out whether and what ties exist between

cultural factors 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 Zealand, and the United States are at least twice as likely

as men to receive a diagnosis of unipolar depression. Why the huge difference between the sexes?

460

A variety of theories have been offered and studied (Assari, 2017; Hammen, 2016; Nolen-

Hoeksema, 2012, 2002, 1990).

The artifact theory holds that women and men are equally prone to depression but that

clinicians often fail to detect depression in men. 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

this is a popular explanation, research indicates that women are actually no more willing or able

than men to identify their depressive symptoms and to seek treatment.

A dance metaphor Many theorists believe that the reason for the large gender difference in depression rates is that, on

average, women face more stressors, discrimination, unattainable body ideals, and victimization than men. A popular

description for this gender disadvantage is that women must “dance backwards and in high heels”—a term that has its

origins in the dance team of Ginger Rogers and Fred Astaire, iconic partners in 10 popular movies in the 1930s. Although

they were both remarkably talented, Astaire’s acclaim and professional success ultimately exceeded that of Rogers, who had,

after all, done everything Astaire did, but “backwards and in high heels.”

461

The hormone explanation holds that hormone changes trigger depression in many women,

particularly during puberty, pregnancy, and menopause. Research suggests, however, that the

social and life events that accompany these developmental milestones are also profound and may

account for experiences of depression as well as, or better than, hormone shifts. Hormone

explanations have also been criticized as sexist, since they imply that a woman’s normal biology is

flawed.

The life stress theory suggests that women in our society are subject to more stress than men.

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, but particularly during adolescence, to seek a low body weight and slender body

shape—goals that are unreasonable, unhealthy, and often unattainable. As you’ll read in Chapter

9, research finds that, as adolescence unfolds, girls do become more and more dissatisfied with

their weight and body and, on average, display an increased rate of depression. However, it is not

clear that eating and weight concerns actually cause depression; they may instead be the result of

depression.

The lack-of-control theory, which draws on the learned helplessness research, 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 discrimination to burglary to rape, often

produces a sense of helplessness and increases the symptoms of depression—and women in our

society are, on average, more likely than men to be victims across various domains (BJS, 2017,

2016).

A final explanation for the gender differences found in depression is the rumination theory. As

you read earlier, rumination is related to depression. Research reveals that women are more likely

than men to ruminate when their mood darkens, perhaps making them more vulnerable to the

onset of clinical depression.

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.

462

CULTURAL BACKGROUND AND DEPRESSION Depression is a worldwide phenomenon, 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 ability

to concentrate, ideas of insufficiency, and thoughts of suicide (WHO, 2017; Matsumoto &

Juang, 2016). Beyond such core symptoms, however, research suggests that the precise picture of

depression varies from country to country (Shafi & Shafi, 2014; Kok et al., 2012). 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.

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.

463

Do you think culture-sensitive therapies might be more

useful for some kinds of disorders than for others? Why or

why not?

Within the United States, researchers have found few differences in the symptoms 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,

research reveals 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 non-Hispanic white Americans to have recurrent episodes of depression (Krishnan, 2017).

Why this difference? Around 54 percent of depressed non-Hispanic 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, depression 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 are designed to address the unique issues

faced by members of cultural minority groups (Comas-Díaz, 2019; Chu et al., 2016). For such

approaches, therapists typically have special cultural training and a heightened awareness of their

clients’ cultural values and the culture-related stressors, prejudices, 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.

In the treatment of unipolar

depression, culture-sensitive approaches

increasingly are being combined with

traditional forms of psychotherapy to help

minority clients overcome their disorders

(Aguilera et al., 2017, 2010; Chu et al., 2016). A number of today’s therapists, for example, offer

464

#FathersToo At least 8% of new fathers may also experience some degree of

postpartum depression (Cameron et al., 2017). Research

indicates that, as in cases of a mother’s postpartum depression,

this syndrome can affect a child’s psychological development

(Gentile & Fusco, 2017; Koh et al., 2014).

cognitive-behavioral therapy 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 (Aguilera et al., 2017, 2010; Chowdhary et al.,

2014).

Integrating the Models: The Developmental Psychopathology Perspective

As with their explanations of other

psychological disorders, proponents of the

developmental psychopathology

perspective contend that unipolar

depression is caused by a combination of

the factors we have been examining

throughout this chapter. Moreover, they

believe that the factors unfold and intersect in a developmental sequence, with early negative

factors generally setting the stage for later negative factors and ultimately for depression, but with

later positive factors sometimes able to offset the lingering impact of early negative factors.

Developmental psychopathology explanations of unipolar depression have received considerable

research support (Meng et al., 2018; Lieberman & Chu, 2016).

Consistent with biological findings, developmental psychopathologists believe that the road to

unipolar depression often begins with a genetically inherited predisposition—a predisposition

that is characterized by low activity of key neurotransmitters (serotonin and norepinephrine) in

key brain structures, an overly reactive HPA stress pathway (see pages 178–179), and a

dysfunctional depression-related brain circuit (Newman et al., 2017; Bagot et al., 2016).

Researchers from this perspective have found that such biological predispositions will most likely

result in later depression if the individual is also subjected to significant losses or other traumas

early in life and/or inadequate parenting, such as parenting that is disrupted, depressive in style,

inconsistent, or rejecting (Dittrich et al., 2018; Wang et al., 2018). Still other studies indicate

that this combination of biological and childhood factors often leads to a low self-concept, a

temperament marked by guilt, a negative style of thinking, general feelings of helplessness, and

interpersonal dependence—variables that are themselves each linked to depression (Reinfjell et

al., 2016; Lau et al., 2014). According to developmental psychopathologists, individuals who

465

travel through this unfavorable developmental sequence are particularly likely to become

depressed when they experience stress in adult life, especially interpersonal stress (Hammen,

2016; Morris et al., 2014).

However, this precise sequence of intersecting factors is not the only avenue to later

depression. Developmental psychopathology studies indicate, for example, that individuals who

experience severe childhood traumas or inadequate parenting often develop depression when they

later encounter life stress, even if they have no genetic predisposition for the disorder (Nishikawa

et al., 2018; Mullins et al., 2016). Such findings are apparently related to the two-way

relationship that exists between many of these factors. Research has found, for example, that

exposure to severe traumas at key points early in life may negatively alter a child’s HPA stress

pathway and depression-related brain circuit, even if the pathway and circuit had previously been

functioning properly (Hammen, 2016; Starr et al., 2014). One study even found that the

adoption of a negative attribution style and related forms of negative thinking by child

participants adversely affected the ongoing operation of their HPA stress pathway (Palagini et al.,

2019; Hammen, 2016).

“Katia, I know that with the right combination of therapy and medication I could have a committed relationship with you.”

466

At the same time, the developmental psychopathology perspective is not all gloom and doom.

The presence of negative developmental factors does not inevitably produce a march toward

depression. Studies have found, for example, that individuals who experience moderate and

manageable adversities throughout their childhood often develop resilience and become better

able to withstand the depressive effects of life stress in adulthood (Meng et al., 2018; Oldehinkel

et al., 2014). One study even found that participants who had repeatedly experienced moderate

adversities throughout their lives were less likely to become depressed in the face of significant life

stress than were participants who had faced little or no adversity in their lives (Seery, Holman, &

Silver, 2010). Correspondingly, research has revealed that the HPA stress pathway of children

exposed to manageable adversities typically operates more properly than the HPA pathway of

children exposed to few adversities (Gunnar et al., 2009).

Born to run “The Boss,” Bruce Springsteen, performs at a sold-out concert while his image is projected on a mega-screen

behind him. In his 2016 memoir, Born to Run, Springsteen detailed his long history of depression, describing one episode as

“a freight train bearing down … running quickly out of track.”

SUMMING UP

UNIPOLAR DEPRESSION People with unipolar depression suffer from depression only. The various disorders characterized by unipolar

depression are called depressive disorders. 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.

467

According to the biological view, low activity of two neurotransmitters, norepinephrine and serotonin, are linked

to depression. Hormonal factors, the result of an HPA stress pathway that is overly reactive to stress, may also be at

work. Research has also tied depression to abnormalities in a circuit of brain structures, including the prefrontal

cortex, hippocampus, amygdala, and subgenual cingulate. Most biological treatments for unipolar depression consist

of antidepressant drugs, but several brain stimulation techniques are also used.

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

therapists try to help depressed persons recognize and work through their losses and excessive dependence on others.

The cognitive-behavioral view features explanations of depression that are primarily behavioral, primarily

cognitive, or a combination of behavioral and cognitive principles. On the behavioral side, the model says that when

people experience a large reduction in their positive rewards in life, they become more and more likely to become

depressed.

On the cognitive side, Beck’s theory of negative thinking holds that maladaptive attitudes, the cognitive triad,

errors in thinking, and automatic thoughts help produce unipolar depression. Also, according to Seligman’s learned

helplessness theory, people become depressed when they believe that they have lost control over the reinforcements in

their lives and when they attribute this loss to causes that are internal, global, and stable. Cognitive-behavioral

therapists reintroduce clients to pleasurable events, reinforce nondepressive behaviors, teach interpersonal skills, and

further help the clients change their dysfunctional cognitions.

Sociocultural theories propose that unipolar depression is influenced by social and cultural factors. Family-social

theorists point, for example, to a low level of social support. Correspondingly, interpersonal psychotherapy and

couple therapy are often helpful in cases of depression. Multicultural theories have noted that the character and

prevalence of depression may vary by gender and culture, an issue that culture-sensitive therapies for depression seek

to address.

The developmental psychopathology perspective contends that unipolar depression is caused by a combination of

the factors cited by the various models and that these factors unfold and intersect in a developmental sequence.

468

#FrenziedMasterpiece George Frideric Handel wrote his Messiah in less than a month

during a manic episode (Roesch, 1991).

Bipolar Disorders People with a bipolar disorder experience both the lows of depression and the highs of mania.

Many describe their lives as an emotional roller coaster, as they shift back and forth between

extreme moods. A number of sufferers become suicidal. Approximately 10 to 15 percent of them

eventually end their own lives, usually out of a sense of hopelessness (Suppes, 2018). Their roller

coaster ride also has a dramatic impact on relatives and friends.

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.

“Sometimes Mommy cries” Lawyer and social worker Loran Kundra reads and laughs with her daughters at their home in

Pennsylvania. Kundra, who has bipolar disorder, is co-founder of a program called Child and Family Connections, which

helps parents with psychological disorders effectively discuss their disorders with their children. During a depressive episode,

469

#WrongCall Around 70 percent of people with a bipolar disorder are

initially misdiagnosed by a physician or psychologist (Statistic

Brain, 2018).

Kundra found herself explaining to her daughter, “Sometimes Mommy cries and gets upset just the way that you cry and get

upset”—an exchange that spurred her to reach out to other persons with similar parenting issues.

A person in the throes of mania has active, powerful emotions in search of an outlet. The

mood of euphoric joy and well-being is out of all proportion to the actual happenings 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 overwhelming, 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 uncommon: 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, interrupt their buying sprees, or prevent them from

investing money unwisely. 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 (Suppes, 2018). 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

470

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.

TABLE: 6-4 Dx Checklist Manic Episode

1. For 1 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.

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, having

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).

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 (hypomanic) episodes and major depressive episodes.

471

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 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 depression 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 overwhelmed 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 are 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 (NIMH, 2017; Kessler et al., 2012). As many

as 4 percent experience one of the bipolar disorders 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 (Bressert, 2018; Sareen et al., 2011). Onset

usually occurs between the ages of 15 and 44 years (Stovall, 2018). In most untreated cases, the

manic and depressive episodes eventually subside, only to recur at a later time.

472

PSYCHWATCH

Abnormality and Creativity: A Delicate Balance

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 alcoholism and received electroconvulsive therapy for depression; poet Sylvia

Plath, who was depressed for most of her life and eventually died by suicide at age 31; and ballet dancer Vaslav Nijinsky,

who suffered from schizophrenia and spent many years in institutions. In fact, a number of studies indicate that artists and

writers are somewhat more likely than others to suffer from certain mental disorders, particularly bipolar disorders (Vellante

et al., 2018; Collingwood, 2016).

Why might creative people be prone to such psychological disorders? Some may be predisposed to such disorders long

before they begin their artistic careers (Vellante et al., 2018; Simonton, 2010). Indeed, 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.

473

Kanye’s “superpower” Based on his unusual behaviors, proclamations, and emotional displays, fans and the media

have long speculated about the mental state of Kanye West, one of the twenty-first century’s most acclaimed

musicians. In “Ye,” his 2018 album, West acknowledged having psychological difficulties and hinted at a diagnosis of

bipolar disorder—on the album cover (shown here), in the album’s lyrics, and during promotional interviews. Indeed,

he suggested that his bipolar functioning enhances his creativity and serves as a kind of “superpower” in his endeavors.

A second explanation for the link between creativity and psychological disorders is that the creative professions offer a

welcome climate for those with psychological 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 success

(Collingwood, 2016; Galvez et al., 2011).

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 creativity. Most “creative

geniuses” are, in fact, psychologically stable and happy throughout their entire lives (Rothenberg, 2015; Kaufman, 2013).

Second, mild psychological disturbances relate to creative achievement much more strongly than severe disturbances do

(Collingwood, 2016; Galvez et al., 2011). For example, 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 creativity would disappear if their psychological suffering were to stop. In fact, however,

research suggests that successful treatment for severe psychological disorders more often than not improves the creative

process (Rothenberg, 2015; Ludwig, 1995). Romantic notions aside, severe mental dysfunction has little redeeming value,

in the arts or anywhere else.

Some people have numerous periods of hypomanic symptoms and mild depressive 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).

cyclothymic disorder A disorder marked by numerous periods of hypomanic symptoms and mild depressive symptoms.

What Causes Bipolar Disorders? Throughout the first half of the twentieth century, the search for the cause of bipolar disorders

made little progress. More recently, biological research has produced some promising clues. The

biological insights have come from research into neurotransmitter activity, ion activity, brain

structure, and genetic factors.

Neurotransmitters

474

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 (Schildkraut, 1965). And indeed, some studies did find the

norepinephrine activity of people with mania to be higher than that of depressed or control

participants (Post et al., 1980, 1978).

Speaking out A few months after this New Year’s Eve performance in Times Square on December 31, 2017, singer and

songwriter Mariah Carey revealed that she is being treated for bipolar disorder, a diagnosis she first received almost two

decades ago (Cagle, 2018). Carey says that after years of living “in constant fear someone would expose me … , I knew it

was time to finally share my story.” The superstar’s public acknowledgment and positive outlook have received enormous

praise from mental health advocacy groups.

Because serotonin activity often parallels norepinephrine activity in unipolar depression,

theorists at first expected that mania would also be related to high serotonin activity, but no such

relationship has been found. Instead, research suggests that mania, like depression, may be linked

to low serotonin activity (Nikolaus, Müller, & Hautzel, 2017; Nugent et al., 2013). Perhaps low

activity of serotonin 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

depression; low serotonin activity accompanied by high norepinephrine activity may lead to

mania.

Ion Activity

475

#HigherRisk “The risk of developing bipolar disorder is 6 times higher for

children of older men (over 45 years when their children were

born) than children of young men (20−24 years). Why? One

While neurotransmitters play a significant role in the communication between neurons, ions seem

to play a critical role in relaying messages within a neuron. That is, ions help transmit messages

down the neuron’s axon to the nerve endings. Positively charged sodium ions (Na ) sit on both

sides of a neuron’s cell membrane. When the neuron is at rest, more sodium ions sit outside the

membrane. When the neuron receives an incoming message at its receptor sites, pores in the cell

membrane open, allowing the sodium ions to flow to the inside of the membrane, thus

increasing the positive charge inside the neuron. This starts a wave of electrical activity that

travels down the length of the neuron and results in its “firing.”

If messages are to be relayed effectively down the axon, the ions must be able to travel 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) (Gottschalk et

al., 2017).

Brain Structure Brain imaging and postmortem studies have identified a number of abnormal brain structures in

people with bipolar disorders (Ivleva et al., 2017; Eker et al., 2014). For example, the

hippocampus, basal ganglia, and cerebellum of these people tend to be smaller than those of

other people; they have lower amounts of gray matter in the brain; and their raphe nuclei,

striatum, amygdala, and prefrontal cortex have some structural abnormalities (Dusi et al., 2019;

Sun et al., 2018; Janicak, 2017). It is not clear what role such abnormalities play in bipolar

disorders. Some researchers believe that they collectively reflect dysfunction throughout a

bipolar-related brain circuit (Gong et al., 2019). It may also be that they are related to the brain’s

depression-related circuit that you read about earlier (see page 180).

Genetic Factors Many theorists believe that people inherit a biological predisposition to develop bipolar disorders

(Stovall, 2018). Family pedigree studies support this idea. Identical twins of those with a bipolar

disorder have a 40 to 70 percent likelihood of developing the same disorder, and fraternal twins,

siblings, and other close relatives of such persons have a 5 to 10 percent 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 in large

476

theory is that, as men age, they produce increased genetic

mutations during the manufacture of sperm cells (Stovall,

2018; Chudal et al., 2014).

families. Their work has linked bipolar

disorders to genes on chromosomes 1, 4,

6, 10, 11, 12, 13, 15, 18, 20, 21, and 22

(Charney et al., 2017; Bigdeli et al.,

2013). Such wide-ranging findings suggest that a number of genetic abnormalities probably

combine to help bring about bipolar disorders.

While the world observed In this 2013 photo, then-President Barack Obama delivers a speech next to a sign language

interpreter (right) at a memorial service for the late Nelson Mandela, former president of South Africa. However, the

interpreter’s signs were gibberish and unintelligible, alarming and confusing people around the world. The interpreter later

explained that he had been hearing voices and seeing angels during the speech, symptoms caused by his struggle with bipolar

disorder and/or schizophrenia.

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

early antidepressant drugs were of limited help. In fact, the drugs sometimes triggered a manic

episode (Stovall, 2018).

477

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

treatment for bipolar disorder. Additional mood stabilizing, or antibipolar, drugs have since

been developed, including carbamazepine (Tegretol), valproate (Depakote), and certain

antipsychotic drugs, and several of them are now used more widely than lithium, either because

they produce fewer undesired effects or because they are even more effective than lithium.

lithium A metallic element that occurs in nature as a mineral salt and is an effective treatment for bipolar disorders. mood stabilizing drugs Psychotropic drugs that help stabilize the moods of people suffering from bipolar disorder. Also known as antibipolar drugs.

Nevertheless, it was lithium that first brought hope to those suffering from bipolar disorder.

In her widely read memoir, An Unquiet Mind, psychiatric researcher Kay Redfield Jamison

describes how lithium, combined with psychotherapy, enabled her to overcome 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

periods 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,

such as, for example, in treating manic episodes (Stovall, 2018). 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). These findings suggest that the mood stabilizers are also prophylactic drugs, ones that

actually help prevent symptoms from developing. Thus, today’s clinicians usually continue

patients on some level of a mood stabilizing drug even after their manic episodes subside (Post,

478

2017).

Powerful plot device In the popular soap opera General Hospital, actor Maurice Bernard plays Sonny Corinthos (left), a

mob kingpin who is mercurial, impulsive, and unpredictable, to the delight of viewers. One of the show’s key features is the

character’s bipolar disorder, which greatly affects his behaviors, decisions, and relationships. Interestingly, Bernard himself

has bipolar disorder, a diagnosis he first received at the age of 22.

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 (Stovall, 2018; Malhi et al., 2013). Given the

drugs’ less powerful impact on depressive episodes, many clinicians use a combination of mood

stabilizers and antidepressant drugs to treat bipolar depression, although research suggests that

antidepressants may trigger manic episodes in some patients (Stovall, 2018).

Researchers do not fully understand how mood stabilizing drugs reduce the symptoms of

bipolar disorder (Janicak, 2017). One possibility is that the drugs change synaptic activity in

neurons, but in a way different from that of antidepressant 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.

479

#IrresistableWriting Hypergraphia a compulsive need to write. People with this rare

problem write constantly, not only filling up notebooks or

computer screens but also feverishly finding unusual writing

surfaces, including their own skin. The problem has been

linked to bipolar disorders, temporal lobe epilepsy, and

schizophrenia. Famous sufferers include prolific author Fyodor

Dostoyevski and painter Vincent van Gogh.

#TheirWords “You cannot outrun insanity, anymore than you can outrun

your own shadow.”

—Alyssa Reyans, Letters from a Bipolar Mother

In a similar vein, it has been found that lithium and other mood stabilizing drugs also increase

the production of a protein called brain-derived neurotrophic factor (BDNF) and other proteins

within certain neurons whose job it 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).

Finally, it may be that lithium and other mood stabilizers reduce bipolar symptoms by

improving the functioning of or communications between key structures in the brain (Altinay,

Karne, & Anand, 2018). In support of this possibility, it has been found that lithium actually

increases the size of the hippocampus and the amount of gray matter in bipolar patients (Sun et

al., 2018; Janicak, 2017). Recall that bipolar individuals have a smaller hippocampus and lower

amount of gray matter than other people, among other abnormalities.

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, individuals stop

taking mood stabilizers on their own because they are bothered by the drugs’ unwanted effects,

feel too well to recognize the need for the drugs, miss the euphoria felt during manic episodes, or

worry about becoming less productive when they take the drugs (Vieta & Colom, 2017).

In view of these problems, many

clinicians now use individual, group, or

family therapy as an adjunct to mood

stabilizing drugs (Chu et al., 2018; Post,

2017). Most often, therapists use these

formats to emphasize the importance 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 problems caused by their disorder; and to help prevent

480

patients from attempting suicide. Studies have found that such adjunctive therapy at least

doubles the likelihood that bipolar individuals will continue to take their medications properly,

and it helps reduce hospitalizations, improve social functioning, and increase patients’ ability to

obtain and hold a job (Vieta & Colom, 2017; 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.

Mania may be related to improper neurotransmitter activity, improper transport of ions, or abnormalities 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 effective in the treatment of bipolar disorders. Patients

tend to fare better when mood stabilizing and/or other psychotropic drugs are combined with adjunctive

psychotherapy.

481

CLINICAL CHOICES 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.

Making Sense of All That Is Known During the past 50 years, researchers have made significant 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, perhaps accompanied by psychotherapy, is the single most successful approach. The

picture for unipolar depression is more varied and complex, although no less promising.

Cognitive-behavioral, interpersonal, couple, drug, and brain stimulation treatments can each be

helpful.

Several factors have been tied closely to

unipolar depression, including biological

abnormalities, a reduction in positive

reinforcements, negative ways of thinking,

a perception of helplessness, and life stress

and other sociocultural influences.

Indeed, more contributing factors have

been associated with unipolar depression

than with most other psychological

disorders. Developmental psychopathology theorists and researchers have done an admirable and

promising job of trying to put these various factors together; it is still not entirely clear, however,

how all of these factors relate to unipolar depression.

As with unipolar depression, clinicians and researchers have learned much about bipolar

disorders during the past 50 years. But bipolar disorders appear to be best explained by a focus on

one kind of variable—biological factors. The evidence suggests 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.

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 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 suggest even better ways to predict, prevent, and treat these

disorders.

482

483

Chapter 6 Review

Key Terms

depression

mania

depressive disorders

unipolar depression

bipolar disorders

anhedonia

major depressive disorder

persistent depressive disorder

premenstrual dysphoric disorder

disruptive mood dysregulation disorder

norepinephrine

serotonin

cortisol

depression-related brain circuit

subgenual cingulate

MAO inhibitors

tyramine

tricyclics

selective serotonin reuptake inhibitors (SSRIs)

brain stimulation

electroconvulsive therapy (ECT)

vagus nerve stimulation

484

transcranial magnetic stimulation (TMS)

deep brain stimulation (DBS)

symbolic loss

cognitive triad

automatic thoughts

rumination

learned helplessness

behavioral activation

cognitive therapy

interpersonal psychotherapy (IPT)

couple therapy

developmental psychopathology

hypomanic episode

bipolar I disorder

bipolar II disorder

cyclothymic disorder

ions

lithium

mood stabilizing drugs

second messengers

BDNF

adjunctive psychotherapy

Quick Quiz

1. What is the difference between depressive disorders and bipolar disorders? pp. 173–174

485

2. What are the key symptoms of depression and mania? pp. 174–175, 201–202

3. Describe the role of norepinephrine, serotonin, and the repression-related brain circuit in unipolar depression. pp. 178–180

4. Describe Freud and Abraham’s psychodynamic theory of depression and the evidence that supports it. pp. 187–188

5. How do cognitive-behavioral theorists describe the role of rewards, negative thinking, and learned helplessness in depression? pp. 188–192

6. What approaches do cognitive-behavioral therapists use in the treatment of people with unipolar depression? pp. 192–195

7. How do sociocultural theorists account for unipolar depression? pp. 195–199

8. How do developmental psychopathology theorists integrate the factors and concepts from the various models to help explain unipolar depression? p. 200

9. What roles do biological and genetic factors seem to play in bipolar disorders? pp. 204– 205

10. Discuss the leading treatments for unipolar depression and bipolar disorders. How effective are these various approaches? pp. 181–188, 192–197, 199, 206–208

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

486

CHAPTER 7 Suicide

TOPIC OVERVIEW

What Is Suicide?

487

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 Interpersonal 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?

Psychological and Biological Insights Lag Behind

The 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 invasion 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 [died by] 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

488

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 heroism 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, causing 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 breeding ground.

Lemmings rush to the sea and drown. But only humans knowingly 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 Marilyn Monroe, rock star Kurt Cobain, and comedian Robin Williams

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.

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 42,000 in the

United States alone (AFSP, 2018; CDC, 2017) (see Table 7-1). Around 25 million other people

throughout the world — 650,000 in the United States—make unsuccessful attempts to kill

489

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. 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.

parasuicide A suicide attempt that does not result in death.

TABLE: 7-1 Most Common Causes of Death in the United States Rank Cause Deaths per Year

1 Heart disease 614,348

2 Cancer 591,699

3 Chronic respiratory diseases 147,101

4 Accidents 136,053

5 Stroke 133,103

6 Alzheimer’s 93,541

7 Diabetes 76,488

8 Pneumonia and influenza 55,227

9 Kidney disease 48,146

10 Suicide 42,773

Information from: CDC, 2017.

Suicide is not officially classified as a mental disorder, although DSM-5 proposes that a

category called suicidal behavior disorder be studied for possible inclusion in future revisions of

DSM-5. Regardless of whether suicidal acts themselves represent a distinct disorder,

psychological dysfunction—a breakdown of coping skills, emotional turmoil, 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.

490

#StunningComparison1 More people die by suicide (42,773) than by motor vehicle

crashes (33,736) in the United States each year (CDC, 2017;

Heron, 2016).

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

intentioned death—a self-inflicted death in which one makes an intentional, direct, and

conscious effort to end one’s life.

suicide A self-inflicted death in which the person acts intentionally, directly, and consciously.

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 spacious

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 president 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 overqualified. 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 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.

491

#StunningComparison2 More people die by suicide (42,773) than by homicide

(15,809) in the United States each year (CDC, 2017; Heron,

2016).

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 comfort 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.

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. Accordingly, 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

492

How should clinicians decide whether to hospitalize a

person who is considering suicide or even one who has made

an attempt?

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 darers? A teenager jumps from one high rooftop to another, performing flips and other creative moves along the way,

all part of the extremely dangerous “sport” called Parkour, or Freerunning. Are practitioners of this increasingly popular

activity searching for new challenges or highs, as many of them claim, or are some actually death darers?

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 suicides 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

happier existence. Many child suicides,

like Demaine, fall into this category, as do those of adult believers in a hereafter who kill

493

#SteadyRise The rate of suicide in the United States has gone up year by

year throughout the twenty-first century. Today’s rate is 28

percent higher than the rate in the year 2000 (CDC, 2017).

themselves 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 died by 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, recurrent physical fighting, and

medication mismanagement as behaviors that may contribute to subintentional deaths. 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 have proposed that a category called

nonsuicidal self-injury be studied for possible inclusion in future revisions of DSM-5.

subintentional death A death in which the victim plays an indirect, hidden, partial, or unconscious role.

Self-injurious behavior is more

common than previously recognized,

particularly among teenagers and young

adults, and it may be on the increase

(Cipriano, Cella, & Cotrufo, 2017).

Studies suggest that 17 percent of all

adolescents try to injure themselves at least once (Brown & Plener, 2017). It appears that the

behavior becomes addictive in nature. The pain brought on by self-injury seems to offer some

relief from tension or other kinds of emotional suffering, the behavior serves as a temporary

distraction from problems, and the scars that result may document the person’s distress (Skodol,

2017). More generally, self-injury may help a person deal with chronic feelings of emptiness,

boredom, and identity confusion. Although self-injury and the other risky behaviors mentioned

494

earlier may indeed represent an indirect attempt at suicide (Burke et al., 2018), the true intent

behind them is unclear, so, for the most part, these behaviors are not included in the discussions

of this chapter.

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.

Creative expression At least 17 percent of teenagers and young adults purposely injure themselves, particularly by skin

cutting (MHA, 2017). Thus, Olivia Stewart, a high school student in Colorado, chose mental illness as the topic for her

senior project and produced this remarkable sculpture on self-mutilation. Stewart, whose project also featured art

representations of other psychological disorders, hopes that her work will help increase education and public awareness

regarding mental disorders.

One strategy is retrospective analysis, a kind of psychological autopsy in which clinicians and

researchers piece together data from the suicide victim’s past (Nock et al., 2017; Riblet et al.,

2017). 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. However, such sources of information are not

495

What factors besides religious affiliation and beliefs might

help account for national variations in suicide rates?

always available or reliable (Stack & Rockett, 2018). Many suicide victims do not leave notes.

Moreover, a grieving, perhaps guilt-ridden relative or a distraught therapist may be incapable of

objective recollections or simply reluctant to discuss an act that is so stigmatizing in our society

(Fouet, 2017).

retrospective analysis A psychological autopsy in which clinicians piece together information about a person’s suicide from the person’s past.

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, 2018). 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 survivors of suicide

attempts, and this chapter shall consider those who attempt suicide and those who complete

suicide as more or less alike.

Patterns and Statistics Suicide happens within a larger social setting (see Trending), 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 (WHO, 2017). Sri Lanka, Guyana,

South Korea, Lithuania, and Angola have very high rates—more than 20 suicides annually per

100,000 persons; conversely, Egypt, Mexico, Greece, and Indonesia have relatively low rates,

fewer than 5 per 100,000. Falling in between are England (7.4), China (8.5), Germany (9.1),

Canada (10.4), the United States (12.6), and Russia (17.9).

Religious affiliation and beliefs may

help account for these national differences

(Hsieh, 2017). For example, countries

that are largely Catholic, Jewish, or

Muslim tend to have low suicide rates. Perhaps in these countries, strict prohibitions against

suicide or a strong religious tradition deter many people from attempting suicide. Yet there are

exceptions to this tentative rule. Poland, a largely Roman Catholic country, has a suicide rate of

18.5 suicides per 100,000 persons, one of the higher suicide rates in the world (WHO, 2017).

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 particular persuasion, very religious

people seem less likely to die by suicide (Kralovec et al., 2018).

496

The suicide rates of men and women also differ. Three times as many women attempt suicide

as men, yet men die from their attempts at more than three times the rate of women (AFSP,

2018). Although various explanations have been proposed for this gender difference, a popular

one points to the different methods used by men and women (Anestis & Houtsma, 2018). 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 62 percent of the male

suicides in the United States, compared with 37 percent of the female suicides (Schreiber &

Culpepper, 2018; CDC, 2014).

TRENDING

Internet Horrors

Two current trends on the Internet have produced enormous concern.

One trend is the increasing availability and use of pro-suicide Web sites. These sites vary in their specific messages, but

many of them celebrate former users who have died by suicide, others help set up appointments for joint or partner

suicides, and several offer specific instructions about suicide methods, prospective suicide locations, and the writing of

suicide notes (Miguel et al., 2017; Minkkinen et al., 2017, 2016; Thornton et al., 2017).

The sites have spread across the Internet—on Web forums and chat groups; on social networks such as Facebook,

Instagram, Tumblr, and Live Journal; and on video platforms such as YouTube and Vimeo (Miguel et al., 2017).

According to one study, 7.5 percent of teenagers seek out information about suicide on the Internet (Mars et al., 2015).

While most such individuals access sites offering support, help, or constructive advice, more than a third of them further

access sites that provide information on how to hurt or kill oneself.

A second trend of great concern is the live-streaming of suicides. On January 22, 2017, a 14-year-old girl named Nakia

Venant hanged herself in her Florida bathroom while live-streaming the act on Facebook (see photo). Nakia had a long

history of significant behavioral problems, as well as a background of being physically abused and rejected. She had been in

and out of numerous foster care homes for the previous eight years (Barnes, 2017; Miller & Burch, 2017). Just months

before her suicide, the teen had texted her biological mother seeking to return home, but such a return never took place.

497

A tragic end On January 22, 2017, 14-year-old Nakia Venant broadcast her suicide on Facebook while sending and

receiving texts—one of at least three suicides that were live-streamed in the United States that same month.

Although precise numbers are not yet available, live-streaming of suicides is clearly on the rise (Reidenberg, 2017).

Indeed, Nakia was the third person in the United States to broadcast her suicide on social media that same month (Bever,

2017). Public suicides are not new, but they have never before been able to reach so many viewers. Clinicians do not really

know why certain people attempt suicide online. Some propose that, in addition to being in great psychological pain, the

individuals may be trying to display their pain to others, memorialize their death, or solicit interventions by others (Bever,

2017).

Worried about the increase in broadcast suicides and the possible risk of copycat deaths, Facebook has recently taken

steps to help prevent both live-streamed and other forms of suicides. First, it has updated tools to make it easier for users to

alert Facebook about suicide and self-harm postings that may come their way (O’Brien, 2017; Schuster, 2016). Upon

receiving such alerts, Facebook offers immediate guidance and resources to the concerned friends or acquaintances, for

example, providing them with tips on how to talk with a suicidal friend or how to contact a mental health professional

through a lifeline. In cases of live-streaming, Facebook also tries to help the streamers directly (Harris, 2017). The screens

of the streamers are partially blocked by a message that says, “Someone thinks you might need extra support right now and

asked us to help.” In turn, the streamer can contact a suicide helpline, view tips from Facebook, and/or text a friend directly

from their window (Harris, 2017).

Facebook also now makes it possible for troubled individuals to immediately chat with a trained counselor from the

National Suicide Prevention Lifeline, Crisis Text Line, and other crisis support organizations through its Facebook

Messenger platform (Guynn, 2017). In addition, the social networking service is currently testing the use of pattern

recognition software to help identify self-harm and suicide warning signals in user posts and comments. The network’s

community monitor team then acts proactively by reaching out to the posters and beyond (Harris, 2017). Certainly, such

efforts by Facebook and other social networking services regarding suicidal posters and live-streamers are very welcome

indeed.

Suicide is also related to social environment and marital status. Studies suggest that at least

half of individuals who carry out suicide are socially isolated and have few or no close personal

friends, although they may be active on social network sites (Berman, 2018; Maris, 2001). In a

related vein, research has revealed that never-married and divorced persons have a higher suicide

rate than married or cohabitating individuals (Schreiber & Culpepper, 2018).

Finally, in the United States at least, suicide rates seem to vary according to race and ethnicity

(see Figure 7-1). The overall suicide rate of non-Hispanic white Americans is more than twice as

high as that of African Americans, Hispanic Americans, and Asian Americans (AFSP, 2018;

CDC, 2016). A major exception to this pattern is the suicide rate of American Indians, which is

higher than that of non-Hispanic white Americans. 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 (Dillard et al., 2017;

Lanier, 2010).

498

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:

AFSP, 2018, 2017; CDC, 2016, 2014, 2010; SPRC, 2013.)

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 people 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 rates vary from country to country. One reason for that seems to be cultural differences in

religious affiliation, beliefs, and degree of devoutness. Suicide rates also vary according to race, gender, and marital

status.

499

#FatalAccess The rate of gun-related suicide is 11 times higher in the United

States than in all other industrialized countries.

People who die by suicide are at least twice as likely to have a

gun in their house as people who survive their suicide attempts.

Suicide rates increase 4 to 10 times among teenagers who live

in a house with a gun.

(Anestis & Houtsma, 2018; Schreiber & Culpepper, 2018;

Kennebeck & Bonin, 2017)

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.

Stressful Events and Situations Researchers have counted more stressful events in the recent lives of suicide attempters than in

the lives of nonattempters (Buchman-Schmitt et al., 2017; McFeeters et al., 2015). One stressor

that has been consistently linked to suicide is combat stress. Research indicates that combat

veterans from various wars are more than twice as likely to die by suicide as nonveterans (Nock et

al., 2017, 2014, 2013). At the beginning of this chapter, for example, you read about a young

man who killed himself upon returning to civilian life, after experiencing the enormous stressors

of combat in Iraq.

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; loss of a job; significant

financial loss; and stress caused by

hurricanes, earthquakes, or other natural

disasters, even among very young children

(Cawley et al., 2019; Kerr et al., 2017;

Fujiwara et al., 2017). 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 carry out 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 (Schreiber &

500

Culpepper, 2018).

Serious Illness People whose illnesses cause them great pain or severe disability may attempt 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 (Schreiber & Culpepper, 2018). Illnesses that have

been linked to higher suicide rates include cancer, heart disease, chronic lung disease, stroke, and

diabetes mellitus (Bartoli et al., 2017; Conti et al., 2017; Zhang et al., 2017).

Abusive or Repressive Environment Victims of an abusive or repressive environment from which they have little or no hope of escape

sometimes pursue suicide. For example, some prisoners of war, inmates of concentration camps,

abused spouses, abused children, and prison inmates try to end their lives (Vadini et al., 2018;

Ayhan et al., 2017). 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.

Famous prison suicide In 2015, Aaron Hernandez, a star tight end in the National Football League, was convicted of first-

degree murder and sentenced to life in prison without parole for the 2013 killing of an acquaintance. Hernandez, shown

here at a locker room press interview during his playing days, killed himself by hanging at a Massachusetts prison in 2017,

just days after being acquitted of two additional killings. Around 11 percent of all prison deaths are due to suicide (BJS,

2018, 2016).

501

Occupational Stress Some jobs create feelings of tension or dissatisfaction that may trigger suicide attempts. Studies

have revealed higher suicide rates among people working in unskilled occupations. For persons in

skilled occupations, research has found relatively high rates for psychiatrists and psychologists,

physicians, nurses, dentists, lawyers, police officers, firefighters, emergency workers, and farmers

(Mckew, 2017; Witt et al., 2017). 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 significant shift from the

person’s past mood. The most common change is an increase in sadness (James et al., 2017). Also

common are increases in feelings of anxiety, tension, frustration, anger, or shame (Hill et al.,

2018; Reisch et al., 2010).

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 (Schreiber & Culpepper, 2018). They often develop a sense of hopelessness—a

pessimistic belief that their present circumstances, problems, or mood will never change (Sun et

al., 2018). Some clinicians believe that a feeling of hopelessness is the single most likely indicator

of suicidal intent.

hopelessness A pessimistic belief that one’s present circumstances, problems, or mood will never change.

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:

502

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)

dichotomous thinking Viewing problems and solutions in rigid either/or terms.

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 (Choi et al., 2018; McCloud et al., 2004). Autopsies reveal that about one-

quarter of these people are legally intoxicated (Schreiber & Culpepper, 2018; Flavin et al., 1990).

Moreover, the more intoxicated suicide attempters are, the more lethal their chosen suicide

method (Park et al., 2017). It may be that the use of alcohol lowers a person’s inhibitions,

reduces his or her fears of suicide, releases underlying aggressive feelings, or impairs 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 (Beckman et al., 2019).

Mental Disorders Although people who attempt suicide may be troubled or anxious, they do not necessarily have a

psychological disorder. Nevertheless, the vast majority of all suicide attempters do have such a

disorder (Schreiber & Culpepper, 2018; Nock et al., 2017, 2013). Research suggests that as

many as 70 percent of all suicide attempters had been experiencing severe depression (unipolar or

bipolar), 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 substance-dependent seem particularly prone to suicidal impulses (Harford et al.,

2018; Bohnert et al., 2017). It is also the case that many people with borderline personality

disorder, a broad pattern that you will read about in Chapter 13, try to harm themselves or make

suicidal gestures as part of their disorder (Soloff & Chiappetta, 2018).

As you saw in Chapter 6, people with major depressive disorder often have suicidal thoughts.

Even when depressed people begin showing improvements in mood, 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. Severe

503

depression also may play a key role in suicide attempts made by those with serious physical

illnesses (Cheung & Sundram, 2017).

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 (Beckman et al., 2019; Mukamal, 2018; Agrawal

et al., 2017). The basis for the link between substance use 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. Alternatively, a third factor—psychological

pain, for instance, or desperation—may cause both substance abuse and suicidal thinking.

Research indicates that suicides by people with schizophrenia and other disorders featuring

psychosis usually reflect feelings of demoralization, a sense of being entrapped by their disorder,

and fears of further mental deterioration (Owen et al., 2018). 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.

Acting happy Fans of megastar, comedian, and actor Robin Williams were shocked when he killed himself by hanging in

2014. Close friends reported that Williams had been battling depression and the early stages of Parkinson’s disease for some

504

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.

Modeling: The Contagion of Suicide It is not unusual for people, particularly teenagers, to attempt suicide after observing or reading

about someone else who has done so (Vitelli, 2016). 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, and suicides 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 (Campos, Holden, & Santos, 2018; 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

continue for years (Schreiber & Culpepper, 2018). 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. This additional risk factor is often called the social contagion

effect.

505

Far from a game The Blue Whale Game, or Blue Whale Challenge, is an Internet “game” that is currently stirring great

public concern. The challenge is comprised of daily tasks that participants are assigned by administrators, culminating, on

the 50th day, with an instruction to kill oneself. It is estimated that dozens of teenagers across the world have died by

suicide playing the game, whose name is derived from the behavior of whales that strand themselves on beaches and die.

Celebrities Research suggests that suicides by entertainers, political figures, and other well-known people are

regularly followed by unusual increases in the number of suicides across the nation. Studies on

this issue have found, for example, that the national suicide rate rose around 19 percent during

the weeks after the 2014 suicide of comedian Robin Williams and the 1963 suicide of actress

Marilyn Monroe (Fink, Santaella-Tenorio, & Keyes, 2018; Phillips, 1974).

Some clinicians argue that more responsible reporting could reduce the impact of celebrity or

other highly publicized suicides (Fink et al., 2018; 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, thousands of young people called MTV

and other radio and television stations in the hours after Cobain’s death, upset, frightened, and

in some cases suicidal. 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 2 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 individuals of all ages, put into action programs

of this kind after a student dies by suicide (AFSP, 2018; Joshi et al., 2015). Such postsuicide

programs are often referred to by clinicians as postvention.

506

Parallel journeys In 1994 rock star Kurt Cobain (left), leader of the grunge band Nirvana, shot himself to death at age 27,

shaking millions of young fans to their core. In 2017, rock star Chris Cornell (right), a contemporary of Cobain’s and lead

singer in the grunge band Soundgarden, hanged himself at age 52. Cornell’s suicide, occurring 23 years after Cobain’s,

stunned and disheartened many of the same (now middle-aged) fans.

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 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.

507

#DealBreaker If clients state an intention to kill themselves, therapists may

break the doctor–patient confidentiality agreement that usually

governs treatment discussions (Middleman & Olson, 2017).

#AdditionalPunishment 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 (Wertheimer, 2001;

Fay, 1995).

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 models. Some of these hypotheses have, however, received limited research support

and fail to address the full range of suicidal acts. Thus the clinical field currently lacks a

satisfactory understanding of suicide.

The Psychodynamic View Many psychodynamic theorists believe that suicide results from depression and from anger at

others that is redirected toward oneself. To make this point, the 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

come to “introject” the lost person; that

is, they unconsciously 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 and self-punishment (Campbell & Hale, 2017).

In support of Freud’s view, researchers

have often found a relationship between

childhood losses—real or symbolic—and

later suicidal behaviors (Burrell, Mehlum,

& Qin, 2018). 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, Bouckoms, & Streiner, 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

508

Why might towns and countries in past times have been

inclined to punish both those who attempted suicide and

their relatives?

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 aiming 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 (Osman & Parnell, 2015; Maris, 2001), when, one

could argue, people are encouraged to direct their self-destructive energy against “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).

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

(Campbell & Hale, 2017).

Durkheim’s Sociocultural View Toward the end of the nineteenth

century, Emile Durkheim (1897), a

sociologist, developed a broad theory of

suicidal behavior. Today this theory is still

influential and is often supported by

research (Osman & Parnell, 2015; 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.

509

In the service of others According to Emile Durkheim, people who intentionally sacrifice their lives for others are

committing altruistic suicide. In the 2016 movie Rogue One, renegade Jyn Erso leads a small band of Rebel volunteers on a

“suicide mission” to capture the schematic diagram of the Death Star, a powerful superweapon capable of destroying

planets. Jyn and her group successfully capture and transmit the diagram back to the Rebel command ship, setting in

motion the destruction of the Death Star and the saving of the galaxy, but all of them die in the process—as they knew they

would.

Egoistic suicides are carried out 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 undertaken 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 undertaking altruistic suicide.

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.

510

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 (Lankford, 2013; Humphrey, 2006).

Anomic suicides, another category proposed by Durkheim, are those pursued 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 suicide rates

increase. Historical trends support this claim. Periods of economic depression may bring about

some degree of anomie in a country, and national suicide rates tend to rise during such times

(Kerr et al., 2017). 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).

511

A major change in a person’s immediate surroundings, rather than general societal 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 predicted that societies with more opportunities for

changes in individual wealth or status would have higher suicide rates; this prediction is also

supported by research (Cutright & Fernquist, 2001).

Although today’s sociocultural theorists do not always embrace Durkheim’s particular ideas,

most agree that interpersonal variables, social structure, and cultural stress often play major roles

in suicide. The recent work of researcher Thomas Joiner, which is discussed in the following

section, is a case in point.

The Interpersonal View For more than a decade, clinical researcher Thomas Joiner and his colleagues have been

developing the interpersonal theory of suicide (Joiner et al., 2017; Joiner, 2009, 2005). This

view, also called the interpersonal-psychological theory, asserts that people will be inclined to pursue

suicide if they hold two key interpersonal beliefs—perceived burdensomeness and thwarted

belongingness—and, at the same time, have a psychological capability to carry out suicide, a

capability that they have acquired from life experiences. The theory does not dismiss the

importance of the other factors you have been reading about throughout this chapter. However,

says the Joiner research team, without the further presence of perceived burdensomeness,

thwarted belongingness, and acquired capability, those factors are not likely to result in self-

inflicted death (Rogers et al., 2017).

interpersonal theory of suicide A theory that asserts that people with perceived burdensomeness, thwarted belongingness, and a psychological capability to carry out suicide are the most likely to attempt suicide. Also called interpersonal-psychological theory.

According to this theory, people with perceived burdensomeness believe that their existence

places a heavy and permanent burden on their family, friends, and even society. This belief—

typically inaccurate—may produce the notion that “my death would be worth more than my life

to my family and friends” (Silva et al., 2017; Joiner, 2009).

People with thwarted belongingness feel isolated and alienated from others—not an integral

part of a family or social network. Their sense of social disconnect may be overstated or it may be

accurate, but, either way, it feels enduring, unchangeable, and confining.

Research indicates that people who experience both of these interpersonal perceptions are

512

#HeightenedRisk Some studies find that birthdays are associated with a greater

risk of suicide. People are significantly more likely to complete

suicide on their birthday (Stickley et al., 2016).

Suicide sometimes runs in families. How might clinicians

and researchers explain such family patterns?

inclined to develop a desire for suicide (Buckner et al., 2017; Ma et al., 2016). However, studies

also indicate that such individuals are unlikely to attempt suicide unless they further possess the

third variable cited by the theory—the psychological capability to inflict lethal harm on

themselves (Ribeiro & Joiner, 2009).

According to Joiner, we all have a basic

motive to live and preserve ourselves—a

motive that weakens for certain people as

a result of their repeated exposure to

painful or frightening life experiences, like

abuse, trauma, severe illness, or the like. Given such recurrent experiences, these individuals may

develop a heightened tolerance for pain and a fearlessness about death (Rogers et al., 2017;

Joiner, 2009). In Joiner’s terms, they acquire a psychological capability for suicidal acts.

Studies conducted across a range of populations—from adolescents to the elderly—reveal that

people with a combination of perceived burdensomeness, thwarted belongingness, and acquired

suicide capability are significantly more likely to attempt suicide than people without these

characteristics (Rogers et al., 2017; Horton et al., 2016).

Although this trio of factors has certainly been linked to civilian suicides, the theory’s ability

to help account for military suicides, which are twice as prevalent as civilian suicides, has stirred

particular interest among clinical researchers (Monteith et al., 2018; Nock et al., 2017). Studies

have revealed that many soldiers and veterans, perhaps due in part to the nature and impact of

military training and combat, eventually develop feelings that they are a hardship on their

families (perceived burdensomeness), have difficulty integrating into civilian life (thwarted

belongingness), and grow accustomed to violence (acquired suicide capability) (Lusk et al.,

2015). Correspondingly, studies have found that such individuals often develop suicidal thoughts

(Silva et al., 2017).

The Biological View For years, biological researchers repeatedly found higher rates of suicide among the parents and

close relatives of suicidal people than among those of nonsuicidal people (Wang et al., 2017).

Such findings may suggest that genetic, and so biological, factors are at work.

Laboratory studies also offer more

direct support for a biological view of

suicide. One promising line of research

513

focuses on serotonin. The activity level of

this neurotransmitter has often been found to be low in people who complete suicide (Fanelli &

Serretti, 2019; Kennebeck & Bonin, 2017). At first glance, this finding may seem to tell us only

that depressed people often attempt suicide. After all, depression is itself related to low serotonin

activity and to dysfunction of the depression-related brain circuit. On the other hand, there is

evidence of low serotonin activity and brain-circuit dysfunction even among suicidal people who

have no history of depression (Mann & Currier, 2007). That is, low serotonin activity and brain-

circuit dysfunction also seem to play a role in suicide separate from depression.

How might such serotonin and brain-circuit abnormalities directly increase the likelihood of

suicidal behavior? One possibility is that they contribute to aggressive and impulsive behaviors

(Huang et al., 2017; Rizzi & Marras, 2017). It has been found, for example, that aggressive and

impulsive men (including those who commit arson and murder) display lower serotonin activity

and poorer brain-circuit functioning than do other men (Mann & Currier, 2007; Oquendo et

al., 2006, 2004). Such findings suggest that low serotonin activity and brain-circuit dysfunction

help produce aggressive feelings and impulsive behavior. In people who are clinically depressed,

these biological abnormalities may lead to 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 and a dysfunctional brain circuit may develop such aggressive

feelings that they, too, are dangerous to themselves or to others.

Is aggression the key? Biological theorists believe that heightened feelings of aggression and impulsivity, produced by low

serotonin activity and poor brain-circuit functioning, are key factors in suicide. In 2007, professional wrestling champion

514

Chris Benoit (right) killed his wife and son and then hanged himself, a tragedy that seemed consistent with this theory. In

addition, toxicology reports found steroids, drugs known to help cause aggression and impulsivity, in Benoit’s body.

SUMMING UP

WHAT ARE THE UNDERLYING CAUSES OF SUICIDE? The leading explanations for suicide come from the psychodynamic, sociocultural, and biological models.

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. A more recent theory, the interpersonal theory, asserts that people with

perceived burdensomeness, thwarted belongingness, and a psychological capability to carry out suicide are more likely

to attempt suicide. And biological theorists suggest that low serotonin activity and abnormalities in the depression-

related brain circuit contribute to suicide.

515

Is Suicide Linked to Age? Although people of all ages may try to kill themselves, the likelihood of dying by 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 75 (see Figure 7-2). Currently, 2 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, 16 of every 100,000 people between 25 and

44 years old, 20 of every 100,000 between 45 and 64 years old, 16 of every 100,000 between 65

and 74, and 21 of every 100,000 people over age 75 (AFSP, 2018; CDC, 2016). The exceptional

rate of suicide among those who are middle-aged is a relatively recent phenomenon and is not

fully understood (Schreiber & Culpepper, 2018).

FIGURE 7-2

Suicide and Age

In the United States, suicide rates keep rising through middle age, then fall during the first decade of old age, then rise again

among people over the age of 74. (Information from: AFSP, 2018, 2017; CDC, 2016.)

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

516

key roles in the suicidal acts of its members.

Children Suicide is infrequent among children, although it has been increasing over the past several

decades (Schreiber & Culpepper, 2018). For children under 11 years of age, one out of every

million individuals kill themselves. That rate rises to two per 100,000 among children aged 11 to

14 years and, as you will see shortly, 8 per 100,000 among teens aged 15 to 19 years (Kennebeck

& Bonin, 2017; CDC, 2016). 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 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 commonly 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

hallucinations; marked personality change; and overwhelming interest in death and suicide

(Soole et al., 2015; Wong et al., 2011). Further, studies 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 (Kennebeck &

Bonin, 2017; van Geel, Vedder, & Tanilon, 2014).

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 limited, children who attempt suicide fall

into Shneidman’s category of “death ignorers,” like Demaine, who sought to join his mother in

heaven (Kennebeck & Bonin, 2017). 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, interviews with

schoolchildren have revealed that between 6 and 33 percent have thought about suicide (Riesch

et al., 2008; Culp, Clyman, & Culp, 1995).

517

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,” participates in summer juku, a camp

where children receive special academic training, extra lessons, and exam practice 11 hours a day.

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. Each year, according to official records, 8 of

every 100,000 teenagers (age 14 to 18) in the United States end their lives (Kennebeck & Bonin,

2017; Nock et al., 2013). In addition, at least 12 percent of teenagers have persistent suicidal

thoughts and 4 to 8 percent make suicide attempts. Because fatal illnesses are uncommon among

the young, suicide has become the second leading cause of death in this age group, after accidents

(CDC, 2017). Around 19 percent of all adolescent deaths are the result of suicide (Heron, 2016).

518

#LimitedHelp More than 55 percent of teens who attempt suicide received

some form of therapy before the onset of their suicidal

behavior, but it failed to prevent their later actions (Nock et al.,

2013).

About half of teenage suicides, like those of people in other age groups, have been tied to

clinical depression, low self-esteem, and feelings of hopelessness, but many teenagers who try to

kill themselves also appear to struggle with anger and impulsiveness or to have serious alcohol or

drug problems (Schreiber & Culpepper, 2018; Kennebeck & Bonin, 2017). Some also have

deficiencies in their ability to sort out and solve problems.

Teenagers who consider or attempt suicide are often under great stress (Steele et al., 2018;

Stewart et al., 2018). They may be dealing with long-term pressures such as poor (or missing)

relationships with parents, family conflict, inadequate peer relationships, social isolation, or

repeated bullying. Indeed, suicide attempts are at least twice as common among teenage victims

of bullying as among other teenagers. Alternatively, their actions also may be triggered by more

immediate stress, such as a parent’s unemployment or medical illness, financial setbacks for the

family, or a social loss such as a breakup with a boyfriend or girlfriend. 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.

One group under particular stress are

LGBTQ teenagers (lesbian, gay, bisexual,

transgender, and questioning). In

addition to possible sexual or gender

doubts and concerns, they often

experience abuse, prejudice,

stigmatization, and victimization by peers, including bullying, in their lives. Studies indicate that

they are three times more likely than other teenagers to have suicidal thoughts and to attempt

suicide (Forcier & Olson-Kennedy, 2018).

Some theorists believe that the period of adolescence itself produces a stressful climate in

which suicidal actions are more likely. Adolescence is a period of rapid growth that 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 suggestibility of adolescents and their eagerness to

imitate others, including others who attempt suicide, may set the stage for suicidal action

(Kennebeck & Bonin, 2017). One study found that adolescents exposed to suicide by an

acquaintance or relative within the past year were more likely to attempt suicide than adolescents

519

without a personal exposure of this kind (Swanson & Colman, 2013). It is believed that recent

suicides by individuals on social networking sites—including individuals never met in person—

may also raise the likelihood of attempted suicide by many young users (Briggs, Slater, &

Bowley, 2017).

Teen Suicides: Attempts Versus Completions Far more teenagers attempt suicide than actually kill themselves—most experts believe that the

ratio is at least 100 to 1, and in fact estimates range as high as 200 to 1 (Schreiber & Culpepper,

2018; Kennebeck & Bonin, 2017). In contrast, the ratio is thought to be 4 to 1 among the

elderly (AFSP, 2018). 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, Czyz, & King, 2014; Wong et al., 2008).

13 Reasons Why Few TV series have produced the stir caused by 13 Reasons Why, a Netflix drama wildly popular among

teenagers. The show depicts young Hannah Baker who fatally cuts her wrists after experiencing a number of traumatic

events, each brought on by a different classmate. After Hannah’s suicide, those classmates receive a package of tapes from

her—an audio diary—describing the 13 reasons she killed herself. On the plus side, the show has raised awareness about

teenage suicide and helped generate peer-to-peer and parent−child discussions about this topic. On the negative side, many

clinicians and educators worry that the show depicts suicide too graphically, inadvertently normalizes it, and may trigger

520

#TwitterAlert Numerous tweeters express suicidality on Twitter. All suicide-

related tweets should be taken seriously, but research has found

that those with a higher word count, greater use of first-person

pronouns, and more references to death may be of particular

concern (O’Dea et al., 2018).

acts of self-destruction and self-harm by some viewers.

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 academic and athletic honors has intensified for

them, leading increasingly to shattered dreams and ambitions (Kim & Cho, 2017; 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 (Kennebeck & Bonin, 2017; 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 (Shain & AAP

Committee on Adolescence, 2016). 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 (Gould et al., 2014).

Teen Suicides: Multicultural Issues Teenage suicide rates vary by race and ethnicity in the United States. Around 9 of every 100,000

non-Hispanic white American teenagers die by suicide each year, compared with 5 of every

100,000 African American teens and 5 of every 100,000 Hispanic American teens (CDC, 2016;

Goldston et al., 2008). At the same time, the rates of these three groups are becoming closer

(Schreiber & Culpepper, 2018). This closing trend may reflect increasingly similar pressures on

young African, Hispanic, and non-Hispanic white Americans—competition for grades and

college opportunities, for example, is now intense for all three groups. The growing suicide rates

for young African and Hispanic Americans may also be linked to their rising unemployment, the

many pressures of inner-city life, and the indignation many feel over racial inequities and

discrimination in our society (Kennebeck & Bonin, 2017). Studies further indicate that 5.7 of

every 100,000 Asian American teens now end their lives each year.

521

Why do people often view the suicides of elderly or

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.

The highest teenage suicide rate of all is displayed by American Indians. Currently, around 18

of every 100,000 American Indian teenagers die by suicide each year, double the rate of non-

Hispanic white American teenagers and triple that of other minority teenagers (CDC, 2016).

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 (SAMHSA, 2018; Dillard et al., 2017). 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 (SAMHSA, 2017).

The Elderly More than 16 of every 100,000 people between the ages of 65 and 74 years in the United States

kill themselves, a rate that rises to 21.4 per 100,000 among people over the age of 74 years, as

you read earlier (AFSP, 2018; CDC, 2016). Elderly people account for over 18 percent of all

suicides in the United States, yet they comprise only 15 percent of the total population (NVSR,

2016; U.S. Census Bureau, 2016).

Many factors contribute to this high

522

chronically sick people as less tragic than those of young or

healthy people?

#TheirWords “What an amount of good nature and humor it takes to endure

the gruesome business of growing old.”

Sigmund Freud, 1937

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 (Steele et al., 2018). Such experiences may result in feelings of

hopelessness, loneliness, depression, “burdensomeness,” or inevitability among aged persons and

so increase the likelihood that they will attempt suicide (Steele et al., 2018; Kim et al., 2014).

One study found that two-thirds of particularly elderly individuals (those over 80 years old) who

died by suicide had been hospitalized for medical reasons within 2 years preceding the suicide

(Erlangsen et al., 2005), and another found a heightened 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

(Schreiber & Culpepper, 2018).

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). As you read

earlier, an estimated one of every four

elderly persons who attempts suicide succeeds. 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 (Emanuel, 2017) (see InfoCentral). 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 (Kiosses et al., 2017; Draper, 2014). In fact, research suggests that

treating depression in older persons helps reduce their risk of suicide markedly.

523

A right to die? Although she has not tried to end her life, Nel Bolten, a resident of the Netherlands, recently brought

attention to the right-to-die debate when she had her chest tattooed with these words (which mean “Do not resuscitate. I

am 91 plus”). The Dutch health minister has confirmed that the tattoo is a legally binding declaration in that country,

where euthanasia and physician-assisted suicide are permitted.

The suicide rate among the elderly in the United States is lower in some minority groups

(Heron, 2016). 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 non-Hispanic white Americans.

524

The power of respect Elderly people are held in high esteem in many traditional societies because of the store of knowledge

they have accumulated. Perhaps not so coincidentally, suicides among the elderly seem to be less common in these cultures

than in those of many industrialized nations.

Similarly, the suicide rate is only one-quarter as high among elderly African Americans as

among elderly non-Hispanic white Americans (CDC, 2016). One reason for this low suicide rate

may be the pressures faced by African Americans, of whom it has been 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 significant achievement for non-Hispanic white Americans, their attitude toward aging

may be more negative. Another possible explanation is that aged African Americans have

managed to overcome or reduce the feelings of indignation that prompt many suicides in

younger African Americans.

INFOCENTRAL

THE RIGHT TO DIE BY SUICIDE

In ancient Greece, citizens with a grave illness or mental anguish could obtain official permission

from the Senate to take their own lives. In contrast, most Western countries have traditionally

discouraged suicide, based on their belief in the “sanctity of life.” Today, however, a person’s

“right to die by suicide” is receiving more and more support from the public, particularly in

525

connection with ending great pain and terminal illness (Quill & Battin, 2018; Braverman et al.,

2017).

SUMMING UP

IS SUICIDE LINKED TO AGE? The likelihood of suicide varies with age. It is uncommon among children, although it has been rising in that group

during the past several decades. Adolescent suicide has been linked to clinical depression, anger, impulsiveness, major

526

stress, and adolescent life itself. Suicide attempts by this age group are numerous. The rate of suicide among

American Indian teens is twice as high as that among non-Hispanic 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 end their lives 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.

527

#HospitalAlert Suicidal behavior or thinking is the most common reason for

admission to a mental hospital. Around two-thirds of patients

who are admitted have aroused concern that they will harm

themselves (Miret et al., 2011; Jacobson, 1999).

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 complete or attempt suicide. Indeed, their feelings of loss, guilt, and anger after a

suicide fatality or attempt can be intense (Fouet, 2017). However, 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, 2018, 2014). Some are left with

severe injuries, brain damage, or other medical problems. Once the physical damage is treated,

psychotherapy 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 the lack of follow-up care. In others, the person who has attempted suicide refuses

therapy (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 (Sun et al., 2018). Studies

indicate that people who receive therapy after their suicide attempts have a lower risk of future

suicide attempts and deaths than do attempters who do not receive such therapy (Schreiber &

Culpepper, 2018; Kennebeck & Bonin, 2017). Various therapies have been employed, including

drug, psychodynamic, cognitive-behavioral, group, and family therapies.

Research indicates that cognitive-behavioral therapy may be particularly helpful (Asarnow et

al., 2017; Mewton & Andrews, 2016). When clients are suicidal, this approach focuses largely on

identifying and changing the painful thoughts, sense of hopelessness, dichotomous thinking,

poor coping skills, weak problem-solving abilities, and other cognitive and behavioral features

528

that characterize suicidal people. Applying the principles of mindfulness-based cognitive-

behavioral therapy (see pages 53 and 110), the therapists may also guide the clients to accept

many of the negative thoughts that keep streaming through their minds rather than try to

eliminate them. Acceptance of this kind is expected to increase the clients’ tolerance of

psychological distress. All such treatment features are particularly prominent in a new-wave

cognitive-behavioral approach called dialectical behavior therapy (DBT), which is being used

increasingly in cases of suicidal thinking and attempts. You will be reading about DBT in

Chapter 13, Personality Disorders.

What Is Suicide Prevention? During the past half-century, emphasis around the world has shifted from suicide treatment 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.

suicide prevention program A program that tries to identify people who are at risk of killing themselves and to offer them crisis intervention.

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 individuals 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. Because crises can occur at any time, the centers advertise their hotlines

and also welcome people who walk in without appointments. A growing number of centers also

offer their services through modalities such as text messaging and Internet chat (Predmore et al.,

2017; Nauert, 2016).

crisis intervention

529

What limitations or problems might result from attempts to

prevent suicides by the use of texting?

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.

One nonprofit service, the Crisis Text

Line, has been offering text counseling

since 2013, in partnership with a number

of hotlines across the United States

(Greenberg, 2018; Lublin, 2014). In the first half year of operation, it exchanged nearly a million

texts with 19,000 teenagers, with only minimal advertising, and by 2017 it had processed a total

of 28 million texts. As you read earlier, Facebook and Google now link suicidal users or friends

and relatives of suicidal persons to this service (Guynn, 2017).

Some prevention centers and hotlines reach out to particular suicidal populations. The Trevor

Lifeline, for example, is a nationwide, around-the-clock hotline available for LGBTQ teenagers

who are thinking about suicide. This hotline is one of several services offered by the Trevor

Project, a wide-reaching organization dedicated to providing support, guidance, and information

and to promoting acceptance of LGBTQ teens.

Today, suicide prevention takes place not only at prevention centers and hotlines but also in

therapists’ offices. A number of guidelines have been developed to help therapists effectively

uncover, assess, prevent, and treat suicidal thinking and behavior in their daily work (de Beurs et

al., 2015).

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

530

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. Counselors 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 in recent years (Schreiber & Culpepper,

2018). In addition, if callers are in the midst of a suicide attempt, counselors try to find out

their whereabouts and get medical help to them immediately.

531

Working with suicide After persuading this man to not jump to his death, California Highway Patrol officers help him

back over a rail of the Golden Gate Bridge. Police departments across the world typically provide special crisis intervention

training so that officers can develop the skills to help suicidal individuals.

Although crisis intervention may be sufficient treatment for some suicidal people, longer-term

therapy is needed for most. 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 particularly

lethal and common means of suicide through measures such as gun control, safer medications,

better bridge barriers, and car emission controls (Sinyor et al., 2019; Anestis & Houtsma, 2018;

Zalsman et al., 2016). In the 1990s, for example, Canada passed a law restricting the availability

of and access to certain firearms. Since then, there has been a decrease in firearm suicides across

532

the country.

Life-saving performance In a powerful moment at the 2018 Grammy Awards, rapper Logic (center) performs his song “1-

800-273-8255,” flanked by singer-songwriters Khalid and Alessia Cara and joined onstage by individuals personally affected

by suicide. The title of the song is the phone number of the National Suicide Prevention Lifeline. Help-seeking phone calls

and Web site visits to the suicide prevention organization tripled during the hours following this performance. Similarly, the

organization had previously experienced a 50 percent increase in calls after Logic performed the song at the MTV Video

Music Awards, and it had received the second-most calls in its history the day the song was released.

Do Suicide Prevention Programs Work? It is difficult for researchers to measure the effectiveness of suicide prevention programs. 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). Studies 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 &

533

#RecentRockSuicides

Chester Bennington, singer/songwriter (2017)

Chris Cornell, singer/songwriter/musician (2017)

Bob Welch, guitarist/singer/songwriter (2012)

Ronnie Montrose, guitarist (2012)

Mark Linkous, singer/songwriter/musician (2010)

Vic Chesnutt, singer/songwriter (2009)

Johnny Lee Jackson, rapper (2008)

Brad Delp, singer (2007)

Vince Welnick, keyboardist (2006)

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). On the

other hand, prevention programs do seem

to reduce the number of suicides among

those high-risk people who do call. One

famous 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 killed themselves, 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 announcements on the Web, television, radio, and billboards indicate

movement in this direction.

A key difficulty for suicide prevention programs is that they depend on accurate assessments

of suicide risk, and accurate assessments are elusive (Nock et al., 2018). People who are suicidal

do not necessarily recognize, admit to, or talk about their true feelings in discussions with

professionals. With this in mind, some researchers are working to develop tools of suicide

assessment that rely less on verbal self-reports and more on nonverbal behaviors,

psychophysiological measures, brain scans, and the like.

One alternative assessment approach is the Self-Injury Implicit Association Test, developed by

researcher Matthew Nock. Rather than asking people if they plan to attempt suicide, this

cognitive test simply instructs them to pair various suicide-related words (for example, “dead,”

“lifeless,” “suicide”) with words that are personally relevant (“I,” “myself,” “mine”) and with

words that are not personally relevant (“they,” “them,” “other”). It turns out that individuals who

are inclined to attempt suicide pair the suicide-related words with personally relevant words

much more quickly than with nonpersonally relevant words. In a number of studies, this test has

detected and predicted past and future suicide behavior more accurately than traditional self-

report assessment scales (Barnes et al., 2017; Glenn et al., 2017). Needless to say, this promising

534

Why might some schools be reluctant to offer suicide

education programs, especially if they have never

experienced a suicide attempt by one of their students?

approach to assessment has captured the attention of many suicide researchers and clinicians.

While the field awaits more accurate

assessment tools and more effective

interventions, many theorists believe that

public education about suicide is the

ultimate form of prevention—and a

number of suicide education programs have emerged. Most of these programs take place in schools

and concentrate on students and their teachers (SAMHSA, 2017; Zalsman et al., 2016). There

are also a growing number of online sites that provide education about suicide—targeting

troubled persons, their family members, and friends. 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 half-century, emphasis has shifted to suicide prevention. Suicide prevention programs include 24-

hour-a-day hotlines and walk-in centers staffed largely by paraprofessionals. Many of today’s centers also offer services

through text messaging and Internet chat. During their initial contact with a suicidal person, counselors try to

establish a positive relationship, understand and clarify the problem, 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.

535

#TheirWords “I am extremely thankful that I did not take my own life.”

Michael Phelps, 2018, decorated Olympic swimmer, discussing

his struggles with depression

Psychological and Biological Insights Lag Behind

Once a mysterious and hidden problem,

hardly acknowledged by the public and

barely investigated by professionals,

suicide today is the focus of much

attention. During the past 50 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. Sociocultural 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 explain and

understand 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.

536

Chapter 7 Review

Key Terms

parasuicide

suicidal behavior disorder

suicide

death seeker

death initiator

death ignorer

death darer

subintentional death

nonsuicidal self injury

retrospective analysis

hopelessness

dichotomous thinking

postvention

Thanatos

egoistic suicide

altruistic suicide

anomic suicide

interpersonal theory of suicide

serotonin

brain-circuit dysfunction

suicide prevention program

suicide hotline

537

paraprofessional

crisis intervention

Self-Injury Implicit Association Test

suicide education program

Quick Quiz

1. Define suicide and subintentional death. Describe four different kinds of people who attempt suicide. What is nonsuicidal self-injury? pp. 212–215

2. What techniques do researchers use to study suicide? p. 215

3. How do statistics on suicide vary according to country, religion, gender, marital status, and race? pp. 215–217

4. What kinds of immediate and longterm stressors have been linked to suicide? pp. 217– 218

5. What other conditions or events may help trigger suicidal acts? pp. 218–220

6. How do psychodynamic, sociocultural (including work by Emile Durkheim and Thomas Joiner), and biological theorists explain suicide, and how well supported are their theories? pp. 221–224

7. Compare the risk, rate, and causes of suicide among children, adolescents, and elderly persons. pp. 225–230

8. How do theorists explain the high rate of suicide attempts by adolescents and young adults? p. 227

9. Describe the nature and goals of treatment given to people after they have attempted suicide. Do such people often receive this treatment? pp. 230–231

10. Describe the principles of suicide prevention programs. What procedures are used by counselors in these programs? How effective are the programs? pp. 231–234

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

538

LearningCurve, as well as study aids including flashcards, FAQs, and research exercises.

539

CHAPTER 8 Disorders Featuring Somatic Symptoms

TOPIC OVERVIEW

540

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-Behavioral Interventions Support Groups and Emotion Expression Combination Approaches

Expanding the Boundaries of Abnormal Psychology

It 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 became 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?

541

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. Alternatively, 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 frequently have physical

causes. Dysfunctional brain circuits and abnormal neurotransmitter activity, for example,

contribute to generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. Is it

surprising, then, that bodily illnesses may have psychological causes? Today’s clinicians recognize

the wisdom of Socrates’ assertion made many centuries ago: “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 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, the

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 unconscious needs can contribute in major ways to

bodily illness.

542

“My back is fine. My mind went out.”

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 symptoms; 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.

543

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 suspect that other factors are

involved. Perhaps the patient is malingering—intentionally feigning illness to achieve some

external gain, such as financial compensation or time off from work.

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 (Irwin &

Bursch, 2018). Physicians would then decide that the patient is manifesting factitious disorder

(see Table 8-1). Consider, for example, the symptoms of Adia, a patient with bacteremia—

presence of bacteria in the blood, which can, if not corrected, lead to the life-threatening

condition called sepsis. As you will see, the medical team’s handling of Adia’s right to privacy

raises ethical issues, but the case itself illustrates the features of factitious disorder.

[Adia] was referred to [the medical center] for evaluation of recurrent urinary tract infections and bacteremia. … She also

had a skin disorder with blisters. An extensive workup showed … a completely normal genitourinary tract. …

Based on [Adia’s unexplained] symptoms … , one of the several doctors on this case suspected that the patient was inducing

her own illness, and he decided to secretly search her personal possessions. …

While the patient was having an x-ray, her room was searched. Her purse contained a Petri dish with growing bacterial

colonies, as well as needles, a syringe, and a tourniquet. The … Petri dish [was] replaced. Later that day, the patient was asked

whether she might be harming herself by injection [of bacteria into her body]. She denied this, saying that she wanted to get better.

Still later that day, the doctor told the patient that he knew she had some incriminating items in her purse. She then opened her

purse so the doctor could see inside, and the items were apparently no longer present. To prove her point, the patient turned her

purse upside down. At that point, one needle and a syringe fell out, which she had apparently overlooked when she returned from

her x-ray and suspected that someone had searched her purse. The patient was upset about the room search but not visibly angry.

She readily agreed to see a psychiatrist but continued to deny self-injection.

The next day, the patient tearfully confessed that she had had bacteriological materials in her purse, but she said she used them

only to aspirate and culture some blisters on her skin. She still denied self-injection with bacteria and said she wanted the doctors

to “keep looking for the cause of my problems.”

(Savino & Fordtran, 2006, pp. 201–202)

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.

TABLE: 8-1 Dx Checklist Factitious Disorder Imposed on Self

544

#SeekingRelief Research suggests that 17 percent of patients under the care of

family physicians display physical symptoms that have no

apparent physical cause (Greenberg, 2016).

1. False creation of physical 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 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 supposed 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, infections, or other problems (Yates & Feldman, 2017). Still

others use laxatives to produce chronic diarrhea. High fevers are especially easy to create. In

studies of patients with a prolonged mysterious fever, 9 percent were eventually diagnosed with

factitious disorder (Irwin & Bursch, 2018).

People with factitious disorder often research their supposed ailments and are impressively

knowledgeable about medicine. Many eagerly undergo painful testing or treatment, even surgery.

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

factitious disorder, since patients with the

disorder hide the true nature of their

problem (Kapfhammer, 2017). 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) received 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 (Yates & Feldman, 2017). A

number have poor social support, few enduring social relationships, and little family life (Irwin &

Bursch, 2018; McDermott et al., 2012).

545

The precise causes of factitious disorder are not understood, although clinical reports have

pointed to factors such as depression, unsupportive parental relationships during childhood, and

extreme needs for attention and/or social support that are not otherwise available (Irwin &

Bursch, 2018). Nor have clinicians been able to develop dependably effective treatments for this

disorder.

Psychotherapists and medical practitioners often report feelings of annoyance or anger toward

people with factitious disorder, feeling that these people are, at the very least, wasting their time

(Jafferany et al., 2018; Weis et al., 2016). 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 produce physical illnesses in their children,

leading in some cases to repeated painful diagnostic tests, medication, and surgery (Roesler &

Jenny, 2018) (see Table 8-1 again). If the children are removed from their parents and placed in

the care of others, their symptoms disappear (see PsychWatch).

PSYCHWATCH

Munchausen Syndrome by Proxy

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 intestines. 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 it, “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. They say Mommy

was making me feel bad, putting bad stuff in my tube. But there’s no way Mommy made me feel that bad.”

546

Should society treat or punish those parents who produce

Munchausen syndrome by proxy in their children?

Convalescent, 1867, by Frank Holl

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 medications, contaminating a feeding tube, or even smothering the child, for example (Roesler &

Jenny, 2018; Akin et al., 2016). The illness can take almost any form, but the most common symptoms are bleeding,

seizures, asthma, comas, diarrhea, vomiting, “accidental” poisonings, infections, fevers, and sudden infant death syndrome

(Wittkowski et al., 2017).

Between 6 and 30 percent of the victims of Munchausen syndrome by proxy die as a result of their symptoms, and 8

percent of those who survive are permanently disfigured or physically impaired (Braham et al., 2017; Ayoub, 2006).

Psychological, educational, and physical development are also affected (Bass & Glaser, 2014).

The syndrome is very hard to diagnose and

may be more common than clinicians once thought

(Roesler & Jenny, 2018). The parent (usually 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. In

many cases, siblings of the sick child are also victimized (Braham et al., 2017).

What kind of parent carefully inflicts pain and illness on her own child? The typical Munchausen mother is

emotionally needy: she craves the attention and praise she receives for her devoted care of her sick child (Anderson,

Feldman, & Bryce, 2018; Ashraf & Thevasagayam, 2014). She may have little social support outside the medical system.

Often the mothers have a medical background of some kind—perhaps having worked formerly in a doctor’s office (Yates &

Bass, 2017). A number have medically unexplained physical problems of their own (Roesler & Jenny, 2018). Typically,

they deny their actions, even in the face of clear evidence, and initially may refuse to undergo therapy.

Law enforcement authorities approach Munchausen syndrome by proxy as a crime—a carefully planned form of child

abuse (Irwin & Bursch, 2018). They almost always require that the child be separated from the mother (Koetting, 2015;

547

Ayoub, 2010, 2006). At the same time, a parent who resorts to such actions is seriously disturbed and greatly in need of

clinical help. In the majority of cases, particularly those that are of moderate or modest severity, treatment makes it possible

for the parent to be reintegrated into the family (Roesler & Jenny, 2018). Currently, clinical researchers and practitioners

are working to develop still clearer insights and more effective treatments for such parents and their young victims.

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. In a related pattern, factitious disorder imposed on another, a parent fabricates or induces a physical

illness in his or her child.

548

Conversion Disorder and Somatic Symptom Disorder When a bodily ailment has an excessive and disproportionate impact on the person, 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 sailboat 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

horror: the Coast Guard finding Helen’s body … texts, e-mails, 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, e-mailing, 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

549

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.

conversion disorder A disorder in which bodily symptoms affect voluntary motor and sensory functions, but the symptoms are inconsistent with known medical diseases.

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 often is hard, even for physicians, to distinguish from a genuine medical

problem (Redinger et al., 2018; Tsui, Deptula, & Yuan, 2017). 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 (Stone & Sharpe, 2018, 2017). Because conversion disorders

are so similar to “genuine” medical ailments, physicians sometimes rely on oddities in the

patient’s medical picture to help distinguish the two (Tsui et al., 2017). The symptoms of a

conversion disorder may, for example, be at odds with the way the nervous system is known to

work. In a conversion 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.

550

FIGURE 8-1

Glove Anesthesia

In this conversion symptom (left figure) the entire hand, extending from the fingertips to the wrist, becomes numb. Actual

physical damage (right figure) to the ulnar nerve, in contrast, causes anesthesia in the ring finger and little finger and beyond

the wrist partway 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.)

The physical effects of a conversion disorder may also differ from those of the corresponding

medical problem (Stone & Sharpe, 2018, 2017). 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. 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 (Ding & Kanaan, 2017). Although some theorists

551

still believe that conversion 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 often appears suddenly,

at times of extreme stress. In some, but far from all, cases, conversion disorder lasts a matter of

weeks (Stone & Sharpe, 2018, 2017). Some research suggests that people who develop the

disorder tend to be generally suggestible (see MindTech); many are highly susceptible to hypnotic

procedures, for example (Tsui et al., 2017). It is thought to be a rare problem, occurring in at

most 5 of every 1,000 persons (Stone & Sharpe, 2018, 2017).

Somatic Symptom Disorder People with somatic symptom disorder become excessively distressed, concerned, and anxious

about bodily symptoms that they are experiencing, and their lives are greatly disrupted by those

symptoms (APA, 2013) (see Table 8-3). The symptoms last longer but are less dramatic than

those found in conversion disorder. In some cases, the somatic symptoms have no known cause;

in others, the cause can be identified. Either way, the person’s concerns are disproportionate to

the seriousness of the bodily problems.

somatic symptom disorder A disorder in which people become excessively distressed, concerned, and anxious about bodily symptoms they are experiencing, and their lives are disproportionately disrupted by the symptoms.

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 unreasonable number of thoughts, feelings, and behavior 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.

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.

552

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 because 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 experience 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 (Witthöft, Gropalis, & Weck, 2018; Walentynowicz et al., 2017). The pattern

typically lasts for many years, fluctuating over time but rarely disappearing completely without

therapy (Greenberg, 2016; Abbey, 2005).

As many as 4 percent of all people in the United States may experience a somatization pattern

in any given year, women much more commonly than men (Greenberg, 2016). 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

553

#AdditionalPain

32% Percentage of low-income people with chronic knee or leg pain

19% Percentage of high-income people with chronic knee or leg pain

(Information from: Anson, 2017; Brown, 2012)

#DiagnosticConfusion In the past, whiplash was regularly misdiagnosed as a

psychologically caused condition.

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 (Witthöft et al.,

2018; Cozzi et al., 2017). It may begin at

any age, and women seem more likely

than men to experience it. Often it

develops after an accident or during an

illness that has caused genuine pain, after

which the pain 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

excessive and uncontrolled emotions

underlie the bodily symptoms found in these disorders.

Work by Ambroise-Auguste Liébault and Hippolyte Bernheim in the late nineteenth century

554

helped foster the notion that such psychological factors were at the root of hysterical 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,

paralysis, 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 dysfunctions, they concluded, hysterical disorders might themselves be caused by

psychological processes.

Today’s leading explanations for conversion and somatic symptom disorders come from the

psychodynamic, cognitive-behavioral, and multicultural models. None has received much

research support, however, and the disorders are still poorly understood (Levenson, 2018; Stone

& Sharpe, 2017).

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 emotional conflicts into physical symptoms and concerns (Ding & Kanaan, 2017).

555

Electra complex goes awry Freud argued that a hysterical disorder may result when parents overreact to their daughter’s

early displays of affection for her father, by repeatedly punishing her, for example. The child may go on to exhibit sexual

repression in adulthood and convert sexual feelings into physical ailments.

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 unconsciously converting them into physical symptoms and

concerns.

MINDTECH

Can Social Media Spread “Mass Hysteria”?

556

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 pages 8–9). 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 (Loharikar et al., 2018; Boissoneault, 2017). Most of today’s clinicians consider

these outbreaks to be a form of conversion disorder.

Modern mass hysteria? A “flash mob” gathers around a security officer at Moscow’s International Airport, waving

their hands and arms. Some theorists believe that these increasingly common gatherings of numerous people are a

form of mass hysteria—especially those flash mobs that are sudden, unplanned, and characterized by chaotic dance

moves and flailing limbs.

New Zealand sociologist Robert Bartholemew (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, demonstrates the suggestive role played by social media (Goldstein & Hall, 2015; Vitelli, 2013). 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 eventually 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

during 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 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 (Boissoneault, 2017; Vitelli, 2013). In these and other

557

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 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.”

Most of today’s psychodynamic theorists take issue with parts of Freud’s explanation of

conversion and somatic symptom disorders, but they continue to believe that sufferers of the

disorders have unconscious conflicts carried forth from childhood that arouse anxiety, and that

they convert this anxiety into “more tolerable” physical symptoms (Levenson, 2018).

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 symptoms 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.

“Try falling down and scraping your knee. Then you can talk to me about pain.”

558

The Cognitive-Behavioral View Cognitive-behavioral theorists point to rewards and communication skills to help explain

conversion and somatic symptom disorders. Regarding rewards, they propose that the physical

symptoms of these disorders yield important benefits to sufferers (see Table 8-4). Perhaps the

symptoms remove the individuals from an unpleasant relationship or perhaps the symptoms

bring attention from other people (Levenson, 2018; Witthöft et al., 2018). In response to such

rewards, the sufferers learn to display the bodily symptoms more and more prominently. The

theorists also hold that people who are familiar with an illness will more readily adopt its physical

symptoms. In fact, studies find that many sufferers develop their bodily symptoms after they or

their close relatives or friends have had similar medical problems (Stone & Sharpe, 2018, 2017).

TABLE: 8-4 Disorders That Have Somatic Symptoms Disorders 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 disorders

No Yes Maybe

Illness anxiety disorder No Yes No

Psychophysiological disorder

No Yes No

Physical illness No Maybe No

*Except for medical attention.

Clearly, this focus on the role of rewards is similar to the psychodynamic 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. Cognitive-

behavioral theorists view them as the primary cause of the development of the disorders.

Like the psychodynamic explanation, the reward explanation 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.

In the communication realm, some cognitive-behavioral theorists propose that conversion and

somatic symptom disorders are forms of self-expression, providing a means for people to reveal

559

emotions that would otherwise be difficult for them to convey (Levenson, 2018). 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 anxiety but to communicate extreme feelings—anger, fear,

depression, 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 conversion and somatic symptom disorders (Erkic et al., 2018). 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 communication (Cozzi et al.,

2017; Shaw et al., 2010). Like the other explanations, this cognitive-behavioral view has not been

widely tested or supported by research.

The Multicultural View Most Western clinicians believe that it is inappropriate to produce or focus excessively on

somatic symptoms in response to personal distress. That is, in part, why conversion and somatic

symptom disorders 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 (Krupić et al., 2019; Bagayogo, Interian, & Escobar, 2013; Moldavsky, 2004).

In fact, the transformation of personal distress into somatic complaints is the norm in many

non-Western cultures (Calzada et al., 2017). In such cultures, 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, Japan, and Arab countries (Löwe &

Gerloff, 2018; Matsumoto & Juang, 2016). People throughout Latin America seem to display

the most somatic reactions (Escobar, 2004, 1995). Even within the United States, Hispanic

Americans display more somatic reactions in the face of stress than do other populations (Calzada

et al., 2017).

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.

560

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. When a physician 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.

Mind over matter The opposite of conversion and somatic symptom disorders are instances in which people “ignore” pain

or other physical symptoms. Here a London performance artist smiles comfortably at onlookers while her skin is being

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 still-living body back into the sea.

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. 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 (Stone &

Sharpe, 2018; Kaplan, 2016). Alternatively, cognitive-behavioral therapists use exposure

treatments. They expose clients to features of the horrific events that first triggered their physical

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

561

#DiagnosticControversy Even people whose physical symptoms are caused by significant

medical problems may qualify for a diagnosis of somatic

symptom disorder if they are overly anxious or upset by their

medical problems. Critics worry that many patients who are

understandably upset by having cancer, heart disease, or other

serious diseases may incorrectly receive a diagnosis of somatic

symptom disorder (Barsky, 2016).

channels (Newby et al., 2018; Tsui et al., 2017). And biological therapists most often use

antidepressant drugs to help reduce anxiety and depression in patients with these disorders

(Levenson, 2018; Kurlansik & Maffei, 2016).

Other therapists try to address the

physical symptoms of these disorders rather

than the causes, using techniques such as

education, reinforcement, and cognitive

restructuring (Stone & Sharpe, 2018).

Those who employ education explain the

disorder to patients, while also offering

emotional support and hope that the

physical symptoms may soon disappear. Therapists who take a reinforcement approach arrange for

the removal of rewards for a client’s “sickness” symptoms and an increase of rewards for healthy

behaviors. And those who offer cognitive restructuring guide clients to think differently about the

nature and causes of physical symptoms and illness (Levenson, 2018). Researchers have not fully

evaluated the effects of these approaches on conversion and somatic symptom disorders; several

studies, however, have found them to be useful interventions (Stone & Sharpe, 2018; 2017; Tsui

et al., 2017). It is also the case that antidepressant medications sometimes help alleviate the

physical symptoms of people with these disorders in addition to reducing their feelings of anxiety

and depression.

SUMMING UP

CONVERSION AND SOMATIC SYMPTOM DISORDERS Conversion disorder involves bodily symptoms that affect voluntary motor and sensory functions, but the symptoms

are inconsistent with known medical diseases. In somatic symptom disorder, 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.

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

cognitive-behavioral theorists, the physical symptoms of these disorders bring rewards to the sufferer, and such

reinforcement helps maintain the symptoms. Some cognitive-behavioral theorists further 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 education,

reinforcement, or cognitive restructuring.

562

563

#StrangeCoincidence? On February 17, 1673, French actor-playwright Molière

collapsed onstage and died while performing in Le Malade

Imaginaire (The Hypochondriac).

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. Some such

people recognize that their concerns are excessive, but many do not.

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.

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 health-related behaviors (e.g., keeps focusing on body) or dysfunctional health- avoidance behaviors (e.g., avoids doctors).

4. Person’s concerns continue to some degree for at least 6 months.

Information from: APA, 2013.

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 seeing many cases. As many as 5 percent of all patients seen

by primary care physicians may display the disorder (Levenson, 2018; Dimsdale et al., 2011).

Theorists typically explain illness anxiety disorder much as they explain anxiety-related

disorders (see Chapter 4). Cognitive-behavioral theorists, for example, believe (1) that the illness

fears are acquired through classical conditioning or modeling, and (2) that people with the

564

disorder are so sensitive to and threatened by bodily cues that they come to misinterpret them

(Levenson, 2018; Marshall et al., 2007).

People with illness anxiety disorder usually receive the kinds of treatments that are used to

treat obsessive-compulsive disorder (see pages 130–133). Studies reveal, for example, that clients

with the disorder often improve considerably when given the same antidepressant drugs that are

helpful in cases of obsessive-compulsive disorder. Many clients also improve when treated with

the cognitive-behavioral approach of exposure and response prevention. 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, the cognitive-behavioral therapists guide the clients to

identify, challenge, and change their beliefs about illness that are helping to maintain their

disorder (Levenson, 2018; Newby et al., 2018).

SUMMING UP

ILLNESS ANXIETY DISORDER People with illness anxiety disorder are chronically 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 and cognitive-behavioral approaches originally

developed for obsessive-compulsive disorder.

565

Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions About 90 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 (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.

psychophysiological disorders Disorders in which biological, psychological, and sociocultural factors interact to cause or worsen a physical illness. Also known as psychological factors affecting other medical conditions.

TABLE: 8-6 Dx Checklist Psychological Factors Affecting 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.

It is important to recognize that significant medical symptoms and conditions are involved in

psychophysiological disorders and that the disorders often result in serious 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

psychophysiological. 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 duodenum, resulting

in burning sensations or pain in the stomach, occasional vomiting, and stomach bleeding. More

566

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 (Vakil, 2017, 2015; Pizzorno, Murray, &

Joiner-Bey, 2016; Simon, 2013). 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 (Lanas & Chan, 2017).

ulcer A lesion that forms in the wall of the stomach or of the duodenum.

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: BLS, 2016; Pew Research Center, 2016, 2011, 2010; Wagstaff, 2015; IWS, 2011; MHA, 2008; NPD

Group, 2008.)

Asthma causes the body’s airways (the trachea and bronchi) to narrow periodically, making it

567

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 suffer from asthma (CDC, 2017; WHO,

2017), 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 (WHO, 2018; Fanta, 2017).

asthma A disease marked by narrowing of the trachea and bronchi, resulting in shortness of breath, wheezing, coughing, and a choking sensation.

Studying sleep Clinicians use special techniques to assess sleep disorders. This woman is undergoing a polysomnographic

examination, a procedure that measures physiological activity during sleep, including measurements of brain, eye, lung, and

heart activity.

Insomnia, difficulty falling asleep or maintaining sleep, plagues 30 percent of the population

each year (ASA, 2017). 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 population—have insomnia that lasts

months or years (see InfoCentral). 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 (Bonnet & Arand, 2018, 2017).

insomnia

568

Difficulty falling or staying asleep.

INFOCENTRAL

SLEEP AND SLEEP DISORDERS

Sleep is a naturally recurring state that features altered consciousness, 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.

569

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 (Burch, Rizzoli, & Loder,

2018; CDC, 2015, 2010).

muscle contraction headache A headache caused by a narrowing of muscles surrounding the skull. Also known as tension headache.

570

More than head pain Migraine headaches produce much more pain and a wider range of symptoms than most other kinds

of headaches. Here, at a program in Stockholm, Sweden, a mother massages the head of her young son, who suffers from

migraines. Systematic massaging is partially helpful to him during particularly severe episodes.

Migraine headaches are extremely severe, often nearly paralyzing, 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.

migraine headache A very severe headache that occurs on one side of the head, often preceded by a warning sensation and sometimes accompanied by dizziness, nausea, or vomiting.

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 neurotransmitter serotonin, vascular

problems, or muscle weakness (Cutrer & Bajwa, 2017; Taylor, 2017).

571

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 likelihood of stroke, heart disease, and kidney

problems. It is estimated that 77 million people in the United States have hypertension,

thousands die directly from it annually, and millions more perish because of illnesses caused by it

(Basile & Bloch, 2018; CDC, 2017, 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 (Basile &

Bloch, 2018).

hypertension Chronic high blood pressure.

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, more than 16 million people currently have some form of

coronary heart disease. It is the leading cause of death for both men and women, accounting for

17 million deaths around the world each year, 600,000 of them in the United States—around

one-third of all deaths (CDC, 2017; Wilson & Douglas, 2017). Approximately half of all

middle-aged men and one-third of middle-aged women develop coronary heart disease at some

point in their lives. The majority of all cases of this 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 (Tofler,

2018; Wilson & Douglas, 2017).

coronary heart disease Illness of the heart caused by a blockage in the coronary arteries.

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, respectively.

572

Which jobs in our society might be particularly stressful and

traumatizing? Might certain lifestyles be more stressful than

others?

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 network 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 (Ackland et al., 2016; Lundberg, 2011). 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 reactions 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. Research has indicated, for

example, that some people are particularly likely to have temporary rises in blood pressure when

stressed (Yuenyongchaiwat, 2017; Lundberg, 2011). It may be that they are prone to develop

hypertension.

PSYCHOLOGICAL FACTORS According to many theorists, certain needs, attitudes, emotions, or coping styles may cause

people to overreact repeatedly to stressors, and so increase their chances of developing

psychophysiological disorders. 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 (Howard, Myers, & Hughes,

2017).

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

573

deterioration.

Type A personality style A personality pattern characterized by hostility, cynicism, drivenness, impatience, competitiveness, and ambition. Type B personality style A personality pattern in which a person is more relaxed, less aggressive, and less concerned about time.

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 forties 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).

Type B sea turtle Most people have a clear picture of a Type A personality, but they have difficulty spotting a Type B

personality. They need look no farther than Crush, the ever so relaxed and laid-back sea turtle in the animation films

Finding Nemo and Finding Dory. Crush always goes with the flow and surfs the seas at his own comfortable pace.

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

574

several of the characteristics that supposedly make up the Type A style, particularly hostility,

competitiveness, and time urgency, may indeed be strongly related to heart disease (Tofler, 2018;

Jennings et al., 2017).

SOCIOCULTURAL FACTORS: THE MULTICULTURAL PERSPECTIVE Adverse social conditions may set the stage for psychophysiological disorders. 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 impoverished people have more psychophysiological disorders,

poorer health in general, and poorer health outcomes than wealthier people (Robinson-Papp et

al., 2017; Singh & Siahpush, 2014). One obvious reason for this relationship is that poor people

typically experience higher rates of crime, unemployment, overcrowding, and other negative

stressors than wealthier people. In addition, they typically receive inferior medical care.

The relationship between race and psychophysiological and other health problems is

complicated. On the one hand, as one might expect from the economic trends just discussed,

African Americans have more health problems than do non-Hispanic white Americans. African

Americans have, for example, higher rates of high blood pressure, high cholesterol, diabetes, and

asthma (CDC, 2017, 2016, 2014). They are also more likely to die of heart disease and stroke.

Certainly, economic factors may help explain this racial difference. Many African Americans live

in poverty, and those who do often must contend with the high rates of crime and

unemployment that can contribute to poor health (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 44 percent of African Americans have high blood pressure, compared

with 33 percent of non-Hispanic white Americans (CDC, 2018, 2016, 2011). Although this

difference may be explained in part by the dangerous environments in which many African

Americans live and the unsatisfying jobs at which many must work (Marden et al., 2016), other

factors may also be operating (Muntner et al., 2017). A physiological predisposition among

African Americans may, for example, increase their risk of developing high blood pressure. Or it

may be that repeated experiences of racial discrimination constitute special stressors that help

raise the blood pressure of African Americans (see Figure 8-3). Studies have found, for example,

that the more discrimination people experience over a 1-year period, the greater their daily rise in

blood pressure, and the more discrimination African Americans experience over the course of

575

their lives, the more likely they are to have high blood pressure in middle age and old age (Colen

et al., 2018; Beatty Moody et al., 2016; Dolezsar et al., 2014).

FIGURE 8-3

How Much Discrimination Do Racial Minority Teenagers Face?

It depends on who’s being asked the question. In surveys of teenagers and young adults, African American respondents were

more likely than non-Hispanic white American respondents to recognize that African American teens experience various

forms of discrimination. (Information from: Black Youth Project, 2018, 2016, 2011; OA, 2017.)

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 (U.S. Census Bureau, 2016, 2010; BLS, 2015). However,

despite such disadvantages, the health of Hispanic Americans is, on average, at least as good and

often better than that of both non-Hispanic white Americans and African Americans (CDC,

2017, 2016, 2015). For example, Hispanic Americans have lower rates of high blood pressure

576

and asthma and live longer than non-Hispanic white Americans and 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 explanations have been offered

(Erving, 2017; Giuntella, 2016). 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. Or Hispanic Americans may have a

physiological predisposition that improves their likelihood of having better health outcomes.

New Psychophysiological Disorders Clearly, biological, psychological, and sociocultural factors combine to produce

psychophysiological disorders. In fact, the interaction of such factors is now considered the rule

of bodily functioning, not the exception (Levenson, 2018). 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.

Are Physical Illnesses Related to Stress? Back in 1967 two researchers, 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 8-7). 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.

TABLE: 8-7 Most Stressful Life Events Adults: Social Readjustment Rating Scale* Students: Undergraduate Stress Questionnaire†

1. Death of spouse 1. Death (family member or friend)

2. Divorce 2. Had a lot of tests

3. Marital separation 3. It’s finals week

577

Why are marriage, moving to a new house, and other

positive events also included on stress scales?

4. Jail term 4. Applying to graduate school

5. Death of close family member 5. Victim of a crime

6. Personal injury or illness 6. Assignments in all classes due the same day

7. Marriage 7. Breaking up with boy/girlfriend

8. Fired at work 8. Found out boy/girlfriend cheated on you

9. Marital reconciliation 9. Lots of deadlines to meet

10. Retirement 10. Property stolen

11. Change in health of family member 11. You have a hard upcoming week

12. Pregnancy 12. Went into a test unprepared

*Full scale has 43 items.

(Reprinted from Journal of Psychosomatic Research, Vol. 11, Holmes, T. H., & Rahe, R. H., The Social Readjustment Rating

†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.)

With this scale in hand, Holmes and Rahe (1989, 1967) examined the relationship 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 (Jäger, 2018; Harkness & Monroe, 2016;

Baum et al., 2011). 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

(King et al., 2017).

578

The ultimate body–mind connection? Psychologists have studied the relationship between psychological trauma and

immediate death—called the sudden death, or “giving-up,” phenomenon. In 2017, movie legend Debbie Reynolds (right)

died just one day after the death of her daughter, actress Carrie Fisher (left). According to Reynolds’s son, “She literally said

‘I want to be with Carrie’ and closed her eyes and went to sleep.”

One shortcoming of Holmes and Rahe’s Social Readjustment Rating Scale 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 non-Hispanic 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 non-Hispanic white Americans differ in their stress reactions to various kinds of life

events? Research indicates that indeed they do (Oates, 2016). One recent study found, for

example, that African American and Hispanic American teachers perceived and reacted to

occupational stressors (for example, heavy workload and administrator pressure) very differently

than did non-Hispanic white American teachers (Rauscher & Wilson, 2017).

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 (Kaya et al., 2017; Amirkhan et al.,

2015) (see Table 8-7 again).

Psychoneuroimmunology How do stressful events result in a viral or bacterial infection? Researchers in an area of study

called psychoneuroimmunology seek to answer this question by uncovering the links between

579

psychosocial stress, the immune system, and health. The immune system is the body’s network

of activities 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 stimulated by antigens, lymphocytes spring into action to help the body

overcome the invaders.

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.

First line of defense How do lymphocytes meet up with invading antigens? The lymphocytes 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 lymphocytes. Here a macrophage stretches its long “arms” (pseudopods) to detect and capture the

suspected antigens.

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 (Leem & Deane, 2019).

Researchers now believe that stress can interfere with the activity of lymphocytes and other

parts of the immune system, slowing them down and thus increasing a person’s susceptibility to

580

#MaritalStress

During and after marital spats, women typically release more

stress hormones than men, and so have poorer immune

functioning (Martire et al., 2018; Jaremka et al., 2013; Gouin

et al., 2009; Kiecolt-Glaser et al., 1996).

viral and bacterial infections (Levenson, 2018; Peters et al., 2017). In a landmark study,

investigator Roger Bartrop and his colleagues (1977) in New South Wales, Australia, compared

the immune systems of 26 people whose spouses had died 8 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 poor immune functioning in people who are exposed to long-term stress

(Gao et al., 2018). For example, researchers have found poorer immune functioning among

those who provide ongoing care for a relative with Alzheimer’s disease (Allen et al., 2017).

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 biochemical activity, behavioral changes, personality style, and

degree of social support.

BIOCHEMICAL ACTIVITY

As you’ll recall from Chapter 5, there are

two biological stress pathways by which

stressors produce arousal throughout the

brain and body (see pages 141–142). One

is the sympathetic nervous system, which,

among its many actions, triggers the

release of the neurotransmitter norepinephrine. It turns out that in addition to its role in

producing arousal, an extended release of norepinephrine can influence the immune system

adversely. Research indicates that if stress continues for too long a period, norepinephrine

eventually travels to receptors on certain lymphocytes and gives them an inhibitory message to

stop their activity, thus slowing down immune functioning (Bucsek et al., 2018; Takenaka et al.,

2016).

Recall also that the other biological stress pathway is the hypothalamic-pituitary-adrenal (HPA)

pathway, which, among its various actions, triggers the release of cortisol and other stress

hormones. Apparently, in addition to producing bodily arousal, an extended release of cortisol

and other stress hormones can contribute to poorer immune system functioning. As in the case of

581

norepinephrine, if stress continues for too long, the stress hormones travel to receptor sites

located on certain lymphocytes and give an inhibitory message, again causing a slowdown of the

activity of the lymphocytes (Ciliberti et al., 2017; Huo et al., 2017).

Research has further indicated that another action of norepinephrine and the various stress

hormones is to trigger an increase in the production of cytokines, proteins that bind to receptors

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 norepinephrine and

stress hormones 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 (Huo et al., 2017).

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 depressive 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 (Levenson, 2018).

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 better prepared to

fight off illness (Pandey & Shrivastava, 2017). Some studies have found, for example, that people

with “hardy” or resilient personal styles remain healthy after stressful events, while those whose

personalities are less hardy seem more susceptible to illness (Rolin et al., 2018). Researchers have

even discovered that men with a general sense of hopelessness die at above-average rates from

heart disease and critical illnesses (Orwelius et al., 2017; Kangelaris et al., 2010). 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 (Brooks et al., 2018; Roth et al., 2016).

582

Religious protection? In this famous photo of a 2015 prayer vigil, church congregants hold up pictures of 9 Bible study

participants who had been shot and killed two days earlier at the Emanuel African Methodist Episcopal Church in

Charleston, South Carolina. Some relatives of the victims later talked directly to the mass murderer, telling him they forgave

him and were praying for him. Research indicates that people with strong institutional, religious, and social ties often

recover more readily and more healthfully from the effects of traumatic events.

In related work, researchers have found a relationship between certain personality

characteristics and a person’s ability to cope effectively with cancer. 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 (You et al., 2018; Kim, Nho, &

Nam, 2017). A few investigators have even suggested a relationship between personality and

cancer outcome, but this claim has not been supported clearly by research (Pillay et al., 2014;

Urcuyo et al., 2005).

583

#TheirWords

“I would rather have anything wrong with my body than

something wrong with my head.”

Sylvia Plath, The Bell Jar

The power of support Cancer survivors clasp hands at the Susan G. Komen “Race for the Cure,” a 5K run held annually

throughout the world, with millions of participants. The run, begun almost 30 years ago, not only raises awareness about

cancer, it helps survivors support and encourage one another—applying research findings that social support can help

facilitate recovery from various illnesses.

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 (Russo, 2018; Pandey &

Shrivastava, 2017). In a pioneering study, medical students were given the UCLA Loneliness Scale

and then divided into “high” and “low” loneliness 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

584

illness or surgery (Levenson, 2018; Hicks, 2014). 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 (Imm et al., 2017; Hulett et al., 2015).

SUMMING UP

PSYCHOPHYSIOLOGICAL DISORDERS

Psychological factors affecting other medical conditions, known commonly as 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 factors, such as defects in the autonomic nervous system or particular

organs; psychological 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 illnesses as psychophysiological, such as

ulcers and hypertension. 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 system’s ability to protect against illness

during times of stress. Factors that seem to affect immune functioning include norepinephrine and cortisol activity,

behavioral changes, personality style, and social support.

585

Although doctors now prescribe psychological interventions

for a range of medical problems, many patients resist such

treatments. Why?

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 treatments 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.

behavioral medicine A field that combines psychological and physical interventions to treat or prevent medical problems.

Relaxation Training As you saw in Chapter 4, therapists

sometimes teach clients to relax their

muscles at will. The notion behind such

relaxation training 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. Given that relaxation training is

useful in the treatment of phobias and other anxiety disorders, clinicians believe that it can also

help prevent or treat medical illnesses that are related to stress.

relaxation training A treatment procedure that teaches clients to relax at will so they can calm themselves in stressful situations.

Relaxation training, often in combination with medication, has been widely used in the

treatment of high blood pressure (Aalami et al., 2016). It has also been of some help in treating

somatic symptom disorder, headaches, insomnia, asthma, diabetes, pain, certain vascular diseases,

and the undesirable effects of certain cancer treatments (Martin, 2018; Simkin & Klein, 2018;

Ernst, 2017).

586

Relaxing—and delicious! New stress-relief programs, techniques, and products are constantly being introduced to the

marketplace. These three individuals, for example, are able to unwind and relax in a chocolate spa at the Hakone Yunessun

spa resort in Japan.

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 seemingly involuntary physiological

processes.

biofeedback A technique in which a client is given information about physiological reactions as they occur and learns to control the reactions voluntarily.

The most widely applied method of biofeedback uses a device called an electromyograph

(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 8-4). 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 with changes in muscle tension. Thus clients “see” or

587

“hear” when their muscles are becoming more or less tense. Through repeated trial and error, the

individuals become skilled at voluntarily reducing muscle tension.

FIGURE 8-4

Biofeedback at Work

This biofeedback system records tension in the forehead muscles of a person with severe headaches. 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.

In a classic study, EMG feedback was used to treat 16 patients who had facial pain caused in

part by tension in their jaw muscles (Dohrmann & Laskin, 1978). 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 (Garza & Schwedt, 2018; Tofler, 2018).

Meditation Although meditation has been practiced since ancient times, Western health care professionals

have only recently become aware of its effectiveness in relieving physical distress. Meditation is a

technique of turning one’s concentration inward, achieving a slightly changed state of

consciousness, and temporarily ignoring all stressors. Typically, meditators go to a quiet place,

assume a comfortable posture, utter or think a particular sound (called a mantra) to help focus

their attention, and allow their mind to turn away from all outside thoughts and concerns. Many

588

#FunnyRemedy After watching a humorous video, research participants who

laughed at the video showed decreases in stress and

improvements in natural killer cell activity (Radcliff, 2017;

Bennett, 1998).

#GoodViewTherapy 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 without a

good view (Ulrich, 1984).

people who meditate regularly report feeling more peaceful, engaged, and creative (Basso et al.,

2019). 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 (Bonnet & Arand,

2018; Park & Han, 2017; Tofler, 2018).

One form of meditation that has been used in particular by patients suffering from severe

pain is mindfulness meditation (Gu, Hou, & Fang, 2018; Anheyer et al., 2017). Here, as you read

in Chapters 2 and 4, mindfulness 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 (Simkin &

Klein, 2018; Strada & Portenoy, 2018). A

breakthrough case study described 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 undergoing 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

589

with chemical forms of anesthesia is apparently helpful to many patients. Beyond its use in the

control of pain, hypnosis has been used successfully to help treat such problems as skin diseases,

asthma, insomnia, high blood pressure, warts, and other forms of infection (Sawni & Breuner,

2017; Becker, 2015).

Cognitive-Behavioral Interventions People with physical ailments have sometimes been taught new attitudes or cognitive responses

toward their ailments as part of treatment (Sandler et al., 2017). For example, an approach called

self-instruction training, or stress inoculation training, has helped patients cope with severe pain

(Meichenbaum, 2017, 1993, 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, interventions 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, including online support groups, and

from therapies that guide them to become more aware of and express their emotions and needs

(Gabbe et al., 2017; Cacioppo et al., 2016). 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 (Krupnick et al., 2017; 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.

590

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).

Combination Approaches Studies have found that the various psychological interventions for physical problems tend to be

equally effective (Sawni & Breuner, 2017). Relaxation and biofeedback training, for example, are

equally helpful (and more helpful than placebos) 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 (Strada &

Portenoy, 2018; Sandler et al., 2017). 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 better 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 (Burg, 2017; Burke

& Riley, 2010).

591

The hypnotic way An anesthesiologist hypnotizes a patient undergoing major surgery at the University Hospital Center of

Liege in Belgium. Many surgeries at the hospital are conducted using a combination of hypnosis and a local anesthetic

rather than general anesthesia.

Clearly, the treatment picture for physical illnesses has been changing dramatically. 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 medicine combines psychological and physical interventions to treat or prevent medical problems.

Psychological approaches such as relaxation training, biofeedback training, meditation, hypnosis, cognitive-behavioral

techniques, support groups, and therapies that heighten the awareness and expression of emotions and needs are

increasingly being included in the treatment of various medical problems.

592

CLINICAL CHOICES 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.

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 contributors 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 connection 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 disorders once considered purely

physical.

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.

593

Chapter 8 Review

Key Terms

mind-body dualism

malingering

factitious disorder

Munchausen syndrome

Munchausen syndrome by proxy

conversion disorder

somatic symptom disorder

Electra complex

primary gain

secondary gain

illness anxiety disorder

psychophysiological disorder

psychological factors affecting other medical conditions

ulcer

asthma

insomnia

muscle contraction headaches

migraine headaches

hypertension

coronary heart disease

Type A personality style

Type B personality style

594

Social Readjustment Rating Scale

psychoneuroimmunology

immune system

antigen

lymphocyte

cytokines

behavioral medicine

relaxation training

biofeedback

electromyograph

meditation

hypnosis

self-instruction training

Quick Quiz

1. What are the symptoms of factitious disorder, conversion disorder, and somatic symptom disorder? pp. 238–244

2. How do practitioners distinguish conversion disorder from a “genuine” medical problem? What are two different patterns of somatic symptom disorder? pp. 242–244

3. What are the leading explanations and treatments for conversion and somatic symptom disorder? How well does research support them? pp. 244–248

4. What are the symptoms, causes, and treatments of illness anxiety disorder? pp. 248–249

5. What are the specific causes of ulcers, asthma, insomnia, headaches, hypertension, and coronary heart disease? pp. 249–251

6. What kinds of biological, psychological, and sociocultural factors appear to contribute to psychophysiological disorders? pp. 251–254

7. What kind of relationship has been found between life stress and physical illnesses?

595

What scale has helped researchers investigate this relationship? pp. 254–256

8. Describe the connection between stress, the immune system, and physical illness. Explain the specific roles played by various types of lymphocytes. p. 256

9. Discuss how immune system functioning at times of stress may be affected by a person’s biochemical activity, behavioral changes, personality style, and social support. pp. 256– 258

10. What psychological treatments have been used to help treat physical illnesses? To which specific illnesses has each been applied? pp. 259–262

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

596

CHAPTER 9 Eating Disorders

TOPIC OVERVIEW

Anorexia Nervosa

597

The Clinical Picture Medical Problems

Bulimia Nervosa

Binges Compensatory Behaviors Bulimia Nervosa Versus Anorexia Nervosa

Binge-Eating Disorder

What Causes Eating Disorders?

Psychodynamic Factors Cognitive-Behavioral 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

Prevention of Eating Disorders: Wave of the Future

Shani, age 15: While I was learning to resist the temptation of hunger, I walked into the kitchen when no one was around,

took a slice of bread out 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 dictated 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

598

#EarlyPublication The first diet book was published in England, in the mid-

1800s (Herman, 2015).

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 retaliating 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. …

(Raviv, 2010)

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 morbid 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 is on the rise.

599

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 (NIMH, 2017).

The news media have published many reports about eating disorders. One reason 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 (Keel, 2018; NIMH, 2017).

600

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).

anorexia nervosa A disorder marked by the pursuit of extreme thinness and by extreme weight loss.

TABLE: 9-1 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.

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 eliminate 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.

Between 75 and 90 percent of all cases of anorexia nervosa occur in females (NIMH, 2017).

Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years.

Between 0.6 and 4.0 percent of all females in Western countries develop the disorder in their

lifetime, and many more display at least some of its symptoms (NIMH, 2017; Forman, 2017). 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 (NEDA, 2018; APA, 2015). The escalation toward anorexia nervosa may follow a

stressful event such as separation of parents, a move away from home, or an experience of

personal failure. Although most people with the disorder recover, as many as 6 percent of them

become so seriously ill that they die, usually from medical problems brought about by starvation,

601

or from suicide (Mehler, 2017). The suicide rate among people with anorexia nervosa is five

times the rate found in the general population (Klein & Attia, 2017).

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 (Ekern, 2018; Klein &

Attia, 2017). Many report that their dreams are filled with images of food and 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).

This preoccupation with food may in fact be a result of food deprivation rather than its cause.

In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious

objectors were put on a semistarvation 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.

602

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 (Klein & Attia, 2017). In

addition, they are likely to overestimate their actual proportions. While most women in Western

society overestimate 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 (Klein & Attia,

2017). 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 maladaptive attitudes

and misperceptions (Grzelak et al., 2017). 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.”

People with anorexia nervosa also have certain psychological problems, such as depression,

anxiety, low self-esteem, and insomnia or other sleep disturbances (Klein & Attia, 2017). A

number grapple with substance abuse. And many display obsessive-compulsive patterns. 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. 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.

603

Seeing is deceiving In one assessment and research technique, people look at drawings of bodies, ranging from very thin to

obese, then select the silhouette they believe represents their own body size. Individuals with anorexia nervosa typically pick

the wrong body size even if they hold photos of themselves during the task.

Medical Problems The starvation habits of anorexia nervosa cause medical problems (Lawson & Miller, 2017;

Mehler, 2017). Women develop amenorrhea, the absence of menstrual cycles. Other problems

include lowered body temperature, low blood pressure, body swelling, 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 collapse. 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

604

menstruating, [and] that my hipbones hurt to lie on my stomach and my coccyx hurt to sit on

the floor” (Raviv, 2010).

amenorrhea The absence of menstrual cycles.

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. People with this disorder develop various medical problems, particularly amenorrhea. As many as 90

percent of all cases of anorexia nervosa occur among females.

605

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 episode 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 inappropriate 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:

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 responsibilities 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 brownies. 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 getting 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 fattening. 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)

bulimia nervosa

606

A disorder marked by frequent eating binges followed 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.

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.

Like anorexia nervosa, bulimia nervosa usually occurs in females, again in 75 to 90 percent of

the cases (NIMH, 2017; Forman, 2017). It begins in adolescence or young adulthood (most

often between 15 and 20 years of age) and often lasts for years, with periodic letup. 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 seriously

underweight and may eventually qualify for a diagnosis of anorexia nervosa instead (see Figure 9-

1).

FIGURE 9-1

Overlapping Patterns of Eating Disorders

607

#DietBusiness Americans spend $68 billion each year on weight-reduction

foods, products, and services. The vast majority of that amount

is spent on diet foods (LaRosa, 2018; Fooducate, 2016).

Some people with anorexia nervosa binge and purge their way to weight loss, and some obese people binge eat. However,

most people with bulimia nervosa are not obese, and most overweight people do not binge eat.

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, 2018). Only some of these

individuals, however, qualify for a diagnosis of bulimia nervosa. Surveys in several Western

countries suggest that between 0.5 and 5.0 percent of women develop the full syndrome (Engel,

Steffen, & Mitchell, 2017; NIMH, 2017) (see Table 9-3). Among college students the rate

seems to be particularly high (Jacobson, 2018; Zerbe, 2008).

TABLE: 9-3 Comparing the Eating Disorders One-Year Prevalence

Percentage Who Are Female

Typical Age at Onset

Percentage Who Receive Treatment

Successful Long-Term Recovery After Treatment

Anorexia nervosa

0.6−4.0% 75−90% 14−20 years 34% 75%

Bulimia nervosa

0.5−5.0% 75−90% 15−20 years 43% 75%

Binge- eating disorder

2.0−7.0% 64−70% 22−30 years 44% 60%

Information from: Ekern, 2018, 2014; Mitchell, 2018; Crow, 2017; Engel et al., 2017; Forman, 2017; Klein & Attia, 2017;

NIMH, 2017; Sysko & Devlin, 2017.

Binges People with bulimia nervosa may have between 1 and 30 binge episodes per week (Fairburn et

al., 2015, 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 2,000 to 3,400 calories during an episode

(Engel et al., 2017). Some individuals consume as many as 10,000 calories.

608

#RoyalBulimia During her three years as queen of England, Anne Boleyn,

King Henry VIII’s second wife, displayed a habit, first observed

during her coronation banquet, 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 for sport Many people go on occasional eating binges. In fact, sometimes binges are officially endorsed, as you see in

this photo from the annual Nathan’s Famous International 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.

Binges are usually preceded by feelings of great tension. The person feels irritable, “unreal,”

and powerless to control an overwhelming need to eat “forbidden” 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 the individual has been

experiencing, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well

as fears of gaining weight and being discovered (Engel et al., 2017).

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

prevent the absorption of half of the

calories consumed during a binge.

609

Can you think of other areas of life besides eating and food

in which people sometimes binge and purge?

Furthermore, because repeated vomiting

affects one’s general ability to feel satiated, 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 (Mitchell, 2018).

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

(Mitchell, 2018). The cycle eventually causes people with the disorder to feel powerless and

disgusted with themselves (Engel et al., 2017). Most recognize fully that they have an eating

disorder. Lindsey, the woman we met 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 became 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

returned to the food.

(Hall & Cohn, 2010, p. 55)

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). Studies of both animals and humans have found that normal research participants

placed on very strict diets also develop a tendency to binge (Pankevich et al., 2010). Some of the

participants in the conscientious objector “starvation study,” for example, later binged when they

610

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 (Engel et al., 2017; Klein & Attia, 2017). People with

either of the disorders have a heightened risk of suicide attempts and fatalities. Substance abuse

may accompany either disorder, perhaps beginning with the excessive use of diet pills. People

with either disorder believe that they weigh too much and look too heavy regardless of their

actual weight or appearance (see InfoCentral). And both disorders are marked by disturbed

attitudes toward eating.

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, 2017, 2010,

2008). They also tend to be more sexually experienced and active than people with anorexia

nervosa (Gonidakis et al., 2015). 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 (Engel et al., 2017). More than one-third of

those with bulimia nervosa display the characteristics of a personality disorder, particularly

borderline or avoidant personality disorder, which you will be looking at more closely in Chapter

13.

Another difference is the nature of the medical complications that accompany the two

disorders (Forman, 2017; Mitchell & Zunker, 2017). 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 a host of serious medical problems, including dangerous

potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart

damage.

INFOCENTRAL

611

BODY DISSATISFACTION

People who evaluate their weight and shape negatively are experiencing body dissatisfaction.

Around 73% of all girls and women are dissatisfied with their bodies, compared with 56% of all

boys and men (Ross, 2018; Pop, 2016; Swami et al., 2016). The vast majority of dissatisfied

females believe they are overweight; in contrast, half of dissatisfied males consider themselves

overweight and half consider themselves underweight. The factors most closely tied to body

dissatisfaction are perfectionism and unrealistic expectations. Body dissatisfaction is the single

most powerful contributor to dieting and to the development of eating disorders.

612

SUMMING UP

BULIMIA NERVOSA People with bulimia nervosa go on frequent eating binges and then force themselves to vomit or perform other

inappropriate compensatory 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, sufferers generally feel disgusted with themselves, depressed, and guilty. As many as 90

percent of all cases of bulimia nervosa occur among females.

613

614

#ClimateControl Women 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 in

cooler climates (Delgado, 2018; Paulk et al., 2014; Sloan,

2002).

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 9-4). As a result of their frequent

binges, around half of people with binge-eating disorder become overweight or even obese

(Forman, 2017; Sysko & Devlin, 2017).

binge-eating disorder A disorder marked by frequent binges without extreme compensatory acts.

TABLE: 9-4 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 was first identified 60 years ago as a pattern common among many

overweight people (Stunkard, 1959). It is important to recognize, 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, 2018, 2014).

Between 2 and 7 percent of the

population have binge-eating disorder

(NEDA, 2018; NIMH, 2017; Brownley

et al., 2015). As with the other eating

disorders, women with this disorder

outnumber men; at least 64 percent of

sufferers are female (Forman, 2017;

NIMH, 2017). In addition, 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

615

experienced by individuals during the binge. Moreover, like people with bulimia nervosa or

anorexia nervosa, those with binge-eating disorder typically are preoccupied with food, weight,

and appearance; tend to base their evaluation of themselves largely on their weight and shape;

often misperceive their body size and are extremely dissatisfied with their body; often struggle

with feelings of depression, anxiety, and perfectionism; and may abuse substances (NIMH, 2017;

Sysko & Devlin, 2017). 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. Unlike the other eating disorders, binge-eating disorder does not necessarily

begin with efforts at extreme dieting. And people with this disorder typically first develop it later

than those with the other eating disorders; most often they are in their twenties (Forman, 2017;

NIMH, 2017).

“The Biggest Loser” phenomenon These men participate in a group exercise program as part of the reality television show

Peso Pesado (English: Heavy Weight), the Portuguese version of the remarkably successful American series The Biggest Loser.

In these shows, 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.

SUMMING UP

616

BINGE-EATING DISORDER People with binge-eating disorder have frequent binge-eating episodes in which they feel no control over their eating,

but they do not display inappropriate compensatory behaviors. Although most overweight people do not have binge-

eating disorder, half of those with binge-eating disorder become overweight. Between 2 and 7 percent of the

population have binge-eating disorder.

Like sufferers of anorexia nervosa and bulimia nervosa, people with binge-eating disorder tend to be preoccupied

with food, misperceive their body size, experience body dissatisfaction, and struggle with negative emotions. Unlike

anorexia nervosa and bulimia nervosa, most cases of this disorder begin after the age of 20.

617

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 person at risk for these disorders

(Stice & Desjardins, 2018; Stice et al., 2017). Generally, the more of these factors that are

present, the more likely it is that a person will develop an eating disorder. The multidimensional

risk perspective for eating disorders is not as specific as the developmental psychopathology

perspective, but it does share many principles with the latter perspective. That is, it too contends

that the risk factors for eating disorders unfold over the course of development, that interactions

between these factors are key, and that different risk factors and combinations of factors may lead

to the same eating disorders (Stice & Desjardins, 2018; Stice et al., 2017).

As you will see, most of the risk factors that have been cited and investigated center on

anorexia nervosa and bulimia nervosa. Binge-eating disorder, formally identified as a clinical

syndrome more recently, is only now being broadly investigated. The factors that are also at work

in this “newer” disorder will probably become clear in the coming years.

Downward spiral Aspiring to look like a Victoria’s Secret model, Australian teenager Christie Swadling transformed from a

healthy-weight individual into a 70-pound hospital patient suffering from anorexia nervosa in 2015. Now recovered, she

speaks out on social media about the dangers of disordered eating.

Psychodynamic Factors: Ego Deficiencies Hilde Bruch, a pioneer in the study and treatment of eating disorders, was mentioned earlier in

this chapter. Bruch developed a largely psychodynamic theory of the disorders. She argued that

618

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 (Treasure & Cardi, 2017; 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 comfort 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 confused

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 external guides,

such as their parents. They seem to be “model children,” but they fail to develop genuine self-

reliance and to “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 excessive 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 everybody 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 common—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 something.” 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 (Treasure &

Cardi, 2017; Holtom-Viesel & Allan, 2014). Clinicians have observed that the parents of

teenagers with eating disorders do tend to define their children’s needs rather than allow the

children to define their own needs (Ihle et al., 2005). 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).

619

“What do you eat for anxiety?”

Research has also supported Bruch’s belief that people with eating disorders perceive internal

cues, including emotional cues, inaccurately (Treasure & Cardi, 2017). When research

participants with an eating disorder are anxious or upset, for example, many of them mistakenly

think they are also hungry, and they respond as they might respond to hunger—by eating. And

finally, studies support Bruch’s argument that people with eating disorders rely excessively on the

opinions, wishes, and views of others (Treasure & Cardi, 2017) (see MindTech).

Cognitive-Behavioral Factors If you look closely at Bruch’s explanation of eating disorders, you’ll see that it contains several

cognitive-behavioral 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-behavioral theorists, these deficiencies

620

#TheirWords “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

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 (Mitchell, 2018; Fairburn et al.,

2015, 2008). This “core pathology,” say cognitive-behavioral theorists, contributes to all other

aspects of the disorders, including the repeated efforts to lose weight and the preoccupation with

shape, weight, and eating.

As you saw earlier in the chapter, research indicates that people with eating disorders do

indeed display such cognitive deficiencies (Klein & Attia, 2017). Although studies have not

clarified that the deficiencies are the cause of eating disorders, many cognitive-behavioral

therapists proceed from this assumption and center their treatment for the disorders on

correcting the clients’ cognitive distortions and their accompanying behaviors. As you’ll soon see,

cognitive-behavioral therapies are among the most widely used of all treatments for eating

disorders (Mitchell, 2018; Fairburn et al., 2015, 2008).

Depression Many people with eating disorders, particularly those with bulimia nervosa, have symptoms of

depression (Klein & Attia, 2017). This finding has led some theorists to suggest that depressive

disorders help set the stage for eating disorders.

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 population.

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, the depression-related brain circuit of

many people with eating disorders shows abnormalities that are similar to those of people with

depression. And finally, people with eating disorders are sometimes helped by the same

antidepressant 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.

MINDTECH

Dark Sites of the Internet

621

Besides promoting eating disorders, might there be other

ways in which pro-Ana sites are potentially harmful to

regular visitors?

Mental health practitioners and researchers try to combat psychological disorders—in person, in journals and

books, and online. Unfortunately, today there are also other—more negative—forces that run counter to the work of these

professionals. Among the most common are so-called dark sites of the Internet—sites with the goal of promoting behaviors

that the clinical community, and most of society, consider abnormal and destructive. Pro-anorexia sites are a prime example

of this phenomenon.

By conservative estimates, there are at least 600 pro-anorexia Internet sites, with names such as “Dying to Be Thin”

and “Starving for Perfection” (Yom-Tov, 2018, 2016). 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 symptoms.

Either way, the sites are enormously popular and appear to outnumber “pro-recovery” Web sites.

Many users of the sites exchange tips on how

they can starve themselves and disguise their weight

loss from family, friends, and doctors (Boepple &

Thompson, 2016; Griffiths et al., 2015). The sites

also offer support and feedback about starvation

diets. Many offer mottos, emotional messages, and photos and videos of extremely thin actresses and models as

“thinspiration.”

As with the pro-suicide Web sites you read about in Chapter 7, the pro-Ana movement and its messages appear across

the Internet—for example, on Web forums and chat groups; social networks such as Facebook, Tumblr, and LiveJournal;

and video platforms such as YouTube and Vimeo (Branley & Covey, 2017). Most social networks try to seek out and

delete pro-Ana material and groups. A few years ago, for example, Instagram banned hashtags that glorify self-harm and

threatened to disable those accounts. However, despite such efforts, the sites—and their pro-Ana messages—continue to

flourish.

622

Research suggests that, on average, regular visitors to the sites experience a rise in body dissatisfaction and depression,

increase their dieting behavior, display more disordered eating, and attempt more self-harm as a result of their many visits

(Yom-Tov et al., 2018, 2016; Rodgers et al., 2016). This worries professionals and parents alike.

Many people are concerned that pro-Ana sites place vulnerable people at great risk, and they have called for more active

efforts to ban the 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.

Biological Factors Biological theorists suspect that certain genes may leave some people particularly susceptible to

eating disorders (Mayhew et al., 2018; Bulik, Kleiman, & Yilmaz, 2016). 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. 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 (Kendler et al., 2018, 1995, 1991; Thornton, Mazzeo, & Bulik, 2011).

Laboratory obesity Biological theorists believe that certain genes leave some individuals particularly susceptible to eating

disorders. To help support this view, researchers have created 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.

623

One factor that has captured the attention of biological investigators is the possible role of

dysfunctional brain circuits in people with eating disorders (Monteleone et al., 2018). As you

have read throughout this book, a brain circuit is a network of particular brain structures that

work together, triggering each other into action to produce a distinct kind of behavioral,

cognitive, or emotional reaction (see pages 38–39). Research suggests that each of the circuits

linked to generalized anxiety, obsessive-compulsive, and depressive disorders also acts

dysfunctionally to some degree in people with eating disorders (Donnelly et al., 2018; Foerde et

al., 2015; Frank et al., 2013). For example, among individuals with eating disorders, the insula (a

structure in the anxiety-related circuit) is abnormally large and active, the orbitofrontal cortex (a

structure in the obsessive-compulsive-related circuit) is uncommonly large, the striatum (another

structure in the obsessive-compulsive-related circuit) is hyperactive, and the prefrontal cortex (a

structure in the anxiety-related, obsessive-compulsive-related, and depression-related circuits) is

unusually small. Similarly, the activity levels of serotonin, dopamine, and glutamate (key

neurotransmitters in the anxiety-related, obsessive-compulsive-related, and depression-related

circuits) are abnormal in people with eating disorders (Godlewska et al., 2017).

Given such findings, some researchers believe that dysfunction across or within those various

brain circuits collectively help cause eating disorders. However, at this early stage of research, it is

just as possible that the dysfunctions in those circuits are actually the result of eating disorders

(Forman, 2017). Alternatively, the observed circuit dysfunctions may simply reflect the fact that

many people with eating disorders also suffer from anxiety, obsessive-compulsive, and/or

depressive disorders (Engel et al., 2017; Klein & Attia, 2017).

Finally, a number of biological theorists focus their explanation of eating disorders on one

part of the brain in particular, the hypothalamus, a structure that regulates many bodily

functions (Gao et al., 2017; Tandon et al., 2017). 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.

hypothalamus A brain structure 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.

624

#TheirWords “Nothing tastes as good as skinny feels.”

Kate Moss, model

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. One

such brain chemical is the natural appetite suppressant glucagon-like peptide-1 (GLP-1) (Harada

et al., 2017; Dossat et al., 2014). When one team of researchers collected and injected GLP-1

into the brains of rats, the chemical traveled to receptors 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 hypothalamus, they more than doubled their food intake.

Some researchers believe that the hypothalamus, related brain structures, and chemicals such

as GLP-1, working together, comprise a “weight thermostat” 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,

2017; Chhabra et al., 2016). 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.

weight set point The weight level that a person is predisposed to maintain, controlled in part by the hypothalamus.

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,

2017; Chhabra et al., 2016). Once the brain and body begin conspiring to raise weight in this

way, dieters 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 continues to be accepted by many theorists and practitioners.

625

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?

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 (Forman, 2017; MacNeill & Best, 2015). Western standards of

female beauty have changed throughout history, with a noticeable shift in preference toward a

thin female frame over the past 60 years or so. For example, some “pioneering” studies conducted

throughout the second half of the twentieth century tracked the weight, bust, and hip

measurements of Playboy magazine centerfold models and Miss America Pageant contestants and

found a steady year-by-year decrease in those measurements that has continued into the current

century (Gilbert et al., 2005; Garner et al., 1980).

Dangerous professions Certain occupations—fashion modeling, dancing, acting, and sports—place a premium on

626

thinness, thus putting their professionals at particular risk for eating disorders. In a recent autobiography, Dancing

Throughout, famous ballet artist Jenifer Ringer (performing here in the ballet The Nutcracker) described her struggles with

eating disorders, both prior to and during her successful career as a principal dancer with the New York City Ballet.

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 criticized

about their weight. For example, after undergoing an inpatient treatment program for eating

disorders, the popular singer and rapper Kesha 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 (Forman, 2017). 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, 2018; Van Durme et al., 2012). By

some estimates, a full 20 percent of gymnasts may have an eating disorder.

Attitudes toward thinness may also help explain economic differences 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, dieting and a preoccupation with thinness have increased to some degree in all

socioeconomic classes, as has the prevalence of these eating disorders (Javier, Moore, & Belgrave,

2016).

Western society not only glorifies thinness but also creates a climate of prejudice against

overweight people (Brewis, SturtzSreetharan, &Wutich, 2018.). 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 indicates 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. Thus it is small wonder that the number of children under 12 years who

627

develop a full eating disorder is growing, especially among girls (Ekern, 2018; NIMH, 2017).

Given these trends, it is not totally surprising that one survey of 248 adolescent girls directly

tied eating disorders and body dissatisfaction to social networking, Internet activity, and

television browsing (Latzer, Katz, & Spivak, 2011). 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 (see Figure 9-2). 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.

FIGURE 9-2

What Does Teenage Eating Look Like?

Teenage eating habits are not particularly healthful in general and are, in fact, poor for many teens, according to research.

Small wonder that the majority of adolescents fail to meet dietary recommendations for nutrient intake. (Information from:

Demory-Luce & Motil, 2018; Lehman, 2016; CDC, 2015; Johnson, 2011; Sebastian et al., 2010.)

Family Environment Families may play an important role in the development and maintenance of eating disorders

(Cerniglia et al., 2017). Research suggests that as many as half of the families of people with

anorexia nervosa or bulimia nervosa have a long history of emphasizing thinness, physical

appearance, and dieting. In fact, the mothers in these families are more likely to diet themselves

628

and to be generally perfectionistic than are the mothers in other families (Zerbe, 2017, 2008;

Woodside et al., 2002). Tina, a 16-year-old, describes her view of the roots of her eating

disorder:

When I was a kid, say 6 or 7, my Mom and I would go to the drugstore all the time. She was heavy and bought all kinds of

books and magazines on how to lose weight. Whenever we talked, like after I got home from school, it was almost always about

dieting and how to lose weight. … I [went] on diets with my Mom, to keep her company. … My eating disorder is my Mom’s

therapy. … We’ve stopped talking about diets since I got anorexia, and now I don’t know what we can talk about.

(Zerbe, 2008, pp. 20–21)

Abnormal interactions and forms of communication within a family may also set the stage for

an eating disorder (Cerniglia et al., 2017). Family systems 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, believed that an enmeshed family pattern often leads to eating disorders

(Minuchin et al., 2017, 2006).

enmeshed family pattern A family system in which members are overinvolved with each other’s affairs and overly concerned about each other’s welfare.

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 argued that adolescence 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 appearance

of harmony. A sick child needs her family, and family members can rally to protect her.

Although some studies have supported such family systems explanations (Cerniglia et al., 2017),

they have failed to show that particular family patterns consistently set the stage for the

development of eating disorders.

Multicultural Factors: Racial and Ethnic Differences

629

Are girls and women in Western society destined to struggle

with at least some issues of eating and appearance?

In 1995 there was a popular movie titled Clueless in which Cher and Dionne, wealthy teenage

friends of different races, had similar tastes, beliefs, and values about everything from boys to

schoolwork. In particular, they had the same kinds of eating habits and beauty ideals, and they

were even similar in weight and physical form. But did the story of these young women reflect

the realities of non-Hispanic 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

Clueless indicated that the eating

behaviors, values, and goals of young African American women were considerably healthier than

those of young non-Hispanic 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 non-Hispanic white American women. It found, specifically, that

“only” 70 percent of the African American respondents were dissatisfied with their weight and

body shape, compared with nearly 90 percent of the non-Hispanic white American teens.

The study also suggested that non-Hispanic white American and African American adolescent

girls had different ideals of beauty. The former 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 American respondents emphasized personality traits over physical

characteristics. They defined the “perfect” African American girl as smart, fun, easy to talk to, not

conceited, 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 non-Hispanic white American respondents to diet for

extended periods.

Unfortunately, research conducted over the past two decades 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

(Rodgers et al., 2017; Starr & Kreipe, 2014; Gilbert, 2011). For example, in a frequently cited

survey conducted by Essence, a popular magazine geared toward African Americans, 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 percent vomited to lose

630

weight.

Embracing diversity? The Western ideal of extreme thinness remains the standard for fashion models, regardless of their

nationality or cultural background. Psychologists worry that the success of supermodels such as Ethiopia’s Liya Kebede

(above) and Sudan’s Alek Wek may contribute to thinner body ideals and more eating disorders in their African countries.

The shift in the eating behaviors and eating problems of African American women appears to

be partly related to their acculturation (Rittenhouse, 2016; Ford, 2000). One study compared

African American women at a predominately non-Hispanic 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.

Still other studies indicate that Hispanic American female adolescents and young adults

engage in disordered eating behaviors (particularly bingeing behavior) and express body

dissatisfaction at rates about equal to those of non-Hispanic white American women (Perez,

631

Ohrt, & Hoek, 2016; Cachelin et al., 2006). Moreover, those who consider themselves more

oriented to non-Hispanic white American culture have particularly high rates of anorexia nervosa

and bulimia nervosa. These eating disorders also appear to be on the increase among young Asian

American women and young women in several Asian countries (Thomas, Lee, & Becker, 2016;

Pike et al., 2013).

Multicultural Factors: Gender Differences Males account for only 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 reason. 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).

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 and develop anorexia nervosa or bulimia nervosa. Singer Zayn Malik (left) has acknowledged falling into this

pattern when he was a member of the boy band One Direction. Other men want the ultramuscular look displayed by

bodybuilders (right) and may develop an eating disorder called muscle dysmorphia. These individuals inaccurately consider

632

Why do you think that the prevalence of eating disorders

among men has been on the increase in recent years?

themselves to be scrawny and small and keep striving for a “perfect” body through excessive weight lifting and abuse of

steroids.

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 and studies, men are more likely to use exercise to lose weight,

whereas women more often diet (Thackray et al., 2016). 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 number of cases, the

disorder is linked to the requirements and pressures of a job or sport (Cottrell & Williams, 2016;

Braun, 1996). 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. The highest rates of male eating disorders have been found among jockeys,

wrestlers, distance runners, body builders, and swimmers.

For other men who develop anorexia nervosa or bulimia nervosa, body image appears to be a

key factor, just as it is in women (Lavender et al., 2017; Mayo & George, 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.

Still other men seem to be caught up

in a different kind of eating disorder,

called reverse anorexia nervosa or muscle

dysmorphia. Men with this disorder are

very muscular 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

(Lavender et al., 2017). People with muscle dysmorphia 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 multidimensional risk perspective to explain eating disorders and to identify several key

contributing factors. Principal among these are ego deficiencies; cognitive-behavioral factors; depression; biological

factors such as dysfunctional brain circuits, problematic activity of the hypothalamus, and disturbances of the body’s

633

weight set point; society’s emphasis on thinness and bias against obesity; family environment; racial and ethnic

differences; and gender differences.

634

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 problem. Family and friends can also

play an important role in helping to overcome the disorder.

A dangerous trip back When actress and model Zoe Kravitz agreed to play an anorexic woman in the movie The Road

Within, she believed her past history with eating disorders would be an asset. However, Kravitz reported that dieting down

to 90 pounds for the movie “triggered some old stuff,” and she had difficulty calling an end to the new weight loss (Takeda,

2015).

Treatments for Anorexia Nervosa Around one-third of those with anorexia nervosa receive treatment (NIMH, 2017). The

immediate aims of treatment for anorexia nervosa are to help people regain their lost weight,

635

recover from malnourishment, and eat normally again (Mehler, 2017). 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, a phase of treatment called nutritional rehabilitation

(Peebles et al., 2017). In the past, treatment almost always took place in a hospital, but now it is

often offered in day hospitals or outpatient settings.

In life-threatening cases, clinicians may need to force tube and intravenous feedings on a

patient who refuses to eat (Rocks et al., 2014). Unfortunately, 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.

Perhaps the most popular nutritional rehabilitation approach is a combination of supportive

nursing care, nutritional counseling, and a relatively high-calorie diet (Steinglass, 2016). Here

nurses and other staff members gradually increase a patient’s diet over the course of several weeks,

to more than 3,000 calories a day (Zerbe, 2017, 2010, 2008). The nurses educate patients about

the program, track their progress, provide encouragement, and help them appreciate that their

weight gain is under control and will not lead to obesity. In some programs, the nurses also use

motivational interviewing, an intervention that uses a mixture of empathy and inquiring review

to help motivate clients to recognize they have a serious eating problem and commit to making

constructive choices and behavior changes (Pike, 2017). Studies find that patients in nutritional

rehabilitation programs usually gain the necessary weight over 8 to 12 weeks.

motivational interviewing A treatment that uses empathy and inquiring review to help motivate clients to recognize they have a serious psychological problem and commit to making constructive choices and behavior changes.

How Are Lasting Changes Achieved? Clinical researchers have found that people with anorexia nervosa must overcome their

underlying psychological 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). Psychotropic drugs, particularly antipsychotic drugs, are sometimes

used when patients do not respond to the other forms of treatments, but research has found that

such medications are typically of limited benefit (Walsh, 2018).

636

#TheirWords

“Girls should be encouraged to take an interest in their

appearance when they are very young.”

Ladies’ Home Journal, 1940

COGNITIVE-BEHAVIORAL THERAPY A combination of cognitive and behavioral interventions are included in most treatment

programs for anorexia nervosa. Such techniques are designed to help clients appreciate and alter

the behaviors and thought processes that help keep their restrictive eating going (Pike, 2017). On

the behavioral side, clients are typically required to monitor (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

characteristics. The clients may also be taught alternative ways of coping with stress and of

solving problems.

The therapists who provide cognitive-

behavioral therapy are particularly careful

to help patients with anorexia nervosa

recognize their need for independence

and teach them more appropriate ways to

exercise control (Pike, 2017). The

therapists may also teach them to better identify and trust their internal sensations and feelings.

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 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 polite 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 promise you that you are free to speak your mind, and that I won’t turn away.

637

#FamilyTeasing

Adolescents teased about their weight by family members are

twice as likely as nonteased teens to become overweight within

five years and 1.5 times more likely to become binge eaters and

use extreme weight control measures (Saltzman & Liechty,

2016; Neumark-Sztainer et al., 2007).

(Strober & Yager, 1985, pp. 368–369)

Finally, cognitive-behavioral therapists

seek to help clients with anorexia nervosa

change their attitudes about eating and

weight (Pike, 2017; Fairburn et al., 2015,

2008) (see Table 9-5). The therapists

may guide the clients to identify,

challenge, and change maladaptive

assumptions, such as “I must always be perfect” or “My weight and shape determine my value.”

They may also educate the clients about the body distortions typical of anorexia nervosa and help

them see that their own assessments of their size are incorrect. Even if a client never learns to

judge her body shape accurately, she may at least reach a point where she says, “I know that a key

feature of anorexia nervosa is a misperception of my own size, so I can expect to feel fat regardless

of my actual size.”

TABLE: 9-5 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; Garner, Olmsted, & Polivy, 2004, 1991, 1984.

According to research, cognitive-behavioral techniques are often very effective in cases of

anorexia nervosa, more effective than psychodynamic therapies, psychoeducation, or supportive

therapy alone (Pike, 2017). The approach helps many individuals to restore their weight,

overcome their fear of becoming overweight, develop greater self-esteem, correct their body

distortions and dissatisfaction, adopt more accurate and adaptive eating attitudes, acquire more

638

appropriate eating and exercise habits, and develop better problem-solving skills. The treatment

is most successful at preventing relapses when it continues for at least a year beyond a patient’s

recovery—the maintenance therapy strategy that you read about in Chapter 6 (see pages 183 and

185). At the same time, studies further suggest that the cognitive-behavioral approach brings the

best results when it is supplemented by other approaches. In particular, family therapy is often

included in treatment.

“You can’t keep comparing yourself to those skinny little aliens you see in movies.”

CHANGING FAMILY INTERACTIONS Family therapy can be an invaluable part of treatment for anorexia nervosa, particularly for

children and adolescents with the disorder (Pike, 2017). 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 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 (Richards et al., 2018).

Mother:

I think I know what [Susan] is going through: all the doubt and insecurity 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.

639

#FashionDownsizing In 1968, the average fashion model was 8 percent thinner than

the typical woman. In 2016, models were 32 percent thinner

(Firger, 2016; Tashakova, 2011).

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 between 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, with cognitive-behavioral

therapy typically at the center, 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. As many as 75 percent of patients continue to show

improvement—either full or partial—when they are interviewed several years or more after their

initial recovery (Klein & Attia, 2017; Isomaa & Isomaa, 2014).

Another positive note is that most females with anorexia nervosa menstruate again when they

regain their weight, and other medical improvements follow (Mehler, 2016). Also encouraging is

that the death rate from anorexia nervosa seems to be falling. Earlier diagnosis and safer and

faster weight-restoration techniques may account for this trend. Deaths that do occur are usually

640

Why might some people who recover from anorexia nervosa

and bulimia nervosa remain vulnerable to relapse even after

recovery?

caused by suicide, starvation, infection, gastrointestinal problems, or electrolyte imbalance

(Mehler, 2017).

The beginning of a movement An early effort at responsible advertising regarding body shape and eating disorders occurred

back in 2007 when the Nolita clothing brand launched a major ad campaign against excessive thinness. One of the brand’s

billboards featured an emaciated naked woman appearing beneath the words “No Anorexia.” The billboard model Isabelle

Caro died in 2010 of complications from anorexia nervosa.

On the negative side, as many as 25 percent of persons with anorexia nervosa remain seriously

troubled for years (Klein & Attia, 2017; Isomaa & Isomaa, 2014). 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., 2017, 2013; Fennig et al., 2002). Even years later, many who have

recovered continue to express concerns about their weight and appearance (Klein & Attia, 2017).

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 psychological 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

641

#CelebrityEatingDisorders

Kesha, singer

Demi Lovato, singer

the end of treatment (Steinglass, 2016).

The more weight persons have lost and the more time that passes before they enter treatment,

the poorer the recovery rate (Klein & Attia, 2017; Zerwas et al., 2013). 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. People whose family or interpersonal relationships are

troubled have less positive treatment outcomes. Younger sufferers seem to have a better recovery

rate than older patients.

Treatments for Bulimia Nervosa Around 43 percent of those with bulimia nervosa receive treatment (NIMH, 2017). Treatment

programs for the disorder are often offered in eating disorder clinics. Such programs offer (1)

nutritional rehabilitation, which, for bulimia nervosa, means helping clients to eliminate their

binge-purge patterns and establish good eating habits, and (2) a combination of therapies aimed

at eliminating the underlying causes of bulimic patterns (Mitchell, 2018; Crow, 2017; Fairburn

& Cooper, 2014). The programs emphasize education as much as therapy. Cognitive-behavioral

therapy is particularly helpful in cases of bulimia nervosa—perhaps even more helpful than in

cases of anorexia nervosa. 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.

Cognitive-Behavioral Therapy When treating clients with bulimia nervosa, 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) and to the

specific beliefs at work in bulimia nervosa (Mitchell, 2018).

The 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

(Mitchell, 2018). This helps the clients to observe their eating patterns more objectively and

recognize the emotions and situations that trigger their desire to binge. Smartphone apps have

been particularly useful in keeping track of such changes throughout the day.

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,

642

Zane Malik, singer

Zosia Mamet, actress

Alanis Morissette, singer

Ashlee Simpson, singer

Adam Rippon, figure skater

Zoe Kravitz, actress

Kate Winslet, actress

Lady Gaga, singer/songwriter

Mary-Kate Olsen, actress

Kelly Clarkson, singer

Jessica Alba, actress

Elton John, singer

Ashley Rickards, actress

Fiona Apple, singer

Princess Diana, British royalty

Kate Beckinsale, actress

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 encouragement 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

exposure and response prevention to help

break the binge-purge cycle. As you read

in Chapter 4, this approach consists of

exposing people to situations that would

ordinarily raise anxiety and then

preventing 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 clients to eat particular kinds and amounts of food and then prevent them from

vomiting to show that eating can be a harmless and even constructive activity that needs no

undoing (Mitchell, 2018; Agras, Fitzsimmons-Craft, & Wilfley, 2017). Typically the therapist

sits with the client while the client eats the forbidden foods and stays until the urge to purge has

passed. Studies find that this treatment often helps reduce eating-related anxieties, bingeing, and

vomiting.

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. 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. They may also guide clients to recognize, question, and eventually change

their perfectionistic standards, sense of helplessness, and low self-concept (see Trending).

643

Cognitive-behavioral approaches help as many as 75 percent of patients stop or reduce bingeing

and purging (Mitchell, 2018; Poulsen et al., 2014).

Other Forms of Psychotherapy Because of its effectiveness in the treatment 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 (Mitchell, 2018;

Crow, 2017). A common alternative is interpersonal psychotherapy, the treatment that is used to

help improve interpersonal functioning (Gomez Penedo et al., 2018). Psychodynamic therapy has

also been used in cases of bulimia nervosa, but only a few research studies have tested and

supported its effectiveness (Thompson-Brenner, 2016; Tasca et al., 2014). The various forms of

psychotherapy—cognitive-behavioral, interpersonal, and psychodynamic—are often

supplemented by family therapy (Mitchell, 2018).

It was only a matter of time A new app hit the marketplace a few years ago enabling users to “doctor” their selfies before

posting them. Like the woman in this app demonstration, a user’s appearance can, through facial recognition software, be

made to look lighter by 5 pounds (left), 10 pounds (center), or 15 pounds (right). Critics worry that the app, whose sales

have boomed, is likely to further fuel body dissatisfaction and eating disorders.

TRENDING

Shame on Body Shamers

“What happened to … ? Did she eat all her back-up singers?” Thousands of cruel tweets like this one about a

popular singer’s weight appear on social media every day. They are examples of body shaming, the practice of criticizing

644

people publicly for being overweight, or, less frequently, underweight.

Responding to shamers As Lady Gaga was giving a universally acclaimed half-time performance at the 2017 Super

Bowl (above), many viewers took to social media to criticize her for daring to wear a crop-top and displaying the

“flab” on her stomach. In an Instagram post, the superstar responded, “I’m proud of my body and you [i.e., all

people] should be proud of yours too. No matter who you are or what you do.”

Body shaming itself is not new. It has been around since the mid-nineteenth century (Herman, 2015). What is new is

the current and ever-increasing volume of this practice. Our world of tweets, social networking, blogging, provocative Web

sites, opinionated talk shows, and the like has provided numerous platforms for cruel comments, including ones about

people’s appearance (Green & Lankford, 2017). As one eating disorder expert has said, “We are learning the language of

body shaming from the mass media culture” (Mysko, 2016).

Of course, the body shaming of celebrities receives the most attention, but widely read comments of that kind have

opened the door to an onslaught of body shaming in smaller circles and in everyday life. A recent survey revealed that a

staggering 94 percent of today’s teenage girls and 64 percent of teenage boys have been body shamed in one form or

another (Miller, 2016).

Body shaming can bring great personal pain to the victims of such comments (Chomet, 2018; Webb et al., 2016). In

addition, the practice appears to be contributing, along with other factors, to an increase in body dissatisfaction and

disordered eating throughout our society, especially among women (Kolata, 2016).

The good news is that a counter-trend is currently also taking place across society—growing concern and anger by

millions of people, including clinicians and educators, over the unacceptability and harmful impact of these forms of

communication, along with a determination to fight back. In the legal arena, criminal charges have been brought against

body shamers whose actions have been particularly ugly, invasive of privacy, and/or damaging (Feuer, 2016).

Perhaps the most important development in the fight against body shaming is that hundreds of influential celebrities

are now calling out the perpetrators. Over the past year, for example, in response to negative tweets or posts about their

bodies, celebrities have posted self-affirming messages such as the following:

“I will never conform to your skinny standards.”

—Reality TV star Kim Kardashian

645

“I am not a woman whose self-worth comes from her chest size.”

—Actress Kristen Bell

“I am so proud of what my body has done for me.”

—Actress Gabourey Sidibe

“I’m healthy and happy, and if you’re hating on my weight, you obviously aren’t.”

—Singer Demi Lovato

“[Body shaming] lets you know something’s wrong with our culture and we all need to work together to change it.”

—Comedian Amy Schumer

“People … body shame me because … I’m not good enough for their standards. … But at the end of the day I’m good

enough for me.”

—Model Ashley Graham

“I love being happy with me.”

—Singer and actress Selena Gomez

These are but a small fraction of the countershaming messages being posted by celebrities every day. Hopefully, the

self-acceptance, independent thinking, and body satisfaction contained in such responses will come to influence readers

more than the body-shaming messages themselves.

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

(Mitchell, 2018; Valbak, 2001).

Antidepressant Medications During the past 15 years, antidepressant drugs—all forms of antidepressant drugs—have been

used to help treat bulimia nervosa. In contrast to people with anorexia nervosa, those with

bulimia nervosa are often helped considerably by these drugs (Crow, 2017; Starr & Kreipe,

2014). 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

therapy. Alternatively, some therapists wait to see whether cognitive-behavioral therapy or

another form of psychotherapy is effective before trying antidepressants (Agras et al., 2017).

Studies suggest that psychotherapy is more effective than antidepressant drugs, but that a

combination of the two is more effective than either form of treatment alone (Crow, 2017).

646

Battling ad campaigns In 2015, the weight loss company Protein World released an ad in London featuring a thin, bikini-

clad model asking, “Are You Beach Body Ready?” The ad (left) quickly produced a wave of protests by critics who believed

that it implied other body shapes were inferior. In fact, the plus-size fashion brand Simply Be countered with an ad

campaign featuring a larger-sized model (right) asserting, “Every Body Is Beach Body Ready.” The controversial Protein

World ad is now banned in England.

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 (Mitchell, 2018; Isomaa & Isomaa, 2014). Another 40 percent show a

moderate response—at least some decrease in binge eating and purging. Follow-up studies,

conducted years after treatment, suggest that around 75 percent of people with bulimia nervosa

have recovered, either fully or partially (Engel et al., 2017).

Relapse can be a problem even among people who respond successfully to treatment (Engel et

al., 2017). As with anorexia nervosa, relapses are usually triggered by a new life stress, such as an

upcoming exam, a job change, marriage, or divorce (Liu, 2007). One study found that 28

percent of those who had recovered from bulimia nervosa relapsed within six months (Olmsted

et al., 2015). 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 (Engel et al., 2017; Vall & Wade, 2015).

Treatments for Binge-Eating Disorder Approximately 44 percent of people with binge-eating disorder receive treatment (NIMH,

2017). Given the key role of binges in both this disorder (bingeing without purging) and

bulimia, today’s treatments for binge-eating disorder are often similar to those for bulimia

647

nervosa. In particular, cognitive-behavioral therapy, other forms of psychotherapy, and in some

cases, antidepressant medications are provided to help reduce or eliminate the binge-eating

patterns and to change disturbed thinking such as being overly concerned with weight and shape

(Sysko & Devlin, 2017; Fischer et al., 2014). According to research, psychotherapy is generally

more helpful than antidepressants.

Evidence indicates that these kinds of interventions are indeed often effective, at least in the

short run. As many as 60 percent of clients no longer fit the criteria for binge-eating disorder by

the end of treatment (Sysko & Devlin, 2017). Many of these early gains may continue for years.

However, only around one-third of the recovered individuals showed total improvement in those

follow-up studies. 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, 2018, 2014;

Sysko & Devlin, 2017).

“Normal Barbie” For years, the ultra-slim measurements of the Barbie doll have introduced young girls to an unattainable

ideal. Hoping to show instead that “average is beautiful,” artist Nickolay Lamm has designed a Normal Barbie (right), using

the CDC measurements of the average 19-year-old woman. Normal Barbie turns out to be shorter, curvier, and bustier than

the classic doll.

Of course, many people with binge-eating disorder also are overweight, a problem that

requires additional kinds of intervention. Their weight problems are often resistant to long-term

improvement, even if regular binge eating is reduced or eliminated (Sysko & Devlin, 2017; Grilo

et al., 2014). In one follow-up study of hospitalized patients with severe symptoms of binge-

648

eating disorder, 36 percent of those who had been treated were still significantly overweight 12

years after hospitalization (Fichter et al., 2008).

SUMMING UP

HOW ARE EATING DISORDERS TREATED? The first step in treating anorexia nervosa is to help patients regain weight and return to health, a part of treatment

called nutritional rehabilitation. 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 75 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 pattern (nutritional rehabilitation) and

then on addressing the underlying causes of the disorder. Often several treatment strategies are combined, including

education, psychotherapy (particularly cognitive-behavioral therapy), and, in some cases, antidepressant medications.

As many as 75 percent of those who receive treatment eventually improve either fully or partially. While relapse can

be a problem, treatment leads to lasting improvements in psychological and social functioning for many people.

Similar treatments are used to help people with binge-eating disorder. These individuals, however, may also require

interventions to address their excessive weight.

649

CLINICAL CHOICES 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.

Prevention of Eating Disorders: Wave of the Future Clearly, eating disorders are profoundly destructive. Moreover, the various treatments for these

disorders, while improving greatly in recent years, do not bring about a full recovery (or, in some

instances, any recovery) for many people with these disorders. Thus, some clinical theorists

believe that researchers must invest more work into the development of programs that prevent the

onset of eating disorders.

One of today’s promising prevention

programs is called Body Project, a program

developed and expanded by psychologists

Eric Stice and Carolyn Black Becker and

their colleagues (Becker et al., 2017; Stice

et al., 2017, 2015, 2013). Keeping in

mind the key factors that predispose

people to the development of eating

disorders, Body Project offers a total of

four weekly group sessions for high school

and college-age women. In these sessions, group members are guided through a range of intense

verbal, written, role-playing, and behavioral exercises that critique Western society’s ultra-thin

ideal. The participants also engage in body acceptance exercises, eating and related activities that

run counter to the ultra-thin ideal, motivation enhancement techniques, skill-building training,

and social support exercises.

Although early in its development, the Body Project prevention program has performed well

in research (Stice et al., 2017, 2015). In comparison to other young women who received

education-only prevention programs or no prevention programs at all, participants in Body

Project develop fewer eating disorders, hold more realistic and healthful appearance ideals,

display fewer maladaptive eating attitudes and behaviors, have greater body satisfaction, and

experience more positive emotions in follow-up studies conducted a year or more after the

program.

Clearly, this program is promising and important. Whether in the form of Body Project or

other such undertakings, prevention programs address a critical need in the clinical field’s

commitment to overcome eating disorders and are likely to increase in the years to come.

650

651

Chapter 9 Review

Key Terms

anorexia nervosa

restricting-type anorexia nervosa

amenorrhea

bulimia nervosa

binge

compensatory behavior

binge-eating disorder

multidimensional risk perspective

effective parents

brain circuits

hypothalamus

lateral hypothalamus (LH)

ventromedial hypothalamus (VMH)

glucagon-like peptide-1 (GLP-1)

weight set point

enmeshed family pattern

nutritional rehabilitation

motivational interviewing

prevention

Body Project

Quick Quiz

652

1. What are the symptoms and main features of anorexia nervosa and bulimia nervosa? How are people with anorexia nervosa similar to those with bulimia nervosa? How are they different? pp. 266–272

2. What are the symptoms and main features of binge-eating disorder? How is this disorder different from bulimia nervosa? pp. 272, 274

3. According to Hilde Bruch, how might parents’ failure to attend appropriately to their baby’s internal needs and emotions contribute to the later development of an eating disorder? pp. 275–276

4. How might a person’s brain circuits, hypothalamus, and weight set point contribute to the development of an eating disorder? pp. 277–279

5. What evidence suggests that sociocultural pressures and factors may set the stage for eating disorders? pp. 279–282

6. When clinicians treat people with anorexia nervosa, what are their short-term and long- term goals? What approaches do they use to accomplish them? pp. 283–285

7. 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. 285– 286

8. What are the key goals and approaches used in the treatment of bulimia nervosa, and how successful are they? What factors affect a person’s recovery? What risks and problems may linger after recovery? pp. 286–289

9. How are treatments for binge-eating disorder similar to and different from treatments for bulimia nervosa? pp. 289–290

10. What are some of the key features of eating disorder prevention programs such as Body Project? pp. 290–291

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

653

654

CHAPTER 10 Substance Use and Addictive Disorders

TOPIC OVERVIEW

655

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 The Developmental Psychopathology View

How Are Substance Use Disorders Treated?

Psychodynamic Therapies Cognitive-Behavioral Therapies Biological Treatments Sociocultural Therapies

Other Addictive Disorders

Gambling Disorder Internet Gaming Disorder: Awaiting Official Status

New Wrinkles to a Familiar Story

“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

656

#FamilyVictims More than 10 percent of children live with a parent with

alcohol problems (NIAAA, 2018).

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

different. … 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 different 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 physically

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)

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

657

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 consume 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 $740 billion each year in the United

States alone (NIDA, 2017).

Not only are numerous substances available in our society, new ones are introduced almost

every day. Some are harvested from nature, others derived from natural substances, and still

others produced in the laboratory. Some, such as antianxiety 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 131 million (SAMHSA, 2018). In fact, 27 million people have used

illegal substances within the past month. A quarter of all teenagers have used an illegal substance.

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 frequently 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, emotion, 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.

substance intoxication A cluster of temporary undesirable behavioral or psychological changes that develop during or shortly after the ingestion of a substance.

Some substances can also lead to long-term problems. People who regularly ingest them may

develop substance use disorders, patterns of maladaptive behaviors and reactions brought about

658

by the repeated use of substances (APA, 2013). People with a substance use disorder 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 withdrawal reactions. When people

develop tolerance, they need increasing doses of the substance to produce the desired effect.

Withdrawal reactions consist of unpleasant and sometimes 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 tolerance for alcohol over time and had withdrawal symptoms

such as vomiting and shaking when he tried to stop using it.

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 produce earlier effects. withdrawal Unpleasant, sometimes dangerous reactions that may occur when people who use a drug regularly stop taking it or reduce the dosage.

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 substance-produced symptoms within a 1-year period: Substance is often taken in larger amounts Unsuccessful efforts to reduce or control substance use Much time spent trying to obtain, use, or recover from effects of substance Failure to fulfill major role obligations Continued use despite persistent interpersonal problems Reduction of important activities Continued use in dangerous situations Continued use despite worsening of physical or psychological problems Craving for substance Tolerance effects Withdrawal reactions.

Information from: APA, 2013.

In any given year, 7.8 percent of all teens and adults in the United States, around 21 million

people, have a substance use disorder (SAMHSA, 2018). American Indians have the highest rate

of substance use disorders in the United States (11.6 percent), while Asian Americans have the

659

lowest (3.8 percent). Non-Hispanic white Americans, Hispanic Americans, and African

Americans have rates between 7 and 8.2 percent (SAMHSA, 2018) (see Figure 10-1). Only 18

percent of all those with substance use disorders receive treatment from a mental health

professional.

FIGURE 10-1

How Do Racial/Ethnic Groups Differ in Substance Use Disorders?

In the United States, American Indians are more likely than members of other ethnic or cultural groups to have substance

use disorders. (Information from: SAMHSA, 2018.)

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.

660

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, 2018). Purchases of beer, wine, and liquor amount to tens of billions

of dollars each year in the United States alone.

alcohol Any beverage containing ethyl alcohol, including beer, wine, and liquor.

When people consume five or more drinks on a single occasion, it is called a binge drinking

episode. Twenty-five percent of people in the United States over the age of 11, most of them

male, binge drink each month (SAMHSA, 2018). 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 2 to 1.

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 alcohol 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, functioning 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 (Farokhnia et al., 2018; Nace, 2011, 2005).

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 central 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.

661

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, and women may

be at greater risk for physical and psychological damage from alcohol than men who drink similar

quantities of it (Mukamal, 2018).

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.

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

662

(Mukamal, 2018; Hart & Ksir, 2017).

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 carbon 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 23 percent of middle school students admit to some

alcohol use, while 33 percent of high school seniors drink alcohol each month (most to the point

of intoxication) and 1.3 percent report drinking every day (Johnston et al., 2017). Alcohol

misuse is also a major problem on college campuses (see PsychWatch).

Surveys indicate that over a one-year period, 5.9 percent of all people over 11 years of age in

the United States display alcohol use disorder, known in popular terms as alcoholism (SAMHSA,

2018). For teenagers specifically, the rate is 2.5 percent. Men with this disorder outnumber

women by 2 to 1.

The current prevalence of alcoholism is around 6.1 percent for non-Hispanic white

Americans, 6.4 percent for Hispanic Americans, and 4.9 percent for African Americans

(SAMHSA, 2018). American Indians, particularly men, tend to display a higher rate of alcohol

use disorder than any of these groups. Overall, 9.7 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 (3.2 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 (Chang, Hsiao, & Chen, 2017).

PSYCHWATCH

College Binge Drinking: An Extracurricular Crisis

Drinking large amounts of alcohol in a short time, or binge drinking, is a serious problem on college

campuses, as well as in many other settings. Studies show that 38 percent of college students binge drink at least once each

663

month, one-third of them six times or more per month (SAMHSA, 2018; NIAAA, 2017). In many circles, alcohol use is

an accepted part of college life, but consider some of the following statistics:

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 is a factor in at least 25 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 effect on mood, memory, brain functioning, and heart functioning.

Binge drinking is tied to 4,300 deaths among college-age persons every year.

The number of female binge drinkers among college students has increased 31 percent over the past decade.

(CDC, 2018, 2017, 2016; NIAAA, 2017; Nourse et al., 2017; NCASA, 2007; Abbey, 2002)

These findings have led some educators to describe binge drinking as “the number one public health hazard” for full-

time college students, and many researchers and clinicians have turned their attention to it. Studies have collectively

surveyed more than 100,000 students at college campuses around the United States (CDC, 2018, 2017; Greene & Maggs,

2017; NIAAA, 2017). Among other useful information, the surveys have found that the students most likely to binge drink

are those who live in fraternity or sorority houses, pursue a party-centered lifestyle, and engage in high-risk behaviors such

as substance misuse. The surveys have also suggested that students who are binge drinkers in high school are more likely to

binge drink in college.

Testing the limits College binge drinking, which involves behaviors similar to that shown here, has led to a number

664

#EndangeredAthletes

College athletes (both male and female) are more likely to

drink, drink heavily, and binge drink than college students who

are not athletes (Taylor et al., 2017; Burnsed, 2014).

of deaths in recent years.

Efforts to change such patterns have begun. For example, many universities now provide substance-free dorms. Studies

indicate that the rate of binge drinking by residents in these college housing facilities is half the rate displayed by students

who live in a fraternity or sorority house (Lippy & DeGue, 2016; 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, prevent, and treat what has become a major societal problem.

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. 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 structures of their brains and,

correspondingly, impairments in their memory, speed of thinking, attention skills, and balance

(Tetrault & O’Connor, 2017).

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 (Pace, 2017; Tetrault & O’Connor, 2017). As their bodies 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 pressure 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 consists of terrifying visual

665

hallucinations that begin within three 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 2

to 3 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.

delirium tremens (DTs) A dramatic alcohol withdrawal reaction that consists of confusion, clouded consciousness, and visual hallucinations.

What Are the Personal and Social Impacts of Alcoholism? Alcoholism destroys millions of families, social relationships, and careers (Mukamal, 2018).

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 29 percent of all fatal automobile

accidents in the United States (CDC, 2017; Gifford et al., 2010). Altogether, intoxicated drivers

are responsible for more than 10,000 deaths each year. Around 10 percent of all adults have

driven while intoxicated at least once in the past year (SAMHSA, 2018). Although this is a

frightening number, it represents a significant drop since 2002 when 14 percent of adults had

driven in an intoxicated state.

666

If alcohol is highly addictive and capable of causing so many

psychological, physical, social, and personal problems, why

does it remain legal in most countries?

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 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.

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 (Thapa,

Selya, & Jonk, 2017; Gold, 2016). 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 (Mukamal,

2018; Gramlich, Tandon, & Rahman, 2017). It so overworks the liver that people may develop

an irreversible condition called cirrhosis, in which the liver becomes scarred and dysfunctional.

Cirrhosis accounts for more than 38,000 deaths each year (CDC, 2017). 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 deficiency of vitamin B1 (thiamine), for

example, may lead to Korsakoff’s syndrome, a disease marked by extreme confusion, memory loss,

and other neurological symptoms (Mukamal, 2018; Gramlich et al., 2017). 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 (Chang, 2018;

Popova et al., 2017). 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, hyperactivity, head and face

deformities, heart defects, and slow growth (Weitzman & Rojmahamongkol, 2018). It has been

estimated that in the overall population, around 1 of every 1,000 babies is born with this

syndrome (CDC, 2017). The rate may increase to as many as 67 of every 1,000 babies of women

who are problem drinkers (Popova et al., 2017). 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-

667

drinking women. In addition, heavy drinking early in pregnancy often leads to a miscarriage.

According to surveys, 9.3 percent of pregnant American women have drunk alcohol during the

past month and 4.6 percent of pregnant women have had binge drinking episodes (SAMHSA,

2018).

fetal alcohol syndrome A cluster of problems in a child, including irregularities in the head and face and intellectual deficits, caused by excessive alcohol intake during pregnancy.

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 hypnotics. 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.

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 antianxiety drugs; includes Xanax.

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 prescriptions are written annually for

benzodiazepines (Soyka, 2017; Bachhuber et al., 2016). Like alcohol and barbiturates, they calm

people by binding to receptors on the neurons that receive GABA and by increasing GABA’s

activity at those neurons (Tietze & Fuchs, 2017). 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 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 it became clear that in high enough

doses the drugs can cause intoxication and lead to sedative-hypnotic use disorder, a pattern marked

by craving for the drugs, tolerance effects, and withdrawal reactions (Greller & Gupta, 2017;

Park, 2017). Over a one-year period, 0.4 percent of all adults in the United States display this

668

disorder (SAMHSA, 2018).

Opioids Opioids include opium, which is taken from the sap of the opium poppy; drugs derived from

opium, such as heroin, morphine, and codeine; and similar synthetic (laboratory-blended) drugs.

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.

Eventually, however, physicians discovered that the drug was addictive.

opioid Opium, drugs derived from opium, and similar synthetic drugs. opium A highly addictive substance made from the sap of the opium poppy.

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).

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 opium did and initially was

considered safe. However, wide use of the drug eventually revealed that it, too, could lead to

addiction. During the United States Civil War, so many wounded soldiers received morphine

injections that morphine addiction became known as “soldiers’ disease.”

morphine A highly addictive substance derived from opium that is particularly effective in relieving pain.

669

Can you think of other substances or activities that, like

opioids, can be helpful in controlled portions but dangerous

when used excessively or uncontrollably?

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.

heroin One of the most addictive substances derived from opium.

Still other drugs have been derived from opium, and, as noted above, synthetic opioids such

as methadone have also been developed. These various opioid drugs are also 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 opioids

usually prescribed to relieve pain. In contrast to these opioids, heroin is illegal in the United

States in all circumstances.

Most opioids are smoked, inhaled, snorted, injected, or, as in the case of many pain relievers,

swallowed in pill or liquid form. In injections, the opioid may be deposited just beneath the skin

(“skin-popping”), deep into a muscle, or directly into a vein (“mainlining”). An injection quickly

brings on a rush—a spasm of warmth and ecstasy that is sometimes 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, particularly 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 (Stolbach &

Hoffman, 2018). When neurons at these receptor sites receive opioids, they produce pleasurable

and calming feelings just as they would do if they were receiving endorphins. In addition to

reducing pain and tension, opioids cause nausea, narrowing of the pupils (“pinpoint pupils”),

and constipation—bodily reactions that can also be brought about by releases of endorphins in

the brain.

endorphins Neurotransmitters that help relieve pain and reduce emotional tension. They are sometimes referred to as the body’s own opioids.

670

Opioid Use Disorder Heroin use exemplifies the kinds of problems posed by opioids. After taking heroin repeatedly

for just a few weeks, users may develop opioid use disorder. Their heroin use 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 (Sevarino, 2017; Strain, 2017). 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 symptoms 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

many cases turning to criminal activities, such as theft and prostitution, to support the expensive

“habit” (Hart & Ksir, 2017).

Surveys suggest that more than 1 percent of adults in the United States, a total of 2.6 million

people, display an opioid use disorder within a given year (SAMHSA, 2018). Among teenagers

specifically, the prevalence may be even higher (Johnston et al., 2017). Most of these persons (80

percent) are addicted to pain-reliever opioids, prescription drugs such as oxycodone (see Figure

10-2). Around 20 percent of those with opioid use disorder are addicted to heroin. The rate of

opioid dependence dropped considerably during the 1980s, rose in the early 1990s, fell in the

late 1990s, and now is high once again. Indeed, the accelerated increase of this rate over the past

several years—including the increase among teenagers—and the growing number of deaths

caused by opioid overdoses have many clinicians referring to it as an epidemic (see Trending).

According to some studies, the mortality rate of persons with untreated opioid use disorder is 63

times the rate of other persons (Strain, 2017).

671

FIGURE 10-2

Where Do People Obtain Painkillers for Nonmedical Use?

More than 40 percent get the drugs from friends or relatives and 36 percent obtain them from doctors. Only 5 percent buy

them from drug dealers. (Information from: SAMHSA, 2018.)

Injecting heroin Opioids may be taken by mouth, inhaled, snorted, injected just beneath the surface of the skin, or injected

intravenously. 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.

672

What Are the Dangers of Opioid Use? The most immediate danger of opioid use is an overdose, which closes down the respiratory

center in the brain, almost paralyzing breathing and in many cases causing death (Coffin, 2017;

Stolbach & Hoffman, 2018). Death is particularly likely during sleep, when a person is unable to

fight this effect by consciously working to breathe. People who resume heroin or pain reliever 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 such opioids for some time,

however, they can no longer tolerate this high level. There has been a 400 percent increase in the

number of deaths caused by opioid overdoses in the past decade (CDC, 2017). Currently,

approximately 20,000 people in the United States die from pain reliever overdoses each year,

15,000 from heroin overdoses, and 8,000 from overdoses of other opioids (Moberg, 2018;

Coffin, 2017). These numbers represent two-thirds of all drug overdose deaths.

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 addition, dirty needles and other

unsterilized equipment spread infections such as AIDS, hepatitis C, and skin abscesses (Strain,

2017). In some areas of the United States, the HIV infection rate among active heroin users is

reported to be as high as 60 percent.

673

Deadly effects In 2016 music giant Prince died at the age of 57 from an overdose of the opioid drug fentanyl, an extremely

powerful prescription pain reliever. Immediately after his death, fans started leaving messages outside his residential

compound in Minnesota, including this one with apt lyrics from Prince’s song “Let’s Go Crazy.”

TRENDING

The Opioid Crisis

The United States is in the midst of an opioid epidemic—a staggering increase in the number of addictions

and overdose deaths related to painkillers and heroin (Stevens et al., 2018; CDC 2017). In 2016, 62,000 people died from

various kinds of drug overdoses; by comparison, 16,000 died from overdoses in 2010 and 4,000 in 1999 (Katz, 2017;

NIDA, 2014). Two-thirds of all such drug deaths involve opioids. The last drug epidemic of this magnitude was the crack

epidemic of the 1980s, which witnessed a comparable number of annual deaths if one calculates both overdoses and crack-

related homicides (Regier, 2016).

“Fed Up!” At the National Mall in Washington, D.C., this man and thousands of other activists and family members

674

rally for federal funding to help end the opioid epidemic. The rally was organized by Fed Up!, a coalition that is

working for an end to the epidemic of opioid addictions and overdoses.

How did the current opioid epidemic emerge? Several factors have contributed. First is the painkiller factor (Becker &

Starrels, 2018; Piper et al., 2018). Back in the 1990s, the number of Americans diagnosed with some form of chronic pain

rose to one hundred million (a third of the population), leading to increased prescriptions of several powerful pain

medications such as Percocet, Vicodin, and Oxycontin—drugs more powerful than morphine or heroin (CDC, 2017).

These medications soon became overprescribed, despite the good intentions of physicians, and between 1991 and 2011, the

number of U.S prescriptions for painkillers tripled to 219 million per year (Trotter Davis et al., 2017; Voon, Karamouzian,

& Kerr, 2017). Many patients developed a painkiller use disorder, and, as word about the opioid impact of these drugs

spread, the illicit acquisition and use of prescription painkillers rose as well.

While the use of painkillers was increasing between 1991 and 2011, so was their potency, as pharmaceutical companies

sought to develop more effective and powerful painkillers. One of the most powerful pain relief drugs is fentanyl, which is

50 to 100 times more powerful than morphine, 20 to 35 times more powerful than heroin, and, correspondingly, more

dangerous than either (Phalen et al., 2018; Caldwell, 2017). Given its potency, rapid onset, and short duration, fentanyl

became a very popular street drug. Illegal—and, thus, uncontrolled—manufacture of this drug escalated correspondingly

(CDC, 2017; Beletsky & Davis, 2017). Fentanyl is by far the painkiller most commonly linked to overdose deaths. (The

2016 death of the iconic musical performer Prince was caused by a fentanyl overdose.)

A second and related factor in the opioid explosion is the rising availability of heroin. As painkiller prescriptions were

tripling between 1991 and 2011, foreign drug cartels recognized the growing thirst of the United States population for

opioids, and, in turn, they flooded the United States marketplace with heroin (CRS, 2016; Nolan & Amico, 2016). This

increased heroin availability led, in turn, to lower heroin prices, easier acquisition, and greater heroin use.

Since 2011, the increased affordability, availability, and potency of opioid drugs have produced a still greater demand

for opioids—both illicitly acquired painkillers and heroin—that has resulted in the current opioid epidemic. As the head of

the CDC observed, “America is awash in opioids” (Frieden, 2016). Moreover, heroin and painkillers are not necessarily

competing with each other in the U.S. marketplace. Rather, they are often combined or intermixed for users—a

phenomenon that has multiplied their dangers exponentially. Fentanyl-laced heroin is, for example, now common on the

streets (Perry, 2017). Users who think they are taking heroin at their usual dose often are taking the much more powerful

fentanyl—a misperception that can readily lead to their death. Similarly, illegal manufacturers of painkillers often make the

pain drugs look identical—although their potencies differ significantly. As one U.S. attorney stated, purposeful disguises of

this kind represent “an overdose waiting to happen” (STAT, 2016).

The opioid epidemic is currently being fought on all fronts: federal and state legislatures have, for example, passed laws

calling for more funding to fight the opioid epidemic, greater efforts to combat international opioid trafficking, more

coordination between the states, more monitoring of doctors’ prescription practices, more accountability from

pharmaceutical companies, and better funding of opioid treatment programs (Kolodny & Frieden, 2018; CDC, 2017). In

addition, the clinical field is devoting a greater portion of its professionals and resources to the prevention and treatment of

opioid use disorders. These efforts seem to be making an impact in some realms. For example, the number of prescriptions

of opioid painkillers dropped 10.2 percent in 2017 (Herper, 2018). Thus authorities and clinicians are hopeful that the

epidemic will soon recede, but how soon and how much it will recede are far from clear at the present time (Piper et al.,

2018; Stevens et al., 2018).

SUMMING UP

675

SUBSTANCE MISUSE AND DEPRESSANTS

Repeated and excessive use 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 system. Repeated and excessive use of

these substances can lead to problems such as alcohol use disorder, sedative-hypnotic use disorder, or opioid use

disorder. Alcohol 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. The

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. Opioids reduce tension and pain and cause other

reactions. They operate by binding to neurons that ordinarily receive endorphins.

676

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).

INFOCENTRAL SMOKING, TOBACCO, AND NICOTINE

Around 24% percent of all Americans over the age of 11 regularly smoke tobacco—a total of 63

million people (NSDUH, 2017). Similarly, 20% of the world population over 11 smoke

regularly—a total of 1.1 billion people (WHO, 2017).

677

Cocaine Cocaine—the central active ingredient of the coca plant, found in South America—is the most

powerful natural stimulant now known (Nelson & Odujebe, 2017). 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

678

(hydrochloride powder) 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.

cocaine An addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.

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.

For years people believed that cocaine posed few problems aside from intoxication and, on

occasion, temporary psychosis (see Table 10-2). Only later did researchers come to appreciate its

many dangers (Gorelick, 2017). 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 39 million people have tried it, and 1.9

million—most of them teenagers or young adults—are using it currently (SAMHSA, 2018).

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 & Behavioral Change

Opioids High High Moderate High Low to moderate

Sedative-Hypnotics Barbiturates Benzodiazepines

Moderate Moderate

Moderate to high Moderate

Moderate to high Low

Low Low

Stimulants (cocaine, amphetamines)

High High Moderate Low to moderate Moderate to high

679

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: Mukamal, 2018; Hart & Ksir, 2017; APA, 2013.

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 users feel excited, energetic, talkative, and

even euphoric. As more is taken, it stimulates 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 (Gorelick, 2017). Excessive

amounts of dopamine travel to receiving neurons throughout the central nervous system and

overstimulate them. Cocaine appears to also increase the activity of the neurotransmitters

norepinephrine and serotonin in some areas of the brain.

High doses of the drug produce cocaine intoxication, whose symptoms are poor muscle

coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and

confusion (Nelson & Odujebe, 2017). Some people have hallucinations, delusions, or both, a

condition called cocaine-induced psychosis.

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

(Gorelick, 2017). 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.

680

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 ingestion that has less powerful effects than either smoking or injection

(AAC, 2018; 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 freebasing, 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.

freebasing 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 with a pipe.

Millions more people use crack, a powerful form of freebase 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. Back in the 1980s,

its affordability led to an epidemic of use among people who previously could not have afforded

cocaine, primarily those in poor, urban areas (Turner, 2017). Although the prevalence of crack

use has declined over the past two decades, around 0.3 percent of all people over the age of 11

(almost 1 million individuals) have used it within the past year (SAMHSA, 2018).

crack A powerful, ready-to-smoke freebase cocaine.

What Are the Dangers of Cocaine? Aside from cocaine’s harmful effects on behavior, cognition, and emotion, the drug poses serious

physical dangers (Chang, 2017; Morgan, 2017). 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

(Gorelick, 2017). Cocaine use has also been linked to many suicides.

The greatest danger of cocaine use is an overdose (Nelson & Odujebe, 2017). Excessive doses

have a strong effect on the respiratory center of the brain, at first stimulating it and then

depressing 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

(Morgan, 2017). In addition, pregnant women who use cocaine run the risk of having a

miscarriage and of having children with predispositions to later drug use and with abnormalities

in immune functioning, attention and learning, thyroid size, and dopamine and serotonin

681

activity in the brain (Jansson, 2017).

Addicted at birth Babies of mothers who have opioid or stimulant use disorders during pregnancy may be born with

significant physical and psychological problems, including drug addiction. Here, at a pediatric hospital that specializes in

weaning newborns off of heroin and methadone, a recreational therapist examines one such infant.

Amphetamines Amphetamines are stimulant drugs that are manufactured in the laboratory. Some common

examples are amphetamine (Benzedrine), dextroamphetamine (Dexedrine), 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. Physicians now know the drugs are far too dangerous to be

used so casually, and they prescribe them much less freely.

amphetamine A stimulant drug that is manufactured in the laboratory.

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 appetite when taken in small doses;

682

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 (Stock, Rädle, & Beste, 2019; Arnold & Ryan, 2017).

One kind of amphetamine, methamphetamine (nicknamed crank), has surged in popularity

over the past decade and so warrants special focus. Almost 6 percent of all people over the age of

11 in the United States have used methamphetamine at least once (SAMHSA, 2018). Around

0.3 currently have methamphetamine use disorder. The drug is available in the form of crystals

(also known by the street names ice and crystal meth), which users smoke.

methamphetamine A powerful amphetamine drug that has surged in popularity in recent years, posing major health and law enforcement problems.

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 (Boyer et al., 2017). Such laboratories have been around since the 1960s, but

they have increased eightfold—in number, production, and in being confiscated by authorities—

this century. A major health concern is that the secret laboratories expel dangerous fumes and

residue.

683

Methamphetamine dependence: Spreading the word This powerful ad shows the degenerative effects of

methamphetamine addiction on a woman over a 4-year period—from age 36 in the top photo to age 40 in the bottom one.

Since 1989, when the media first began reporting about the dangers of smoking

methamphetamine crystals, the rise in usage has been dramatic. Until recently, it had been much

more prevalent in western parts of the United States, but its use has now spread east as well.

Methamphetamine-linked emergency room visits are rising in hospitals throughout all parts of

the country (SAMHSA, 2018).

Methamphetamine is about as likely to be used by women as men. Around 40 percent of

current users are women (Paulus, 2017). The drug is popular today among a wide range of

people, from biker gangs to rural Americans to urban gay communities, and it 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” (NIDA, 2018).

Like other kinds of amphetamines, methamphetamine increases activity of the

neurotransmitters dopamine, serotonin, and norepinephrine, producing increased arousal,

attention, and related effects (Paulus, 2017). It can have serious negative effects on a user’s

physical, mental, and social life. Of particular concern is that it damages nerve endings, a

684

problem called neurotoxicity (Stock et al., 2019). But users focus more on methamphetamine’s

immediate positive impact, including perceptions by many that it makes them feel hypersexual

and uninhibited (Paulus, 2017).

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 relationships and at work. People may develop tolerance

and withdrawal 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 (Gorelick, 2017). These withdrawal symptoms can last for

weeks or even months after drug use has ended. In a given year, 0.1 percent of all people over the

age of 11 years display stimulant use disorder that is centered on cocaine, and 0.3 percent display

stimulant use disorder centered on amphetamines (SAMHSA, 2018).

SUMMING UP

STIMULANTS Stimulants, including cocaine, amphetamines, caffeine, and nicotine, 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, norepinephrine, and serotonin in the brain.

685

#DiagnosticControversy DSM-5 combines two past disorders, substance abuse (excessive

and chronic reliance on drugs) and substance dependence

(excessive reliance accompanied 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 depend on substances.

Why do various club drugs (for example, Ecstasy and crystal

meth), often used at “raves,” fall in and out of favor rather

quickly?

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 combinations of substances.

Hallucinogens Hallucinogens are substances that cause

powerful changes in sensory perception,

from strengthening a person’s normal

perceptions to inducing illusions and

hallucinations. 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 person’s mind interacts with the drugs. Also called psychedelic drugs, the hallucinogens

include LSD, mescaline, psilocybin, and MDMA (Ecstasy). Many of these substances come from

plants or animals; others are produced in laboratories.

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),

one of the most famous and most

powerful 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 of social rebellion and experimentation,

millions of people turned to the drug as a way of expanding their experience. Within 2 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

686

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.

LSD (lysergic acid diethylamide) A hallucinogenic drug derived from ergot alkaloids.

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 6

hours.

Lingering popularity Although less popular than in the 1960s, LSD continues to be a drug of some favor, especially among

younger people at many raves, rock concerts, and similar events. This participant at the annual Burning Man art festival in

687

Nevada’s Black Rock Desert has a message written on her back that leaves no doubt about how important the drug is to her.

It seems that LSD produces these symptoms primarily by binding to some of the neurons that

normally receive the neurotransmitter serotonin, changing the neurotransmitter’s activity at those

sites (Delgado, 2017). 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 15 percent of all people in the United States have used LSD or another

hallucinogen at some point in their lives. Around 0.5 percent, or 1.2 million people, are currently

using them (SAMHSA, 2018). Although people do not usually develop tolerance to LSD or have

withdrawal 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. Sometimes the reactions are extremely

unpleasant—a so-called bad trip (when LSD users injure themselves or others, for instance, they

are usually 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

micrograms, 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 inappropriately. Her stream of talk was illogical and affect labile. Two days later, this reaction had

ceased.

(Frosch, Robbins, & Stern, 1965)

Another danger is the long-term effect that LSD may have. 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 (Delgado, 2017).

Cannabis Cannabis sativa, the hemp plant, grows in warm climates throughout the world. The drugs

688

produced 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 flowering tops of hemp plants. More than 22 million people

over the age of 11 (8.3 percent of the population) currently smoke marijuana at least monthly

(SAMHSA, 2018).

cannabis Drugs produced from the varieties of the hemp plant Cannabis sativa. They cause a mixture of hallucinogenic, depressant, and stimulant effects. marijuana One of the cannabis drugs, derived from the buds, leaves, and flowering tops of the hemp plant Cannabis sativa.

Each of the cannabis drugs is found in various 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.

tetrahydrocannabinol (THC) The main active ingredient of cannabis substances.

The source of marijuana Marijuana is made from the leaves of the hemp plant, Cannabis sativa, such as the plants being

689

#StreetTags

Alcohol booze, brew

Cocaine blow, Charlie, rock, snow

Heroin black tar, horse, smack

Marijuana grass, Mary Jane, reefer, weed

Amphetamines bennies, speed, uppers

MDMA Ecstasy, X, beans, hug

Methamphetamine meth, crank, crystal, ice

Pain relievers Oxy, Percs, Vikes

cultivated in this grow room at a medical marijuana dispensary in Massachusetts. Cannabis sativa is grown in a wide range

of altitudes, climates, and soils.

When smoked, cannabis produces a

mixture of hallucinogenic, depressant,

and stimulant effects. At low doses, the

smoker typically has feelings of joy and

relaxation 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 experiences, changes in body image, and

hallucinations. Smokers may become confused or impulsive. Some worry that other people are

trying to hurt them. Most of the effects of cannabis last 2 to 6 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 academic lives very much affected (Kerridge et al., 2018) (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 (Gorelick, 2018). Around 4 million people, 1.5

percent of all teenagers and adults in the United States, have displayed cannabis use disorder

within the past year (SAMHSA, 2018).

690

#ChangingCourse In 1907, California was the first state to declare marijuana a

poison and to criminalize its sale or possession.

In 1996, California was the first state to legalize medical

marijuana.

In 2016, California was the fifth state to legalize recreational

marijuana.

FIGURE 10-3

How Easy Is It for Teenagers to Acquire Substances?

Most surveyed high school seniors say it is easy to get alcohol and marijuana, and more than a third say it is easy to get

amphetamines, pain relievers, and Ecstasy. (Information from: Johnston et al., 2017.)

Why have more and more marijuana users developed cannabis use disorder over the past three

decades? Mainly 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 increased, researchers have discovered that smoking it

may pose certain dangers (Wang, 2018; Price, 2011). It occasionally causes panic reactions

similar to the ones caused by hallucinogens, and some smokers may fear they are losing their

minds. Typically, such reactions end in 2 to 6 hours, along with marijuana’s other effects.

Because marijuana can interfere with

the performance of complex sensorimotor

tasks and with cognitive functioning, it

has caused many automobile accidents

(Wang, 2018; Brady & Li, 2014). And,

indeed, 4 percent of adults have driven

691

while under the influence of marijuana at

least once during the past year

(SAMHSA, 2018). Furthermore, 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

(Gorelick, 2018).

There are research indications that regular marijuana smoking may also lead to long-term

health problems (Gorelick, 2018; Hartney, 2014). It may, for example, contribute to lung

disease, although there is considerable debate on this issue. 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.

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 percent

of high school seniors smoke it daily, and 69 percent of seniors do not believe that regular use

poses a great risk (Johnston et al., 2017).

Cannabis and Society: A Rocky Relationship For centuries, cannabis played a respected role in medicine. It was recommended as a surgical

anesthetic by Chinese physicians 2,000 years ago and was used in other lands to treat cholera,

malaria, coughs, insomnia, and rheumatism. When cannabis 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 cannabis

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.”

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 inventions

opened the door to new medical applications for cannabis (Wang, 2018), 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.

692

In light of these findings, several interest groups campaigned 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 resisted this movement, saying

prescriptions for pure THC served all needed medical functions. 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, 30 states (plus Washington, D.C., Guam, and Puerto Rico) have laws allowing

marijuana to be used for medical purposes, and several more have such laws pending (NCSL,

2018). Medical marijuana is now legal in about a dozen countries (Gorelick, 2018).

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.

Heartened by such developments in the realm of medical marijuana, the U.S. movement to

legalize the recreational use of marijuana has gained enormous momentum in recent years. In

fact, since 2012 residents in eight states have voted to legalize marijuana for use of any kind—

although such state measures still can be blocked by the federal government (Robinson, 2017).

Moreover, according to recent polls, 57 percent of respondents believe that marijuana should be

made legal, up from 12 percent in 1969 and 41 percent in 2010 (Pew Research Center, 2016).

In such polls, more than half of respondents acknowledge they have tried marijuana and most say

that the federal government should not enforce federal antimarijuana laws in states where

marijuana is legal. Several other countries have moved faster than the United States with regard

to the recreational use of marijuana. In 2017, for example, Canada’s prime minister introduced

693

legislation to completely legalize marijuana as a consumer product, for any purpose—legislation

that now allows legal sales throughout the country (Austen, 2017).

Creative protesting People hold a huge cannabis cigarette, or “joint,” during a march in Brazil calling for the legalization of

marijuana—for both medical and recreational uses.

Combinations of Substances Because people often take more than one drug at a time, a pattern called polysubstance use,

researchers have studied the ways in which drugs interact with one another (Jarlenski et al.,

2017). 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.

synergistic effect In pharmacology, an increase of effects that occurs when more than one substance is acting on the body at the same time.

One kind of synergistic effect occurs when two or more drugs have similar actions (Buckley et

al., 2017). For instance, alcohol, benzodiazepines, barbiturates, and opioids—all depressants—

may severely depress the central nervous system when mixed. Combining them, even in small

doses, can lead to extreme intoxication, coma, and even death. A young man may have just a few

694

Who has more impact on the drug behaviors of teenagers

and young adults: rock performers who speak out against

drugs or rock performers who praise drugs?

alcoholic drinks at a party, for example, and shortly afterward takes 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 antagonistic, actions.

Stimulant drugs, for example, interfere with the liver’s usual disposal of barbiturates and alcohol.

Thus, people who combine barbiturates or alcohol with cocaine or amphetamines may build up

toxic, even lethal, levels of the depressant drugs 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 unknowingly 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, 2018). Sometimes the cause is

carelessness or ignorance. Often, however, people use multiple drugs precisely because they enjoy

the synergistic effects (Patrick et al., 2018). In fact, as many as 90 percent of those who use one

illegal drug are also using another to some extent (Jarlenski et al., 2017; Rosenthal, Levounis, &

Herron, 2016).

Easy to make, dangerous to take A drug user in Greece prepares a cocktail known as a speedball, a mixture of cocaine and

heroin. The pink capsule in her hand contains heroin and the blue one contains cocaine. Speedballs have been linked to

numerous polysubstance deaths.

Fans mourn the deaths of many

celebrities who have died from

polysubstance use. In the past several

695

years, for example, medical examiners

have found multiple drugs in the bodies of actress Carrie Fisher, actor Philip Seymour Hoffman,

Glee star Cory Monteith, and singers Tom Petty, Whitney Houston, and Michael Jackson—

mixtures that may have contributed to their deaths. 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 Hallucinogens, 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 tetrahydrocannabinol (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.

696

#BadAge 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 phenomenon has been called

“The 27 Club” in some circles.

What factors might explain the finding that different ethnic,

religious, and national groups have different rates of alcohol

use disorder?

What Causes Substance Use Disorders? Clinical theorists have developed sociocultural, psychological, and biological explanations for

why people develop substance use disorders. No single explanation, however, 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. Studies have found that

regions with higher unemployment levels

have higher rates of alcohol or opioid use

disorder (Khazan, 2017; Marsiglia & Smith, 2010). Similarly, people in lower socioeconomic

classes have rates of substance use disorder that are higher than those of the other classes. In a

related vein, 18 percent of unemployed adults currently use an illegal drug, compared with 11

percent of full-time employed workers and 13 percent of part-time employees (SAMHSA, 2018).

Sociocultural theorists hold that people confronted regularly by other kinds of stress also have

a heightened risk of developing substance use disorders. A range of studies conducted with

Hispanic, African American, and LGBTQ individuals, for example, find higher rates of substance

use disorders among those participants who live or work in environments of particularly intense

discrimination (Rose et al., 2018; Slater et al., 2017).

Still other sociocultural theorists

propose that people are more likely to

develop substance use disorders if they are

part of a family or social environment in

which substance use is valued or at least

accepted (Mahboubi et al., 2017). 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 (Calhoun et al., 2018; Wilens et al., 2014).

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

697

rates are higher among the Irish and Eastern Europeans, who do not, in general, draw as clear a

line (Hart & Ksir, 2017; 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 (Bressert, 2016; Dodes & Khantzian,

2016). They suggest that when parents fail to satisfy 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

experimentation 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 particularly prone to

drug abuse. Personality inventories, patient interviews, and even animal studies have in fact

indicated that individuals who abuse drugs tend to be more dependent, antisocial, impulsive,

novelty-seeking, risk-taking, and depressive than other individuals (Martino et al., 2017).

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 (Littlefield & Sher, 2010; 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 various 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 (Spoelder et al., 2017).

698

#PopularTitles 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,” Cyprus

Hill’s “I Wanna Get High,” Eminem’s “Drug Ballad,” Lil’

Kim’s “Drugs,” and Missy Elliott’s “Pass That Dutch.”

Feeling the effects Shortly after taking MDMA (“Ecstasy”) at a rave, this couple displays a shift in mood, energy, and

behavior. Each week, partygoers and other consumers take hundreds of thousands of doses of this drug (Johnston et al.,

2017), which is technically a stimulant but also considered a hallucinogenic drug. MDMA produces its effects largely by

altering serotonin and dopamine activity in the brain.

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. Inasmuch as

some people with these disorders appear to be dependent, others impulsive, and still others

antisocial, researchers cannot presently conclude that any one personality trait or group of traits

stands out in the development of the disorders (Garofalo & Wright, 2017).

Cognitive-Behavioral Views According to cognitive-behavioral

theorists, 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 (Duperrouzel et

al., 2018; Nock, Minnes, & Alberts, 2017). Similarly, the rewarding effects may eventually lead

users to try higher dosages or more powerful methods of ingestion. Beyond these conditioning

explanations, cognitive-behavioral theorists further argue that such rewards eventually produce an

expectancy that substances will be rewarding, and this expectation helps motivate people to

699

increase drug use at times of tension (Montes et al., 2017).

In support of these views, studies have found that many people do drink more alcohol or seek

heroin when they feel tense (Collins et al., 2018; Frone, 2016). In one study, as participants

worked on a difficult anagram task, a confederate planted by the researchers unfairly criticized

and belittled them. 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 20 percent of all adults who suffer from psychological disorders

also display substance use disorders (Dworkin et al., 2018; SAMHSA, 2018).

A number of cognitive-behavioral theorists have proposed that classical conditioning may also

play a role in these disorders (Goltseker et al., 2017; O’Brien, 2013). 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,

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 nauseated 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.

Biological Views Over the past few decades, researchers have become clear that biological factors play a major role

in drug misuse (Volkow et al., 2018). Studies on genetic predisposition, neurotransmitters, and

brain circuits have all pointed in this direction.

Genetic Predisposition For years, breeding experiments have been conducted to see whether certain animals are

700

genetically predisposed to become addicted to drugs (Logrip et al., 2018; Weiss, 2011). In several

studies, for example, investigators have first identified animals that prefer alcohol to other

beverages and then mated them to one another. Generally, the offspring of these animals have

been found also to display an unusual preference for alcohol.

Crack cookies? Researchers at Connecticut College found that the lab-induced addiction 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.

Similarly, research with human twins has suggested that people may inherit a predisposition

to misuse substances (Stickel et al., 2017; Ystrom et al., 2014). Numerous studies have found an

alcoholism concordance rate of around 50 percent in identical twins; that is, if one identical twin

displays alcoholism, the other twin also does in 50 percent of the cases. In contrast, in these same

studies, fraternal twins have a concordance rate of only 30 percent. As you have read, however,

such findings do not rule out other interpretations. 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 (Stickel et al., 2017; Samek et al.,

2014). 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 nonalcoholic biological

parents.

Genetic linkage strategies and molecular biology techniques provide more direct evidence in

701

support of a genetic explanation (Walker & Nestler, 2018; Way et al., 2017). 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 (Blum et al., 2018, 2015, 1990). Other studies have

tied still other genes to substance use disorders (Patriquin et al., 2017; Rezaei et al., 2017).

Neurotransmitters Over the past few decades, some researchers have pieced together a neurotransmitter-focused

explanation of drug tolerance and withdrawal symptoms (Lohani et al., 2017; Byrne et al., 2016;

Kosten et al., 2011, 2005). These theorists contend that 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. Because the drug

is increasing neurotransmitter activity or efficiency, the brain’s release of the neurotransmitter is

less necessary. As drug intake increases, the body’s production of the neurotransmitters continues

to decrease, leaving the person in need of progressively more of the drug to achieve its effects. In

this way, drug takers 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 suddenly 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.

702

Victims of a reward deficiency syndrome? The brain reward circuits 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 take

those substances, their reward circuits (right) are generally less active than the reward circuits of nonabusers (left) (Volkow et

al., 2016, 2004, 2002).

To some extent, the abused substance dictates which neurotransmitters will be affected.

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 production of endorphins,

and regular use of cocaine or amphetamines may lower the brain’s production of dopamine

(Vaquero et al., 2017; 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.

The Brain’s Reward Circuit

703

The neurotransmitter-focused explanation of substance abuse helps explain why people who

regularly take substances have tolerance and withdrawal reactions. But why are drugs so

rewarding, and why do certain people turn to them in the first place? Brain-imaging studies

conducted in recent years answer these questions by pointing to the operation of a particular

brain circuit—the circuit within which the neurotransmitters under discussion do their work. As

you’ve read earlier, a brain circuit is a network of brain structures that work together, triggering

each other into action to produce a distinct behavioral, cognitive, or emotional reaction. The

circuit that has been tied to substance misuse is the reward circuit, also called the reward center

and the pleasure pathway (Volkow et al., 2018, 2016).

reward circuit A dopamine-rich circuit in the brain that produces feelings of pleasure when activated.

Apparently, whenever a person ingests a substance (from foods to drugs), the substance

eventually activates the brain’s reward circuit (Hadar et al., 2017). This reward circuit features

the brain structure called the ventral tegmental area (in the midbrain), a structure known as the

nucleus accumbens, and the prefrontal cortex (see Figure 10-4). In addition, the circuit includes

the striatum, hippocampus, and several other important structures (Vaquero et al., 2017). The

key neurotransmitter in this circuit is dopamine (Volkow et al., 2018, 2016). When dopamine is

activated throughout this circuit, a person feels pleasure. Music may activate dopamine in the

reward circuit. So may a hug or a word of praise. And so do drugs. Although other

neurotransmitters also play roles in the reward circuit, dopamine is the primary one.

704

FIGURE 10-4

Pleasure Center in the Brain

One of the reasons substances produce feelings of pleasure is because they increase the activity of the neurotransmitter

dopamine in the brain’s reward circuit. Chronic dysfunction of this circuit—which includes the ventral tegmental area,

nucleus accumbens, and prefrontal cortex—can lead to a substance use disorder.

Certain drugs directly stimulate the structures in the reward circuit. Remember that cocaine

and amphetamines directly increase dopamine activity. Other drugs seem to stimulate it in

roundabout ways. The biochemical reactions triggered by alcohol, opioids, and marijuana set in

motion a series of chemical events that eventually lead to increased dopamine activity in the

reward circuit and, in turn, excessive communications (that is, heightened interconnectivity)

between the structures in the reward circuit (Hadar et al., 2017; Vaquero et al., 2017). A number

of studies further suggest that as substances repeatedly stimulate this reward circuit, the circuit

develops a hypersensitivity to the substances. That is, neurons in the circuit fire more readily

when stimulated by the substances, contributing to future desires for them (Moeller & Paulus,

2018).

Still other theorists suspect that people who chronically use drugs may suffer from a reward

705

deficiency syndrome: their reward circuit 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 (Blum et

al., 2018, 2016, 2000). Abnormal genes, such as the abnormal D2 receptor gene, have been cited

as possible contributors to this syndrome. In short, the chronic intake of certain substances helps

to produce a dysfunctional reward circuit in the brain and, along with that, the symptoms of a

substance use disorder.

The Developmental Psychopathology View Over the years, a list of factors that may contribute to substance use disorders has unfolded, but

no single factor fully predicts or explains the disorders. Thus, as with other psychological

disorders, a number of substance use theorists have tried to integrate the variables identified by

each of the models. Once again, developmental psychopathology theorists have been active in

this effort.

According to this perspective, the road to substance use disorders begins with genetically

inherited predispositions—predispositions characterized by a less-than-optimal reward circuit in

the brain and by a problematic temperament featuring some of the negative traits discussed

earlier in this chapter. Developmental psychopathologists suggest that such predispositions will

eventually result in a substance use disorder if the individual further experiences numerous

stressors throughout childhood, inadequate parenting (such as substance misuse modeling),

satisfying substance use experiences, relationships with peers who use drugs, and/or significant

adult stressors (Forster et al., 2018; Zucker et al, 2016). At the same time, individuals who

experience manageable adversities throughout childhood and adolescence can develop a level of

resilience that may help counter such unfavorable predispositions, stressors, and negative family

and peer influences.

In short, the developmental psychopathology perspective provides a framework for

understanding why the factors discussed in this chapter sometimes lead to substance use disorders

and sometimes do not. But the perspective also does more than this: it offers an explanation for

seeming contradictions in the substance abuse research literature. Recall, for example, our earlier

discussion of substance abuse personalities (see page 314). As you read, a variety of personality

traits have been linked to substance use disorders—dependency, antisocial inclinations,

impulsivity, novelty seeking, risk taking, and depressive functioning—but different studies have

tied different such traits to the disorders. These findings are not conflicting at all, according to

developmental psychopathology theorists.

706

#FamousDrugDeaths

Tom Petty, singer and songwriter (polydrug, 2017)

Lil Peep, rapper (polydrug, 2017)

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 propellants (APA, 2013). Such behavior may lead to inhalant use

disorder and poses a number of serious medical dangers.

The theorists propose that either of two very different temperaments may set the stage for

later substance abuse. On the one hand, some individuals may begin with a disinhibited

temperament, also called an externalizing temperament—featuring impulsivity, aggressiveness,

overactivity, limited persistence, low frustration tolerance, and inattention (Trucco et al., 2018;

Zucker et al., 2016, 1996). These individuals have great difficulty controlling their behaviors,

thus increasing their risk of having early family conflicts, behavioral problems, and school

difficulties—variables that may, in turn, lead to social problems, relationships with undesirable

peers, rewards from those peers for repeated drug use, and, ultimately, the onset of substance use

disorders. Studies have confirmed that this cluster and sequence of variables does indeed unfold

in many cases of substance use disorder (Chassin et al., 2016).

On the other hand, according to the

developmental psychopathology

perspective, other individuals may begin

with a temperament of inhibition and

707

Carrie Fisher, actress (polydrug and sleep apnea, 2017)

Prince, singer and songwriter (opioid, 2016)

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 songwriter (polydrug, 2009)

Heath Ledger, actor (polydrug, 2008)

Anna Nicole Smith, model (polydrug, 2007)

Ol’ Dirty Bastard, rapper, Wu-Tang Clan (polydrug, 2004)

Rick James, singer (cocaine, 2004)

negative affectivity, sometimes called an

internalizing temperament—characterized

by multiple fears, depression, negative

thinking, and dependence. This

temperament may contribute to worrying

and sadness throughout the individuals’

development, low self-concept, and

interpersonal rejections. These individuals

may eventually turn to alcohol and drugs

largely because the substances reduce their

emotional pain, quiet their troublesome

thoughts, and help them through

interpersonal difficulties. Studies have

indicated that this cluster and sequence of

variables may also lead to substance use

disorders (Menary, Corbin, & Chassin, 2017; Chassin et al., 2016).

This notion that different temperaments may trigger and interact with different

developmental factors to bring about substance use disorders is consistent with one of the key

principles of the developmental psychopathology perspective, equifinality—the principle that

different developmental pathways can lead to the same psychological disorder (see pages 69–70).

In short, identifying key factors in substance use disorders is only part of a comprehensive

explanation. It is also necessary to identify when and how those factors interact.

SUMMING UP

WHAT CAUSES SUBSTANCE USE DISORDERS? Several explanations for substance use disorders have been put forward. According to sociocultural theorists, the

people most likely to develop these disorders are those living under stressful socioeconomic conditions or those whose

families value or tolerate drug use. In the psychodynamic view, people who develop substance use disorders have

excessive dependency needs traceable 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 cognitive-behavioral

views, drug use is seen as being reinforced initially because it reduces tensions, and such reductions lead to an

expectancy that drugs will be comforting and helpful.

The biological explanations are supported by twin, adoptee, and genetic studies, suggesting that people may

inherit a predisposition 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 chronic

drug use. Biological studies suggest that many, perhaps all, drugs may ultimately lead to increased dopamine activity

708

in the brain’s reward circuit.

Developmental psychopathology theorists suggest that a genetically inherited biological predisposition and

temperamental predisposition may interact with life stressors, problematic parenting, and/or other environmental

factors to bring about a substance use disorder.

709

How Are Substance Use Disorders Treated? Many approaches have been used to treat substance use disorders, including psychodynamic,

cognitive-behavioral, and biological approaches, along with several sociocultural therapies. These

various approaches are often combined with motivational interviewing (see page 283) in which

therapists help motivate the clients to make constructive choices and behavioral changes

(Kampman, 2018; Ingersoll, 2017). Although treatment sometimes meets with great success,

more often it is only moderately helpful (Peavy, 2017; Strain, 2017). Today the various

treatments are typically used on either an outpatient or inpatient basis or a combination of the

two.

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 disorder. The therapists then try to

help the clients change their substance-related styles of living. Although this approach is often

used, it has not been found to be particularly effective (Dodes & Khantzian, 2016; McCrady et

al., 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 multidimensional treatment program.

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

(Kampman, 2018; Aronson, 2017). The leading cognitive-behavioral interventions for these

disorders are aversion therapy, contingency management, relapse prevention training, and acceptance

and commitment therapy (ACT).

Aversion Therapy In aversion therapy, a widely used approach based on the behavioral 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 A treatment in which clients are repeatedly presented with unpleasant stimuli while they are performing undesirable behaviors such as taking a drug.

710

#StayingSober 73% of current AA members have been sober for more than 1

year (AA World Services, 2017).

Aversion therapy has been used to treat

alcoholism more often than it has to treat

other substance use disorders. In one

version of this therapy, drinking is paired

with drug-induced nausea and vomiting

(Elkins et al., 2017; Cole, 2016). The pairing of nausea with alcohol is expected to produce

negative responses to alcohol itself. Another version of aversion therapy requires people with

alcoholism 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 yourself 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 remember 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 realize 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)

Aversion therapy for substance use disorders has had only limited success when it is the sole

form of treatment (Elkins et al., 2017; Belendiuk & Riggs, 2014). A major problem is that the

approach can be effective only if people are motivated to subject themselves to multiple sessions

of this unpleasant procedure, and many people are not.

Contingency Management Based on the behavioral principles of operant conditioning, contingency management programs

offer clients incentives (such as vouchers, prizes, cash, or privileges) that are contingent on the

submission of drug-free urine specimens (Rash et al., 2017; Stitzer, Cunningham, & Sweeney,

2017). In essence, this procedure—usually lasting 8 to 16 weeks—is rewarding clients for

abstaining from the use of the substances upon which they are dependent.

Studies indicate that clients in contingency management programs maintain a higher

attendance record than those in other kinds of programs. However, unless the programs are part

of a larger treatment approach, they are at best moderately effective at helping clients abstain

from substances for an extended period (Kampman, 2018; Stitzer et al., 2017). As with aversion

711

therapy, a major limitation is that the approach can be effective only when people are motivated

to continue despite its unpleasantness or demands.

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.

Relapse-Prevention Training One of the most prominent cognitive-behavioral approaches to substance misuse is relapse-

prevention training (Menon & Kandasamy, 2018). 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.

relapse-prevention training An approach to treating alcohol use disorder in which clients are taught to plan ahead and to apply coping strategies in situations that typically trigger excessive drinking.

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, people become more aware

of the situations that place them at risk for excessive drinking. (2) Therapists teach clients coping

strategies to use when such situations arise. Clients learn, for example, to recognize when they are

712

approaching their drinking limits; to control their rate of drinking (perhaps by spacing their

drinks or by sipping them rather than gulping); and to practice relaxation techniques,

assertiveness skills, and other coping behaviors in situations in which they would otherwise be

drinking. (3) Therapists teach clients to plan ahead of time. Clients may, for example, determine

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 (Menon & Kandasamy, 2018; Hart & Ksir, 2017). People who are young

and do not have the tolerance and withdrawal features of chronic alcohol use seem to do best

with this approach.

Acceptance and Commitment Therapy Another form of cognitive-behavioral treatment that has been used in cases of substance use

disorder is acceptance and commitment therapy (ACT). As you read in Chapters 2 and 4, ACT

therapists use a mindfulness-based approach to help clients become aware of their streams of

thoughts as they are occurring and to accept such thoughts as mere events of the mind. 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 is more effective than placebo

treatments and at least as effective as other cognitive-behavioral treatments for substance use

disorders, and sometimes more effective (Narayanan & Naaz, 2018; Smallwood et al., 2016).

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.

713

http://nyc.gov/health/naloxone

In case of an emergency In 2017 the New York City Health Department launched the “I Saved a Life” public awareness

campaign, which urges people to carry the opioid antagonist drug naloxone for possible use in opioid-overdose crises. The

campaign features powerful posters and stories about real-life people who were able to save the life of a friend or relative by

using naloxone. This medication is now available in pharmacies throughout the city.

Detoxification Detoxification is systematic and medically supervised withdrawal from a drug. Some

detoxification programs are offered on an outpatient basis. Others are located in hospitals and

clinics and may also include individual and group therapy, a “full-service” institutional approach

that has become popular. One detoxification approach is to have clients withdraw gradually from

the substance, 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 (Sevarino, 2018). 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. 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 detoxifying (Strain, 2018, 2017).

detoxification

714

Why has the legal, medically supervised use of heroin (in

Great Britain) or heroin substitutes (in the United States)

sometimes failed to combat drug problems?

Systematic and medically supervised withdrawal from a drug.

Antagonist Drugs After successfully stopping a drug, people must avoid falling back into a pattern of chronic use.

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 (Strain, 2018; Sofin et al., 2017).

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 prescribed (Sofin et

al., 2017). In addition to disulfiram, several other antagonist drugs are now being tested.

antagonist drugs Drugs that block or change the effects of an addictive drug.

For substance use disorders centered on opioids, several opioid antagonist drugs, such as

naloxone, are used (Strain, 2018). 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. In addition, by blocking endorphin

receptors during an opioid overdose, opioid antagonists can actually reverse the deadly effect of

respiratory depression, thus saving the user’s life. Research indicates that opioid antagonists may

also be useful in the treatment of substance use disorders involving alcohol or cocaine (Busch et

al., 2017; Johnson, 2017).

naloxone A widely used opioid antagonist drug.

Drug Maintenance Therapy

A drug-related lifestyle may be a bigger

problem than the drug’s direct effects.

Much of the damage caused by heroin

addiction, for example, comes from

overdoses, unsterilized needles, and an

accompanying life of crime. Thus, clinicians were very enthusiastic when methadone

maintenance programs were developed in the 1960s to treat heroin addiction (Dole &

715

Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory

opioid methadone as a substitute, or agonist, 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.

methadone maintenance program A treatment in which clients are given legally and medically supervised doses of methadone—a heroin substitute—to treat various opioid use disorders.

Drug use … under medical supervision Methadone is itself an opioid that can be as dangerous as other opioids when not

taken under safe medical supervision. Here a nurse at a methadone treatment facility prepares the drug for administration to

clients.

At first, methadone programs seemed very effective, and many of them were set up

throughout 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

716

disorder, and many people with an addiction complained that methadone addiction was creating

an additional drug problem that simply complicated their original one (Strain, 2018; Dalsbø et

al., 2017). Methadone is sometimes harder to withdraw from than heroin because the withdrawal

symptoms can last longer.

Despite such concerns, maintenance treatment with methadone has again sparked interest

among clinicians in recent years, partly because of new research support (Strain, 2018) and partly

because of the rapid spread of the HIV and hepatitis C viruses among intravenous drug abusers

and their sex partners and children (Kharasch, 2017). Not only is methadone treatment safer

than street opioid use, but many methadone programs now include AIDS education and other

health instruction in their services. Research suggests that methadone maintenance programs are

most effective when they are combined with education, psychotherapy, family therapy, and

employment counseling (Strain, 2018). Today thousands of clinics provide methadone treatment

across the United States.

Another opioid substitute drug, buprenorphine, has been gaining momentum as a form of

maintenance therapy during the past decade (Sevarino, 2018; SAMHSA, 2017). Like

methadone, this drug is itself an opioid that is administered to patients as a safer alternative to

heroin, painkillers, and the like. However, according to research, buprenorphine is a less potent

substitute drug than methadone and produces less tolerance and fewer withdrawal reactions

(Strain, 2018; Gowing et al., 2017). For these reasons, buprenorphine is permitted by law to be

prescribed by physicians in their offices rather than as part of a highly structured clinic program.

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 (Aronson, 2017). The drug self-help movement dates

back to 1935, when two Ohio men suffering from alcoholism met and wound up discussing

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

717

provided support. The organization became known as Alcoholics Anonymous (AA).

Alcoholics Anonymous (AA) A self-help organization that provides support and guidance for people with alcohol use disorder.

End of a dream In 2016, Florida Marlins pitcher Jose Fernandez was killed along with two passengers when he plowed his

32-foot boat into a jetty. A toxicology report showed that the 24-year-old, who defected from Cuba in 2008, was very

intoxicated (blood-alcohol level of 0.147) and had cocaine in his system at the time of the pre-dawn accident.

Today AA has approximately 2 million members in 110,000 groups across the world (AA

World Services, 2018). 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 spiritual dimension (Kelly, 2017). Meetings

take place regularly, and members are available to help each other 24 hours a day.

718

By offering guidelines for living, the organization helps members abstain “one day at a time,”

urging them to accept as “fact” the idea that they are powerless over alcohol and that they must

stop drinking entirely and permanently if they are to live normal lives. AA views alcoholism as a

disease and takes the position that “Once an alcoholic, always an alcoholic.” 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 (Peavy, 2017; Lembke & Humphreys, 2016).

It is worth noting that the abstinence goal of AA is in direct opposition to the controlled-

drinking goal of relapse-prevention training and several other interventions for substance misuse

(see pages 320–321). In fact, this issue—abstinence versus controlled drinking—has been

debated for years (Zemore, 2017; Rosenthal, 2011). 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 (Best, 2017;

Zemore, 2017). Studies suggest that abstinence may be a more appropriate goal for people who

have a long-standing alcohol use disorder, whereas controlled drinking can be helpful to younger

drinkers whose pattern does not include tolerance and withdrawal reactions. Those in the latter

group may indeed need to be taught a nonabusive form of drinking.

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 environment while undergoing individual, group,

and family therapies and making a transition back to community life (Aronson, 2017;

Gruenewald et al., 2016).

residential treatment center A place where people who were formerly addicted to drugs live, work, and socialize in a drug-free environment. Also called a therapeutic community.

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 the number of such studies has been limited

(Best, 2017; Peavy, 2017).

719

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

(Upshur et al., 2018; McKinney & Caetano, 2016). 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 (Grella, 2018; Gamboa, 2017). 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 become pregnant while taking drugs, the stresses of raising

children, and the fear of criminal prosecution for abusing drugs during pregnancy (SAMHSA,

2017). Thus, many women with such disorders feel more comfortable seeking help at gender-

sensitive clinics or residential programs; some such programs also allow children to live with their

recovering mothers.

Fighting drug abuse while in prison Inmates shake hands during a drug counseling session at a prison in Utah. The session

is part of a statewide program—for people living in communities, rehabilitation centers, and prisons—called Addict II

Athlete (pronounced “addict-to-athlete”). The program emphasizes exercise and athletic endeavors as an alternative to drug-

related behaviors, while also providing support, psychoeducation, and other interventions to help individuals address their

720

What impact might admissions by celebrities about past

drug use have on people’s willingness to seek treatment for a

substance use disorder?

substance use disorders.

Community Prevention Programs

Perhaps the most effective approach to

substance use disorders is to prevent them

(Mewton et al., 2018; Gruenewald et al.,

2016). The first drug prevention

programs were conducted in schools.

Today such programs are also offered in workplaces, activity centers, and other community

settings and even through the media (SAMHSA, 2018). Around 12 percent of adolescents report

that they have participated in drug prevention programs outside school within the past year.

Around 75 percent have seen or heard a substance use prevention message. And almost 60

percent have talked to their parents in the past year about the dangers of alcohol and other drugs.

Some prevention programs are based on a total abstinence model, while others teach

responsible use. Some seek to interrupt drug use; others try to delay the age at which people first

experiment with drugs. Programs may also differ in whether they offer drug education, teach

alternatives to drug use, try to change the psychological state of the potential user, help people

change their peer relationships, or combine these techniques.

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 pressure), the school (by setting up firm enforcement of drug policies), or the

community at large. The most effective prevention efforts focus on several of these areas in order

to provide a consistent message about drug misuse in all areas of people’s lives (Mewton et al.,

2018). 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 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 teenagers. Originally created by the U.S. Office of National Drug Control

Policy, Above the Influence became a private, not-for-profit program in 2014. A number of

studies are being conducted to assess the actual impact of the various community-based

prevention programs (SAMHSA, 2017; Allara et al., 2014).

721

http://TheTruth.com

SUMMING UP

HOW ARE SUBSTANCE USE DISORDERS TREATED?

Usually several approaches are combined to treat substance use disorders. Psychodynamic therapists try to help clients

become aware of and correct the underlying needs and conflicts that may have led to their use of drugs. Cognitive-

behavioral techniques include aversion therapy, contingency management, relapse-prevention training, and

acceptance and commitment therapy. Biological treatments include detoxification, antagonist drugs, and drug

maintenance therapy. Sociocultural treatments approach substance use disorders in a social context by means of self-

help groups (e.g., Alcoholics Anonymous), residential treatment programs, culture- and gender-sensitive treatments,

and community prevention programs.

722

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 A disorder marked by persistent and recurrent gambling behavior, leading to a range of life problems.

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 (Floros, 2018; Nowak & Aloe, 2014). 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 substance use disorder (APA,

2013).

TABLE: 10-3 Dx Checklist Gambling Disorder

1. Individual displays a maladaptive pattern of gambling, featuring at least 4 of the following symptoms over the course of a full year:

Can achieve excitement only by increasing gambling Feels restless or irritable during gambling reduction Repeated failures at controlling gambling Consumed with gambling thoughts Gambling often triggered by upset feelings Frequently returns to gambling to recoup previous losses Lies to cover up amount of gambling Gambling puts important relationships, job, or education at risk Seeks money from others to address gambling debts.

2. Individual experiences significant distress or impairment.

723

Information from: APA, 2013.

The explanations proposed for gambling disorder often parallel those for substance use

disorders (Yazdi et al., 2019; Nautiyal et al., 2017). Some studies suggest, for example, that

people with gambling disorder may: (1) inherit a genetic predisposition to develop the disorder;

(2) experience heightened dopamine activity and dysfunction of the brain’s reward circuit when

they gamble; (3) have impulsive, novelty-seeking, and other personality styles that leave them

prone to gambling disorder; and (4) make repeated and cognitive mistakes such as inaccurate

expectations and misinterpretations of their emotions and bodily states. However, the research on

these theories has been limited 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 (Choi et al., 2017). These treatments include cognitive-behavioral approaches

like relapse-prevention training, and biological approaches such as opioid antagonists. 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. People who

attend such groups seem to have a better recovery rate.

724

Increase in gambling venues This woman plays a slot machine while vacationing—harmless fun for her, but not for

everyone. Some theorists believe that recent increases in the prevalence of gambling disorder are related to the heightened

availability of casinos and online gambling sites.

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 participating in a

community—a new psychological problem has emerged: an uncontrollable need to be online

(Lindenberg et al., 2018; Young, 2017). This pattern has been called Internet use disorder and

Internet addiction, 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,

725

Internet browsing, e-mailing, blogging, visiting virtual worlds, shopping online, or viewing

online pornography (McNicol & Thorsteinsson, 2017). Specific symptoms of this pattern

parallel those found in substance use disorders and gambling disorder, extending from the loss of

outside interests to possible withdrawal 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 workgroup recommended that one

version of the pattern, which it calls Internet gaming disorder, receive further study for possible

inclusion in future editions (Paulus et al., 2018; APA, 2013). In the meantime, the World

Health Organization has indeed decided to include “gaming disorder” as a formal category inov

its newest edition of the International Classification of Diseases (ICD-11), the classification

system used in most countries outside of North America (WHO, 2018).

SUMMING UP

OTHER ADDICTIVE DISORDERS DSM-5 groups gambling disorder alongside the substance use disorders as an addictive disorder. Treatments for

gambling disorder include cognitive-behavioral approaches, opioid antagonists, and self-help groups.

726

CLINICAL CHOICES 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.

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-related

disorders continue to have only limited effect.

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

treatment, 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 investigators and clinicians have stopped working in isolation and are instead looking for

intersections between their own work and work from other models. They have come to recognize

that social pressures, personality characteristics, rewards, and genetic predispositions all play roles

in substance use disorders, and in fact they operate together. Similarly, the various forms of

treatment seem to work best when they are combined 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 disorders 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.

727

Chapter 10 Review

Key Terms

substance intoxication

hallucinosis

substance use disorder

tolerance

withdrawal

alcohol

delirium tremens (DTs)

cirrhosis

Korsakoff’s syndrome

fetal alcohol syndrome

sedative-hypnotic drug

barbiturates

benzodiazepines

opioid

opium

morphine

heroin

endorphins

cocaine

freebasing

crack

amphetamines

728

methamphetamine

hallucinogen

LSD (lysergic acid diethylamide)

cannabis

marijuana

tetrahydrocannabinol (THC)

polysubstance use

synergistic effect

substance abuse personality

reward circuit

reward-deficiency syndrome

aversion therapy

contingency management

relapse-prevention training

detoxification

antagonist drug

disulfiram (Antabuse)

opioid antagonist drugs

naloxone

methadone maintenance program

buprenorphine

self-help program

Alcoholics Anonymous (AA)

residential treatment center

community prevention program

729

gambling disorder

Gamblers Anonymous

Internet gaming disorder

Quick Quiz

1. What are substance use disorders? pp. 294–295

2. How does alcohol act on the brain and body? What are the problems and dangers of alcohol misuse? pp. 295–299

3. Describe the features and problems of the misuse of barbiturates and benzodiazepines. p. 299

4. Compare the various opioids (opium, heroin, morphine). What problems may result from their use? pp. 299–303

5. List and compare two kinds of stimulant drugs. Describe their biological actions and the problems caused by each of them. pp. 303–307

6. What are the effects of hallucinogens, particularly LSD? pp. 307–309

7. What are the effects of marijuana and other cannabis substances? Why is marijuana a greater danger today than it was decades ago? pp. 309–311

8. What special problems does polysubstance use pose? pp. 312–313

9. Describe the leading explanations and treatments for substance use disorders. How well supported are these explanations and treatments? pp. 313–325

10. Why is gambling disorder categorized as an addictive disorder in DSM-5, alongside substance use disorder? pp. 325–326

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

730

731

CHAPTER 11 Sexual Disorders and Gender Variations

TOPIC OVERVIEW

732

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 Variations

Transgender Functioning Gender Dysphoria

Personal Topics Draw Public Attention

Robert, 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

733

#SexualCensus The World Health Organization estimates that around 115

million acts of sexual intercourse occur each day.

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 dysfunctions and

paraphilic disorders. People with sexual dysfunctions have problems with their sexual responses.

Robert, for example, had a dysfunction known as erectile disorder, a repeated failure to attain or

maintain an erection 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.

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 different 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 researchers have only recently

begun to attend systematically to the importance of culture and race.

After examining the sexual disorders, this chapter will turn to a discussion of variations in

gender, specifically transgender functioning. Transgender people have a sense that their gender

identity (one’s personal experience of one’s gender) is different from the gender they were

assigned at birth. DSM-5 does not consider such individuals to be abnormal; however, it does

include a diagnostic category called gender dysphoria, a pattern in which individuals experience

significant distress or impairment as a consequence of their transgender feelings. As you will see,

the inclusion of this category in the DSM is controversial.

By convention, sexual disorders and

issues of gender are often discussed in the

same chapter, and we shall do the same in

this chapter. At the same time, it is

important to be clear that issues of sex are

different from issues of gender. Sexual functioning refers to how one reacts and performs in the

sexual realm, whereas gender identity is about whether one considers oneself male or female.

734

735

Rates for sexual behavior are typically based on population

surveys. What factors might affect the accuracy of such

surveys?

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 dysfunction

during their lives (Cunningham & Rosen, 2018). Sexual dysfunctions are typically very

distressing, and they often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal

problems. Often these dysfunctions are interrelated; many patients with one dysfunction have

another as well. Sexual dysfunction 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.

sexual dysfunction A disorder marked by a persistent inability to function normally in some area of the sexual response cycle.

The human sexual response can be described as a cycle with four phases: desire, excitement,

orgasm, and resolution (Shifren, 2018) (see Figure 11-1 and Figure 11-2). 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 dysfunction 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).

FIGURE 11-1

The Normal Sexual Response Cycle

736

Researchers have found a similar sequence of phases in both males and females. Sometimes, 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.)

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.)

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).

desire phase The phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction to others.

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). These people are not

diagnosed as having one of the sexual desire disorders.

Men with male hypoactive sexual desire disorder persistently lack or have reduced interest in

sex and engage in little sexual activity (see Table 11-1). Nevertheless, when they do have sex,

737

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

(Cunningham & Rosen, 2018; Martin et al., 2014).

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.

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 thought 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.

Women with female sexual interest/arousal disorder also lack normal interest in sex and

rarely initiate sexual activity (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 39 percent of women

worldwide have reduced sexual interest and arousal (Shifren, 2018; Lewis et al., 2010). Around

half of those individuals feel significant distress due to their level of arousal, and, as such, they

qualify for a diagnosis of female sexual interest/arousal disorder. Note that many sex researchers

and therapists believe it is inaccurate to combine desire and excitement symptoms into a single

female disorder.

female sexual interest/arousal disorder A female dysfunction marked by a persistent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensations during sexual activity.

A person’s sex drive is determined by a combination of biological, psychological, and

sociocultural factors, any of which may reduce sexual desire (Roslan et al., 2017). Most cases of

low sexual desire are caused primarily by sociocultural and psychological factors, but biological

738

conditions can also lower sex drive significantly.

Biological Causes of Low Sexual Desire A number of hormones interact to help produce sexual desire and behavior, and abnormalities in

their activity can lower a person’s sex drive (Cunningham & Rosen, 2018; Shifren, 2018). 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.

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 and heroin (Hirsch &

Birnbaum, 2018, 2017). Low levels of alcohol may enhance the sex drive by lowering a person’s

inhibitions, but high levels may reduce it (Cunningham & Khera, 2018).

Long-term physical illness can also lower a person’s sex drive (Cunningham & Rosen, 2018).

The 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.

Psychological Causes of Low Sexual Desire A general increase in anxiety, depression, or anger may reduce sexual desire in both men and

women (Nimbi et al., 2018; Shifren, 2018). Frequently, as cognitive-behavioral theorists 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 (Nimbi et al., 2018). 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

(Cunningham & Rosen, 2018; 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—divorce, a death

739

in the family, job stress, infertility difficulties, having a baby (Shifren, 2018; Hamilton &

Meston, 2013). Other people may be having problems in their relationships. People who are in

an unhappy relationship, have lost affection for their partner, or feel powerless 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 (Cunningham &

Rosen, 2018; 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 (Nimbi et

al., 2018; Antfolk, 2017). 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.

The trauma of sexual molestation or assault is especially likely to produce the fears, attitudes,

and memories found in disorders of sexual desire (Shifren, 2018; Giraldi et al., 2013). Some

survivors of sexual abuse may feel repelled by sex, sometimes for years, even decades. In some

cases, survivors may have vivid flashbacks of the assault during adult consensual sexual activity.

“It’s not you, babe—I’ve been neutered.”

INFOCENTRAL

SEX THROUGHOUT THE LIFE CYCLE

740

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 behavior often differs by age and by gender.

741

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

742

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.

Helping sexual arousal along Peacocking involves dressing with enormous flair—often in ostentatious ways with accessories

like scarves, dyed hair, and piercings—to attract sexual partners. The strategy is so-named because of its similarity to the

behavior of male peacocks who expand and fan their bright and beautiful feathers to attract mates.

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 15 to 25 percent of the male population,

including Robert, the man whose difficulties opened this chapter (Cunningham & Rosen, 2018;

Lewis et al., 2010). Carlos Domera also has erectile disorder:

743

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 intercourse

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 regarding 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 temporarily, 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 failure.” 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 … feeling that he was “cheating” his wife.

(Spitzer et al., 1983, pp. 105–106)

erectile disorder A dysfunction in which a man repeatedly fails to attain or maintain an erection during sexual activity.

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 (Agronin, 2017). Around 7

percent of men in their twenties also have the disorder; that number increases to as many as 40

percent of men in their sixties and early seventies and 70 percent of those in their late seventies

and older (Cunningham & Rosen, 2018; Lewis et al., 2010). Moreover, according to surveys,

half of all adult men experience erectile difficulty during intercourse at least some of the time.

Most cases of erectile disorder result from an interaction of biological, psychological, and

sociocultural processes.

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.

744

Information from: APA, 2013.

BIOLOGICAL CAUSES The same hormonal imbalances that can cause male hypoactive sexual desire disorder can also

produce erectile disorder (Cunningham & Rosen, 2018; Hyde, 2005). More commonly,

however, vascular problems—problems with the body’s blood vessels—are involved. An erection

occurs 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

(Hackett et al., 2018). 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 (Gigante

et al., 2018; Goldstein et al., 2018). 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 (Hirsch & Birnbaum, 2018, 2017; Mazzilli et

al., 2018).

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 erections 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 screening 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 problem 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

(Li et al., 2017).

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 (Cunningham & Rosen, 2018; Montejo

et al., 2011).

One well-supported psychological explanation for erectile disorder is the cognitive-behavioral

745

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 (Johnson, 2018). 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 ongoing problem. In this vicious cycle, the original cause of the erectile failure

becomes less important than fear of failure.

performance anxiety The fear of performing inadequately and a related tension that are 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.

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.

SOCIOCULTURAL CAUSES Each of the sociocultural factors that contribute to male hypoactive sexual desire disorder has also

746

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 (Nobre, 2017). Marital

stress, too, has been tied to this dysfunction (Cunningham & Rosen, 2018; LoPiccolo, 2004,

1991).

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 early ejaculation and

delayed ejaculation in men and female orgasmic disorder in women.

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.

FIGURE 11-3

Normal Male Sexual Anatomy

Changes in the male anatomy occur during the different phases of the sexual response cycle. (Information from: Hyde,

1990, p. 199.)

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

747

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 girlfriend, 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.

A man suffering from premature ejaculation (also called early, or rapid, ejaculation)

persistently reaches orgasm and ejaculates within 1 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 (Cunningham & Rosen, 2018; Lewis et al., 2010). 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 contend with the dysfunction, research suggests that men of any age may suffer from it

(Canat et al., 2018).

premature ejaculation A dysfunction in which a man persistently reaches orgasm and ejaculates within 1 minute of beginning sexual activity with a partner and before he wishes to. Also called early or rapid ejaculation.

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.

748

“Well, how convenient.”

Psychological, particularly cognitive-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

(Cunningham & Rosen, 2018; 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 infrequent sex are also prone to

ejaculate early.

Clinicians have also suggested that premature ejaculation may be related to anxiety, hurried

masturbation experiences during adolescence (in fear of being “caught” by parents), or poor

recognition of one’s own sexual arousal. However, these theories have only sometimes received

clear research support.

There is a growing belief among many clinical theorists that biological 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. One theory states that some men are born with a genetic

predisposition to develop this dysfunction. Indeed, one study found that 91 percent 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

749

#GoingNegative People who are totally unable to find sexual partners sometimes

refer to themselves as incels (“involuntary celibates”). The

number of incel forums on the Internet has grown over the

past two decades, as has the mysogynistic and threatening

rhetoric of some incels—a subgroup of individuals who

contend they are being unfairly deprived of sex and who even

endorse violence against sexually active women and men. As a

result, this once-supportive online movement has been banned

by numerous Web sites.

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 (Roaiah et al., 2018; Guo et al., 2017).

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). As many as 10 percent of men worldwide have this

disorder (Morgentaler et al., 2017; Lewis et al., 2010). 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.

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 suggested 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)

delayed ejaculation A male dysfunction characterized by persistent inability to ejaculate or very delayed ejaculations during sexual activity with a partner.

A low testosterone level, certain

neurological diseases, and some head or

spinal cord injuries can interfere with

ejaculation (Abdel-Hamid & Ali, 2018).

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.

750

Are there other problem areas in life that might also be

explained by performance anxiety and the spectator role?

For example, certain serotonin-enhancing antidepressant drugs appear to interfere with

ejaculation in at least 30 percent of men who take them (Hirsch & Birnbaum, 2018, 2017).

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 (Nimbi et al., 2018). 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. Another psychological cause of delayed ejaculation

may be past masturbation 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. A man who engages in sex

without any real desire for it may not get aroused enough to ejaculate.

Female Orgasmic Disorder Janel and Isaac, married for 3 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 family.

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 A’s 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). Around 21 percent of

women apparently experience this pattern to some degree (Shifren, 2018; Bradford, 2017).

Studies indicate that 10 percent or more of women have never had an orgasm, either alone or

during intercourse, and at least another 9 percent rarely have orgasms. 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).

female orgasmic disorder

751

A dysfunction in which a woman persistently fails to reach orgasm, has very low intensity orgasms, or has very delayed orgasms.

Around 50 to 70 percent of all women experience orgasm in intercourse at least fairly

regularly (Frederick et al., 2018; Bancroft et al., 2003). Women who are more sexually assertive

tend to have orgasms more regularly. At the same time, most clinicians agree that orgasm during

intercourse is not mandatory for normal sexual functioning (Shifren, 2018). 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 (Bradford, 2017; Laan et al., 2013). It is important to note that a number of clinicians

further believe that the achievement of orgasm, under any circumstance, is not a defining feature

of an acceptable and normal sex life (Shifren, 2018).

Biological, psychological, and sociocultural factors may combine to produce female orgasmic

disorder. 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 (Hirsch & Birnbaum, 2018, 2017).

752

753

Some theorists believe that the women’s movement has

helped to enlighten clinical views of sexual disorders. How

might this be so?

“The region of insanity” Medical authorities 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.”

PSYCHOLOGICAL CAUSES Research suggests that women with a high level of sexual inhibition are particularly likely to

experience female orgasmic disorder (Tavares, Laan, & Nobre, 2018). These individuals worry

greatly about their sexual performance, have related negative thoughts about it, and are easily

distracted during sexual activity.

More generally, the psychological causes of female sexual interest/arousal disorder, including

depression, may also lead to female orgasmic disorder (Bradford, 2017). In addition, as both

psychodynamic and cognitive theorists might predict, memories of childhood traumas and

relationships have sometimes been associated with orgasm problems (Carpenter et al., 2017). In

various 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).

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” (Bradford, 2017; Laan et al., 2013).

A sexually restrictive history, however,

is just as common among women who

function well during sexual activity

(LoPiccolo, 2002). 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 or traumas may help produce the fears, memories, and

attitudes that often characterize these sexual problems (Carpenter et al., 2017; Meana, 2012). For

example, many women molested as children or raped as adults have female orgasmic disorder

754

(Hall, 2017, 2007).

Research has also related orgasmic behavior to certain qualities in a woman’s intimate

relationships (Bradford, 2017; Kingsberg et al., 2017). Studies have found, for example, that the

likelihood of reaching orgasm may be tied to how much emotional involvement and pleasure a

woman had during her first experience of intercourse, her current attraction to her partner’s

body, and her relationship 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.

Grooming is key Humans are not the only animals that follow a sexual response cycle or, for that matter, display sexual

dysfunctions. Here a male macaque monkey grooms a female monkey while they sit in a hot spring in the snow in central

Japan. Such grooming triples the likelihood that the female will engage in sexual activity with the male.

Disorders of Sexual Pain Certain sexual dysfunctions are characterized by enormous physical discomfort during

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 (Kingsberg & Spadt, 2018; Hellstrom & DeLay, 2017).

genito-pelvic pain/penetration disorder A sexual dysfunction characterized by significant physical discomfort during intercourse.

755

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 prevent 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 (Barbieri, 2017; 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 (Meana et al., 2017). They just fear the discomfort of penetration of

the vagina.

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.

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 (Meana et al., 2017; 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 (Kingsberg & Spadt, 2018; Barbieri, 2017). 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 involuntary

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 14 to 16 percent of all women (and 40 percent of all

postmenopausal women) suffer from this problem to some degree (Kingsberg & Spadt, 2018;

Shifren, 2018). 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 (Meana et al.,

2017).

This form of genito-pelvic pain/penetration disorder usually has a physical cause (Kingsberg

756

& Spadt, 2018). 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, vaginal 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. Although

psychological factors (for instance, heightened anxiety or overattentiveness to one’s body) or

relationship problems may contribute to dyspareunia, psychosocial factors alone are rarely

responsible for it (Kingsberg & Spadt, 2018). It also is the case that 1 to 5 percent of men suffer

from pain in the genitals during intercourse, and many of these men also qualify for a diagnosis

of genito-pelvic pain/penetration disorder (Hellstrom & DeLay, 2017).

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 disorder. Men with the former disorder persistently lack or have reduced interest in

sex and, in turn, engage in little sexual activity. Women with the latter disorder lack normal interest in sex, rarely

initiate sexual activity, and may also feel little excitement during sexual activity or in the presence of erotic cues.

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, a repeated inability to attain or maintain an erection

during sexual activity. Biological causes of erectile 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, situational pressures such as job loss, and relationship problems.

Premature ejaculation, a disorder of the orgasm phase, has been attributed most often to cognitive-behavioral

causes, such as inappropriate early learning and inexperience. Delayed ejaculation, a repeated absence of or long delay

in reaching orgasm, 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. Female orgasmic disorder 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 typically has a physical cause, such as injury resulting from childbirth.

757

758

Self-Satisfaction A large Finnish study found that half of all male and female

participants were satisfied with the appearance of their genitals

and, in the case of women, of their breasts (Ålgars et al., 2011).

Treatments for Sexual Dysfunctions The last 40 years have brought major changes in the treatment of sexual dysfunctions. 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 (Avery-Clark & Weiner, 2017). The goal of sex therapy is to help clients

function better sexually and to achieve a higher level of sexual satisfaction and psychological well-

being (Peterson, 2017). In recent years, biological interventions, particularly drug therapies, have

been added to the treatment arsenal (McCarthy & Wald, 2017).

What Are the General Features of Sex Therapy? Modern sex therapy is short-term and

instructive, typically lasting 15 to 20

sessions. It centers on specific sexual

problems rather than on broad personality

issues (Peterson, 2017). Carlos Domera,

the Argentinian 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 embarrassment, 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. …

[T]he 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 anxiety in subsequent weeks and a return of the initial problem. They were … encouraged to try again to

have sexual contact involving caressing and nondemand light genital stimulation, without an expectation of erection or orgasm,

and to avoid intercourse.

759

Sex is one of the topics most commonly searched on the

Internet. Why might it be such a popular search topic?

#TheirWords “Whoever called it ‘necking’ was a poor judge of anatomy.”

Groucho Marx, comedian and actor

#TheirWords “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

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 stimulation and that, although she enjoyed

intercourse, she enjoyed these other stimulations as much, as long as he was relaxed. [Carlos] … 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 medical 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 dysfunction (Cunningham & Khera, 2018; Hackett et al., 2018).

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 (Shifren, 2018; Kingsberg et al., 2017).

3. Education about sexuality. Many patients who suffer from sexual dysfunctions know very little about the physiology and techniques of sexual activity (Khera & Cunningham, 2018). Thus sex therapists may discuss these topics and offer educational materials, including instructional books, videos, and Internet sites (van Lankveld, 2017).

4. Emotion identification. Sex therapists help patients identify and express upsetting emotions tied to past events that may keep interfering

760

with sexual arousal and enjoyment (Johnson, 2017; Kleinplatz, 2010).

5. Attitude change. Following a cardinal principle of cognitive-behavioral therapy, sex therapists help patients examine and change any beliefs about sexuality that are preventing sexual arousal and pleasure (Bradford, 2017; Kingsberg et al., 2017).

“When I touch him he rolls into a ball.”

6. Elimination of performance anxiety and the spectator role. Therapists often teach couples sensate focus, or nondemand pleasuring, a series of sensual tasks, sometimes called “petting” exercises, in which the partners focus on the sexual pleasure 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. 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 (Khera & Cunningham, 2018; Avery-Clark & Weiner, 2017).

7. Increasing sexual and communication skills. Couples are taught to use their sensate-focus skills and apply new sexual techniques and positions at home (Shifren, 2018; Bradford, 2017). 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 location of sexual contact (Heiman, 2007). Couples are also taught to give instructions 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

761

#EarlyPleasure In some studies, the majority of female participants from

sexually positive marriages report that foreplay is the most

satisfying component of sexual activity with their partner

(Herbenick et al., 2018; Basson, 2007; Hurlbert, 1993).

me on”).

8. Changing destructive lifestyles and couple interactions. A therapist may encourage 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 (Kingsberg et al., 2017; Rosen, 2007).

9. Addressing physical and medical factors. Systematic increases in physical activity have proved helpful for persons with various kinds of sexual dysfunctions (Khera & Cunningham, 2018). 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 (Shifren, 2018; Korda et al., 2010).

What Techniques Are Used to Treat Particular Dysfunctions? In addition to the general components of sex therapy, specific techniques 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 (Both, Schultz, &

Laan, 2017). Thus therapists typically use

a combination of techniques (Althof & Needle, 2017). In a technique called affectual awareness,

patients visualize sexual scenes in order to discover any feelings of anxiety, vulnerability, and

other negative emotions they may have concerning sex. In another technique, 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

762

read books and view videos with erotic content, and to fantasize about sex. They also may

encourage pleasurable shared activities such as dancing and walking together. If the reduced

sexual desire has resulted from sexual assault or childhood molestation, additional techniques

may be needed (Shifren, 2018; Hall, 2017, 2007). A patient may, for example, be encouraged to

remember, talk about, and think about the assault until the memories 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 (Khera & Cunningham,

2018; Both et al., 2017).

Finally, biological interventions, such as hormone treatments, have been used, particularly for

women whose problems arose after removal of their ovaries or later in life. These interventions

have received some research support (Shifren, 2018). In addition, several pharmaceutical drugs

have been developed specifically for the treatment of these disorders (Khera & Cunningham,

2018).

Erectile Disorder Treatments for erectile disorder focus on reducing a man’s performance anxiety, increasing his

stimulation, or both, using a range of behavioral, cognitive, and relationship interventions

(Nobre, 2017). In one technique, the couple may be instructed to try the tease technique during

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 erections occur naturally in response to stimulation,

as long as the partners do not keep focusing on performance.

Biological approaches gained great momentum with the development in 1998 of sildenafil

(trade name Viagra) (Nobre, 2017). 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). 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 (Khera & Cunningham, 2018). Soon after Viagra

emerged, two other erectile dysfunction drugs were also approved—tadalafil (Cialis) and

vardenafil (Levitra)—and, more recently, yet another such drug, avanafil (Stendra), was added to

the mix. Collectively, the drugs are the most common form of treatment for erectile disorder.

They effectively restore erections and enable sexual intercourse in 60 to 80 percent of men who

use them, compared to a rate of 21 percent among men taking placebo drugs (Khera &

Cunningham, 2018). Some research, though, suggests that a combination of one of these erectile

763

dysfunction drugs and a psychological intervention such as those mentioned above may be more

helpful than either kind of treatment alone (Nobre, 2017; Schmidt et al., 2014).

sildenafil One of the drugs used to treat erectile disorder that helps increase blood flow to the penis during sexual activity. Marketed as Viagra.

Viagra around the world Few drugs have had the worldwide impact of Viagra and related erectile dysfunction drugs. Here

technicians at a pharmaceutical factory in Cairo sort thousands of Viagra pills for distribution and marketing in Egypt’s

pharmacies.

Prior to the development of Viagra, Cialis, Levitra, and Stendra, 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 unsuccessful or

too risky for individuals (Lazarou, 2017). Such treatments include gel suppositories, injections of

drugs into the penis, a surgical implantation of a penile prosthesis, and a vacuum erection device

(VED), a hollow cylinder that is placed over the penis. For the VED, 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 (Rowland &

Cooper, 2017). 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 experiences much more total time of

stimulation than he has ever experienced before (LoPiccolo, 2004, 2002). Eventually the couple

764

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 2 or 3 months, many

couples can enjoy prolonged intercourse without any need for pauses (Puppo & Sharif, 2017;

Althof, 2007).

PSYCHWATCH

Sexism, Viagra, and the Pill

Most of us would like to 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. Periodically, however, such illusions are

shattered. The responses of government agencies and insurance companies to the discovery and marketing of Viagra in

1998 may be a case in point.

Consider, first, the nation of Japan. In early 1999, just 6 months after it was introduced in the United States, Viagra

was approved for use among men in Japan (Goldstein, 2014). In contrast, low-dose contraceptives—“the pill”—were not

approved for use among women in Japan until later that same year—a full 40 years after their introduction elsewhere! Some

observers believe that birth control pills would still be unavailable to women in Japan had Viagra not received its quick

approval.

“The pills”: Cialis, Viagra, and Levitra

Has the United States been able to avoid such an apparent double standard in its health care system? Not really. Before

Viagra was introduced, insurance companies were not required to reimburse women for the cost of prescription

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 (Hollander, 2006; Hayden, 1998). Some legislators had tried to correct

this problem by requiring contraceptive coverage in health insurance plans, but their efforts failed in state after state for

more than a decade.

765

#NightlyVisits People 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

“The pill”

In contrast, when Viagra was introduced in 1998, many insurance companies readily agreed to cover it, and many

states included Viagra as part of Medicaid coverage. As the public outcry grew over the contrast between coverage of Viagra

for men and lack of coverage of oral contraceptives for women, laws across the country finally began to change. By the end

of 1998, nine states required prescription contraceptive coverage. Today 28 states require such coverage by private

insurance companies (Guttmacher Institute, 2018). The Affordable Care Act (ACA)—the federal health care law passed in

2010 and enacted a few years later—includes provisions that require all insurance companies to cover contraceptives.

However, with Congress repeatedly considering the repeal of the ACA—and possibly, along with it, the elimination of

contraceptive coverage requirements—the future of contraceptive insurance coverage is very much at risk.

Many clinicians treat premature ejaculation with SSRIs, the serotonin-enhancing

antidepressant drugs (Khera & Cunningham, 2018). 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).

Delayed Ejaculation Therapies for delayed ejaculation include techniques to reduce performance anxiety and increase

stimulation (Rowland & Cooper, 2017; Hartmann & Waldinger, 2007). 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

damage or injury, treatment may include

766

night man” who visited women (Kahn & Fawcett, 1993). a drug to increase arousal of the

sympathetic nervous system (Khera &

Cunningham, 2018). However, few

studies have systematically tested the effectiveness of such biological treatments.

Female Orgasmic Disorder Specific treatments for female orgasmic disorder include cognitive-behavioral techniques, self-

exploration, enhancement of body awareness, and directed masturbation training (Carpenter et

al., 2017; Kingsberg et al., 2017). 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 (Shifren, 2018; Bradford, 2017).

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 thrusting 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 (Bradford, 2017; Laan et al., 2013).

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.

As you read earlier, a lack of orgasm during intercourse is not necessarily a sexual dysfunction,

provided the woman enjoys intercourse. 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, and to further teach them how to reach orgasm, if

they wish, through caressing by their partner or by herself.

Genito-Pelvic Pain/Penetration Disorder Specific treatment for involuntary contractions of the muscles around the vagina typically

involves two approaches (Shifren, 2018; Meana et al., 2017). 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 ending with the insertion of her partner’s penis. Most clients

767

#DividedFocus According to surveys, 1 in 10 respondents admit to having

used their cell phones during sex (Archer, 2013).

treated with such procedures 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 (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 procedures (see page 340) and sex therapy

techniques may be tried, including helping a couple to learn intercourse positions that avoid

putting pressure on the injured area (Meana et al., 2017; Fugl-Meyer et al., 2013). 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 (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 (Shifren,

2018; Berry & Berry, 2013).

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 personality disorders (Buehler, 2017). In addition,

sex therapists no longer screen out LGBTQ clients, individuals with severe relationship discord,

the elderly, the medically ill, the physically handicapped, the intellectually disabled, or

individuals who have no long-term sex partner (Cohen & Savin-Williams, 2017; Hough et al.,

2017; Zhou & Bober, 2017). Sex therapists are also paying more attention to excessive sexuality,

sometimes called persistent sexuality disorder, hypersexuality, or sexual addiction (Hallberg et al.,

2017), 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

768

low sexual desire and erectile disorder. Their concern 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 (McCarthy & Wald, 2017). 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 techniques have been developed for each

of the sexual dysfunctions. The use of biological treatments for sexual dysfunctions is also increasing.

769

Is the abundance of sexual material on the Internet

psychologically healthy or damaging?

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 special circumstances. Some people with one kind of

paraphilia have others as well. The large consumer market in paraphilic pornography and

growing trends such as sexting and cybersex lead clinicians to suspect that paraphilias may be far

more common than previously thought (see MindTech).

paraphilias Patterns in which a person has recurrent and intense sexual urges, fantasies, or behaviors involving nonhuman objects, children, nonconsenting adults, or experiences suffering or humiliation.

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 (Moreno, 2018). The term “sexting” did not make its debut until 2005.

One survey of almost 6,000 single adults found that 21 percent of cell phone users have sent a sexually explicit text

message and 16 percent have texted a sexually explicit photo of themselves. On the other side of the coin, 28 percent of

users have received sext messages and 23 percent have received sexual photos (Madigan et al., 2018; Garcia et al., 2016). In

general, half of all people save the sexual images and text messages they receive, and a quarter of recipients—men much

more than women—forward the sexual photos that they receive to others (Strassberg et al., 2017, 2013; McAfee, 2014).

770

What texting activities outside the sexual realm might also

have either a negative or positive psychological impact

depending on how and when they are performed?

Putting sexting on the map In response to media revelations about his multiple episodes of sexting in 2011 and

2016, former New York congressman Anthony Weiner had to resign his congressional seat and, eventually, give up

his political ambitions.

Naïve behavior? Not always. The majority of all sexters say they recognize that the act could lead to legal, social, career,

or personal problems (Garcia et al., 2016). They are also aware that sexted images sometimes wind up as “revenge porn”—

images that are posted on social media by vengeful former friends or relationship partners for all the world to see (LeBlanc,

2017). Young adults (18 to 24 years old) are the largest group of sexters (Englander & McCoy, 2018). And males sext more

often than females by a 3 to 2 margin (Frankel et al., 2018).

Is sexting a symptom of abnormal functioning? It depends. Certainly, some sexters—particularly those who sext to

nonconsenting recipients—fit the criteria for exhibitionistic disorder, the paraphilic pattern in which people act on urges to

expose their genitals to others. Sixteen percent of sexters send sexual photos of themselves to complete strangers (McAfee,

2014). And like other forms of exhibitionism, sexting can cause psychological stress for nonconsenting recipients.

There are yet other ways in which sexting may

reflect psychological or relationship problems

(Weisskirch et al., 2017; Drouin & Landgraff,

2012). 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. In addition, research indicates that

sexting (when done outside of one’s marriage or monogamous relationship) 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 (Cable, 2008).

On the other side of the coin, sexting can be a constructive activity, according to some research (Drouin, Coupe, &

Temple, 2017; McDaniel & Drouin, 2015; Wiederhold, 2015). Many couples engage in it as an added dimension to their

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. Research suggests that this often enhances the in-person romantic relationship,

771

creates more bonding, and heightens sexual satisfaction in the relationship.

According to DSM-5, a diagnosis of paraphilic disorder should be applied when paraphilias

cause a person significant distress or impairment or when the satisfaction 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). 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

(Brown, 2017).

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.

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.

As you will see, although theorists have proposed various explanations for paraphilic disorders,

there is little formal evidence to support such explanations (Martin & Levine, 2018). Moreover,

none of the many treatments applied to these disorders has received much research or proved

clearly effective (Thibaut et al., 2016). 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 production of

testosterone, the male sex hormone, and reduce the sex drive (Turner et al., 2017). Although

antiandrogens may indeed reduce paraphilic patterns, several of them disrupt normal sexual

feelings and behavior as well (Thibaut et al., 2016, 2010). 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

772

#TheirWords “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’s Masterpiece, 1684

SSRIs will reduce these compulsion-like sexual behaviors just as they help reduce other kinds of

compulsions (Anupama et al., 2016).

A word of caution is in order before

examining the various 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 (Fuss, Briken, & Klein,

2018). Some clinicians argue that except

when other people are hurt by them, at least some paraphilic behaviors should not be considered

disorders at all (Joyal, 2017, 2015; Giami, 2015). 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 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. Only in 1987, 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 entirely from the DSM. Even

then, as you read in Chapter 1, many clinicians continued for years to recommend and offer

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 behaviors 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 (Martin & Levine, 2018). 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 (Bressert, 2017). Some of these features are seen in the case of Jaylen, a

teenager whose mother, Kiara, discovered his fetishistic disorder over the course of six months:

773

[Kiara] reported that she first recognized [Jaylen’s] sexual interest in women’s shoes six months ago. He started to disappear

repeatedly from their apartment and [one day, Kiara] found him on the stairs … handling the shoes of a female neighbor. Later

on, [Kiara] came across [Jaylen] rubbing and smelling the shoes in such a fascinated manner that he did not even recognize his

mother’s presence. … [Kiara] also noticed that [Jaylen] was increasingly staying within their apartment building, taking the

neighbor’s shoes down to the ground floor rather than going outside. … After a week [Jaylen] visited the neighbor’s home while

helping her carry shopping goods. After an apparently normal visit, the neighbor recognized that her shoes were missing. [Kiara]

tried to talk with [her son], but he became agitated and refused to talk. After several weeks, she recognized that her own shoes were

missing … The mother then started keeping track of [Jaylen] and recognized that he was awaking at night and was … rubbing

and smelling her shoes. [Kiara] did not recognize the sexual nature of his behaviors and thought that he had a compulsive interest

in shoes. [However, one day] she entered the bathroom and found [Jaylen] there masturbating while he was holding and rubbing

her shoe in his hand. At that point, she recognized the sexual nature of his interest in shoes for the first time. Subsequently she came

across some videos on his mobile phone. They were recordings of young women’s feet with or without shoes, including videos of

[Kiara’s own] naked feet. There were dozens of these videos, … dating back four months.

(Coskun & Ozturk, 2013, p. 199)

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 clinically significant distress or impairment.

Researchers have not been able to pinpoint the causes of fetishistic disorder. Psychodynamic

theorists view fetishes as defense mechanisms that help people avoid the anxiety produced by

normal sexual contact. Psychodynamic treatment for this problem, however, has met with little

success (Martin & Levine, 2018).

Viewing fetishes as learned behaviors, cognitive-behavioral theorists propose that fetishes are

acquired through classical conditioning (Martin & Levine, 2018). 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 particular objects, perhaps the stage is

set for the development of fetishes.

774

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.

Cognitive-behavioral therapists have sometimes treated fetishistic disorder with aversion

therapy (Thibaut et al., 2016; Plaud, 2007). In a famous study, an electric shock was

administered to the arms or legs of participants with this disorder while they imagined their

objects of desire (Marks & Gelder, 1967). After 2 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 cognitive-behavioral treatment for fetishistic disorder is masturbatory satiation

(Thibaut et al., 2016; Plaud, 2007). In this method, the client masturbates to orgasm while

fantasizing 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.

775

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 gender—arousal expressed

through fantasies, urges, or behaviors (APA, 2013). The individual’s transvestic needs and

behaviors must cause significant distress or impairment to warrant a diagnosis of transvestic

disorder. The typical person with the disorder, almost always a heterosexual male, begins cross-

dressing in childhood or adolescence (Brown, 2017; Thibaut et al., 2016). He may be 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 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 distress or impairment. Also known as transvestism or cross-dressing.

Transvestic disorder is often confused with transgender feelings and behaviors, but, as you will

see, they are two separate patterns that overlap only in some individuals. Specifically, a transvestic

disorder is about the sexual arousal certain persons feel when they dress in opposite-gender

clothes, whereas transgender functioning is about the gender a person considers himself or herself

to be.

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

776

dress like women, plant a kiss on actress Kerry Washington. Washington was receiving the club’s 2016 Woman of the Year

award.

As with fetishes, cognitive-behavioral theorists view transvestic arousal and behavior as learned

responses, acquired most often through classical conditioning. That is, if early sexual experiences

occur while a person is—out of curiosity, playfulness, or the like—wearing the attire of the other

gender, the stage may be set for transvestic arousal and related reactions throughout life. This

explanation has, however, received little support in clinical reports or research (Anupama et al.,

2016).

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 provoke shock or surprise rather than

initiate sexual activity with the victim. Sometimes 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.

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 significant distress or impairment.

Generally, exhibitionistic disorder begins before age 18 and usually, but not always, is found

among men (Brown, 2017; Thibaut et al., 2016). 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 (Brown, 2017; 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, masturbatory

satiation, social skills training, and some form of insight therapy (Marshall & Marshall, 2016;

Thibaut et al., 2016).

Voyeuristic Disorder

777

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.

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.

A person with voyeuristic disorder may masturbate during the act of observing or when

thinking about it afterward but does not generally seek to have sex with the person being spied

on (Brown, 2017). The vulnerability of the people being observed and the probability 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, as you can see in 25-year-old

Sam’s description of his disorder during an interview:

I’ve had girlfriends, but it’s not the same. It’s fun at first, but I get bored after a while in relationships. I never get that kick,

that excitement, that I do when I look at others.

The biggest thrill is when I’m watching my neighbor having sex with one of her boyfriends, or maybe watching Zoe down the

block changing her clothes. Neither of them fully shuts their drapes, so there’s always a little angle where I can see into their rooms

if I get in just the right position on the lawn. Sometimes I’ll take a walk and try to find someone I haven’t watched before.

Thinking about it afterwards, I also get excited, especially if I came close to getting caught. I realize what a chance I was

taking, and it gets my heart going and gets the rest of me going as well. Sometimes I’ll make up extra details when remembering

what happened, especially details about barely getting away or even being spotted, and that makes it even better. Of course, if I

ever did get caught, it would be horrible.

778

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 persuade 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.

Voyeurism, like exhibitionism, is often a source of sexual excitement in fantasy; it can also

play a role in normal sexual interactions if a partner consents to voyeuristic-like behaviors. The

clinical disorder of voyeuristic disorder is marked by the repeated invasion of other people’s

privacy. Some people with the disorder are unable to have normal sexual relations; others have a

normal sex life apart from their disorder.

Many psychodynamic clinicians propose that people with voyeuristic disorder are seeking by

their actions to gain power over others, possibly because they feel inadequate or are sexually or

socially shy (Pfäfflin, 2016). Cognitive-behavioral theorists explain the disorder as a learned

behavior a 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

779

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, 2011). 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).

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 person or experiences clinically significant distress or impairment.

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, early pubescent

children, or both. 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 (Geradt et al., 2018). Some people

with the disorder are attracted only to children; others are attracted to adults as well (Brown,

2017; Stephens et al., 2017). Both boys and girls can be pedophilic victims, but there is evidence

suggesting that two-thirds are girls (NSOPW, 2018).

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.

People with pedophilic disorder usually develop their pattern of sexual need during

adolescence (Thibaut et al., 2016). Some were themselves sexually abused as children, and many

were neglected, excessively punished, or deprived of genuinely close relationships during their

childhood (Brown, 2017). It is not unusual for them to be married and to have sexual difficulties

780

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, they may

have limited self-control and poor planning skills, and thoughts of normal sexual relationships fill

them with anxiety (Massau et al., 2017; 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” (Geradt et al., 2018; O Ciardha et al., 2016). 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.

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 advocate 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 (Pieters, 2018; Durkin & Hundersmarck, 2008).

Studies have found that most men with pedophilic disorder also display at least one additional

psychological disorder (Brown, 2017; Farkas, 2013). Some theorists have proposed that

pedophilic disorder may be related to biochemical or brain structure abnormalities such as

irregular patterns of activity in the amygdala or in the frontal areas of the brain, but such

abnormalities have yet to receive consistent research support (Ponseti et al., 2018; Massau et al.,

2017).

Most pedophilic offenders are imprisoned or forced into treatment if they are caught (Thibaut

et al., 2016). After all, they are committing child sexual abuse when they take any steps toward

sexual contact with a child. 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 (NSOPW, 2018).

781

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 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 defendants ranged from 27 to 73 years.

Treatments for pedophilic disorder include those already mentioned for other paraphilic

disorders, such as aversion therapy, masturbatory satiation, cognitive-behavioral therapy, and

antiandrogen drugs (Brown, 2017; Marshall & Marshall, 2016, 2015; Thibaut et al., 2016). 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 pages 320–321). 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 (Laws, 2016; Federoff & Marshall,

2010).

Sexual Masochism Disorder A person with sexual masochism disorder is repeatedly and intensely sexually aroused by the act

782

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

partners restrain, tie up, blindfold, spank, paddle, whip, beat, electrically shock, “pin and pierce,”

or humiliate them (APA, 2013).

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.

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 surrounding particular acts of these paraphilias. On the light side, the annual

Folsom Street Fair in San Francisco celebrates S/M and invites people (like this participant) to go on stage, display their

trademark outfits, and in some cases, participate in pseudo whippings or spankings.

783

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 facility that meets those desires:

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 … 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.”

(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

(Sendler, 2018; Coluccia et al., 2016). 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. There is 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

(Frias et al., 2017; Krueger, 2010).

In many cases, sexual masochism disorder seems to have developed through the learning

process of classical conditioning (Wylie & Wylie, 2016; Stekel, 2010). 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.

784

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 (Longpré et

al., 2018, 2017). 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.

sexual sadism disorder A paraphilic disorder 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 individuals or experiences clinically significant distress or impairment.

Cinematic introduction In one of filmdom’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.

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 disorder (Joyal, 2017). Some, however, act out

their urges on nonconsenting victims. A number of rapists and sexual murderers, for example,

exhibit sexual sadism disorder (Longpré et al., 2018, 2017). In all cases, the real or fantasized

victim’s suffering is the key to arousal.

Fantasies of sexual sadism, like those of sexual masochism, may first appear in childhood or

adolescence (Thibaut et al., 2016; Stone, 2010). People who engage in sadistic acts begin to do

so by early adulthood (APA, 2013). 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

785

#LegalOption In 1996 the California state legislature passed the first law in

the United States allowing state judges to order antiandrogen

drug treatments, often referred to as “chemical castration,” for

repeat sex crime offenders, such as men who repeatedly commit

pedophilic acts or rape. At least eight other states now have

similar laws.

the years (Robertson & Knight, 2014). Obviously, people with severe forms of the disorder may

be highly dangerous to others.

Some cognitive-behavioral theorists believe that classical conditioning is at work in sexual

sadism disorder (Akins, 2004). While inflicting pain, perhaps unintentionally, on an animal or

person, a teenager may feel intense emotions and sexual arousal. The association between

inflicting pain and being aroused sexually sets the stage for a pattern of sexual sadism. Cognitive-

behavioral theorists also propose that the disorder may result from modeling, when adolescents

observe others achieving sexual satisfaction by inflicting pain. The many Internet sex sites and

sexual videos, magazines, and books in our society make such models readily available (Thibaut

et al., 2016).

Both psychodynamic and cognitive-behavioral theorists further 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. The sense of power in turn increases their

sexual arousal (Marshall & Marshall, 2016, 2015). Alternatively, certain biological studies have

found signs of possible brain and hormonal abnormalities in people with sexual sadism (Luo et

al., 2017; Jacobs, 2011). None of these explanations, however, has been thoroughly investigated.

Cognitive-behavioral therapists have

treated the disorder with aversion therapy

(Thibaut et al., 2016). 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 (Laws, 2016; Marshall &

Marshall, 2016, 2015).

SUMMING UP

PARAPHILIC DISORDERS Paraphilias are patterns characterized by recurrent and intense sexual urges, fantasies, or behaviors involving objects or

786

situations outside the usual sexual norms—for example, nonhuman objects, children, nonconsenting adults, or

experiences of suffering or humiliation. When an individual’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, exhibitionistic disorder, voyeuristic disorder, frotteuristic disorder, pedophilic disorder, sexual

masochism disorder, and sexual sadism disorder. Although various explanations have been proposed for paraphilic

disorders, research has revealed little about their causes. A range of treatments have been tried, including aversion

therapy, masturbatory satiation, and relapse-prevention training.

787

Gender Variations 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 (or birth anatomy), the gender to

which they are born. But society has come to appreciate that many people do not experience such

gender clarity. These people are transgender, individuals who have a sense that their gender

identity (one’s personal experience of one’s gender) is different from their assigned gender. It is

estimated that 25 million people in the world are transgender—0.8 percent of the adult

population (Tangpricha & Safer, 2018; Winter et al., 2016). Many transgender people come to

terms with their gender inconsistencies. They accept the incongruence or seek out interventions,

such as hormone therapy or surgery, to change their birth anatomy into physical characteristics

that fit their gender identity. Some transgender people, however, may experience extreme distress

over the incongruence. DSM-5 categorizes these latter people as having gender dysphoria (see

Table 11-6).

transgender Individuals who have a strong sense that their gender identity is different from their birth anatomy. 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.

TABLE: 11-6 Dx Checklist Gender Dysphoria in Adolescents and Adults

1. For 6 months or more, an individual’s gender-related feelings and/or behaviors are 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.

The DSM-5 categorization of gender dysphoria is controversial. Many argue that since a

transgender pattern reflects an alternative—not pathological—way of experiencing one’s gender

identity, it should never be considered a psychological disorder, even if it is accompanied by

significant unhappiness. Indeed, this is rapidly becoming the dominant view in the clinical field

and society (Russo, 2017). In 2017, for example, Denmark’s Parliament actually ruled that

transgender individuals should no longer be considered mentally ill in the country’s mental

health system. And in 2018, the World Health Organization decided to remove transgender

788

#KeyDistinction Sexual orientation is about whom one is sexually attracted to.

Gender identity is about whether one considers oneself male,

female, a mixture of the genders, or neither of the genders.

Why might labeling transgender people as mentally ill be

harmful to them?

functioning from the list of mental disorders in ICD-11, the new edition of its classification

system.

In this climate, it is expected that the

category of gender dysphoria may be

dropped from the next revision of DSM-

5. If so, the DSM would be following a

route that it travelled in past times with regard to homosexuality. As you read earlier (see page

349), in its first two editions, the developers of the DSM listed homosexuality as a sexual

disorder, such as a paraphilic disorder. Protests by gay activist groups and many clinicians

eventually led to the DSM’s 1973 elimination of this category as a sexual disorder per se, but the

DSM did retain a category called ego dystonic homosexuality—the experience of extreme distress

over one’s homosexual orientation. Finally, this latter category too was dropped in a 1987

revision of the DSM. Similarly, in early editions of the DSM, persons with transgender thoughts

and needs qualified for a diagnosis of transgender identity disorder. This classification was dropped

when DSM-5 was published in 2013 and replaced by the current category gender dysphoria.

To help distinguish what is known about transgender functioning (an alternative, but not

abnormal, pattern) from what is known about gender dysphoria (an abnormal pattern, according

to DSM-5), let us look first at transgender functioning, then turn to gender dysphoria.

Transgender Functioning Given their gender identity, many transgender people would like to get rid of their primary and

secondary sex characteristics—some of them find their own genitals repugnant—and to acquire

characteristics that correspond to their gender identity (APA, 2013). Transgender women (that is,

people who identify as female but were assigned male at birth) outnumber transgender men

(people who identify as male but were assigned female at birth) by around 2 to 1.

Sometimes transgender feelings emerge

in children (Olson-Kennedy & Forcier,

2018). Like transgender adults, the

children feel uncomfortable with their

assigned gender and yearn to be members

of another gender. This childhood pattern often disappears by adolescence or adulthood, but in

some cases the individuals do become transgender adults (Forcier & Olson-Kennedy, 2018).

Thus transgender adults may have had transgender feelings when they were children, but many

789

children with transgender feelings do not become transgender adults. 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, as we noted earlier, less than 1 percent of

adults are transgender (Zucker, 2010). This age shift is, in part, why many experts on

transgender functioning strongly recommend against any form of irreversible physical procedures

for this pattern until the individual is at least 14 to 16 years of age, except in extraordinary

instances (Levine, 2017). Certain kinds of pharmacological interventions are, however,

considered acceptable and are being administered increasingly to transgender adolescents

(Corathers, 2018; Nahata et al., 2017).

Explanations of Transgender Functioning Increasingly, today’s medical and psychological theorists believe that biological factors—perhaps

genetic or prenatal—are key to transgender functioning (Burke et al., 2018; Spizzirri et al.,

2018). Consistent with a genetic explanation, transgender functioning does sometimes run in

families. Research indicates, for example, that people with transgender siblings are more likely to

be transgender than are people without such siblings (Gómez-Gil et al., 2010). Indeed, one study

of identical twins found that when one of the twins was transgender, the other twin was as well

in 9 out of 23 pairs (Heylens et al., 2012).

Biological investigators have uncovered some interesting findings when they examine and

compare the brains of transgender and nontransgender individuals. Keeping in mind that male

and female brains usually differ slightly, researchers have looked for indications that the brains of

transgender people are more similar to brains of the gender with which they identify than the

gender to which they were assigned at birth (Mueller, De Cuypere, & T’Sjoen, 2017; Russo,

2017, 2016). For example, using MRI scanning, one team of researchers found that the brains of

transgender men (people who identify as male but were assigned female at birth) have relatively

thin subcortical areas, much like those of nontransgender men, and the brains of transgender

women (people who identify as female but were assigned male at birth) have relatively thin

cortical regions in the right hemisphere, much like those of nontransgender women (Guillamon

et al., 2016; Luders et al. 2012). Correspondingly, other research has found similarities between

transgender individuals and their nontransgender counterparts with regard to the activity and size

of brain structures such as the insula, anterior cingulate cortex, and bed nucleus of stria terminalis

(BST)—structures known to play roles in gender functioning and consciousness (Spizzirri et al.,

2018).

Similar results have been uncovered in studies of brain reactions to strong unpleasant odors.

790

In general, male and female brains react to strong smells differently, particularly in the

hypothalamus. Here again, transgender studies have found that, when exposed to strong

unpleasant smells, the hypothalamic responses of transgender males are similar to those of

nontransgender males, whereas the hypothalamic responses of transgender females are similar to

those of nontransgender females (Burke et al., 2018, 2016, 2014; Mueller et al., 2017). Brain

response similarities between transgender individuals and their nontransgender counterparts have

likewise been found in studies that expose participants to certain sounds, visual stimuli, and

memory challenges.

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 movement and to the special needs of children with transgender feelings, a

growing number of parents, educators, and clinicians are now supportive of children like this.

Based on such findings, it might be tempting to conclude that transgender people are

individuals whose male brain is simply trapped inside a female body or whose female brain is

trapped inside a male body, but, as researcher Antonio Guillamon cautions, “Trans people have

brains that are different from males and females, a unique kind of brain” (Guillamon, 2016).

That is, they do not have a male or female brain, but rather a transgender brain.

Options for Transgender Individuals As you read earlier, transgender people often address the incongruence between their gender

identity and birth anatomy through biological procedures. For example, many change their

sexual characteristics by means of hormone administration (Corathers, 2018; Ferrando &

Thomas, 2018). Physicians prescribe the female sex hormone estrogen for transgender females, as

791

well as other medications designed to suppress their bodies’ production of the male sex hormone

testosterone. This leads to breast development, loss of body and facial hair, and changes in body

fat distribution. Some of these patients also go to speech therapy, raising their tenor voice to alto

through training, and some have facial feminization procedures (Ferrando & Thomas, 2018;

Tangpricha & Safer, 2018). In contrast, transgender men are administered the male sex hormone

testosterone, resulting in a deeper voice, increased muscle mass, and changes in facial and body

hair.

Hormone administration enables many transgender persons to lead a fulfilling life in the

gender that fits them. For others, however, this is not enough, and they may seek out gender

reassignment surgery, or gender change surgery—also called gender confirmation surgery or

gender-affirming surgery (Crandall, 2018). Such surgery is usually preceded by 1 to 2 years of

hormone administration. For transgender women, the surgery can involve one or more of the

following procedures: face-changing plastic surgery, breast augmentation, and genital

reconstruction (partial removal of the penis and restructuring of its remaining parts into a clitoris

and vagina). For transgender men, surgery may include a bilateral mastectomy, chest

reconstruction, a hysterectomy, and/or genital reconstruction (the formation of a functioning

penis—a procedure not yet perfected—or a silicone prosthesis that can give the appearance of

male genitals). Genital reconstruction is performed much less often than the other surgical

procedures, especially among transgender men (ASPS, 2017; Mainwaring, 2017). According to a

report by the American Society of Plastic Surgeons, more than 3,200 gender reassignment

surgeries were performed in the United States in 2016, an increase of 20 percent over the

number in 2015. The surgeries were conducted on more transgender women than transgender

men. Some insurance companies refuse to cover these (or even nonsurgical) biological treatments

for transgender people, but a growing number of states now prohibit such insurance exclusions

(Canner et al., 2018; Seelman et al., 2018).

gender reassignment surgery A surgical procedure that changes a person’s sex organs and gender features. Also known as gender change surgery.

Clinicians have debated whether gender change surgery is an appropriate option for

transgender persons (à Campo & Nijman, 2016; Gozlan, 2011). Some consider it a humane

procedure, perhaps the most satisfying one to many transgender people. Others argue that gender

change surgery is a “drastic nonsolution” for a complex issue. Either way, as indicated above,

such surgery appears to be on the increase (Crandall, 2018; Ferrando & Thomas, 2018).

792

Lea T. Transgender model Lea T. emerged in 2010 as the face of Givenchy, the famous French fashion brand. Born with an

assigned gender of male, the Brazilian model has become a leading female figure in runway fashion shows and magazines,

including Vogue Paris, Cover magazine, and Love magazine, and she is currently the face of the hair-care brand Redken. In

2012 she underwent gender reassignment surgery.

Research into the outcomes of gender reassignment surgery has yielded generally positive

findings. Across a number of studies, at least 70 percent of patients report satisfaction with the

outcome of the surgery, improvement in the quality of their lives, a better psychological state,

more positive body satisfaction, better interpersonal interactions, and improvements in sexual

functioning (Ferrando & Thomas, 2018; Lindqvist et al., 2017). On the other hand, several

studies have yielded less favorable findings. A long-term follow-up study in Sweden, for example,

found that gender-reassigned participants had a higher rate of psychological disorders and of

suicide attempts than the general population (Dhejne et al., 2011). All of this argues for careful

screening prior to surgical interventions, continued research to better understand the long-term

impact of the surgical procedures, and, more generally, improved medical and clinical care for

793

transgender people.

Gender Dysphoria Surveys reveal that 90 percent of transgender persons experience at least a moderate degree of

distress or dysfunction at home, school, or work, or in social relationships, especially during

adolescence (Billard, 2018; Robles et al., 2016). As you have read, if that level of distress and

impairment becomes significant, DSM-5 categorizes the pattern as gender dysphoria. Some

individuals with this disorder—children, adolescents, and adults—feel severe anxiety or

depression, display substance abuse, and may have thoughts of suicide (Mueller et al., 2017;

Schulman & Erickson-Schroth, 2017).

A new audience When he won the gold medal for the decathlon at the 1976 Olympics (left), Bruce Jenner was widely

viewed as the personification of masculinity—the world’s best male athlete. When in 2015 Jenner appeared in Vanity Fair

magazine (right) as a transgender woman, Caitlyn, transgender persons hoped that this high-profile revelation would help

reduce the public’s prejudice against transgender individuals.

Although such features of dysphoria have been documented, the cause of gender dysphoria

has been hard to sort out. On the one hand, most transgender people do indeed report that the

incongruence between their gender identity and birth anatomy directly causes them some distress

794

#GenderTerms Trans: Short for transgender

Cisgender persons: Individuals whose gender identity matches

their assigned gender

(Robles et al., 2016). On the other hand, surveys suggest that the primary cause for intense

dysphoric reactions is the enormous prejudice that transgender persons typically face. According

to surveys across the United States and other countries, for example, 80 to 90 percent of

transgender people have been harassed or attacked in their schools, workplaces, or communities

(some have even been murdered); 50 percent have been fired from a job, not hired, or not

promoted; and 20 percent have been denied a place to live (Wirtz et al., 2018; Steinmetz, 2014).

Many have been stigmatized, excluded from social groups, and denied access to appropriate

health care (both general health care and care related to their gender needs) (Seelman et al.,

2018). This is why so many clinicians favor the elimination of gender dysphoria from the DSM.

That is, society’s reactions to a transgender person may be much more responsible for the

individual’s psychological pain than the individual’s dismay over transgender issues themselves,

difficult though they may be. In fact, more and more studies are finding that when transgender

individuals are supported in their identities by their family members and friends, they typically

do not experience significant mental health problems (Johns et al., 2018; Seibel et al., 2018).

That said, people in psychological pain still need help, and, indeed, many individuals with

gender dysphoria receive psychotherapy (Witcomb et al., 2018; Majumder & Sanyal, 2017,

2016). Here, they typically try to become more aware of their needs and feelings; reduce their

feelings of anxiety, depression, and anger; improve their self-image; learn how to cope with the

stress caused by their gender issues; and develop a sense of self that also extends beyond gender

identity. No single form of psychotherapy has been more widely used than other forms in cases

of gender dysphoria. Nor has research indicated that psychotherapy alone consistently brings

significant psychological improvement in cases of gender dysphoria.

Actually, the interventions that seem to be of greater help to people with gender dysphoria are

the biological gender-change procedures that so many transgender persons undergo. In an

analysis of 28 studies—some of them long-term follow-up studies—with a total of 1,833

transgender individuals who received hormone therapy and/or gender reassignment surgery, it

was found that 80 percent of participants experienced significant improvements in their

symptoms of gender dysphoria as a result of the biological interventions (Tangpricha & Safer,

2018; Murad et al., 2010).

Finally, two positive developments in

recent years have been the emergence and

growth of transgender education

programs and an increase in support

programs for transgender people

795

(Valentine & Shipherd, 2018; Vance et

al., 2018). Across the world, many hundreds of educational programs, which are offered in

locations ranging from schools to workplaces to the Internet, now target transgender persons

themselves (both young and old), health care professionals, family members, and the general

public. Similarly, numerous support, or mutual help, groups—both in-person and online—are

now available for transgender adolescents and adults, providing social support, advice, and

relevant information. Research indicates that these various programs help prevent or reduce

gender dysphoria or other forms of psychological distress among transgender individuals (Johns

et al., 2018; Cipolletta et al., 2017).

A special bond Two men, 64-year-old Juani Santos (left) and 28-year-old Liam Duran (right), catch up on recent events at

a cafe in Cuba. Despite a significant age difference, they are close friends, partly because they share an important gender

identity experience—they are both transgender men. Santos, one of Cuba’s oldest documented transgender individuals, had

gender reassignment surgery just a few years ago. He says he first knew he was a boy at the age of 5.

SUMMING UP

GENDER VARIATIONS DSM-5 does not consider transgender functioning to be a psychological disorder, but it does still categorize gender

dysphoria—a pattern of significant distress or impairment due to one’s transgender feelings and thoughts—as a

disorder. Transgender feelings and thoughts in children often disappear by adolescence or adulthood, but in some

796

cases, children with such feelings develop into transgender adults. Hormone treatments have been used to help some

people adopt the gender role they believe to be right for them. Gender reassignment surgery has also been performed.

797

CLINICAL CHOICES Now that you’ve read about sexual disorders and gender

variations, try the interactive case study for this chapter. See if

you are able to identify Cheryl’s issues and suggest a possible

diagnosis based on them. What kind of interventions might be

most helpful for Cheryl? Go to LaunchPad to access Clinical

Choices.

Personal Topics Draw Public Attention At the beginning of this chapter, we noted that sexual disorders and gender variations are, in fact,

very different topics. However, they do share two things. They have both received considerable

study over the past few decades, and a key to progress in both areas appears to be public

education.

As a result of research in the realm of

sexual disorders, people with sexual

dysfunctions are no longer doomed to a

lifetime of sexual frustration. Studies of

sexual dysfunctions have uncovered many

psychological, sociocultural, and

biological causes. Correspondingly,

important progress has been made in the

treatment of sexual dysfunctions. At the

same time, it has become clear that education about sexual dysfunctions can be as important as

therapy. When taken seriously, sexual myths often lead to feelings of shame, self-hatred,

isolation, and hopelessness—feelings that themselves contribute to sexual difficulty. Thus 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.

Similarly, as a result of research in the realm of gender diversity, transgender persons are no

longer doomed to a life of gender confusion and frustration. In addition, the clinical field is now

clear that transgender functioning does not represent a mental disorder. And, finally, it has

become clear that public education about gender variations is a key to further understanding and

progress in this realm. Recent increases in such educational programs have already begun to make

some difference in the levels of discrimination, stigmatization, harassment, and hardship faced

regularly by transgender people. Clearly, more such education is needed.

798

Chapter 11 Review

Key Terms

sexual dysfunction

desire phase

male hypoactive sexual desire disorder

female sexual interest/arousal disorder

excitement phase

erectile disorder

nocturnal penile tumescence (NPT)

performance anxiety

spectator role

orgasm phase

premature ejaculation

delayed ejaculation

female orgasmic disorder

genito-pelvic pain/penetration disorder

vaginismus

dyspareunia

sex therapy

sensate focus

sildenafil (Viagra)

directed masturbation training

paraphilia

paraphilic disorder

799

fetishistic disorder

masturbatory satiation

transvestic disorder

exhibitionistic disorder

voyeuristic disorder

frotteuristic disorder

pedophilic disorder

relapse-prevention training

sexual masochism disorder

sexual sadism disorder

transgender

gender dysphoria

hormone administration

gender reassignment surgery

Quick Quiz

1. What sexual dysfunctions are associated with the desire phase of the sexual response cycle? How common are they, and what causes them? pp. 330–332

2. What are the symptoms and prevalence of erectile disorder? To which phase of the sexual response cycle is it related? p. 334

3. What are the possible causes of erectile disorder? pp. 334–336

4. Which sexual dysfunctions seem to involve performance anxiety and the spectator role? pp. 335, 338

5. What are the symptoms, rates, and leading causes of premature ejaculation, delayed ejaculation, and female orgasmic disorder? To which phase of the sexual response cycle are they related? pp. 338–340

6. Identify, describe, and explain disorders of sexual pain. p. 340

800

7. What are the general features of modern sex therapy? What particular techniques are further used to treat specific sexual dysfunctions? pp. 341–346

8. List, describe, and explain the various paraphilic disorders. pp. 347–355

9. Describe the treatment techniques of aversion therapy, masturbatory satiation, and relapse-prevention training. Which paraphilic disorders have they been used to treat, and how successful are they? pp. 350–355

10. Why is transgender functioning no longer considered a mental disorder, and why is gender dysphoria a controversial diagnostic category? What interventions and options are currently available for transgender individuals? pp. 356–360

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

801

CHAPTER 12 Schizophrenia and Related Disorders

TOPIC OVERVIEW

802

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 Developmental Psychopathology View

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

An Important Lesson

Laura, 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 veterinarians 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 husband, 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

husband. … 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)

803

Richard, 23 years old: In high school, Richard was an average student. After graduation 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, undressing, 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)

Eventually, Laura and Richard each received a diagnosis of schizophrenia (APA, 2013). People

with schizophrenia, though they previously 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

(Marder & Davis, 2017). They may have hallucinations (false sensory perceptions) or delusions

(false beliefs), or they may withdraw into a private world. DSM-5 calls for a diagnosis of

schizophrenia only after the symptoms continue for six months or more (see Table 12-1).

schizophrenia A psychotic disorder in which functioning deteriorates 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.

TABLE: 12-1 Dx Checklist Schizophrenia

1. For 1 month, individual displays two or more of the following symptoms much of the time: Delusions Hallucinations Disorganized speech Very abnormal motor activity, including catatonia

804

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.

As you saw in Chapter 10, taking LSD or abusing amphetamines or cocaine may also 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. 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. Clinical theorists believe that most of the explanations and

treatments offered for schizophrenia are applicable to the other disorders as well (Bole et al.,

2017).

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

805

Information from: Rosell, 2018; Manschreck, 2017; Marder & Davis, 2017; APA, 2013.

Approximately 1 of every 100 people in the world suffers from schizophrenia during his or

her lifetime (Fischer & Buchanan, 2018). An estimated 21 million people worldwide are afflicted

with it, including 3.6 million in the United States (WHO, 2018; NIMH, 2017). Equal numbers

of men and women experience the disorder. The average age of onset for men is 23 years,

compared with 28 years for women.

The financial cost of schizophrenia is enormous, and the emotional cost is even greater. As

you read in Chapter 7, people with this disorder are much more likely to attempt suicide than

the general population. It is estimated that as many as 25 percent of people with schizophrenia

attempt suicide and 5 percent die from suicide (SAMHSA, 2018). In addition, people with the

disorder have an increased risk of physical—often fatal—illness. On average, they live 10 to 20

fewer years than other people (Fischer & Buchanan, 2018).

Although schizophrenia appears in all socioeconomic groups, it is found more frequently in

the lower levels (Gruebner et al., 2017; Uher & Zwicker, 2017) (see Figure 12-1). This has led

some theorists to believe that the stress of poverty is itself a cause of the disorder. However, 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.

FIGURE 12-1

Socioeconomic Class and Schizophrenia

806

Poor people in the United States are more likely than wealthy people to experience schizophrenia. (Information from:

Gruebner et al., 2017; Uher & Zwicker, 2017; Sareen et al., 2011.)

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 developed, many sufferers live without adequate treatment and

never fully achieve their potential as human beings.

807

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, most of today’s clinicians believe

that schizophrenia is actually a group of distinct disorders that happen to have some features in

common (Fischer & Buchanan, 2018). 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 (Fischer & Buchanan, 2018).

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.

positive symptoms Symptoms of schizophrenia that seem to be excesses of or bizarre additions to thoughts, emotions, or behaviors.

DELUSIONS Many people with schizophrenia develop delusions, ideas that they believe wholeheartedly but

that have no basis in fact. The deluded person may consider the ideas enlightening or may feel

confused by them. 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.

808

Philosopher Friedrich Nietzsche said, “Insanity in

individuals is something rare—but in groups, parties,

nations and epochs, it is the rule.” What did he mean?

delusion A strange false belief firmly held despite evidence to the contrary.

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.

Shared delusions When two or more persons share a delusion or hallucination, it is called folie à deux or shared psychosis. In

an infamous case, two 12-year-old girls recently stabbed a classmate multiple times, saying they were trying to appease and

impress Slender Man, a mythical “boogie man” whom many internet users report seeing and fearing in their everyday lives.

(He is portrayed here at a science fiction convention.) Clinicians later testified that each assailant had a schizophrenia

spectrum disorder.

DISORGANIZED THINKING AND SPEECH People with schizophrenia may not be able to think logically and may speak in peculiar ways.

809

These difficulties, collectively called 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, neologisms, perseveration,

and clang.

formal thought disorder A disturbance in the production and organization of thought.

People who have loose associations, or derailment, the most common formal thought disorder,

rapidly shift from one topic to another, believing that their incoherent 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 schizophrenia unfolds (Remington et al.,

2014).

HEIGHTENED PERCEPTIONS AND HALLUCINATIONS The perceptions and attention of some people with schizophrenia seem to intensify (Spagna et

al., 2018). The persons may feel that their senses are being flooded by all the sights and sounds

that surround them. This makes it almost impossible for them to attend to anything important.

Such problems as these that people with schizophrenia have may develop years before the onset

of the actual disorder (Fischer & Buchanan, 2018). It is also possible that such problems further

contribute to the memory impairments that are common to many people with schizophrenia

(Boudewyn, 2017).

810

Another kind of perceptual problem in schizophrenia consists of hallucinations, perceptions

that a person has in the absence of external stimuli (see InfoCentral). People who have auditory

hallucinations, 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.

INFOCENTRAL

HALLUCINATIONS

Hallucinations are the experiencing of sights, sounds, smells, and other perceptions that occur in

the absence of external stimuli.

811

hallucination The experiencing of sights, sounds, or other perceptions in the absence of external stimuli.

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

(Hugdahl & Sommer, 2018). One line of research has measured blood flow in Broca’s area, the

region of the brain that helps people produce speech (Cui et al., 2018, 2016; McGuire et al.,

1996). The investigators have found more blood flow in Broca’s area while patients are having

812

auditory hallucinations. A related study instructed six men with schizophrenia to press a button

whenever they had an auditory hallucination (Silbersweig et al., 1995). Brain scans revealed

increased activity in the tissues of the auditory cortex, the brain’s hearing center, when they

pressed the button.

The human brain during hallucinations This PET scan, taken while a patient was having auditory hallucinations, shows

heightened activity (yellow-orange) in Broca’s area, a brain region that helps people produce speech, and in the auditory

cortex, the brain area that helps people hear sounds. Thus people who are hallucinating seem to hear sounds produced by

their own brains (Juckel, 2014; Silbersweig et al., 1995).

Hallucinations can also involve any of the other senses. Tactile hallucinations may take the

form of tingling, burning, or electric-shock sensations. Somatic hallucinations feel as if something

is happening inside the body, such as a snake crawling 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). 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.

813

I thought the voices I heard were being transmitted through the walls of my apartment 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 (Fischer & Buchanan, 2018). They may smile when making a somber statement or

upon being told terrible news, or they may become upset in situations that should make them

happy. They may also undergo inappropriate shifts in mood.

inappropriate affect Displays of emotions that are unsuited to the situation.

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.

Negative Symptoms Negative symptoms are those that seem to be “pathological deficits,” characteristics that are

lacking in a person. Poverty of speech, blunted and flat affect, loss of volition, and social withdrawal

are commonly found in schizophrenia (Fischer & Buchanan, 2018; Rocca et al., 2014). Such

deficits greatly affect one’s life and activities.

negative symptoms Symptoms of schizophrenia that seem to be deficits in normal thought, emotions, or behaviors.

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.

alogia A decrease in speech or speech content; a symptom of schizophrenia. Also known as poverty of speech.

814

#TheirWords “Her face was a solemn mask, and she could neither give nor

receive affection.”

Mother, 1991, describing her daughter who has schizophrenia

RESTRICTED AFFECT Many people with schizophrenia have a blunted affect—they display less anger, sadness, joy, and

other feelings than most people. Indeed, a number 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.

Restricted affect of this kind may

actually 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). There is, in fact, a growing recognition in

the clinical field that many people with schizophrenia not only experience emotions internally,

they grapple with high levels of anxiety and/or depression (Siris & Braga, 2018, 2017).

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. 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, dressing, and undressing impossible ordeals for him.

SOCIAL WITHDRAWAL People with schizophrenia may withdraw from their social environment and attend only to their

own ideas and fantasies (Swain et al., 2017). 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 (Fischer & Buchanan, 2018).

Psychomotor Symptoms People with schizophrenia sometimes experience psychomotor symptoms. Many move relatively

slowly, and a number make awkward movements or repeated grimaces and odd gestures that

seem to have a private purpose—perhaps ritualistic or magical (Janssens et al., 2018; Grover et

815

al., 2015).

The psychomotor symptoms of schizophrenia may take certain extreme forms, collectively

called catatonia. Around 10 percent of people with schizophrenia experience some degree of

catatonia (Coffey, 2017). 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, sometimes wildly waving their arms and legs.

catatonia A pattern of extreme psychomotor symptoms, found in some forms of schizophrenia, which may include catatonic stupor, rigidity, or posturing.

A catatonic pose These patients, photographed in the early 1900s, show features of catatonia, including catatonic posturing,

in which they assume bizarre positions for long periods of time.

What Is the Course of Schizophrenia? Schizophrenia usually first appears between the person’s late teens and mid-thirties (Fischer &

Buchanan, 2018). Although its course varies widely from case to case, many sufferers seem to go

through three phases—prodromal, active, and residual (Lee et al., 2017; Fukumoto et al., 2014).

816

During the prodromal phase, symptoms are 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 (Fischer & Buchanan, 2018; an der Heiden & Häfner, 2011).

Each of these phases may last for days or for years. A fuller recovery from schizophrenia is

more likely in people who functioned quite well before the disorder; whose initial disorder is

triggered by stress, comes on abruptly, or develops during middle age; and who receive early

treatment. Relapses are apparently more likely during times of life stress (Lange et al., 2017;

Remberk et al., 2015).

Many researchers believe that in order to help predict the course of schizophrenia, there

should be a distinction between so-called Type I and Type II schizophrenia. People with Type I

schizophrenia (80 to 85 percent of cases) seem to be dominated by positive symptoms, such as

delusions and hallucinations (Crow, 2008, 1995, 1985, 1980). Those with Type II schizophrenia

(15 to 20 percent of cases) display mostly negative symptoms, such as restricted affect and

poverty of speech.

817

Relationships of the mind Like Taylor Swift, most celebrities grow used to the constant crush of fans and curious

onlookers. However, when they are stalked, the matter grows more serious. Some stalkers have erotomanic delusions, false

beliefs that they are loved by and in a relationship with the object of their attention. In recent years, Swift and other

celebrities have had to seek court protection against stalkers who are constantly following them, trying to enter their

premises, seeking expressions of love, and threatening them.

SUMMING UP

THE CLINICAL PICTURE OF SCHIZOPHRENIA

818

Schizophrenia is a disorder in which personal, social, and occupational functioning deteriorate as a result of disturbed

thought processes, distorted 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 perception

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.

819

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 biological 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 diathesis–stress relationship may be at work: people with a

biological predisposition (i.e., a diathesis) will develop schizophrenia only if certain kinds of

events or stressors are also present (Pruessner et al., 2017). Similarly, a diathesis–stress

relationship often seems to be operating in the development of other kinds of psychotic disorders

(see PsychWatch).

PSYCHWATCH

Postpartum Psychosis: A Dangerous Syndrome

On the morning of June 20, 2001, the nation’s television viewers watched in horror as officials escorted

36-year-old Andrea Yates to a police car. Just minutes before, she had called police and explained that she had drowned her

five children in the bathtub because “they weren’t developing correctly” and because she “realized [she had not been] a

good mother to them.”

Homicide sergeant Eric Mehl described how she looked him in the eye, nodded, answered 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 number 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

between 10 and 30 percent display the clinical 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

(Denno, 2017).

Postpartum psychosis affects about 1 to 2 of every 1,000 mothers who have recently given birth (Payne, 2018). The

symptoms apparently are triggered, in part, by the enormous shift in hormone levels that takes place after delivery (Jones et

al., 2014; Meinhard et al., 2014). Within days or weeks, 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 disorientation; disturbed sleep; and illogical or chaotic thoughts (for example, thoughts

about killing herself or her child). Typically, treatment consists of antipsychotic drugs and psychotherapy, although the

effectiveness of this approach has not received much research (Payne, 2017).

Women with a history of bipolar disorder, schizophrenia, or major depressive disorder are particularly vulnerable to the

disorder (Payne, 2018; Di Florio et al., 2014). Women who have previously experienced postpartum depression or

postpartum psychosis have an increased likelihood of developing postpartum psychosis after subsequent births (Payne,

2018; Bergink et al., 2012). Andrea Yates, for example, had developed signs of postpartum depression (and perhaps

postpartum psychosis) and attempted suicide after the birth of her fourth child (Denno, 2017). At that time, however, she

appeared to respond well to a combination of medications, including antipsychotic drugs, and so she and her husband later

decided to conceive a fifth child.

820

Family tragedy In this undated photograph, Andrea Yates poses with her husband and four of the five children she

later drowned.

After the birth of her fifth child, the depressive symptoms recurred, along with features of psychosis. Yates again

attempted suicide. Although she was hospitalized twice and treated with various medications, her condition failed to

improve. Six months after giving birth to Mary, her fifth child, she drowned all five of her children. Although relatively few

women with the disorder actually try to harm their children (estimates run as high as 4 percent), the Yates case reminds us

that such an outcome is possible (Gressier et al., 2015; Posmontier, 2010). The case also reminds us that early detection

and treatment are critical (Payne, 2018, 2017; O’Hara & Wisner, 2014).

On July 26, 2006, after an initial conviction for murder was overturned by an appeals court, Yates was found not guilty

by reason of insanity and sent to a state mental hospital, where she continues to receive treatment today (Denno, 2017).

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

inheritance 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. The genetic view has

821

What factors, besides genetic ones, might account for the

elevated rate of schizophrenia among relatives of people

with this disorder?

been supported by studies of (1) relatives of people with schizophrenia, (2) twins with

schizophrenia, (3) people with schizophrenia who are adopted, and (4) schizophrenia-related

genes.

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 (Henriksen et al.,

2017). 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).

822

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 biological relationship (that is, the more similar the genetic makeup), the greater the risk of

developing the disorder. (Information from: Henriksen et al., 2017; Bhatia et al., 2016; Gottesman, 1991, p. 96.)

823

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 consistently by research (Fischer &

Buchanan, 2018; 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 only 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 biological relatives of adoptees with schizophrenia are

more likely than their adoptive relatives to develop schizophrenia or another schizophrenia

spectrum disorder (Henriksen et al., 2017).

WHAT DO GENE 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 (Uher & Zwicker,

2017). Using such research procedures, 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 this disorder (Zhao et al., 2018; Xu et al., 2017).

Altogether, the number of specific gene sites linked to schizophrenia is no fewer than 281 to date

(Tartakovsky, 2016)! These varied findings may indicate that schizophrenia, like a number of

other disorders, is a polygenic disorder, caused by a combination of gene defects (Fischer &

Buchanan, 2018).

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

824

abnormalities and dysfunctional brain circuitry.

Biochemical Abnormalities Over the past five decades, researchers have developed a dopamine hypothesis to help explain

schizophrenia: certain neurons that use the neurotransmitter dopamine fire too often and

transmit too many messages to receiving neurons, thus producing the symptoms of schizophrenia

(Martino et al., 2018). This hypothesis has undergone challenges and adjustments in recent

years, but it is still very influential. As you will see later in this chapter, the chain of events

leading to the 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, were 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 prescribe them widely (Adams et al., 2014).

dopamine hypothesis The theory that schizophrenia results from excessive activity of the neurotransmitter dopamine. antipsychotic drugs Drugs that help correct grossly confused or distorted thinking. phenothiazines A group of antihistamine drugs that became the first group of effective antipsychotic medications.

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 schizophrenia. 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

antipsychotic 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 hypothesis. 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 (Hamadjida et al., 2018). 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

825

saw in Chapter 10, stimulate the central nervous system by increasing dopamine activity 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 (McKetin, 2018).

Researchers have located areas of the brain that are rich in dopamine receptors, and they have

found that phenothiazines and related antipsychotic drugs bind to many of these receptors,

prevent dopamine from binding there, and so prevent the neurons containing those receptors

from firing (Wang et al., 2018). As it turns out, there are five kinds of dopamine receptors in the

brain—called the D-1, D-2, D-3, D-4, and D-5 receptors—and phenothiazines bind most

strongly to the D-2 receptors. 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.

Though enlightening, the dopamine hypothesis has certain problems. The biggest challenge

to it has come with the discovery of a new group of drugs called second-generation

antipsychotic drugs, which are often more effective than the phenothiazines and related early

drugs, now collectively called first-generation antipsychotic drugs. The newer drugs bind not

only to D-2 dopamine receptors, like the first-generation antipsychotic drugs, but also to many

D-1 and D-4 receptors and to receptors for other neurotransmitters such as serotonin (Fischer &

Buchanan, 2018). 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.

second-generation antipsychotic drugs A relatively new group of antipsychotic drugs whose biological action is different from that of the first-generation antipsychotic drugs. first-generation antipsychotic drugs Phenothiazines and other antipsychotic drugs developed throughout the latter half of the twentieth century.

Dysfunctional Brain Structures and Circuitry As you have read, reactions of various kinds are tied to brain circuits—networks of brain

structures that work together, triggering each other into action and producing particular

behaviors, cognitions, or emotions. Although research is far from complete, studies have begun to

reveal a brain circuit whose dysfunction contributes to schizophrenia (Deng et al., 2019;

Lieberman et al., 2018; Chen et al., 2017). The structures that comprise this schizophrenia-

related circuit include the prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and

substantia nigra, among other brain structures (see Figure 12-3). You may notice, once again,

that several of the structures in this circuit are also members of brain circuits that contribute to

826

other disorders, but in cases of schizophrenia the structures function and interconnect in

problematic ways that are, collectively, unique to this disorder.

FIGURE 12-3

Biology of Schizophrenia

Studies suggest that a dysfunctional brain circuit may lead to schizophrenia. This circuit includes the prefrontal cortex,

hippocampus, amygdala, thalamus, striatum, and substantia nigra, among other structures.

The dysfunction of this schizophrenia-related circuit cannot be characterized in broad terms

as, for example, a generally “hyperactive” or generally “underactive” circuit. But numerous

studies suggest that the circuit does indeed operate abnormally in persons with schizophrenia

(Han et al., 2018; Wang, Chen, & Yang, 2017). For example, the interconnectivity (flow of

communication) is abnormally low between their substantia nigra and prefrontal cortex and

between their striatum and thalamus, while it is abnormally high between their substantia nigra

and striatum, their thalamus and prefrontal cortex, and their hippocampus and prefrontal cortex

827

(Martino et al., 2018; Wang et al., 2017).

Note that this focus on brain circuitry is compatible with the dopamine hypothesis of

schizophrenia that monopolized biological explanations for so many years. After all, dopamine

activity is very prominent throughout the schizophrenia-related brain circuit. The key difference

between the dopamine hypothesis and the newer brain circuit view is that abnormal activity by

this neurotransmitter is now seen as part of a broader circuit dysfunction that can propel people

toward schizophrenia.

Viral Problems What might cause the biochemical and brain circuit abnormalities found in many cases of

schizophrenia? Various studies have pointed to genetic factors, poor nutrition, fetal development,

birth complications, immune reactions, and toxins (Fischer & Buchanan, 2018; Uher &

Zwicker, 2017). In addition, some investigators contend that the brain abnormalities may result

from exposure to viruses before birth. Perhaps a viral infection triggers an immune system

response in the mother, is passed on to the developing fetus, enters his or her brain, and

interrupts proper brain development.

828

Not-so-identical twins The man on the left does not have schizophrenia, while his identical twin, on the right, does. MRI

scans, shown in the background, clarify that the brain of the twin with schizophrenia is smaller overall and has larger

ventricles, brain cavities that contain fluid (indicated by the dark, butterfly-shaped spaces).

Some of the evidence for the viral theory comes from animal model investigations, while other

evidence is circumstantial, such as the finding that an unusually large number of people with

schizophrenia are born during the late winter (Fischer & Buchanan, 2018; Patterson, 2012). The

late winter birth rate among people with schizophrenia is 5 to 8 percent higher than among other

people. This could be because of an increase in fetal or infant exposure to viruses at that time of

year. More direct evidence for the viral theory of schizophrenia comes from studies showing that

mothers of people with schizophrenia were more likely to have been exposed to the influenza

virus during pregnancy than were mothers of people without schizophrenia (Canetta et al.,

2014).

Together, the biochemical, brain circuit, and viral findings are shedding much light on the

mysteries of schizophrenia. At the same time, it is important to recognize that many people who

829

Why have parents and family life so often been blamed for

schizophrenia, and why do such explanations continue to be

influential?

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.

Involvement of the immune system Consistent with explanations that point to viral infections and immune system

reactions, researchers have found that microglia are especially active in the brains of people with schizophrenia. Microglia are

brain immune cells that provide a first line of defense against brain infections and inflammation. These PET scans show that

the microglia activity (orange) of research participants at risk for schizophrenia is higher than that of healthy participants.

The microglia activity of participants with schizophrenia is higher still.

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

the past few decades, however, the tables have been turned and psychological factors are once

again being considered as important pieces of the schizophrenia puzzle (Uher & Zwicker, 2017).

Well-known psychological theories come from the psychodynamic and cognitive-behavioral

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

830

(1924, 1915, 1914) that cold or unnurturing parents may set schizophrenia in motion. Based on

her clinical observations, Fromm-Reichmann described the mothers of people who develop the

disorder as cold, domineering, 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.

Although famous, Fromm-Reichmann’s theory has received little research support (Seeman,

2016; Harrington, 2012). The majority of people with schizophrenia do not appear to have

mothers who fit the schizophrenogenic description.

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.

Cognitive-Behavioral Explanations Cognitive-behavioral theorists have offered two explanations of how and why people develop

schizophrenia. One focuses largely on the behaviors of people with schizophrenia and applies the

principles of operant conditioning. The other focuses on the unusual thoughts of such individuals

and stresses the possible role of misinterpretations.

OPERANT CONDITIONING As you have read, operant conditioning is the process by which people learn to perform behaviors

for which they have been rewarded frequently. The operant explanation of schizophrenia holds

that some people are, for one reason or another, not reinforced during childhood for proper

attention to social cues—that is, attention to other people’s smiles, frowns, and comments. As a

result, they stop attending to such cues and focus instead on irrelevant cues—the brightness of

light in a room, a bird flying above, or the sound of a word rather than its meaning. As they

attend to irrelevant cues more and more, their responses become increasingly bizarre (Pinkham,

2014). Support for this operant explanation of schizophrenia has been circumstantial, and so the

operant view is usually considered at best a partial explanation for schizophrenia.

MISINTERPRETING UNUSUAL SENSATIONS The misinterpretation explanation of schizophrenia begins by accepting the biological position

that the brains of people with schizophrenia are actually producing strange and unreal sensations

—sensations triggered by biological factors—when they have hallucinations and related

experiences. According to the cognitive-behavioral explanation, however, when the individuals

attempt to understand their unusual experiences, more features of their disorder emerge (Waters

831

& Fernyhough, 2017). When first confronted by voices or other troubling sensations, these

people 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.

In short, according to this theory, people with schizophrenia take a “rational path to madness”

(Zimbardo, 1976).

Researchers have established that people with schizophrenia do indeed experience sensory and

perceptual problems. As you saw earlier, many have hallucinations and most have trouble

keeping their attention focused. But researchers have yet to provide clear, direct support for the

cognitive-behavioral notion that misinterpretations of such sensory problems actually produce a

syndrome of schizophrenia.

Famous, but rare, delusion In MTV’s long-running 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.

Sociocultural Views Sociocultural theorists, recognizing that people with mental disorders are subject to a wide range

of social and cultural forces, believe that multicultural factors, social labeling, and family

dysfunction all contribute to schizophrenia. Research has yet to clarify what the precise causal

relationships might be.

832

How might bias by diagnosticians contribute to race-linked

and culture-linked differences in the diagnosis of

schizophrenia?

Multicultural Factors

Rates of schizophrenia appear to differ

between racial and ethnic groups,

particularly between African Americans

and non-Hispanic white Americans

(Coleman et al., 2016). As many as 2.1

percent of African Americans receive a diagnosis of schizophrenia, compared with 1.4 percent of

non-Hispanic white Americans. Research also suggests that African Americans with

schizophrenia are overrepresented in state hospitals (Durbin el 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 non-Hispanic 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 unintentionally biased in their

diagnoses of African Americans or misread cultural differences as symptoms of schizophrenia.

Yet another explanation for the difference between African Americans and non-Hispanic

white Americans may lie in the economic sphere. On average, African Americans are more likely

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 disadvantaged, appear to be more

likely to be diagnosed with schizophrenia than non-Hispanic white Americans, although their

diagnostic rate is not as high as that of African Americans (Coleman et al., 2016).

833

#EasyTargets In the U.S., more than one-third of adults with schizophrenia

are victims of violent crime.

In the U.S., adults with schizophrenia are 14 times more likely

to be victims of violent crime than to be arrested for

committing such a crime.

(MIP, 2017; Kooyman & Walsh, 2011; Cuvelier, 2002;

Hiroeh et al., 2001)

Coming together Different countries and cultures each have their own way of viewing and interacting with people suffering

from schizophrenia and 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. The goal of the carnival is to

promote public acceptance by blurring the lines between normal and abnormal functioning.

It also appears that schizophrenia

differs from country to country in key

ways (Dein, 2017; 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), schizophrenic patients who live in developing countries have better

recovery rates than schizophrenic patients in Western and other developed countries (Dein, 2017;

Jablensky, 2000). The WHO study followed the progress of 467 patients from developing

countries (Colombia, India, and Nigeria) over a two-year period and compared it with that of

603 patients from developed countries (the Czech Republic, Denmark, Ireland, Japan, Russia,

the United Kingdom, and the United States). During the course of the study, the schizophrenic

patients from the developing countries were more likely than those in the developed countries to

834

Rosenhan’s study is one of the most controversial in the

field. What kinds of ethical, legal, and therapeutic concerns

does it raise?

recover from their disorder and less likely to have continuing symptoms, to have impaired social

functioning, or to require heavy antipsychotic drugs or hospitalization.

Some clinical theorists believe that these differences partly reflect genetic differences from

population to population. However, others argue that the psychosocial environments (families

and friends) in developing countries tend to be more supportive and therapeutic than those in

developed countries, leading to more favorable outcomes for people with schizophrenia (Dein,

2017; Vahia & Vahia, 2008).

Social Labeling Many sociocultural theorists believe that the features of schizophrenia are influenced by the

diagnosis itself. In their opinion, society assigns the label “schizophrenic” 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 development of many schizophrenic symptoms.

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 hospitalized. 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 behavior 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 “schizophrenic” can itself have a

negative effect not just on how people are viewed but also on how they themselves feel and

behave.

Family Dysfunction Many studies suggest that schizophrenia, like a number of other mental disorders, is often linked

835

to family stress (Gurak & Weisman de Mamani, 2017, 2016). Parents of people with

schizophrenia often (1) display more conflict, (2) have more difficulty communicating with one

another, and (3) are more critical of and overinvolved with their children than other parents.

“Bad news—we’re all out of our minds. You’re going to have to be the lone healthy person in this family.”

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 schizophrenia 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 (Sadiq et al., 2017; Wang et al., 2017). Do such findings mean that family

dysfunction helps cause and maintain schizophrenia? Not necessarily. It is also the case that

people with schizophrenia greatly disrupt family life (Yu et al., 2018). In so doing, they

themselves may help produce the family problems that clinicians and researchers continue to

observe.

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.

836

Engaging the family Research indicates that people with schizophrenia make more progress in treatment when they feel

positive toward their family. Here a loving mother, Maria Orduna, caresses her son Alfredo during his visit to her

apartment. Alfredo has suffered through homelessness, poverty, and jail, largely due to his schizophrenic disorder.

Developmental Psychopathology View As they do with other psychological disorders, developmental psychopathology theorists offer an

integrative and developmental framework to explain why and how the factors discussed in this

chapter may lead to schizophrenia. The theorists contend that the road to schizophrenia begins

with a genetically inherited predisposition to the disorder—a predisposition that is expressed by

the dysfunctional brain circuit you read about earlier (Nivard et al., 2018). The theorists further

argue that this genetic predisposition may eventually lead to schizophrenia if, over the course of

an individual’s development, he or she experiences significant life stressors, difficult family

interactions, and/or other negative environmental factors (Mayo et al., 2017; Vallejos et al.,

2017).

Of course, as you read earlier, theorists of all kinds have, for years, proposed that a diathesis–

stress relationship is at work in schizophrenia—that is, people with a biological predisposition to

this disorder will develop it if they further experience significant life stress or other negative

events. What theorists and researchers from the developmental psychopathology perspective have

done, however, is provide much more detail about the diathesis–stress processes at work in

schizophrenia. In particular, they have clarified two points:

1. Schizophrenia typically begins to unfold long before the actual onset of the disorder in

837

#PrivateNotions 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 disguised as humans.

(Rojas, 2017; MacIsaac, 2014; Reuters, 2010; Spanton, 2008;

Andrews, 1998)

young adulthood. Previously, you read that people with this disorder often display cognitive, perception, and attention problems earlier in their lives. Developmental psychopathology researchers have found that such people also tend to be more socially withdrawn, disagreeable, and disobedient, and to have more motor difficulties, throughout their early development (Walker et al., 2016). Some of those early problems result largely from the individual’s inherited predisposition, but, according to research, they may also be due to repeated experiences of childhood stress, family dysfunction, and/or difficult social interactions (Kraan et al., 2018).

2. One of the key ways that a dysfunctional brain circuit may adversely affect the functioning of people who later become schizophrenic is through the circuit’s impact on the operation of the hypothalamic-pituitary-adrenal (HPA) stress pathway (see page 142). As you’ll recall, whenever we are stressed, the brain’s hypothalamus activates this brain–body pathway, leading, in turn, to the secretion of stress hormones and to a broad experience of arousal. Developmental psychopathology researchers have found that dysfunction by the schizophrenia-related brain circuit leads to repeated overreactions by the HPA pathway in the face of stress (Walker et al., 2016). Such chronic overreactions leave individuals highly sensitive to and unsettled by stressors throughout their development. The individuals become all the more inclined to later develop schizophrenia in the face of stress (Pruessner et al., 2017).

Developmental psychopathology researchers and other investigators have further discovered

that an overreactive HPA stress pathway and chronic stress reactions lead to the development of a

dysfunctional immune system, characterized by heightened inflammation throughout the brain

(Müller et al., 2015). Thus it is not surprising that numerous studies conducted over the past

several years have found significant immune system problems and chronic inflammation

throughout the brains of people with schizophrenia (Fries et al., 2018).

In addition to adding depth to the

diathesis–stress view of schizophrenia, the

developmental psychopathology

perspective provides an important service

by emphasizing the advantages of

prevention in dealing with this disorder

(Seidman & Nordentoft, 2015).

According to this perspective, each of the

factors discussed in this chapter (from

brain circuit dysfunction to family dynamics to stress reactions) can affect each other. Just as

838

children’s overreactive HPA stress pathways can make them particularly vulnerable to stress, so

too can their acquisition of resilience and coping skills improve the operation of their HPA

pathways. This two-way relationship argues for better identification of children at risk for

schizophrenia and for stronger preventive interventions to help reverse the factors predisposing

them to schizophrenia (Mayo et al., 2017). Unfortunately, as you will see in the next section,

most of today’s approaches to schizophrenia involve treatment after the onset of the disorder

rather than prevention.

“The Devil and Daniel Johnston” For decades, singer-songwriter Daniel Johnston has been very influential in the outsider

and alternative music genres. At the same time, he suffers from schizophrenia and bipolar disorder and has been

institutionalized several times for these problems. His disorders and their effect on his life and career are chronicled in the

film documentary The Devil and Daniel Johnston.

SUMMING UP

HOW DO THEORISTS EXPLAIN SCHIZOPHRENIA Many theorists believe that biological and environmental factors combine in a diathesis–stress relationship to help

produce schizophrenia.

The biological explanations of schizophrenia point to genetic, biochemical, brain structure and circuitry, and

viral causes. The genetic view is supported by studies of relatives, twins, adoptees, and genes. The leading biochemical

839

explanation holds that dopamine may be overactive in the brains of people with schizophrenia. Studies have also

identified a brain circuit whose dysfunction may lead to 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-

behavioral models. One early psychodynamic explanation contended that schizophrenogenic mothers help produce

schizophrenia, but this view has received little research support. Contemporary psychodynamic theorists typically

ascribe the disorder to a combination of biological and psychodynamic factors. Cognitive-behavioral theorists suggest

that people with schizophrenia (1) fail to learn to attend to appropriate social cues and/or (2) misinterpret their

strange biological sensations in ways that produce delusional thinking.

One sociocultural explanation holds that multicultural differences may influence the rate and character of

schizophrenia, as well as recovery from this disorder, both within the United States and around the world. Another

sociocultural explanation says that society expects people who are labeled as having schizophrenia to behave in certain

ways and that such expectations actually lead to further symptoms. Other sociocultural theorists point to family

dysfunction, including family stress and conflict, as a cause of schizophrenia.

Offering an integrative framework, developmental psychopathology theorists contend that an individual’s genetic

predisposition—implemented by a dysfunctional brain circuit—may eventually lead to schizophrenia if, over the

course of the person’s development, he or she also experiences significant life stressors, difficult family interactions,

and/or other negative environmental factors.

840

#TreatmentDelay The average length of time between the first appearance of

psychotic symptoms and the initiation of treatment is two years

(HN, 2018; Brunet & Birchwood, 2010).

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. 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 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.

During [Cathy’s] second year in college … her emotional troubles worsened. … and [she 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 chronically 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

841

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 schizophrenia and other psychotic disorders to think clearly

and profit from psychotherapies that previously would have had little effect for them.

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 twentieth century the label “schizophrenia” was assigned to most

people with psychosis. Clinical theorists now realize that many people with psychotic symptoms

are instead experiencing a severe form of bipolar disorder or major depressive disorder and that

such people were in past times inaccurately diagnosed with schizophrenia (Tondo et al., 2015).

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 (Bustillo & Weil, 2018). Similarly, our discussions about current approaches to

schizophrenia, such as the community mental health movement, often apply to other severe

mental disorders as well.

842

Why have people with schizophrenia so often been victims

of horrific treatments such as overcrowded wards, lobotomy,

and, later, deinstitutionalization?

A long way to go A man with schizophrenia lies on the floor of the emergency room waiting area at Delafontaine Hospital

near Paris, France. The plight of this patient is a reminder that, despite the development of various effective interventions,

the overall treatment picture for many people with severe mental disorders leaves much to be desired.

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

843

#TheirWords “I believe that if you grabbed the nearest 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

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.

state hospitals Public mental hospitals in the United States, run by the individual states.

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, admissions kept rising, and state funding was unable to

keep up.

The priorities of the public mental

hospitals, and the quality of care they

provided, changed over those 110 years.

In the face of overcrowding and

understaffing, the emphasis shifted from

giving humanitarian care to keeping

order. In a throwback to the asylum period, difficult patients were restrained, isolated, and

punished; individual 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). Many patients not only failed to improve under these conditions but

also developed additional symptoms.

PSYCHWATCH

Lobotomy: How Could It Happen?

844

In 1935, a Portuguese neurologist named Egas Moniz performed a revolutionary new surgical procedure,

which he called a prefrontal leucotomy, on a patient with severe mental dysfunction (Wright, 2017; 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 icepick into the brain tissue to cut or destroy nerve fibers. Moniz believed that severe abnormal thinking—

such as that on display 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.

A year after his first leucotomy, Moniz published a monograph in Europe describing his successful use of the procedure

on 20 patients (Raz, 2013). An American neurologist, Walter Freeman, read the monograph, called the procedure to the

attention of the medical community in the United States, performed the procedure on many patients, and became its

foremost supporter. In 1947 he 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 (Collins & Stam,

2015).

Lessons in psychosurgery Neuropsychiatrist Walter Freeman performs a lobotomy in 1949 before a group of

interested onlookers by inserting a needle through a patient’s eye socket into the brain.

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 (Wright, 2017; 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 thousands 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)

845

points first to the extreme overcrowding in mental hospitals at the time—overcrowding that lobotomies helped to alleviate.

Valenstein also points to the personalities of the inventors of the procedure. Although these individuals were 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 and boldly in applying the procedure.

The prestige of Moniz and Freeman were so great and the field of neurology was so small that their procedures drew

little critical review. Physicians may also have been misled by the seemingly positive findings of early studies of the

lobotomy, which, as it turned out, were not based on sound methodology (Wright, 2017; Cooper, 2014).

By the 1950s, better studies 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, incontinence,

endocrine malfunctions, and very poor intellectual and emotional responsiveness (Lapidus et al., 2013). The discovery 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 and hardly resemble the lobotomies of 70 years back. Moreover,

the procedures are usually reserved for only the most severe cases of disorders such as OCD and depression (Neumaier et

al., 2017, 2016; Nair et al., 2014). 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.

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 principles. 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 adopted by many institutions and

are now standard features of institutional care.

846

Institutional life In a scene reminiscent of public mental hospitals in the United States during 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.

Milieu Therapy In 1953, Maxwell Jones, a London psychiatrist, converted a ward of patients with various

psychological disorders into a therapeutic community—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 given the right to run their own lives and make their

own decisions. They may participate in community government, working with staff members to

establish rules and determine 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.

milieu therapy A humanistic approach based on the premise that institutions can help patients recover by creating a climate that promotes self- respect, responsible behavior, and meaningful activity.

Since Jones’s pioneering effort, milieu-style programs have been set up in institutions

throughout the Western world. The programs vary from setting to setting, but at a minimum,

staff members try to encourage interactions (especially group interactions) between patients and

847

#TheirWords “Men will always be mad and those who think they can cure

them are the maddest of all.”

Voltaire (1694–1778)

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 (Smith & Spitzmueller, 2016;

Paul, 2000). 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. Moreover, you will see later in this chapter that

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, clinicians interested primarily in behaviors and in principles of learning discovered

that the systematic use of operant conditioning techniques on hospital wards could help change

the behaviors of patients with schizophrenia (Ayllon, 1963; Ayllon & Michael, 1959). Programs

that apply these techniques are called token economy programs.

token economy program A program in which a person’s desirable behaviors are reinforced systematically by the awarding of tokens that can be exchanged for goods or privileges.

In token economies, patients are

rewarded when they behave acceptably

and are not rewarded when they behave

unacceptably. The immediate rewards for

acceptable behavior are often tokens that

can later be exchanged for food,

cigarettes, hospital 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 (Ivy et al., 2017; Swartz et al., 2012).

Some clinicians have voiced reservations about the claims made regarding token economy

programs. Are operant conditioning procedures changing a patient’s psychotic thoughts and

perceptions or simply improving the patient’s ability to imitate normal behavior? 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

848

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, 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 business to do,

international business, laws to change, people to recruit. And these people keep playing their games.

(Comer, 1973)

Milieu philosophy Although less prominent than they once were, milieu principles continue to influence programs in many

mental hospitals. At the Borda psychiatric hospital in Buenos Aires, Argentina, patients, therapists, and volunteers take a

tango workshop together to help instill in patients a sense of equality, self-respect, and competence.

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

849

well (Ivy et al., 2017). 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 (Ivy et al., 2017; 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 (Jibson, 2017).

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 antihistamines, phenothiazines, could also be used to help calm

patients about to undergo surgery. One of the phenothiazines, chlorpromazine, was eventually

tested on six patients with psychotic symptoms and was 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.

Since the discovery of the phenothiazines, other kinds of antipsychotic drugs have also been

developed. As you read earlier in the chapter, the ones developed throughout the 1960s, 1970s,

and 1980s are now referred to as first-generation antipsychotic drugs in order to distinguish them

from the second-generation antipsychotics that have been developed more recently. The first-

generation drugs are also known as neuroleptic drugs because they often produce undesired

movement effects similar to the symptoms of neurological diseases. As you also read earlier,

antipsychotic drugs reduce psychotic symptoms at least in part by blocking excessive activity of

the neurotransmitter dopamine (Jibson, 2018; Wang et al., 2018).

How Effective Are Antipsychotic Drugs? Research has shown that antipsychotic drugs reduce symptoms in around 70 percent of patients

diagnosed with schizophrenia (Stroup & Marder, 2017). 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.

For patients helped by the drugs, the medications bring about clear improvement within a

period of weeks. However, symptoms may return if the patients stop taking the drugs too soon

(Tiihonen, Tanskanen, & Taipale, 2018). The antipsychotic drugs, particularly the first-

850

generation ones, reduce the positive symptoms of schizophrenia (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) (Jibson, 2018, 2017; Krause et al., 2018).

The Unwanted Effects of First-Generation Antipsychotic Drugs In addition to reducing psychotic symptoms, the first-generation antipsychotic drugs sometimes

produce disturbing movement problems (Olten & Bloch, 2018). These effects are called

extrapyramidal effects because they appear to be caused by the drugs’ impact on the

extrapyramidal areas of the brain, areas that help control motor activity.

extrapyramidal effects Unwanted movements, such as severe shaking, bizarre-looking grimaces, twisting of the body, and extreme restlessness, sometimes produced by antipsychotic drugs.

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

first-generation 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.

Some also have related symptoms such as movements of the face, neck, tongue, and back; and a

number experience significant restlessness and discomfort in their limbs.

Whereas most extrapyramidal drug effects appear within days or weeks, a reaction called

tardive dyskinesia (meaning “late-appearing movement disorder”) does not usually unfold until

after a person has taken first-generation antipsychotic drugs for more than six months (Tarsy,

2018, 2016). This syndrome 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 15 percent of the

people who take first-generation antipsychotic drugs, especially the most powerful ones, for an

extended time develop tardive dyskinesia to some degree, and the longer the drugs are taken, the

higher the risk becomes (Tarsy, 2018, 2016; Achalia et al., 2014). Patients over 50 years of age

are at greater risk. Tardive dyskinesia can be difficult, sometimes impossible, to eliminate

(Bergman et al., 2018; Soares-Weiser et al., 2018).

tardive dyskinesia Extrapyramidal effects involving involuntary movements that some patients have after they have taken antipsychotic drugs for an extended time.

851

Why did psychiatrists in the past keep administering high

dosages of antipsychotic drugs to patients who had adverse

effects from the medications?

The drug revolution Since the 1950s, medications have become a central part of treatment for patients with schizophrenia

and other severe mental disorders. The medications have resulted in shorter hospitalizations that now last weeks rather than

years.

Today clinicians are more

knowledgeable and more cautious about

prescribing first-generation antipsychotic

drugs than they were in the past (see

Table 12-3). Previously, 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 help improve the impact of the antipsychotic

drug, stop the drug and try an alternative one, or stop all medications (Tiihonen et al., 2018;

Stroup & Marder, 2017). Clinicians try to prescribe the lowest effective doses for each patient

and to gradually reduce medications weeks or months after the patient begins functioning

normally.

TABLE: 12-3 Some Antipsychotic Drugs Generic Name Trade Name

First-generation antipsychotics

Chlorpromazine Thorazine

852

Trifluoperazine Stelazine

Fluphenazine Prolixin

Perphenazine Trilafon

Acetophenazine Tindal

Chlorprothixene Taractan

Thiothixene Navane

Haloperidol Haldol

Loxapine Loxitane

Pimozide Orap

Second-generation antipsychotics

Risperidone Risperdal

Clozapine Clozaril

Olanzapine Zyprexa

Quetiapine Seroquel

Ziprasidone Geodon

Aripiprazole Abilify

Iloperidone Fanapt

Lurasidone Latuda

Paliperidone Invega

Asenapine Saphris

Second-Generation Antipsychotic Drugs As you read earlier in the chapter, second-generation antipsychotic drugs have been developed in

recent decades. The most widely used of these newer drugs are 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 at more D-1, D-4, and serotonin receptors than the first-generation drugs (Olten & Bloch,

2018; Tarsy, 2018, 2016).

Second-generation antipsychotic drugs appear to be at least as effective, and often more

effective, than the first-generation drugs (Jibson, 2017; Stroup & Marder, 2017). Clozapine is

often the most effective such drug, but the other second-generation drugs also bring significant

change for many people. Recall, for example, Cathy, the woman whom we met earlier, and how

well she responded to risperidone after years of doing poorly on first-generation antipsychotic

drugs. Unlike the first-generation drugs, the second-generation ones reduce not only the positive

symptoms of schizophrenia, but—to a small degree—the negative ones as well (Krause et al.,

2018). Another major benefit is that the second-generation drugs—especially clozapine—cause

853

fewer extrapyramidal symptoms and seem less likely to produce tardive dyskinesia (Tarsy, 2018,

2016).

Given such advantages, more than half of all patients with schizophrenia who are medicated

now take the second-generation drugs, which are considered the primary line of treatment for the

disorder (Kapitanyan & Su, 2018; Roberts et al., 2018). Many patients with bipolar or other

severe mental disorders also seem to be helped by several of these second-generation antipsychotic

drugs (Jibson, 2017). Yet the second-generation antipsychotic drugs have serious problems as

well. For example, people who use one of these drugs, clozapine, have around a 1 to 1.5 percent

risk of developing agranulocytosis, a life-threatening drop in white blood cells (other second-

generation drugs do not produce this undesired effect) (Coates, 2018; Zhu et al., 2018).

agranulocytosis A life-threatening drop in white blood cells. This condition is sometimes produced by the second-generation antipsychotic drug clozapine.

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 (Morrison et al., 2018). By helping to relieve

thought and perceptual disturbances, antipsychotic drugs allow people with schizophrenia to see

themselves more clearly, learn about their disorder, participate actively in therapy (see

MindTech), 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.

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 virtual reality therapy, clinicians have the clients interact with computer-generated

on-screen virtual human figures. Perhaps the boldest application of avatar therapy is its use with people suffering from

schizophrenia. Clinical researcher Julian Leff and several colleagues have developed an approach that seems to offer

particular promise for such individuals (Craig et al., 2018, 2016; Leff et al., 2014, 2013).

For a pilot study, the researchers selected 16 participants who were being tormented by imaginary voices (auditory

hallucinations). In each case, the therapist presented the individual 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 or she was hearing and

what the patient believed would be a corresponding face.

854

Can you think of any negative effects—short-term or long-

term—that might result from putting a face on auditory

hallucinations?

Voices spring to virtual life This is one of the sinister-looking avatars developed by clinical researcher Julian Leff and

his colleagues in their treatment for people with schizophrenia.

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 frightening 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” (Rus-Calafell et al., 2015; Kedmey, 2013; Leff et al., 2014, 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 improvements

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 have now been followed up by larger studies with more

participants—each producing similar findings (Craig et al., 2018, 2016). The collective results of these studies suggest that

confronting one’s hallucinations in a virtual world can indeed help at least some people with schizophrenia.

Cognitive-Behavioral Therapies Two kinds of cognitive-behavior therapy are now used for people with schizophrenia, (1)

cognitive remediation and (2) hallucination reinterpretation and acceptance. Research indicates that

both approaches are helpful, each in a different way (Bustillo & Weil, 2018).

COGNITIVE REMEDIATION Cognitive remediation is an approach that focuses on the cognitive impairments that often

characterize people with schizophrenia—particularly their difficulties in attention, planning, and

memory (Fan, Liao, & Pan, 2017; John et al., 2017). Here clients are required to complete

increasingly difficult information-processing tasks on a computer. They may start with a simple

task such as responding as quickly as possible to various stimuli that are flashed on the screen—a

855

#TheirWords “If you talk to God, you are praying. If God talks to you, you

have schizophrenia.”

Thomas Szasz, psychiatric theorist

task designed to improve their attention skills. Once they can perform this task with considerable

speed, they move on to more complex computer tasks, such as tasks that challenge their short-

term memory. As they master each computer task, they keep moving up the ladder until they

eventually reach computer tasks that require planning and social awareness.

cognitive remediation A treatment that focuses on the cognitive impairments that often characterize people with schizophrenia—particularly their difficulties in attention, planning, and memory.

Studies indicate that, for many people with schizophrenia, cognitive remediation brings about

moderate improvements in attention, planning, memory, and problem-solving—improvements

that surpass those produced by other treatment interventions (Bustillo & Weil, 2018; Fan et al.,

2017). Moreover, these improvements extend to the client’s everyday life and social relationships.

HALLUCINATION REINTERPRETATION AND ACCEPTANCE

As you read earlier, the cognitive-

behavioral explanation 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 sensations 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.

856

“Yes, you’ve mentioned this ‘Facebook’ in the past—tell me, is ‘Facebook’ saying anything right now?”

With this explanation in mind, many clinicians now employ a cognitive-behavioral treatment

for schizophrenia that is designed to help change how people view and react to their

hallucinations (Lincoln & Peters, 2018; Gottlieb et al., 2017). The therapists believe that if

people can be guided to interpret such experiences 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 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 identify 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 put such notions to the test. What happens, for example, if the clients resist following the orders from their hallucinatory voices?

4. The therapists teach clients to reattribute and more accurately interpret their hallucinations. Clients may, for example, adopt and apply alternative conclusions such as “It’s not a real voice, it’s my illness.”

857

#TheirWords “No great genius was ever without some tincture of madness.”

Aristotle

5. The therapists teach clients techniques for coping with their unpleasant sensations (hallucinations). The clients may, for example, learn ways to reduce the physical arousal that accompanies hallucinations—using special breathing and relaxation techniques, positive self-statements, distraction strategies, and the like.

These cognitive-behavioral techniques

often help people with schizophrenia feel

more control over their hallucinations and

reduce their delusional ideas (Lincoln &

Peters, 2018; Gottlieb et al., 2017). But

they do not eliminate the hallucinations. Can anything 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.

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 highly anxious individuals to become simply mindful of the worries that engulf

their thinking and to accept such negative thoughts as harmless events of the mind (see page

110). 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 (Gaudiano et al., 2017).

Studies indicate that the various cognitive-behavioral treatments are often very helpful to

clients with schizophrenia (Lincoln & Peters, 2018; Morrison et al., 2018). 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.

858

A therapist like myself The AlterEgo project at France’s Hospital of Montpellier uses computerbased technology to help

people with schizophrenia. Based on the premise that people relate better with and learn more from individuals who

resemble them, the program has clients interact with avatars similar to themselves. Here a client helps to program the avatar

with whom he will be working by having his body and movements scanned.

Family Therapy Many persons who are recovering from schizophrenia and other severe mental disorders live with

their families: parents, siblings, spouses, or children. Generally speaking, people with

schizophrenia who feel positive toward their relatives do better in treatment (Bustillo & Weil,

2018). 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 (Joseph, 2018; Wang et al., 2017). Moreover, for their part, family members may be

very upset by the social withdrawal and unusual behaviors of a relative with schizophrenia (Lloyd

et al., 2017; Yu et al., 2017).

To address such issues, clinicians now commonly include family therapy in their treatment of

schizophrenia, providing family members with guidance, training, practical advice,

psychoeducation about the disorder, and emotional support and empathy (Brown & Weisman

de Mamani, 2018; Bustillo & Weil, 2018). In family therapy, relatives develop more realistic

859

#PaternalImpact People whose fathers were over 50 years of age when they were

born are more likely to develop schizophrenia than people born

to fathers under 50 years old. As with bipolar disorder, this

may be explained by the tendency of aging men to produce

more genetic mutations during the manufacture of sperm cells

(Stovall, 2018; Crystal et al., 2012).

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 troublesome 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 and hospital readmissions go down

(Brown & Weisman de Mamani, 2018; Bustillo & Weil, 2018).

The families of people with

schizophrenia and other severe mental

disorders may also turn to family support

groups and family psychoeducational

programs for encouragement and advice

(Norman et al., 2017; Bademli &

Duman, 2016). 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 difficulties in the clients’ lives. These clinicians offer

practical advice; work with clients on problem solving, memory enhancement, decision making,

and social skills; make sure that the clients are taking their medications properly; and may even

help them find work, financial assistance, appropriate health care, and proper housing (Norman

et al., 2017; Granholm 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

hospital (Bustillo & Weil, 2018).

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 conditions in public mental

institutions and partly because of the emergence of antipsychotic drugs, the U.S. government

ordered that patients be released and treated in the community. Congress passed the Community

Mental Health Act, which stipulated 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

860

How might the “revolving door” pattern itself worsen the

symptoms and outlook of people with schizophrenia?

far from home. Patients diagnosed with schizophrenia and other severe disorders, especially those

who had been institutionalized for years, were affected most by this act. Other countries around

the world put similar sociocultural treatment programs into action shortly thereafter.

Community outreach Homeless people are more likely to develop schizophrenia, and having schizophrenia increases one’s

chances of becoming homeless. Thus, extraordinary University of Central Florida graduate student Briana Daniel founded

and directs the Street Team Movement, a volunteer program that helps homeless people in Orlando address their clothing,

laundry, hygiene, and mental health needs. The 25-year-old woman plans to eventually take the program nationwide.

Thus began several decades of

deinstitutionalization, an exodus of

hundreds of thousands of patients with

schizophrenia and other long-term mental

disorders from state institutions into the community. On a given day in 1955, close to 600,000

patients were living in state institutions; today around 42,000 patients live in such facilities

(Statista, 2018; Smith & Milazzo-Sayre, 2014). Clinicians have learned that patients recovering

from schizophrenia and other severe disorders can profit greatly from community programs

(Joshi et al., 2018; Bustillo & Weil, 2018). As you will see, however, the actual quality 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

861

on, over and over (Allison et al., 2018; Burns & Drake, 2011).

deinstitutionalization The discharge of large numbers of patients from long-term institutional care so that they might be treated in community programs.

What Are the Features of Effective Community Care? People recovering from schizophrenia and other severe disorders need medication,

psychotherapy, help in handling daily pressures and responsibilities, guidance in making

decisions, social skills training, residential supervision, and vocational counseling—a

combination of services called assertive community treatment (Gaudiano et al., 2017). Those

whose communities help them meet these needs make more progress than those living in other

communities (Schöttle et al., 2018). Some of the key features of effective community care

programs are (1) coordination of patient services, (2) short-term hospitalization, (3) partial

hospitalization, (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, psychotherapy, 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 (Bustillo & Weil, 2018; Joshi et al., 2018).

Coordination of services is particularly important for so-called mentally ill chemical abusers

(MICAs), patients with psychotic disorders as well as substance use disorders (Campbell, Caroff,

& Mann, 2018, 2017).

community mental health center A treatment facility that provides medication, psychotherapy, and emergency care for psychological problems and coordinates treatment in the community.

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 antipsychotic 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) (Gaudiano et al.,

2017; 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.

862

aftercare A program of posthospitalization care and treatment in the community.

PARTIAL HOSPITALIZATION People’s needs may fall between full hospitalization and outpatient therapy, and so some

communities offer day centers, or day hospitals, all-day programs in which patients return to

their homes for the night. Such programs provide patients with daily supervised activities,

therapy, and instructions to improve social skills. People recovering from severe disorders in day

centers often do better and have fewer relapses than those who spend extended periods in a

hospital or in traditional outpatient therapy (Bustillo & Weil, 2018; Bales et al., 2014). Another

kind of institution that has become a popular setting for the treatment of people with

schizophrenia and other severe disorders is the semihospital, or residential crisis center. These are

houses or other structures in the community that provide 24-hour nursing care for people with

severe mental disorders (Zarzar et al., 2018; Soliman et al., 2008).

day center A program that offers hospital-like treatment during the day only. Also known as a day hospital.

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 (MHA,

2017; Lindenmayer & Khan, 2012). Such residences may shelter between one and two dozen

people. The live-in staff usually 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

(MHA, 2017; Hansson et al., 2002).

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.

OCCUPATIONAL TRAINING AND SUPPORT Paid employment provides income, independence, self-respect, and the stimulation of working

with others. It also brings companionship and order to one’s daily life. For these reasons,

occupational training and placement are important services for people with schizophrenia and

other severe mental disorders (Norman et al., 2017).

863

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. 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 (Bustillo & Weil, 2018; Abraham et al., 2017; Solar, 2014). Unfortunately, like

sheltered workshops, supported employment opportunities are often in short supply. Fewer than

20 percent of individuals with severe psychological disorders have jobs in the competitive job

market.

They met at a day center Sunday and Sam Duncan pose for a portrait at their home in La Junta, Colorado. The married

couple, both of whom have suffered from schizophrenia, met in a day center at Southeast Mental Health Services and,

according to them, fell in love at first sight. The day center has received national awards for its innovative approach to

schizophrenia.

How Has Community Treatment Failed? There is no doubt that effective 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 (Joshi et al., 2018; Addington et al.,

2015). 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 (NAMI, 2018; NIMH, 2017). Two factors are

primarily responsible: poor coordination of services and a shortage of services.

POOR COORDINATION OF SERVICES The various mental health agencies in a community often fail to communicate with one another.

864

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. Still another problem is poor

communication between state hospitals and community mental health centers, particularly at

times of discharge (Bonsack et al., 2016; Torrey, 2001).

“Court to Community” Denver, Colorado, has established a program called Court to Community, which diverts people

with severe mental disorders into court-monitored mental health programs rather than jails. Repeat criminal offenders, like

this man with schizophrenia, plead their cases to the program’s judges, who determine whether the individuals are taking

their medications, avoiding street drugs, and attending therapy. Life in the community is preferable to jail, but it too is

difficult. This man told the judge, “I feel like I’m in prison when I’m out there.”

To help deal with such problems in communication and coordination, a growing number of

community therapists have become case managers for people with schizophrenia and other

severe mental disorders (Schneeberger et al., 2017; Burns, 2010). They try to coordinate available

community services and help protect clients’ legal rights. Like the social therapists 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.

case manager A community therapist who offers and coordinates a full range of services for people with schizophrenia or other severe disorders, including therapy, advice, medication, guidance, and protection of patients’ rights.

865

SHORTAGE OF SERVICES The number of community programs—community mental health centers, halfway houses,

sheltered workshops—available to people with severe mental disorders falls woefully short

(NIMH, 2017; Burns & Drake, 2011). In addition, many of the community mental health

centers that do exist generally devote their efforts and money to people with problems such as

anxiety disorders or social adjustment difficulties. Only a fraction of the patients treated by such

community mental health centers suffer from schizophrenia or other disorders marked by

psychosis (NIMH, 2017).

There are various reasons for this shortage of services. Perhaps the primary one is economic.

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 in 2017

approximately $152 billion in public funding was devoted each year to people with mental

disorders (SAMHSA, 2017, 2014). 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 treatment 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 (SAMHSA, 2017, 2014). 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 such

local resources cannot always meet this challenge (SAMHSA, 2017, 2014; Feldman et al., 2014).

What Are the Consequences of Inadequate Community Treatment? What happens to people with schizophrenia and other severe disorders whose communities do

not provide the services they need and whose families cannot afford private treatment? 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 (NIMH, 2017; Burns & Drake, 2011).

These individuals live in various settings (MIP, 2017; Torrey, 2014, 2001). Many return to

their families and receive medication and perhaps emotional and financial support, but little else

in the way of treatment. Around 8 percent enter an alternative institution such as a nursing home

or rest home, where they receive only custodial care and medication (see Figure 12-4). As many

as 18 percent are placed in privately run residences where supervision often is provided by

866

untrained staff—foster homes (small or large), boardinghouses, care homes, and similar facilities.

These residences vary greatly in quality. Another 34 percent of people with schizophrenia and

other severe disorders live in totally unsupervised settings. Some are equal to the challenge of

living alone, but others cannot really function independently and wind up in rundown single-

room occupancy hotels (SROs) or rooming houses. They may live in conditions that are

substandard and unsafe, which may exacerbate their disorder.

FIGURE 12-4

Where Do People with Schizophrenia Live?

More than one-third live in unsupervised residences, 6 percent are in jails, and 5 percent are homeless. (Information from:

Allison et al., 2018, 2017; MIP, 2017; Torrey, 2014, 2001; Kooyman & Walsh, 2011.)

Finally, a great number of people with schizophrenia and other severe disorders have become

homeless. There are 565,000 homeless people in the United States, and approximately one-

fourth of them—a total of 140,000 homeless people—have a severe mental disorder, commonly

schizophrenia (NAMI, 2018; MIP, 2017). Many have been released from hospitals. Others are

young adults who were never hospitalized in the first place. Another 440,000 or more people

with severe mental disorders are in prisons and jails, often because their disorders have led them

to break the law (Allison, Bastiampillai, & Fuller, 2017). As many as 26 percent of all persons

imprisoned in the United States suffer from schizophrenia or another severe mental disorder

867

#PrisonPopulation There are more people with schizophrenia 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.

(Binswanger & Elmore, 2018; Stürup-Toft et al., 2018;

Pruchno, 2014; Balassone, 2011)

(Binswanger & Elmore, 2018; Judd & Parker, 2018). 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.

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. Indeed, in one study of

34 effective community programs across 21 states—programs that properly provide a

combination of services (medication, psychotherapy, case management, and assertive community

treatment)—clients with schizophrenia were found to make more improvements in their quality

of life, symptom reduction, and participation at work and school than did comparable clients in

other kinds of treatment or in less-comprehensive community programs (Kane et al., 2016).

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, 2018, 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 lobbying 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 dysfunction (Bustillo & Weil, 2018; Joshi et al., 2018).

868

Changing the unacceptable A resident of a group home holds a sign during a rally in New York to protest the shortage of

appropriate community residences for people with severe mental disorders.

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 treatment of schizophrenia and other

disorders marked by psychosis. Today they are almost always a part of treatment. Theorists believe that the first-

generation antipsychotic drugs operate by reducing excessive dopamine activity in the brain. These drugs reduce the

positive symptoms of schizophrenia more completely, or more quickly, than they do the negative symptoms. The

first-generation antipsychotic drugs, however, can also produce dramatic unwanted effects, particularly movement

abnormalities called extrapyramidal effects. More recently, second-generation antipsychotic drugs have been

developed; these cause fewer extrapyramidal effects.

869

Psychotherapy is often employed successfully in combination with antipsychotic drugs. Helpful forms include

cognitive-behavioral therapy, family therapy, and social therapy. Family support groups and family psychoeducational

programs are also growing in number.

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

aftercare), day centers, halfway houses, occupational training and support, and case management. However, the

quality and funding of community care for people with schizophrenia and other severe disorders have been

inadequate, often resulting in a “revolving door” pattern between the community and the hospital. One result is that

many people with such disorders are now homeless or in prison.

870

CLINICAL CHOICES 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.

An Important Lesson After years of frustration and failure, clinicians now have an arsenal of weapons to use against

schizophrenia and other disorders marked by psychosis. It has become clear that antipsychotic

medications open the door for recovery from these disorders, but in most cases other kinds of

treatment are also needed to help the recovery process along.

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 biological discoveries and pharmacological advances, hundreds of

thousands of patients with schizophrenia and other severe mental disorders were released to their

communities 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 treatment for psychological problems.

When the 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 shortages in community care, many

more people with schizophrenia—at least

three times as many—show improvement.

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. 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 hundreds of thousands have become

homeless or imprisoned. It is now up to clinicians, along with public officials, to address the

needs of all people with schizophrenia and other severe disorders.

871

Chapter 12 Review

Key Terms

schizophrenia

psychosis

schizophrenia spectrum disorders

positive symptoms

delusion

formal thought disorder

loose associations

hallucination

inappropriate affect

negative symptoms

alogia

restricted affect

avolition

catatonia

dopamine hypothesis

antipsychotic drug

phenothiazines

second-generation antipsychotic drugs

first-generation antipsychotic drugs

schizophrenia-related brain circuit

schizophrenogenic mother

expressed emotion

872

state hospital

milieu therapy

token economy program

neuroleptic drugs

extrapyramidal effects

tardive dyskinesia

agranulocytosis

cognitive remediation

social therapy

deinstitutionalization

assertive community treatment

community mental health center

mentally ill chemical abuser (MICA)

aftercare

day center

halfway house

sheltered workshop

case manager

national interest groups

Quick Quiz

1. What is schizophrenia, and how prevalent is it? What is its relation to socioeconomic class and gender? pp. 364–365

2. What are the positive, negative, and psychomotor symptoms of schizophrenia? pp. 365– 369

3. Describe the genetic, biochemical, brain circuitry, and viral explanations of

873

schizophrenia, and discuss how they have been supported in research. pp. 370–374

4. What are the key features of the psychodynamic, cognitive-behavioral, multicultural, social labeling, family, and developmental psychopathology explanations of schizophrenia? pp. 375–379

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 treatment programs? pp. 381–383

6. How do antipsychotic drugs operate on the brain? How do first-generation antipsychotic and second-generation antipsychotic drugs differ? pp. 383–385

7. How effective are antipsychotic drugs in the treatment of schizophrenia? What are the unwanted effects of first-generation antipsychotic drugs? pp. 385–386

8. What kinds of psychotherapy seem to help people with schizophrenia and other disorders marked by psychosis? pp. 386–390

9. What is deinstitutionalization? What features of community care seem critical for helping people with schizophrenia and other severe mental disorders? pp. 390–392

10. How and why has the community mental health approach been inadequate for many people with severe mental disorders? pp. 392–393

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

874

CHAPTER 13 Personality Disorders

TOPIC OVERVIEW

“Odd” Personality Disorders

875

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”: DSM-5’s Proposed Dimensional Approach

Rediscovered, Then Reconsidered

While 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 certain 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 important, his self-confidence and boldness

had wowed them.

A year later, many of the same individuals were describing Frederick differently—arrogant, self-serving, cold, egomaniacal,

draining. He had performed well as editor (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 important, when it served his purpose. Thus he

always had his share of friends and admirers. 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 attention 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

876

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 remorse 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 predictable 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, emotional experiences, goals, capacity for

empathy, and/or capacity for intimacy (APA, 2013) (see Table 13-1). 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.

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.

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.

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, and brought considerable pain to others. Witness the upset and

877

turmoil felt by Frederick’s coworkers and girlfriends.

The symptoms of personality disorders last for years and typically become recognizable in

adolescence or early adulthood, although some start during childhood (Skodol, 2017). These

disorders are among the most difficult psychological disorders to treat. Surveys indicate that

around 15 percent of all adults in the United States display a personality disorder at some point

in their lives (Skodol, 2017; APA, 2013).

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 fearfully shy away from all relationships, also display

social anxiety disorder. Research indicates that the presence of a personality disorder complicates

a person’s chances for a successful recovery from other psychological problems (Caligor &

Petrini, 2018; Silverman & Krueger, 2018).

DSM-5 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 problematic personality

symptoms. For example, as you will soon see, paranoid personality disorder is diagnosed when a

person has unjustified suspicions that others are harming him or her, has persistent unfounded

doubts about the loyalty of friends, reads threatening meanings into benign events, persistently

bears grudges, and has recurrent unjustified suspicions about the faithfulness of life partners.

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, resulting in frequent

878

Why do you think personality disorders attract so many

efforts at amateur psychology?

disagreements about which diagnosis is correct for a person with a personality disorder.

Diagnosticians sometimes even determine that particular people have more than one personality

disorder (Lilienfeld & Latzman, 2018). This lack of agreement has raised serious questions about

the validity (accuracy) and reliability (consistency) of the 10 DSM-5 personality disorder

categories.

Given this state of affairs, many theorists have challenged the use of a categorical approach to

personality disorders. They believe that personality disorders differ 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 (Anderson et al.,

2018, 2014; Skodol, 2018). In a dimensional approach, each trait is seen as varying along a

continuum extending from nonproblematic to extremely problematic. People with a personality

disorder are those who display extreme degrees of problematic traits—degrees not commonly

found in the general population.

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. After much debate, they decided to retain a classic 10-disorder

categorical approach in the current DSM. At the same time, however, the framers acknowledged

the likely future direction of personality disorder classifications by also describing an alternative

dimensional approach. Most of the discussions in this chapter are organized around the 10-

disorder categorical approach used in DSM-5. Later in the chapter, we will examine possible

alternative—dimensional—approaches of the future, including 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 majority of instances, such

interpretations are incorrect. We all display personality traits. Only occasionally are they so

maladaptive, distressing, and inflexible that they can be considered disorders.

879

Early notions of personality In the popular 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.

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 15 percent of adults

develop such a disorder at some point in their lives. DSM-5 uses a categorical approach that lists 10 distinct

personality disorders. In addition, the framers of DSM-5 have proposed a dimensional approach to the classification

of personality disorders.

880

881

#BigOverlap Suspiciousness, self-absorption, anxiety, and depression are

prominent features in almost all 10 personality disorders in

DSM-5.

“Odd” Personality Disorders The cluster of “odd” personality disorders

consists of the paranoid, schizoid, and

schizotypal personality disorders. People

with these disorders typically have odd or

eccentric 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. In fact, schizotypal personality disorder is listed twice in DSM-5—as one of the

schizophrenia spectrum disorders and as one of the personality disorders. Directly related or not,

people with an odd-cluster personality disorder often qualify for an additional diagnosis of

schizophrenia or have close relatives with schizophrenia (Lenzenweger, 2018).

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.

Paranoid Personality Disorder As you read earlier, people with paranoid personality disorder deeply distrust other people and

are suspicious of others’ 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 intimidated 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 attention 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.

882

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.

paranoid personality disorder A personality disorder marked by a pattern of distrust and suspiciousness of others.

Ever on guard and cautious and seeing threats everywhere, people like Eduardo continually

expect to be the targets of some trickery (see Figure 13-1). They find “hidden” meanings, which

are usually belittling or threatening, in everything. In an early 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.

883

FIGURE 13-1

Whom Do You Distrust?

Although distrust and suspiciousness are the hallmarks of paranoid personality disorder, even people without this disorder

are often untrusting. In various surveys, the majority of respondents have said they distrust Internet information, the mass

media (newspapers, TV, and radio), and members of Congress. (Information from: Gallup Poll, 2018, 2016, 2015;

Bernstein, 2017; Pew Research, 2017, 2016; Swift, 2016; Ho, 2012.)

Quick to challenge the loyalty or trustworthiness of acquaintances, people with paranoid

personality disorder remain cold and distant. A woman might avoid confiding in anyone, for

example, for fear of being hurt; or a husband might, without any justification, persist in

884

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 (Lee, 2017).

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. As many as 4.4 percent of adults experience this disorder,

which is apparently more common in men than in women (Quirk et al., 2017, 2016; APA,

2013).

How Do Theorists Explain Paranoid Personality Disorder? The theories that have been proposed to explain paranoid personality disorder, like those about

most other personality disorders, have received little systematic research. Psychodynamic theories,

the oldest of these explanations, trace the pattern to early interactions with demanding parents,

particularly distant, rigid fathers and overcontrolling, rejecting mothers (Paris, 2018; 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 (Geoffreys, 2015;

Koenigsberg et al., 2001). Similarly, some cognitive-behavioral 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, Davis, & Freeman, 2015).

885

Biological theorists propose that paranoid personality disorder has genetic causes

(Haghighatfard et al., 2018). A widely reported study that looked at self-reports of suspiciousness

in 3,810 Australian 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 (Skodol, 2017; Kellett & Hardy, 2014). Furthermore, many

who are in treatment view the role of patient as inferior and distrust and rebel against their

therapists. Thus it is not surprising that therapy for this disorder has limited effect and moves

slowly.

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 et al., 2018; Kernberg, 2018). Cognitive-behavioral

therapy has also been used to treat people with paranoid personality disorder. 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

886

more realistic interpretations of other people’s words and actions and to become more aware of

other people’s points of view (Davidson, 2018). Antipsychotic drug therapy seems to be of

limited help (Markovitz, 2018; Skodol, 2017).

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 traditional 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 alienated 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 family 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)

schizoid personality disorder A personality disorder featuring persistent avoidance of social relationships and little expression of emotion.

People like Eli, often described as “loners,” make no effort to start or keep friendships, 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.

887

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 percent of the

adult population (Morgan & Zimmerman, 2018; APA, 2013). Men are slightly more likely to

experience it than are women.

A darker knight In recent years, Batman movies have presented the crime fighter as a singularly driven loner incapable of

forming or sustaining relationships, a portrayal true to the original comic book presentation. In the 2016 film Batman v

Superman: Dawn of Justice, for example, Batman’s asocial personality, including his hatred and distrust of Superman, is

evident. A number of clinical observers have argued that in these recent presentations, Batman displays some of the

symptoms of schizoid personality disorder.

How Do Theorists Explain Schizoid Personality Disorder? Many psychodynamic theorists, particularly object relations theorists, propose that schizoid

personality disorder has its roots in an unsatisfied need for human contact (Kernberg, 2018). 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

888

disorder are left unable to give or receive love. They cope by avoiding all relationships.

Cognitive-behavioral theorists propose, not surprisingly, that people with schizoid personality

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 (Chadwick, 2014). 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).

Treatments for Schizoid Personality Disorder Their social withdrawal prevents most people with schizoid personality disorder from entering

therapy unless some other disorder, such as alcoholism, makes treatment necessary (Skodol &

Bender, 2018, 2016). These clients are likely to remain emotionally distant from the therapist,

seem not to care about their treatment, and make limited progress at best (Sperry, 2016; 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 interactions (Davidson, 2018; Beck

et al., 2015). On the cognitive end, their techniques 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 (Bressert, 2016). As with paranoid

personality disorder, drug therapy seems to offer limited help (Markovitz, 2018; Skodol, 2017).

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

889

#CommonBelief People who think that they have extrasensory abilities are not

necessarily suffering from schizotypal personality disorder. In

fact, according to surveys, more than 73 percent of adults

believe in some form of the paranormal or occult—ESP,

astrology, ghosts, communicating with the dead, or psychics

(Gray & Gallo, 2016; Austin, 2015; Gallup Poll, 2005).

ago. His parents, both successful professionals, 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 first question

was repeated. He described, in … short, bizarre answers, a life devoid 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 expressed no apparent loneliness, however, and appeared entirely emotionless regarding 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 background, 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, stimulation. … He would

simply fade out, becoming blank, losing conscious awareness, and turning off the pressures of the outer world.

(Millon, 2011)

schizotypal personality disorder A personality disorder characterized by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities.

As with Kevin, the thoughts and behaviors of people with schizotypal personality 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 special

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 emotions 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 digressive and vague, even

sprinkled with loose associations

(Lenzenweger, 2018; Rabella et al., 2016).

890

Like Kevin, they tend to drift aimlessly and lead an idle, unproductive life. 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, 2017; APA, 2013).

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 range of studies have supported such expectations (Lenzenweger, 2018; Rosell,

2017). 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 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 (Chan et al.,

2018; Lenzenweger, 2018). As you read in Chapter 12, there are indications that these biological

factors may have a genetic basis.

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.

Around two-thirds of people with schizotypal personality disorder also suffer from major

depressive disorder or bipolar disorder at some point in their lives (Rosell, 2017). Thus, at the

very least, this personality disorder is not tied exclusively to schizophrenia.

891

When personality disorders explode In this 2007 video, Seung-Hui Cho, a student at Virginia Tech, described the slights

he experienced throughout his life. After mailing the video to NBC News, he proceeded to kill 32 people, including himself,

and to wound 25 others in a massive campus shooting. Most clinicians agree that he displayed a combination of features

from the schizotypal, paranoid, schizoid, antisocial, borderline, and narcissistic personality disorders, including strange

thinking, extreme social withdrawal, persistent distrust, boundless fury and hatred, intimidating behavior, arrogance, and

disregard for others.

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 clients “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 (Sperry, 2016; Colli et al., 2014).

Cognitive-behavioral therapists further try to teach clients to evaluate their unusual thoughts

or perceptions objectively and to ignore the inappropriate ones (Davidson, 2018; Beck et al.,

2015). The therapists may keep track of clients’ 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 it is 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

other people (Skodol, 2017; Bressert, 2016).

Antipsychotic drugs have been given to people with schizotypal personality disorder, again

892

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 (Jakobsen et al., 2017;

Skodol, 2017).

SUMMING UP

“ODD” PERSONALITY DISORDERS

Three of the personality disorders in DSM-5 are marked by the kinds of odd or eccentric behavior often seen in

schizophrenia. People with paranoid personality disorder display a broad pattern of distrust and suspiciousness. Those

with schizoid personality disorder persistently avoid social relationships, have little or no social interest, and show

little emotional expression. People with schizotypal personality disorder display a range of interpersonal problems

marked by extreme discomfort in close relationships, very odd forms of thinking and behavior, and behavioral

eccentricities. Treatment gains for people with these disorders tend to be modest at best.

893

“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, running away, cruelty to animals or people, and destroying property.

antisocial personality disorder A personality disorder marked by a general pattern of disregard for and violation of other people’s rights.

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 people and related qualities,

some clinicians suggest that Madoff displays antisocial personality disorder.

894

Robert Hare, a leading clinician and researcher in this realm, 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 intense 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 homosexual

pairing. … 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). … Several months after I had recommended the transfer, there was a mighty eruption below the floorboards directly

under the warden’s [dining] 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

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 … 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 roofing 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 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

895

How do various institutions in our society—business,

government, science, religion—view lying? How might such

views affect lying by individuals?

#PreviousIdentity

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 [pipeline] 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

(Black, 2017). 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 (Olson & Patrick,

2018). Correspondingly, they may be irritable, aggressive, and quick to start fights.

Recklessness is another common trait:

people with antisocial personality disorder

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 relationships. Usually they develop a knack for gaining

personal profit at the expense of others. Because the pain or damage they cause seldom concerns

them, clinicians often say that they lack a moral conscience (see Table 13-2). They think of their

victims as weak and deserving of being conned, robbed, or even physically harmed (see

Trending).

TABLE: 13-2 Annual Hate Crimes in the United States Group Attacked Number of Reported Incidents

Racial/ethnic groups 4,216

LGBT groups 1,410

Religious groups 1,402

Groups with disability 85

Information from: FBI, 2017, 2016.

Surveys indicate that 3.6 percent of adults in the United States meet the criteria for antisocial

personality disorder (Black, 2017; APA, 2013). The disorder is as much as four times more

common among men than women.

Because people with this disorder are

896

Antisocial personality disorder was referred to as “moral

insanity” during the nineteenth century (Jones, 2017). often arrested, researchers frequently look

for people with antisocial patterns in

prison populations (Azevedo et al., 2018).

It is estimated that at least 35 percent of people in prison meet the diagnostic criteria for this

disorder. The criminal behavior of many people with this disorder declines after the age of 40;

some, however, continue their criminal activities throughout their lives (Holzer & Vaughn,

2017; APA, 2013).

Studies and clinical observations also indicate that people with antisocial personality disorder

have higher rates of alcoholism and other substance use disorders than do the rest of the

population (Black, 2017; Robitaille et al., 2017). Thus some theorists speculate that antisocial

personality disorder and substance use disorders both have the same cause, such as a deep-seated

need to take risks. Consistent with this notion, a number of people with antisocial personality

disorder also display gambling disorder (Chamberlain et al., 2017).

TRENDING

Mass Murders: Where Does Such Violence Come From?

At 2:00 A.M. on June 12, 2016, a 29-year-old man entered Pulse, a gay nightclub in Orlando, Florida, and,

using two semi-automatic weapons, proceeded to shoot 100 patrons, killing 49 of them. The mass killing, considered a

terrorist-hate attack, was one of the deadliest by a single shooter in U.S. history. But it was certainly not the only mass

killing. The Orlando horror has been followed by numerous other mass shootings, including ones at a country music

concert in Las Vegas, Nevada, in 2017, and at the Marjory Stoneman Douglas High School in Parkland, Florida, in 2018.

Similarly, it was preceded by numerous mass killings across the country and the world, including the 2015 killings of 9

Bible study members at a church in Charleston, South Carolina; the 2012 killings of 26 students and teachers at the Sandy

Hook Elementary School in Newtown, Connecticut; and the 2012 murders of 12 moviegoers at a Batman movie in

Aurora, Colorado.

897

Unthinkable Friends of the victims of the 2016 mass shooting at Pulse nightclub gather in Orlando to embrace, cry,

and show support for those who died or were injured in the mass murder.

These numbers are numbing, and the public has looked to the clinical field to help it understand why mass killings

occur and why they are on the increase. Clinical theorists and researchers have offered various theories about why

individuals commit such murders, but enlightening research and effective interventions have been elusive (Fox, Levin, &

Fridel, 2018; Abe, 2017).

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 involve the use of guns, and most are

committed by males (FBI, 2017; Hoyer & Heath, 2012).

We also know that despite public perceptions, mass killings are not a new phenomenon. They have occurred—with

regularity—for centuries (Bonn, 2017, 2015). What is new, however, is the increasing frequency of mass public shootings

(for example, schools, shopping malls, and workplaces) and the emergence of certain patterns of mass murder (Fox et al.,

2018; Wilson, 2016). Although specific issues vary from mass murder to mass murder—racial or religious hatred, for

example—two general patterns are on the rise (Abe, 2017). In one pattern, so-called “pseudocommando” 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 incident” (Knoll, 2010). In

another pattern, “autogenic” (self-generated) massacres, individuals kill people indiscriminately to fulfill a personal agenda.

Theorists have suggested a number of factors to help explain pseudocommando, autogenic, and other mass killings,

including the availability of guns, bullying behavior, substance abuse, the proliferation of violent media and video games,

dysfunctional homes, and contagion effects (Lankford & Tomek, 2018; Singal, 2017). Moreover, regardless of one’s

position on gun control, media violence, or the like, almost everyone, including most clinicians, believe that mass killers

typically suffer from a mental disorder (Fox et al., 2018; Winegard & Ferguson, 2016). Which mental disorder? On this,

there is little agreement (Carey, 2016). Each of the following has been suggested:

Antisocial, borderline, paranoid, or schizotypal personality disorder

898

#CharacterIngestion As late as the Victorian era, many English 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).

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

conducted on mass killings. On the other hand, several psychological variables have emerged as a common denominator

across the various studies: severe feelings of anger and resentment, feelings of being persecuted or grossly mistreated, and

desires for revenge (Fox et al., 2018). 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 identifying 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

investigate, 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.

How Do Theorists Explain Antisocial Personality Disorder?

Most explanations of antisocial

personality disorder come from the

psychodynamic, cognitive-behavioral, 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 (Paris, 2018; Meloy &

Yakeley, 2010). 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 the psychodynamic

explanation, researchers have found that people with this disorder 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 (Black, 2017; Gard et al., 2017).

899

Popular sociopaths Television audiences seem to love characters with the symptoms of antisocial personality disorder.

Legendary character Walter White (left), the ruthless meth manufacturer and dealer in Breaking Bad, and the equally

legendary Joffrey Baratheon (right), the amoral and cruel king in Game of Thrones, are two of this decade’s most popular

villains.

Cognitive-behavioral theorists have argued that a combination of behavioral and cognitive

factors contribute to antisocial personality disorder. On the behavioral side, they suggest that

antisocial symptoms may be learned through principles of conditioning, particularly modeling, or

imitation (Cabrera et al., 2017). As evidence, they point to the higher rate of antisocial

personality disorder found among the parents and close relatives of people with this disorder

(Black, 2017). The modeling explanation is also supported by studies of friends and associates of

people with antisocial personality disorder (McKeown & Taylor, 2018). For example, one

investigation found that middle school students who were attracted to antisocial peers went on to

engage in antisocial behavior themselves in order to gain acceptance (Juvonen & Ho, 2008).

Cognitive-behavioral theorists also point to operant conditioning to help explain this disorder.

They suggest that some parents unintentionally teach antisocial behavior by regularly rewarding a

child’s aggressive behavior (Black, 2017; 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.

900

On the cognitive side, cognitive-behavioral theorists say that people with antisocial personality

disorder often hold attitudes that trivialize the importance of other people’s needs (Elwood et al.,

2004). They believe that such a philosophy of life may be far more common in our society than

people recognize. In a related explanation, a number of cognitive-behavioral theorists propose

that people with this disorder have genuine difficulty recognizing points of view or feelings other

than their own (Igoumenou et al., 2017).

Finally, studies suggest that biological factors play an important role in antisocial personality

disorder. Genetic research suggests that the disorder may be linked to particular genes (Raine,

2018; Rosenström et al., 2017). In addition, researchers have found that antisocial people,

particularly those who are highly impulsive and aggressive, have lower activity of the

neurotransmitter serotonin than other people (Eisner et al., 2017). As you’ll recall (see page 224),

in other kinds of studies both impulsivity and aggression have been linked to low serotonin

activity, so the presence of this biological factor in people with antisocial personality disorder is

not surprising.

In related work, studies indicate that individuals with this disorder display deficient

functioning in their prefrontal cortex, anterior cingulate cortex, amygdala, hippocampus, and

temporal cortex—brain structures that, collectively, help people follow rules; plan and execute

realistic strategies; and display sympathy, judgment, and empathy (Gard et al., 2017; Schiffer et

al., 2017). These are, of course, all abilities found wanting in people with antisocial personality

disorder.

901

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 tags like “Ladro” (“Thief”) or “Omicida” (“Murderer”). The display comes from nineteenth-century psychiatrist Cesare

Lombroso’s crude but pioneering research into the nature of criminal and related antisocial behavior.

A different line of biological research has found that research participants with this disorder

often respond to warnings or expectations of stress with low brain and bodily arousal (Thompson

et al., 2014; Perdeci et al., 2010). It is believed that such underarousal may enable people with

the disorder to readily tune out threatening or emotional situations and so be unaffected by

them. This could help explain a phenomenon often observed by clinicians—that people with

antisocial personality disorder seem to feel less anxiety than other people, and so lack a key

ingredient for learning from negative life experiences or tuning in to the emotional cues of others

(Black, 2017; Blair et al., 2005). Such physical underarousal may also help explain why people

with antisocial personality disorder take more risks and seek more thrills than other people do.

These numerous biological factors may be connected more closely than first meets the eye.

Consistent with the field’s increasing emphasis on dysfunctional brain circuits, many theorists

now suspect that antisocial personality disorder is ultimately related to poor functioning by a

brain circuit consisting of the structures mentioned above. Poor communication (that is, poor

interconnectivity) between those structures in the circuit may produce chronic low reactions to

stress by the two brain–body stress pathways—the sympathetic nervous system pathway and the

hypothalamic-pituitary-adrenal pathway—leading, in turn, to a state of low arousal, weak stress

reactions, poor empathy for the pain of others, and other features of antisocial personality

disorder (Aghajani et al., 2017; Glenn et al., 2017, 2015). Although enthusiasm for this circuit-

centered explanation is growing, research regarding its specifics and merits has been limited to

date.

Treatments for Antisocial Personality Disorder Treatments for people with antisocial personality disorder are typically ineffective (Skodol &

Bender, 2018, 2016). Major obstacles to treatment include the individual’s lacking a conscience,

a desire to change, or respect for therapy (Sperry, 2016). Most of those in therapy have been

forced to participate by an employer, their school, or the law, or they come to the attention of

therapists when they also develop another psychological disorder (Bressert, 2016).

Cognitive-behavioral therapists may try to guide clients with antisocial personality disorder to

think about moral issues and about the needs of other people. However, research has not found

this approach to be particularly helpful (Black, 2017). In a similar vein, a number of hospitals

902

and prisons have tried to create a therapeutic community for people with this disorder, a

structured environment that teaches responsibility toward others (Bressert, 2016). Some such

individuals seem to profit from approaches of this kind, but it appears that most do not. In

recent years, clinicians have also used psychotropic medications, particularly antipsychotic drugs,

to treat people with antisocial personality disorder. However, research has not found medication

to be consistently useful in addressing the overall antisocial pattern (Black, 2017).

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, 2018). In her first treatment session, Dal

displays or reveals all of these difficulties, as described by her therapist:

Dal … seems to be unable to maintain a stable sense of self-worth and self-esteem. Her confidence in her ability to “hold on

to men” is at a low ebb, having just parted ways with “the love of her life.” In the last year alone she confesses to having had six

“serious relationships.”

. . . The commencement of each affair was “a dream come true” and the men were all and one “Prince Charming.” But then

she invariably found herself in the stormy throes of violent fights over seeming trifles. She tried to “hang in there,” but the more she

invested in the relationships, the more distant and “vicious” her partners became. Finally, they abandoned her. …

She shrugs and … her posture [becomes] almost violent: “No one f***s with me. I stand my ground, you get my meaning?”

She admits that she physically assaulted three of her last six paramours, hurled things at them, and, amidst uncontrollable rage

attacks and temper tantrums, even threatened to kill them. What made her so angry? She can’t remember now …

As she recounts these sad exploits, she alternates between boastful swagger and self-chastising, biting criticism of her own traits

and conduct. Her affect swings wildly, in the confines of a single therapy session, between exuberant and fantastic optimism and

unbridled gloom.

One minute she can conquer the world, careless and “free at last” (“It’s their loss. …”)—the next instant, she hyperventilates

with unsuppressed anxiety, bordering on a panic attack …

Dal likes to “live dangerously, on the edge.” She does drugs occasionally—”not a habit, just for recreation,” she assures me. She

is a shopaholic and often finds herself mired in debts. She went through three personal bankruptcies … She also binges on food,

especially when she is stressed or depressed which seems to occur quite often.

She sought therapy because she is having intrusive thoughts about killing herself. [She often performs] self-injury and self-

mutilation (she shows me a pair of pale, patched wrists, more scratched than slashed).

(Vaknin, 2016, 2015)

borderline personality disorder A personality disorder characterized by repeated

903

#TheirWords “Anger is a brief lunacy.”

Horace, Roman poet

instability in interpersonal relationships, self-image, and mood and by impulsive behavior.

Like Dal, 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 (Zanarini et al., 2017). Just as

often, however, they direct their impulsive anger inward and inflict bodily harm on themselves.

Many seem troubled by deep feelings of emptiness (Zandersen & Parnas, 2018).

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

Borderline personality disorder is a complex disorder, and it is fast becoming one of the more

common conditions seen in clinical practice. As many as 85 percent of individuals with this

syndrome also experience another psychological disorder, such as major depressive disorder or an

eating disorder, at some point in their lives (Silverman & Krueger, 2018). Their impulsive, self-

destructive activities may range from substance abuse to delinquency, unsafe sex, and reckless

driving (Friedel, 2018; Kienast et al., 2014). Many engage in behaviors that involve self-injury or

self-mutilation, such as cutting or burning themselves or banging their heads. 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 an “emotional

overload” (Skodol, 2018, 2017; Sadeh et al., 2014). Many try to hurt themselves as a way of

dealing with their chronic feelings of emptiness, boredom, and identity confusion.

904

#ExpressingAnger

23% Percentage of adults who report openly expressing their anger

39% Percentage who say they hide or contain their anger

Suicidal threats and actions are also common (Soloff & Chiappetta, 2018; Amore et al.,

2014). Studies suggest that around 75 percent of people with borderline personality disorder

attempt suicide at least once in their lives; as many as 10 percent actually die of suicide. It is

common for people with this disorder to enter clinical treatment by way of the emergency room

after a suicide attempt (Hong, 2016).

People with borderline personality disorder frequently form intense, conflict-ridden

relationships in which their feelings are not necessarily shared by the other person (Skodol, 2018,

2017). They may come to idealize another person’s qualities and abilities after just a brief first

encounter. They also may violate the boundaries of relationships. Thinking in dichotomous

(black-and-white) terms, they quickly feel rejected and become furious when their expectations

are not met; yet they remain very attached to the relationships (Miano et al., 2017). 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 (Skodol, 2018, 2017).

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. They may also occasionally have a sense of dissociation, or detachment, from their own

thoughts or bodies (Krause-Utz et al., 2017). At times they may 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 (Skodol, 2018, 2017; APA, 2013). Close to 75 percent of the patients who receive the

diagnosis are women. 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.

How Do Theorists Explain Borderline Personality Disorder?

Theorists have pointed to a range of

possible psychological, biological, and

sociocultural factors in their explanations

of borderline personality disorder. In

addition, over the past several years, there

905

(Information from: BAAM, 2017, 2016; Kanner, 2005, 1995)have been productive efforts to determine

how such factors may interact to produce

the disorder.

PSYCHOLOGICAL, BIOLOGICAL, AND SOCIOCULTUAL FACTORS Because a fear of abandonment tortures so many people with borderline personality disorder,

psychodynamic theorists have looked once again to early parental relationships to explain the

disorder. 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 (Kernberg, 2018; Huprich et al., 2017). In support of this theory, research has found

that the parents of many people with borderline personality disorder did indeed neglect or reject

them during their childhood, verbally abuse them, or otherwise behave inappropriately (Parker,

McCraw, & Bayes, 2018; Skodol, 2018, 2017). The childhoods were often marked by multiple

parent substitutes, divorce, death, or traumas such as physical or sexual abuse.

Troubled princess Princess Diana, shown here embracing schoolchildren at a Hindu temple in northern London, was

admired by millions during her short life, particularly for her numerous charitable efforts and humane acts. However, she

also had a range of psychological problems that she herself disclosed in books and interviews. Diagnosing and explaining the

princess’s problems has become a common practice—both inside and outside the clinical field—since her death in 1997.

906

#VentingMyth

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

sat quietly for a while (Bushman et al., 1999).

Her self-cutting, possible borderline personality functioning, and disordered eating behaviors have received the most

attention.

Borderline personality disorder also has been linked to biological factors. There are indications

that people may inherit a biological predisposition to this disorder. Research has revealed, for

example, that close relatives of those with the disorder are five times more likely than the general

population to have the same disorder (Bassir Nia et al., 2018; Amad et al., 2014). In a similar

vein, research suggests that the disorder may be linked to particular genes (Agha et al., 2017).

Beyond genetic studies, researchers have found that people with borderline personality

disorder, particularly those who are most impulsive—individuals who attempt suicide or are very

aggressive toward others—have lower brain serotonin activity (Skodol, 2018, 2017; Soloff et al.,

2014). Recall, once again, from Chapters 6 and 7, that low serotonin activity has been linked

repeatedly to depression, suicide, aggression, and impulsivity (see pages 178–180 and 224).

Borderline personality disorder also has been tied to abnormal activity in certain brain

structures, including the amygdala (hyperactive), hippocampus (underactive), prefrontal cortex

(underactive), and other structures in the frontal lobes (Skodol, 2018, 2017; Soloff et al., 2017).

A number of theorists further believe that these structures are members of a particular brain

circuit and that the problems displayed by each structure actually reflect dysfunction (that is,

poor interconnectivity) throughout that entire brain circuit, dysfunction that results in frequent

emotional outbursts, impulsive acts, wrong judgments, and bad decisions (Agha et al., 2017;

Krause-Utz et al., 2017).

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 (Paris, 2018, 2010; Lazzari et al.,

2017).

INTEGRATIVE EXPLANATIONS In recent years, two explanations—the biosocial and the developmental psychopathology

907

explanations—have examined how these various factors might intersect to more fully account for

borderline personality disorder.

According to the biosocial explanation, the disorder results from a combination of internal

forces (for example, difficulty identifying and controlling one’s emotions, social skill deficits,

abnormal neurotransmitter activity) and external forces (for example, an environment in which a

child’s emotions are punished, ignored, trivialized, or disregarded) (Elzy & Karver, 2018;

Neacsiu & Linehan, 2014). Most of the internal and external factors cited by biosocial theorists

are the very factors focused upon in the preceding section. According to biosocial theorists, the

more such factors people experience over the course of life, the more inclined they are to develop

borderline personality disorder. This theory has received some, but not consistent, research

support (Elzy & Karver, 2018; Gill & Warburton, 2014).

Proponents of the other integrative explanation of borderline personality disorder, the

developmental psychopathology explanation, build on and add details to the biosocial view. Like the

biosocial theorists, developmental psychopathologists believe that internal and external factors

may intersect over the course of a person’s life to help produce this disorder (Lenzenweger &

Depue, 2016; Tackett et al., 2016). While these theorists are interested in all such factors—from

genetic to environmental—they believe that early parent−child relationships are particularly

influential in the development of borderline personality disorder. Consistent with the

psychodynamic model’s object relations theorists, developmental psychopathologists contend that

children who experience early trauma and abuse and whose parents are markedly inattentive,

uncaring, confusing, threatening, and dismissive are likely to enter adulthood with a disorganized

attachment style—a severely flawed capacity for healthy relationships (Fonagy & Luyten, 2018,

2016). Unless such individuals are fortunate enough to further experience significant positive

factors throughout their development (positive genetic predispositions, positive life events,

sensitive role models, opportunities to build resilience, and the like), they will become, say

developmental psychopathologists, high-risk candidates for borderline personality disorder

(Fonagy et al., 2017). In support of this theory, studies have found clear ties between poor parent

−child attachments and the development of disorganized attachment styles and between

disorganized attachment styles and borderline personality disorders (Shiner & Allen, 2018;

Beeney et al., 2017).

In recent years, developmental psychopathologists have also come to believe that a central

psychological deficit in borderline personality disorder is the person’s inability to mentalize

(Bateman, Fonagy, & Campbell, 2018). Mentalization refers to people’s capacity to understand

their own mental states and those of other people—that is, to recognize needs, desires, feelings,

908

#WhitherBorderline?

In 1938 the term “borderline” was introduced 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.

beliefs, and goals. When people mentalize effectively, they can predict the behaviors of other

people, and they can react to others in appropriate and trusting ways. These theorists suspect that

persons who emerge from childhood with a disorganized attachment style have a weakened

ability to mentalize and, correspondingly, a poor ability to control their own emotions, attention,

thinking, and behavior, and their relationships (Fonagy & Luyten, 2018, 2016; Quek et al.,

2017). Consistent with this notion, studies have consistently found poor mentalization skills in

people with borderline personality disorder (Badoud et al., 2018; Fonagy et al., 2017).

mentalization The capacity to understand one’s own mental states and those of other people.

“Zero Degrees of Empathy” Psychologist Simon Baron-Cohen has argued in his book Zero Degrees of Empathy that a

common element in many personality disorders is a total lack of empathy. Of course, people without such disorders may

also have empathy difficulties. Thus, in 2017, as part of a film project, 20 actors walked around New York City wearing

mirrored cubes over their heads. Passersby saw only their own reflected faces while they were interacting with the actors—an

exercise designed to increase the pedestrians’ empathy for others by forcing them to “see themselves in others.”

The developmental psychopathology

explanation of borderline personality

disorder has excited many in the clinical

field. However, it is important to

recognize that the explanation’s

supportive research has not actually

909

shown early parent−child attachments to be the primary factor in the development of this

disorder. Nor is it clear that mentalization deficits are at the center of the disorder. Those

important issues are currently being investigated in a range of studies.

Treatments for Borderline Personality Disorder It appears that psychotherapy can eventually lead to some degree of improvement for people with

borderline personality disorder (Livesley, 2017). 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 (Skodol, 2018; Sperry, 2016). Moreover, clients

with borderline personality disorder may violate the boundaries of the client–therapist

relationship (for example, repeatedly calling the therapist’s emergency contact number to discuss

matters of a less urgent nature) (Skodol, 2018; Colli et al., 2014).

Traditional psychoanalytic therapy has not been effective for people with borderline

personality disorder (Doering et al., 2010). However, contemporary psychodynamic approaches,

particularly relational psychoanalytic therapy (see pages 47–48), in which therapists take a more

supportive posture and focus primarily on the therapist−patient relationship, have had some

success (Clarkin et al., 2018; Cristea et al., 2017). In approaches of this kind, therapists work to

provide an empathic setting within which borderline clients can explore their unconscious

conflicts and pay attention to their central relationship disturbance, poor sense of self, and

pervasive loneliness and emptiness.

Over the past two decades, a new-wave cognitive-behavioral therapy for borderline personality

disorder, called dialectical behavior therapy (DBT), has received considerable research support

and is now considered the treatment of choice for people with borderline personality disorder

(Robins et al., 2018; Linehan et al., 2015, 2002, 2001). DBT, developed by psychologist Marsha

Linehan, consists of weekly individual therapy and group skill-building sessions that last for

approximately one year. While targeting all of the features of borderline personality disorder,

DBT places special emphasis on clients’ efforts at self-harm and/or suicide.

dialectical behavior therapy (DBT) A comprehensive treatment approach, applied particularly in cases of borderline personality disorder and/or suicidal intent; includes both individual therapy sessions and group sessions.

The individual therapy sessions of DBT include many of the same behavioral and cognitive

techniques that are applied to other disorders: homework assignments, psychoeducation, the

teaching of coping and related skills, modeling by the therapist, clear goal setting, reinforcements

for appropriate behaviors, mindfulness skill training, ongoing assessment of the client’s behaviors

910

and treatment progress, and collaborative examinations by the client and therapist of the client’s

ways of thinking.

Although primarily cognitive-behavioral, the individual DBT sessions also borrow heavily

from the contemporary psychodynamic and humanistic approaches, placing the client–therapist

relationship itself at the center 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 (Skodol, 2018).

DBT clients also participate in social skill–building groups. 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.

“I wish my identity weren’t so wrapped up with who I am.”

DBT has received more research support than any other treatment for borderline personality

disorder (Robins et al., 2018; Rudge et al., 2018). Many clients who undergo DBT become more

able to tolerate stress, develop more social skills, respond more effectively to life situations, and

develop a more stable identity. They also display significantly fewer self-harm and suicidal

behaviors and require fewer hospitalizations than those who receive other forms of treatment. In

addition, they are more likely to remain in treatment and to report less anger, more social

911

#TheirWords “I honestly didn’t realize at the time that I was dealing with

myself. … But I suppose it’s true that I developed a therapy

[DBT] that provides the things I needed for so many years and

never got.”

Marsha Linehan, psychologist, 2011

gratification, improved work performance, and reductions in substance abuse (Skodol, 2018;

Linehan et al., 2015).

Antidepressant, antibipolar,

antianxiety, and antipsychotic drugs have

helped calm the emotional and aggressive

storms of some people with borderline

personality disorder (Markovitz, 2018;

Bridler et al., 2015). Most professionals

believe that psychotropic drug treatment

for this 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 (Skodol,

2018).

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 whispers; she waved her arms

dramatically while making some points and sat totally still while making others.

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 very devoted to her. She said that

initially she even had thoughts of doing away with herself. But, of course, 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 became petulant and asked, “Do we really

912

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 than the one presented by Lucinda.

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 complain 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 and 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 sister 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 the

way she dresses and her constant flirting. That’ll certainly get people’s attention, keep them around for a while.”

histrionic personality disorder A personality disorder characterized by a pattern of excessive emotionality and attention seeking. Once called hysterical personality disorder.

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 personality

disorder that is marked by such behaviors and symptoms.

913

#TheirWords “The hysterical find too much significance in things. The

depressed find too little.”

Mason Cooley, American aphorist

People with histrionic personality disorder are always “on stage,” using theatrical 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 gratification

for long, they overreact to minor events that get in the way of their quest for attention. Some

make suicide attempts, often to manipulate others (Bressert, 2016; APA, 2013).

People with histrionic personality disorder may draw attention to themselves by exaggerating

their physical illnesses or fatigue (Kayhan et al., 2016). 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.

This disorder was once believed to be more common in women than in men, and clinicians

long described the “hysterical wife” (Novais et al., 2015). 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 (Morgan & Zimmerman, 2018;

APA, 2013).

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

914

#VainPortrait 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).

psychodynamic theorists believe that as children, people with this disorder had cold and

controlling parents who left them feeling unloved and afraid of abandonment (Paris, 2018;

Horowitz & Lerner, 2010). 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-behavioral explanations look instead at the lack of substance and extreme

suggestibility that people with histrionic personality disorder have (Novais et al., 2015; Blagov et

al., 2007). Cognitive-behavioral theorists see these individuals as becoming less and less interested

in knowing about the world at large because they are so self-focused and emotional. With no

detailed memories of what they never learned, they must rely on hunches or on other people to

provide them with direction in life. Some such 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 (Beck et al., 2015; Weishaar & Beck, 2006).

Sociocultural, particularly

multicultural, theorists believe that

histrionic personality disorder is produced

in part by cultural norms and expectations

(Mulder, 2018; Novais et al., 2015).

Until recent decades, our society encouraged women to hold on to childlike dependency

throughout their development. The vain, dramatic, and selfish behavior of the histrionic

personality may actually be an exaggeration of femininity as our culture once defined it.

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 Working with clients with histrionic personality disorder can be very difficult because of the

demands, tantrums, and seductiveness they may deploy. Another problem is that these

individuals 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 professional boundaries (Sperry, 2016).

Cognitive-behavioral therapists have tried to help people with this disorder change their belief

that they are helpless and also to develop better, more deliberate ways of thinking and solving

915

Why do people often admire arrogant deceivers—art

forgers, jewel thieves, or certain kinds of “con” artists, for

problems (Davidson, 2018; Beck et al., 2015). Psychodynamic therapy and various group

therapy formats have also been used (Caligor et al., 2018; Novais et al., 2015). In all of 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 tends to be of limited help except as a means of relieving

the depressive symptoms some patients have (Markovitz, 2018; Bock et al., 2010).

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 we met at the beginning of this chapter, 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, Steven

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 marriage, 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 husband, 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.”

Steven 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 company to that of others.

(Millon, 1969, pp. 261–262)

narcissistic personality disorder A personality disorder marked by a broad pattern of grandiosity, need for admiration, and lack of empathy.

People with narcissistic personality

disorder have a grandiose sense of self-

916

example? 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 (Caligor & Petrini, 2018).

Like Steven, people with narcissistic personality disorder are seldom interested in the feelings

of others. They may not even be able to empathize with such feelings (Marcoux et al., 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 rage, a sense of inadequacy, humiliation, or embitterment (Caligor & Petrini,

2018; Miller et al., 2017). Others may react with cold indifference. And still others experience a

sense of inadequacy, pessimism, or depression (Stanton & Zimmerman, 2018; Gore & Widiger,

2016). They may have periods of zest that alternate with periods of disappointment

(Ronningstam, 2017, 2011).

As many as 6.2 percent of adults display narcissistic personality disorder, up to 75 percent of

them men (Caligor & Petrini, 2018; APA, 2013). Narcissistic-type behaviors and thoughts are

common and normal among teenagers and do not usually lead to adult narcissism (see

MindTech).

How Do Theorists Explain Narcissistic Personality Disorder? Psychodynamic theorists more than others have theorized about narcissistic personality disorder,

and they again propose that the problem begins with cold, rejecting parents (Miller et al., 2017;

Roepke & Vater, 2014). They argue that some people with this background spend their lives

defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world. They

do so by repeatedly telling themselves that they are actually perfect 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 (Kernberg, 2018). In support of the psychodynamic theories, research has

found that children who are neglected and/or abused or who lose parents through adoption,

divorce, or death are at particular risk for the later development of narcissistic personality

917

#StolenGlances

22% Percentage of people who regularly check their reflections in store windows and the like

disorder (Caligor & Petrini, 2018). 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 (Stanton & Zimmerman, 2018; Miller et al., 2017).

“I’m attracted to you, but then I’m attracted to me, too.”

A number of cognitive-behavioral theorists propose that narcissistic personality 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

accomplishments or for no accomplishment at all (Caligor & Petrini, 2018; Miller et al., 2017).

Many sociocultural theorists see a link

between narcissistic personality disorder

and “eras of narcissism” in society (Paris,

918

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)

2014). They suggest that family values

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 competitiveness, are considered likely to produce such generations of narcissism. In fact, one

worldwide study 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, Campbell, & Twenge, 2003).

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 (SMA, 2017; Pew Research

Center, 2014), and, according to some estimates, 93 million selfies are posted online every day (Weigold, 2018;

Whitbourne, 2016). These self-photos have created such a stir that the word “selfie” was elected “Word of the Year” by the

Oxford English Dictionary a few years back.

As the selfie phenomenon has grown, opinions about selfies have intensified (Diefenbach & Christoforakos, 2017). 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

919

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. Several teams of

investigators have found no relationship at all between how many selfies people post and how high they score on narcissism

personality scales (Etgar & Amichai-Hamburger, 2017; Alloway, 2014). Other researchers have found that people who

score high on narcissism scales do, on average, like to take selfies, but many such individuals do not (Kim et al., 2016;

Whitbourne, 2016). Moreover, the vast majority of people who post selfies do not score especially high on narcissism

scales.

This lack of support for the narcissism viewpoint does not mean that selfies, especially repeated selfie behaviors, are

completely harmless. Sherry Turkle, an influential technology psychologist, believes that the near-reflexive instinct to

photograph oneself may limit deeper engagements with the environment or prevent a full experience of events (Turkle,

2017, 2015, 2013; Eisold, 2013). Turkle also suggests 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

excessively 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. They agree with media psychologist Pamela Rutledge (2013) that, for the most part, selfies are an

inevitable by-product of “technology-enabled self-expression.” Rutledge contends that selfie behaviors are simply confusing

to individuals of a predigital generation. Moreover, she concludes that the selfie trend can enhance explorations of identity,

help identify one’s interests, 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). Indeed, several studies have

supported these points and have also uncovered additional positive motives and effects of selfie taking (Christensen, 2017).

In short, like other technological trends you’ve read about, the selfie phenomenon has received mixed grades from

psychology researchers and practitioners so far.

Treatments for Narcissistic Personality Disorder Narcissistic personality 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 (Tanzilli et al., 2017; Ronningstam, 2017). The

clients who consult therapists usually do so because of a related disorder such as depression

(Caligor & Petrini, 2018). Once in treatment, the clients may try to manipulate the therapist

into supporting their sense of superiority (Skodol & Bender, 2018, 2016). Some also seem to

project their grandiose attitudes onto their therapists and develop a love-hate stance toward them

(Sperry, 2016; Colli et al., 2014).

Psychodynamic therapists seek to help people with this disorder recognize and work through

their underlying insecurities and defenses (Caligor et al., 2018; Diamond & Meehan, 2013).

Cognitive-behavioral therapists, focusing on the self-centered thinking of such individuals, try to

redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more

920

rationally, increase their ability to empathize, and change their all-or-nothing notions (Caligor &

Petrini, 2018; Beck et al., 2015). None of the approaches have had clear success, however (Paris,

2018, 2014).

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 violation of the rights of others.

Explanations for this disorder point to psychodynamic, cognitive-behavioral, and biological factors, including a

growing emphasis on a dysfunctional brain circuit. No known treatment is notably effective. People with borderline

personality disorder display a pattern of instability in interpersonal relationships, self-image, and mood, along with

extreme impulsivity. Explanations for this disorder have focused on psychological, biological, and sociocultural

factors, and, prominently, on integrative perspectives such as a biosocial explanation and a developmental

psychopathology perspective. Treatment, particularly dialectical behavior therapy, apparently can be helpful 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 narcissistic

personality disorder display a pattern of grandiosity, need for admiration, and lack of empathy. It is one of the most

difficult disorders to treat.

921

“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. 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 science graduate student, Malcolm watched other new students in his program fraternize 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 anyone.” The best feeling in the world, he stated, was getting out of there. The following 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 encountered.” 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

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)

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.

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, disapproval, or rejection.

They are timid and hesitant in social situations, afraid to say something foolish or to embarrass

922

#ShynessAlert Between 40 and 60 percent of people in the United States

consider themselves to be shy (Bressert, 2016).

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 (Bressert, 2017; 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 (Pellecchia et al., 2018). 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. Other theorists, however, believe that the two disorders reflect the same core

psychopathology and should be combined.

At least 2.4 percent of adults have avoidant personality disorder, men as frequently as women

(Lampe & Malhi, 2018; APA, 2013). Many children and teenagers are also painfully shy and

avoid other people, but this is usually just a normal part of their development.

923

#ShynessRocks Rock music has been strongly influenced by stars with

extremely shy, reticent demeanors.

Meg White, drummer for the popular rock band The White

Stripes, described herself as “very shy” and frequently appeared

uncomfortable both onstage and during her rare interviews.

The group disbanded after “acute anxiety” caused her to cancel

a 2007 tour.

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 tendency to

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

painfully shy, withdrawn, easily embarrassed, and uncomfortable with people. Early temperament is often linked to adult

personality traits, but research has not shown that extreme shyness, a common and normal part of childhood, necessarily

predicts the development of avoidant or dependent personality disorder in adulthood.

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 clearly tied the

personality disorder directly to the anxiety

disorders (Herbert, 2007).

Psychodynamic and cognitive-behavioral

924

look away or at the floor during shows.

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.

#TheirWords “We continue to shape our personality all our life.”

explanations of avoidant personality

disorder are the most popular among

clinicians.

Psychodynamic theorists focus mainly

on the general feelings of shame and

insecurity that people with avoidant personality disorder have (Lampe & Malhi, 2018; 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-behavioral 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 generally fear social involvements—setting the

stage for avoidant personality disorder (Lampe & Malhi, 2018; Weishaar & Beck, 2006). In

several studies, when participants with this disorder were asked to recall their childhood, their

descriptions supported both the psychodynamic and cognitive-behavioral predictions (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.

Cognitive-behavioral theorists also suggest that most people with avoidant personality

disorder fail to develop effective 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 (Moroni et al., 2016; Kantor, 2010). Most of the theorists 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

affection. At the same time, they may distrust the therapist’s sincerity and start to fear his or her

rejection (Skodol & Bender, 2018, 2016). Thus, as with several of the other personality

disorders, a key task of the therapist is to gain the person’s trust (Skodol, 2017; Sperry, 2016).

Beyond building trust, therapists tend

to treat people with avoidant personality

925

Albert Camusdisorder much as they treat people with

social anxiety disorder and other anxiety

disorders. Such approaches have had at

least modest success (Bernecker et al., 2017; Lampe, 2016). Psychodynamic therapists try to help

clients recognize and resolve the unconscious conflicts that may be operating (Caligor et al.,

2018; Leichsenring & Salzer, 2014). Cognitive-behavioral therapists help the individuals change

their distressing beliefs and thoughts, carry on in the face of painful emotions, and improve their

self-image (Davidson, 2018; Lampe, 2016). They also provide social skills training and exposure

treatments that require people to gradually increase their social contacts (Kampmann et al.,

2016). Group therapy formats, especially groups that follow cognitive and behavioral principles,

have the added advantage of providing clients with practice in social interactions (Bressert,

2017). Antianxiety and antidepressant drugs are sometimes useful in reducing the social anxiety

of people with the disorder (Markovitz, 2018; Skodol, 2017).

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 decision for themselves. Lucas is a case in point.

Lucas, an assistant graphics programmer, is a 42-year-old single man who lives with his father. He is currently grappling

with significant feelings of depression and anxiety. These feelings began when he ended his relationship of two years with Orena,

whom he had viewed as the woman of his dreams and his future wife. But Lucas’s father just didn’t like Orena, and he certainly

didn’t like the idea of Lucas marrying her. In fact, he forbid it—forbid his middle-aged son from marrying the woman of his

dreams.

Inside, Lucas was furious at his father, although he knew he could never express his anger. Not that he was afraid of his father

physically. His fear was in the psychological sphere. He simply could not—now or ever—risk his father getting angry at him, being

disappointed in him, not talking to him, or being unsupportive. Then he might have to fend for himself, and that was

unthinkable. At some level, he also thought that maybe his father was right, maybe he should not marry Orena. He always went

along with his father’s advice and decisions. He thought of himself as a person of poor judgment—too poor to make a decision, big

or small, on his own.

So eventually Lucas did what he always knew he would have to do—he broke up with Orena. He was more than ashamed

and critical of himself, for hurting Orena, for being such a weakling, for giving up his dream so readily. But what could he do? He

felt helpless and incapable of taking any other course of action.

Lucas is not particularly accomplished in the various areas of his life. His job of 15 years is at least two levels below what he is

capable of. Over the years, he has rejected promotion offers and has not responded to overtures from other graphic design

companies. The reason was always the same: he didn’t want—no, he was afraid to take on—additional responsibilities, especially

926

#TheirWords “The deepest principle of human nature is the craving to be

appreciated.”

William James, psychologist, 1896

responsibilities for making decisions and leading a team of workers. So he continues to work at the same job, for the same boss, in

the same routine. He is considered dependable and hard-working—a never-changing fixture in the work setting.

His social life is similarly modest and uneventful. Outside of Orena, his social life is limited to a single lifelong friend. They

get together for dinner and an activity three nights a week. If his friend ever cancels, Lucas feels lost.

Growing up, Lucas’s older sisters, mother, and father always pampered and protected him, catering to his every need. Still he

remembers being fearful and tentative throughout his childhood, always wanting to hold a family member’s hand, afraid to do

anything on his own. When his sisters grew older and moved away and after his mother died, it became just him and his father.

Going away to college in another city was unthinkable. Without question, his father is now the most important person in his life.

Although more than a little domineering, he loves Lucas and continues the family tradition of protecting and guiding him.

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.

It is normal and healthy to depend on others, but those with dependent personality 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 observed previously, 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

psychologically abuse them (Leemans & Loas, 2016).

Lacking confidence in their own ability and judgment, people with this disorder seldom

disagree with others and allow even important decisions to be made for them (Bressert, 2017;

Gore & Widiger, 2015). 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,

2016, 2012, 2007). Their fear of separation and their feelings of helplessness may leave them

927

particularly prone to suicidal thoughts, especially when they believe that a relationship is about to

end.

Surveys suggest that fewer than 1 percent of the population experience dependent personality

disorder (Morgan & Zimmerman, 2018; APA, 2013). For years, clinicians 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 similar to those for

depression (Sperry, 2016; 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 dependent 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 (Kernberg, 2018; Caligor &

Clarkin, 2010). Still other psychodynamic theorists suggest that, to the contrary, many parents of

people with this disorder were overinvolved and overprotective, thus increasing their children’s

dependency, insecurity, and separation anxiety (Sperry, 2016).

Cognitive-behavioral theorists point to both behavioral and cognitive factors in their

explanation of dependent personality disorder. In the behavioral realm, they propose that parents

of people with dependent personality disorder unintentionally rewarded their children’s clinging

and “loyal” behavior, while at the same time punishing acts of independence, perhaps through

the withdrawal of love. Alternatively, some parents’ own dependent behaviors may have served as

models for their children (Bornstein, 2012, 2007). In the cognitive realm, the theorists identify

two maladaptive attitudes as further 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 autonomous (Beck et al.,

2015; Borge et al., 2010).

928

#AnimalTraits Researchers have found that animals of every kind—from

spiders to lions—display distinct differences in their

personalities, behaviors, and preferences. Among sheep, for

example, some are leaders and others followers. Similarly, sheep

differ in their individual levels of fearfulness, vocalization,

friendliness, and distraction. These differences often hold

steady throughout their lives (Cherry, 2017; Angier, 2010).

“My self-esteem was so low I just followed her around everywhere she would go.”

Treatments for Dependent Personality Disorder

In therapy, people with dependent

personality disorder usually place all

responsibility for their treatment and

well-being on the clinician. Thus a key

task of therapy is to help patients accept

responsibility for themselves (Bressert,

2017; Sperry, 2016). 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).

Treatment for dependent personality disorder can be at least modestly helpful.

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 (Caligor et

al., 2018). 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

(Bressert, 2017; 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 (Beck

929

et al., 2015). As with avoidant personality disorder, a group therapy format can be useful because

it provides opportunities for clients to receive support from a number of peers rather than from a

single dominant person (Bressert, 2017). Antidepressant drug therapy has been helpful for people

whose personality disorder is accompanied by depression (Markovitz, 2018; Skodol, 2017).

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 efficiency (APA, 2013). Their

concern for doing everything “right” impairs their productivity, 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 college, 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 preoccupation 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 adopted 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 before 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 parents again.”

(Millon, 2011, 1969, pp. 278–279)

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.

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

930

#CriticalDifference 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.

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 activities and friendships (Mike et al., 2017).

People with this personality disorder

set unreasonably high standards for

themselves and others. Their behaviors

extend well beyond the realm of

conscientiousness. They can never be

satisfied with their performance, but they

typically refuse 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 (Wheaton & Pinto, 2017).

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. In

addition, they are often stingy with their time or money. Some cannot even throw away objects

that are worn out or useless (Pinto et al., 2018; Riddle et al., 2016).

According to surveys, as many as 7.9 percent of the adult population display obsessive-

compulsive personality disorder, with white, educated, married, and employed people receiving

the diagnosis most often (Skodol, 2017; APA, 2013). 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

(Starcevic & Brakoulias, 2017). However, it is worth noting that people with the personality

disorder are more likely to suffer from either major depressive disorder, an anxiety disorder, or a

substance use disorder than from obsessive-compulsive disorder (Brakoulias et al., 2017). In fact,

researchers have not consistently found a specific link between obsessive-compulsive personality

disorder and obsessive-compulsive disorder (Starcevic & Brakoulias, 2017, 2014).

How Do Theorists Explain Obsessive-Compulsive Personality Disorder? Most explanations of obsessive-compulsive personality disorder borrow heavily from those of

931

obsessive-compulsive disorder, despite the doubts concerning a link between the two disorders.

Research evidence for these explanations is limited.

Freudian theorists suggest that people with obsessive-compulsive personality 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

persistently 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 (Kanehisa

et al., 2017; Bartz et al., 2007).

Toilet trouble According to Freud, toilet training often produces rage in a child. If parents are too harsh in their approach,

the child may become fixated at the anal stage and prone to obsessive-compulsive functioning later in life.

Cognitive-behavioral theorists have little to say about the origins of obsessive-compulsive

personality disorder, but they do propose that illogical thinking processes help keep it going

(Paast et al., 2016; Weishaar & Beck, 2006). They point, for example, to dichotomous 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

932

#TheirWords “In most of us, by the age of thirty, the character has set like

plaster and will never soften again.”

William James, psychologist, 1887

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 (Smith et

al., 2017; Bartz et al., 2007).

People with obsessive-compulsive personality disorder sometimes respond well to

psychodynamic or cognitive-behavioral therapy (Smith et al., 2017; Kikkert et al., 2016).

Psychodynamic therapists typically try to help these clients recognize, experience, and accept

their underlying feelings and insecurities, and perhaps take risks and accept their personal

limitations (Caligor et al., 2018; Bressert, 2016). Cognitive-behavioral therapists focus on

helping the clients to change their dichotomous—“all or nothing”—thinking, perfectionism,

indecisiveness, procrastination, and chronic worrying (Davidson, 2018; Beck et al., 2015). A

number of clinicians report that people with obsessive-compulsive personality disorder, like those

with obsessive-compulsive disorder, respond well to SSRIs, the serotonin-enhancing

antidepressant drugs; however, researchers have yet to study this issue fully (Markovitz, 2018;

Pinto et al., 2018, 2008).

SUMMING UP

“ANXIOUS” PERSONALITY DISORDER Three of the personality disorders in DSM-5 are marked by anxious and fearful behavior. People with avoidant

personality disorder are consistently uncomfortable and inhibited in social situations, overwhelmed by feelings of

inadequacy, and extremely sensitive to negative evaluation. People with dependent personality disorder have a

persistent need to be taken care of, are submissive and clinging, and fear separation. People with obsessive-compulsive

personality disorder are so preoccupied with 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 have been

modestly to moderately helpful.

933

934

Why have researchers given relatively little attention to the

study of cultural, racial, and gender differences in

personality disorders?

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, and given the enormous clinical interest in personality

disorders, 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 (Mulder, 2018; Ascoli et al., 2017).

The lack of multicultural research is of special concern with regard to borderline personality

disorder, the pattern characterized by extreme mood fluctuations, outbursts of intense anger, self-

injurious behavior, fear of abandonment, feelings of emptiness, problematic relationships, and

identity confusion, because many theorists are convinced that gender and other cultural

differences may be particularly important in both the development and diagnosis of this disorder.

Understudied As illustrated by this diverse group of people, we live in a multicultural nation and world. Nevertheless,

psychologists have devoted relatively little study to cultural and racial differences in the development, features, and

treatment of personality disorders.

As you read earlier, around 75 percent

of all people who receive a diagnosis of

borderline personality disorder are female

(Skodol, 2018, 2017). Although it may be

935

#TheirWords “She is still a prisoner of her childhood; attempting to create a

new life, she reencounters the trauma.”

Judith L. Herman, psychiatrist and author, 2015, 1992

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 some

people with borderline personality disorder are 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 (Kulkarni, 2017; Sherry & Whilde, 2008). In the absence of systematic research,

however, alternative explanations like this remain untested and corresponding treatments

undeveloped.

In a related vein, given the childhood

experiences that typically precede

borderline personality disorder, some

multicultural theorists believe that the

disorder may actually be a reaction to

persistent feelings of marginality,

powerlessness, and social failure (Sherry & Whilde, 2008). That is, the disorder may be

attributable more to social inequalities (including sexism, racism, or homophobia) than to

psychological factors.

Given such possibilities, it is most welcome that a few multicultural studies of borderline

personality disorder have been conducted over the past decade (Skodol, 2017; De Genna &

Feske, 2013). In these undertakings, researchers assessed the prevalence of the personality

disorder in diverse clinical populations (Meaney et al., 2016; Trull et al., 2010; Chavira et al.,

2003). They found that Hispanic American individuals qualified for a diagnosis of borderline

personality disorder more often than non-Hispanic white American or African American

individuals did. Could it be that Hispanic Americans generally are more likely than other cultural

groups to display this disorder, and—if so—why? Questions of this kind underline once again

the need for more multicultural research into personality disorders.

936

Are There Better Ways to Classify Personality Disorders? As you read earlier, DSM-5’s personality disorders are often hard to diagnose and easy to

misdiagnose, difficulties that indicate serious problems with the validy and reliability of these

categories. In light of such problems, the leading criticism of DSM-5’s approach to personality

disorders is, as noted previously, that the classification system defines such disorders by using

categories—rather than dimensions—of personality. Many of today’s 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 (Anderson et al., 2018, 2016; Skodol,

2018). In such an approach, each key trait (for example, disagreeableness, dishonesty, or self-

absorption) would be seen as varying 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).

“You’ll have to excuse me—I’m myself today.”

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.

937

INFOCENTRAL

THE DARK TRIAD

Over the past 15 years, researchers have studied the Dark Triad, a trio of malicious traits that

work together to produce socially offensive behaviors. People with these traits—narcissism,

psychopathy, and Machiavellianism—tend to undermine others, perhaps secretly, to achieve their

own ends (Whitbourne, 2013).

Individuals with just one of these traits often offend, manipulate, or disregard the needs of

others. But those with all three traits are particularly self-absorbed and create serious problems

for others. People who score high on Dark Triad rating scales may display a personality disorder,

but more often, they experience little distress or impairment and function adequately, sometimes

quite effectively, in the personal, social, and occupational realms.

938

The “Big Five” Theory of Personality and Personality Disorders A large body of research conducted with diverse populations consistently suggests that the basic

structure of personality may consist of five “supertraits,” or factors—neuroticism, extroversion,

openness to experiences, agreeableness, and conscientiousness (Wilt & Revelle, 2019; Chapman et al.,

2017). 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,

939

while optimism and friendliness are subfactors of the extroversion factor. Theoretically,

everyone’s personality can be summarized by a combination 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.

Is hatred a disorder? With the term “Skinhead” tattooed on the back of his head, this man awaits trial in Germany for

committing neo-Nazi crimes against foreigners and liberals. Clinicians sometimes confront extreme racism and intolerance,

particularly among clients with paranoid, antisocial, and certain other personality disorders. There is a small but growing

movement to classify extreme hatred and prejudice as a psychological disorder.

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 (Song & Shi, 2017; Glover 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 agreeableness 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.

“Personality Disorder—Trait Specified”: DSM-5’s Proposed Dimensional Approach The “Big Five” approach to personality disorders has received considerable study, and some

theorists would like it to be used as the official classification approach in the United States and

940

around the world. Instead, the framers of the ICD (the classification system used in most

countries outside the United States) and the DSM (the classification system used in the United

States) have each developed their own dimensional approach for classifying personality disorders,

and they plan to use those approaches in their future editions. Indeed, as you read earlier, the

DSM-5 framers have already included a detailed description of their proposed dimensional

approach in DSM-5 so that it can be examined by clinicians and studied and tested by

researchers (Hopwood & Waugh, 2018).

DSM-5’s proposed dimensional approach to personality disorders 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 impairment

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: manipulativeness, 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 following traits: irresponsibility, impulsivity, distractibility, risk taking, and imperfection/disorganization.

Psychoticism People who display psychoticism have unusual and bizarre experiences. They may exhibit any of the following traits: unusual beliefs and experiences, eccentricity, and

941

cognitive and perceptual dysregulation (odd thought processes and sensory experiences).

personality disorder—trait specified (PDTS) A personality disorder undergoing study for possible inclusion in the DSM. People would receive this diagnosis if they had significant impairment in functioning as a result of one or more very problematic traits.

Dysfunctional toons Today’s animated film characters often display significant personality flaws or disorders. Some have a

single dysfunctional trait, as is the case for Angry Birds, while others may have “clusters” of problematic traits, as shown by

the South Park kids. Some observers suggest that the latter (especially Cartman, second from left) show enduring

grumpiness, disrespect for authority, irreverence, self-absorption, disregard for the feelings of others, general lack of

conscience, and a tendency to get into trouble.

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, Lucas, the unhappy 42-year-old assistant graphics programmer

described on page 423. As you’ll recall, Lucas meets the criteria for a diagnosis of dependent

personality disorder under DSM-5’s current categorical approach, based largely on his lifetime of

extreme dependence on his father, mother, sisters, friends, and coworkers. Using the alternative

dimensional approach presented in DSM-5, a diagnostician would instead observe that Lucas is

significantly impaired by several of the traits that characterize the negative affectivity trait group.

He is, for example, greatly impaired by “separation insecurity.” This trait has prevented him from

ever living on his own, marrying his girlfriend, disagreeing with his father, advancing at work,

and broadening his social life. In addition, Lucas seems to be impaired significantly by the traits

of “submissiveness,” “anxiousness,” and “depressivity.” Given this picture, his therapist might

assign him a diagnosis of personality disorder—trait specified, with problematic traits of separation

insecurity, submissiveness, anxiousness, and depressivity.

942

#AsSuspected For years, people have suspected that individuals who like dogs

may be psychologically different from those who like cats.

Research supports such speculation (Cherry, 2017; Gosling et

al., 2015). Almost 5,000 participants filled out a Big Five

personality inventory. On average, the “dog people” scored

higher than the “cat people” on extroversion, agreeableness,

and conscientiousness. In contrast, the cat people scored higher

on introversion and curiosity (i.e., openness to experiences).

According to this dimensional

approach, when clinicians assign a

diagnosis of personality disorder—trait

specified, they also must rate the degree of

dysfunction caused by each of the

person’s traits, using a five-point scale

ranging from “little or no impairment”

(Rating = 0) to “extreme impairment”

(Rating = 4).

Consider Lucas once again. He would probably warrant a rating of “0” on most of the 25

traits listed in the DSM-5 proposal, a rating of “3” on the traits of anxiousness and depressivity,

and a rating of “4” on the traits of separation insecurity and submissiveness. Altogether, he would

receive the following cumbersome, 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. Thus a number of researchers are currently conducting studies

to clarify the merits and drawbacks of the proposed system (Anderson et al., 2018, 2016; Skodol,

2018). Only time and continued research will determine whether the alternative system is indeed

a useful approach to the classification and diagnosis of personality disorders.

SUMMING UP

943

MULTICULTURAL FACTORS AND DIMENSIONAL CLASSIFICATIONS Despite the field’s growing focus on personality disorders, relatively little research has been done on gender and other

multicultural influences.

Given the significant problems posed by DSM-5’s current categorical approach, a number of today’s theorists

believe that personality disorders should instead be described and classified by a dimensional approach. Thus, the

framers of DSM-5 have developed a dimensional approach called the “personality disorder—trait specified” model. A

description of this approach is under study for possible inclusion in a future revision of DSM-5.

944

CLINICAL CHOICES 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 suggest a diagnosis based on

her symptoms. What kind of treatment would be most

effective for Alicia? Go to LaunchPad to access Clinical

Choices.

Rediscovered, Then 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 personality

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 objective tests and interview guides to assess

these disorders, setting in motion a wave of systematic research (Clarkin, Livesley, & Meehan,

2018). So far, the antisocial and borderline personality disorders have received the most 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?

945

Chapter 13 Review

Key Terms

personality

personality traits

personality disorder

comorbidity

categorical

dimensional

paranoid personality disorder

schizoid personality disorder

schizotypal personality disorder

antisocial personality disorder

borderline personality disorder

biosocial explanation

developmental psychopathology

disorganized attachment style

mentalization

relational psychoanalytic therapy

dialectical behavior therapy (DBT)

histrionic personality disorder

narcissistic personality disorder

avoidant personality disorder

dependent personality disorder

obsessive-compulsive personality disorder

946

anal retentive

Big Five theory

personality disorder—trait specified (PDTS)

Quick Quiz

1. What is a personality disorder? pp. 397–398

2. Describe the social relationship problems caused by each of the personality disorders. pp. 397–427

3. What are the three “odd” personality disorders, and what are the symptoms of each? pp. 399–404

4. What explanations and treatments have been applied to the paranoid, schizoid, and schizotypal personality disorders? pp. 400–404

5. What are the “dramatic” personality disorders, and what are the symptoms of each disorder? pp. 405–418

6. How have theorists explained antisocial personality disorder and borderline personality disorder? What are the leading treatments for these disorders, and how effective are they? pp. 407–415

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. 416–420

8. What is the name of the cluster that includes the avoidant, dependent, and obsessive- compulsive personality disorders? What are the leading explanations and treatments for these disorders, and to what extent are they supported by research? pp. 420–427

9. How comprehensively have researchers studied cultural and racial differences in the various kinds of personality disorders? pp. 427–428

10. Describe two of the dimensional approaches that have been proposed to identify and describe personality disorders. pp. 430–432

Visit LaunchPad

947

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

948

CHAPTER 14 Disorders Common Among Children and Adolescents

TOPIC OVERVIEW

949

Childhood and Adolescence

Childhood Anxiety Disorders

Separation Anxiety Disorder and Selective Mutism Treatments for Childhood Anxiety Disorders

Depressive and Bipolar Disorders During Childhood

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

Clinicians Discover Childhood and Adolescence

When Cameron was eight years old, his mother started to worry about him. Not so coincidentally, his teacher was becoming

concerned at the same time. What they both saw was a sad, and seemingly lost, little boy. At home Cameron just wanted to lie

around and watch TV. He would do his chores, and answer his parents’ questions—in as few words as possible—but he initiated

almost nothing. He ate only when told to eat. He showed little interest in his beloved iPad, and stopped playing computer games.

Nor did Cameron seek out playmates anymore. His mother had to virtually drag him to their houses. Nothing gave him pleasure.

Cameron also seemed to have more than a few physical problems—from headaches to stomach pains, it was always something, yet

the doctor said he checked out fine.

The story was similar at school. Cameron was obedient and compliant, always did what his teacher asked, but he seemed sad

and joyless. He rarely joined in class discussions. He stayed in a group with the other kids as they travelled from the classroom to the

cafeteria or the schoolyard, but he interacted very little with anyone in particular. When the school psychologist interviewed him,

she noticed that he made no eye contact, offered little, and rarely smiled.

When the counselor asked Cameron’s mother and teacher if anything special had triggered his unhappiness, they both pointed

to the departure of his two best friends—twins who had moved to another state two months ago. But, at the same time, the more

they thought about it, that was not really the beginning of Cameron’s slide. It certainly worsened things, but his sad mood,

inactivity, and isolation had been increasing for quite a while before that.

950

#TheirWords “It is an illusion that youth is happy, an illusion of those who

have lost it.”

W. Somerset Maugham, playwright and novelist

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. Ricky 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 Ricky’s academic performance was below average … He understood and completed his reading

and math assignments when motivated to do so but his attention was sporadic and insufficient. … Ricky was [also] getting out of

his seat more and more, requiring a constant response. …

(Kearney, 2013, pp. 62–64)

Cameron 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. Cameron,

who may qualify for a diagnosis of major

depressive disorder, struggles constantly with sadness, disinterest in other people and activities, and

lack of pleasure, 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 abnormality, 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 prevalent among the elderly.

951

952

Most people who are bullied are upset by it, but some seem

to be more traumatized by the experience than others. Why

might that be?

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 (Fernandez, 2017; Jovanovic et al.,

2014). 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.

FIGURE 14-1

Are Parents Aware of Their Children’s Stress?

Not always, according to a survey of parents and their children aged 8 to 17. For example, although 44 percent of the child

respondents say they worry about school, only 34 percent of the parent respondents believe their children are worried about

school. (Information from: Munsey, 2010.)

A particular concern among children

and adolescents is that of being bullied

(see InfoCentral). Surveys throughout the

953

world have revealed repeatedly that

bullying ranks as a major problem in the minds of most young respondents, often a bigger

problem than racism, AIDS, and peer pressure to try sex or alcohol (Hymel & Swearer, 2015).

More generally, over 20 percent of students report being bullied frequently, and more than 50

percent report having been bullied at least once (DTL, 2017). Typically, kids who have been

bullied react with feelings of humiliation, anxiety, or dislike for school (Eastman et al., 2018). In

extreme cases, they may attempt suicide (Ford et al., 2017). Moreover, the psychological effects

of being bullied can reach far into adulthood (Arseneault, 2017). Also 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 social media—is now on the rise (Ferrara et al., 2018; Kim et al., 2018).

It gets better Gay activist and journalist Dan Savage accepts a Webby Special Achievement award for co-founding “It Gets

Better”—an Internet outreach program that tells LGBTQ teenagers their lives will get better as they move toward

adulthood and find support from their communities. The project was started in 2010 by Savage and his husband Terry

Miller after a number of gay teens had killed themselves in response to bullying. It now has a Web site featuring more than

50,000 messages of support and inspiration to beleaguered LGBTQ teens.

Beyond these common concerns and psychological difficulties, at least one-fifth of all children

and adolescents in North America also experience a diagnosable psychological disorder (CDC,

2017; Costello & Angold, 2016). Boys with disorders outnumber girls, even though most of the

adult psychological disorders are more common among women.

954

Some disorders displayed by children—childhood anxiety disorders, childhood depression,

and disruptive disorders—have adult counterparts, although they are also distinct in certain ways

(Rice et al., 2019). 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, the former marked by a lack of responsiveness to the environment, the

latter by an extensive disturbance in intellect and adaptive functioning.

INFOCENTRAL CHILD AND ADOLESCENT BULLYING

Bullying is the repeated infliction 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 LGBTQ individuals, are much 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.

(Kaess, 2018; Pontes et al., 2018; USDHHS, 2017)

955

956

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 online predators, child abduction, drugs, school shootings, 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 uncertainty, or if they overprotect

their children, the children may be more likely to respond to the world with anxiety (Kendall et

al., 2018; Kerns et al., 2017, 2014). 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, genetic studies suggest that some children are prone to an anxious

temperament (Buzzell et al., 2017; Tone, Garn, & Pine, 2016).

For some children, these anxieties become long-lasting and debilitating, interfering with their

daily lives and their ability to function appropriately. These children may be suffering from an

anxiety disorder. Surveys indicate that between 14 and 25 percent of all children and adolescents

experience an anxiety disorder (Bennett & Walkup, 2018; Kendall et al., 2018). Some of the

childhood anxiety disorders are similar to their adult counterparts. Childhood specific phobias,

for example, usually look and operate much like the phobias of adulthood, and a number of

untreated childhood phobias grow into adult ones.

More often, however, the anxiety disorders of childhood take on a 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, avoidance,

irritability, and stomach pains (Whalen et al., 2017; Cornacchio et al., 2016). They tend to

center on specific, sometimes imaginary, objects and events, such as monsters, ghosts, or

thunderstorms, rather than broad concerns about the future or one’s place in the world (Kendall

et al., 2018). Similarly, the anxiety symptoms are more often than not triggered by immediate

situations and surroundings, rather than by thoughts about events that could happen in the

future.

Separation Anxiety Disorder and Selective

957

Mutism Two patterns of childhood anxiety, separation anxiety disorder and selective mutism, have received

considerable attention in recent years, partly because they cause children emotional pain and

partly because they leave the parents feeling helpless as they try to help their children.

Separation anxiety disorder, which you read about in Chapter 4, is one of the most common

anxiety disorders among children (see page 104). The disorder often begins as early as the

preschool years, and at least 4 percent of all children experience it (Hannesdottir et al., 2018). As

you’ll recall, children suffering from this disorder have enormous difficulty being away from their

parents or other major attachment figures, and they are often reluctant—or outright refuse—to

go anywhere where they might be separated from their parents—friends’ houses, birthday parties,

or even their own bedrooms. Separation anxiety disorder in childhood may further take the form

of school refusal, in which children fear going to school and often stay home for a long period

(Nayak, Sangoi, & Nachane, 2018). However, many cases of school refusal, particularly those in

later childhood, have causes other than separation fears, such as social or academic concerns,

depression, fears of specific objects or persons at school, or a desire to be defiant.

separation anxiety disorder A disorder marked by excessive anxiety, even panic, whenever the person is separated from home, a parent, or another attachment figure.

Reluctant to speak Children with selective mutism fail to speak in their classrooms and/or other social situations. Often the

children use whispering, either directly to a teacher or through a go-between, to communicate important messages. Here, a

child with the disorder whispers to her counselor at Florida International University’s Center for Children and Families.

958

In selective mutism, children consistently fail to speak in certain social situations but show

no difficulty at all speaking in others (Furr et al., 2019; Rogoll, Petzold, & Strohle, 2018). A

child with this disorder may have no problem talking, laughing, or singing at home with family

members but will offer absolutely no words in other key situations, such as the classroom (see

Table 14-1). Some go an entire school year without speaking a word to their teacher or

classmates. Many have a special friend in the classroom to whom they will discreetly whisper

important things to be communicated to the class, such as answers to a teacher’s questions or the

need to use the restroom. People who only see a selectively mute child at school often find it hard

to believe that the child is an absolute chatterbox at home. Almost 1 percent of all children

display this disorder (SMA, 2018; Hua & Major, 2016).

selective mutism A disorder marked by failure to speak in certain social situations when speech is expected, despite ability to speak in other situations.

TABLE: 14-1 DX Checklist Selective Mutism

1. Individual persistently does not speak in certain social situations in which speech is expected, although speaking in other situations presents no problem.

2. Academic or social interference.

3. Individual’s symptoms last 1 month or more, and are not limited to the first 4 weeks of a new school year.

4. Symptoms not due to autism spectrum disorder, thought disorder, or language or communication disorder.

Information from: APA, 2013.

Many researchers believe that selective mutism is an early version of social anxiety disorder,

appearing in children before they have fully developed the cognitive capacities to worry about

future embarrassment or anticipate potential judgment from others (see pages 120–123). Indeed,

some, but far from all, older children with selective mutism do develop social anxiety disorder

(Rogoll et al., 2018). At the same time, there are many features unique to selective mutism. For

example, some children with this disorder have significant delays in their development of

communication and language skills (Hua & Major, 2016).

Educators and clinicians can underestimate a child’s capabilities when he or she refuses to

speak during an evaluation. Thus some children with selective mutism are misclassified as having

an intellectual disability (which you will read about later in this chapter). This can, in turn, lead

to incorrect interventions that focus on intellectual functioning and language development rather

than on anxiety difficulties.

959

Treatments for Childhood Anxiety Disorders Despite the high prevalence of childhood and adolescent anxiety disorders, around two-thirds of

anxious children go untreated (NIMH, 2017). 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, studies have

found that cognitive-behavioral therapy fares best (Comer et al., 2019; Oerbeck et al., 2018).

These various therapies parallel the adult anxiety approaches you read about in Chapter 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 (Sanchez et al., 2018; Cornacchio et al.,

2017).

Clinicians have also used drug therapy in a number of cases of childhood anxiety disorders,

often in combination with psychotherapy. Not only do they prescribe antianxiety drugs, but

antidepressant and antipsychotic drugs as well (Comer et al., 2019, 2011, 2010; Wang et al.,

2017). Studies suggest that antidepressant drugs, in particular, are helpful for severely anxious

children, often as helpful as cognitive-behavioral therapy (Albano et al., 2018). In a landmark

study called the Child/Adolescent Anxiety Multimodal Study (CAMS), clinicians treated almost 500

children and adolescents with anxiety disorders across the United States, and compared the

effectiveness of cognitive-behavioral therapy alone, antidepressant therapy alone, cognitive-

behavioral and antidepressant therapy combined, and placebo therapy. They found that

combining cognitive-behavioral and antidepressant therapy led to the most favorable outcomes.

Around 80 percent of the anxious children and adolescents receiving the combination treatment

showed substantial clinical improvement (Piacentini et al., 2014; Walkup et al., 2008).

960

Never too young? Young campers at the Camp Honey Shine in Miami, Florida, learn mindfulness meditation and other

techniques for dealing with stress.

Because children typically have difficulty recognizing and understanding their feelings and

motives, many therapists, particularly psychodynamic therapists, use play therapy as part of

treatment. In this approach, the children play with toys, draw, and make up stories; in doing so,

they are thought to reveal the conflicts in their lives and their related feelings. Over the course of

therapy, the therapists introduce more play and fantasy to help the children work through their

conflicts and change their emotions and behavior. In addition, humanistic therapists conduct

child-centered therapy with anxious children, in which, as you read in Chapter 2, the clinician

listens carefully to the child, reflects on what the child is saying, shows empathy, and gives

unconditional positive regard (Silk et al., 2018).

play therapy An approach to treating childhood disorders that helps children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories.

961

Depressive and Bipolar Disorders During Childhood Like Cameron, 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 (NIMH,

2017, 2016; Avenevoli et al., 2015). As many as 20 percent of adolescents experience at least one

depressive episode during their teen years. In addition, a number of clinicians believe that

children can experience a bipolar disorder.

Major Depressive Disorder Very young children lack some of the cognitive skills that help produce clinical depression, thus

accounting for the relatively low rate of depression among the very young (Wesselhoeft et al.,

2016). For example, in order to experience the sense of hopelessness typically found in depressed

adults, children must be able to hold expectations about the future, a skill rarely in full bloom

before the age of 7.

Separation and depression This 3-year-old boy hugs his father as the soldier departs for overseas military duty. Given

evidence that extended family separations often produce depression in children, clinical theorists have been particularly

worried about the thousands of children affected by military deployments, refugee and immigrant detentions, and parent

incarcerations (Kritikos et al., 2019).

Nevertheless, if life situations or biological predispositions are significant enough, even very

young children sometimes have severe downward turns of mood (Whalen et al., 2017).

962

Depression in the young may be triggered by negative life events (particularly losses), major

changes, rejection, or ongoing abuse (see PsychWatch). Childhood depression commonly features

symptoms such as irritability, headaches, stomach pain, and a disinterest in toys and games

(Fristad & Black, 2018; Whalen et al., 2017).

PSYCHWATCH

Child Abuse

A problem that affects all too many children and has an enormous impact on their psychological

development 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. Between 5 and 16 percent of children in the United States are

physically abused each year (Wherry, 2018; Boos, 2017). 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. Although child abuse is perpetrated

in all socioeconomic groups, it is apparently more common among the poor (Boos, 2017; Romero-Martínez et al., 2014).

Abusers are usually the child’s parents (Christian, 2017; Ben-Natan et al., 2014). Clinical investigators have learned

that abusive parents often have poor impulse control, low self-esteem, higher levels of depression, and weak parenting skills

(Boos, 2017). Many were abused themselves as children and have had poor role models. In some cases, they are dealing

with stressors such as marital discord or unemployment (Christian, 2017).

Studies suggest that the victims of child abuse may suffer both immediate and long-term psychological effects (Kolko

& Berkout, 2017). Research has shown, for example, that they may experience psychological symptoms such as anxiety,

depression, or bed-wetting, and display performance and behavior problems in school (Martin, Kidd, & Seedat, 2019;

Keeshin et al., 2014). Long-term negative effects include lack of social acceptance, a higher number of medical and

psychological disorders during adulthood, more abuse of alcohol and other substances, more impulsive and risk-taking

behaviors, more arrests during adolescence and adulthood, a greater risk of becoming criminally violent, a higher

unemployment rate, and a higher suicide rate (Kolko & Berkout, 2017; Afifi et al., 2014). Finally, 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).

963

Lingering impact A mother prepares her adopted 5-year-old son for pajama day at a trauma treatment program in

which the child participates. The program addresses issues that the boy is still dealing with as a result of abuse or

neglect in an earlier family.

Two forms of child abuse have received 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 (Endom, 2017). It probably accompanies all forms of physical 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 (Bechtel & Bennett, 2017; Murray, Nguyen, & Cohen, 2014). Surveys suggest that, worldwide, as many as 25

percent of women were forced into sexual contact with an adult male during childhood, many of them with a parent or

stepparent. As many as 9 percent of men were also sexually abused during childhood. Child sexual abuse appears to be

equally common across all socioeconomic classes, races, and ethnic groups.

A variety of therapies have been used in cases of child abuse, including groups sponsored by Parents Anonymous, which

help parents develop insight into their behavior, provide training on alternatives to abuse, and teach coping and parenting

skills (PA, 2017; Miller et al., 2007). In addition, prevention programs, often in the form of home visitations and parent

training, have proved promising (Beasley et al., 2014; Rubin et al., 2014).

Research suggests that the psychological needs of children who have been abused should be addressed as early as

964

possible (PA, 2017; Murray et al., 2014). 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 fault (PA, 2017; Miller et al.,

2007).

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. 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 (Kennebeck & Bonin, 2017; Nock et al., 2013).

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 (Breslau et

al., 2017). Why this gender shift? Several factors have been suggested, including hormonal

changes, the fact that females increasingly experience more stressors than males, and the tendency

of girls to become more emotionally invested than boys in social and intimate relationships as

they mature. One explanation also focuses on teenage girls’ growing dissatisfaction 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 and demands extreme

thinness as the aesthetic female ideal, many adolescent girls feel imprisoned by their own bodies,

have low self-esteem, and become depressed (Klein & Attia, 2017). Many also develop eating

disorders, as you saw in Chapter 9.

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—particularly, cognitive-

behavioral therapy, interpersonal psychotherapy, and antidepressant drugs—and, in fact, many

studies have indicated the effectiveness of such approaches (Weersing et al., 2017). Moreover,

clinicians have often found success treating children and adolescents with family-focused

approaches that aim to improve parent−child relationships, increase shared family activities, and

build child coping skills (Tompson et al., 2017). At the same time, one development over the

past 15 years has raised significant questions about the treatment of depressed teenagers. This is

the discovery that antidepressant drugs may be dangerous for some depressed children and

teenagers.

965

#CounselingDeficit Currently there is 1 school counselor for every 491 students in

the United States. The recommended ratio is 1 per 250

students (ASCA, 2017, 2016).

Grief camp “Grief camps” have been developed for children 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.

Throughout the 1990s, most

psychiatrists believed that second-

generation antidepressants were safe and

effective for children and adolescents, and

they prescribed them readily. However,

the U.S. Food and Drug Administration (FDA) concluded in 2004, based on a number of

clinical reports, that the drugs may 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.

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” (Morkem et al., 2017).

Arguments about the wisdom of this FDA order have since ensued. Although most clinicians

agree that the drugs may increase the risk of suicidal thoughts and attempts in as many as 2

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 (Pozzi et al., 2016; Isacson & Rich,

2014). They point out, for example, that suicides among children and teenagers decreased by 30

966

percent in the decade leading up to 2004, as the number of antidepressant prescriptions provided

to children and teenagers was soaring. Today’s medicators seem to agree that, on balance,

antidepressants are indeed a useful and relatively safe treatment for most depressed children and

adolescents. In the five years following the initial black box warnings, prescriptions of these drugs

for young persons declined significantly, but, over the past decade, such prescriptions have

steadily increased once again (Morkem et al., 2017).

Bipolar Disorder and Disruptive Mood Dysregulation Disorder For decades, bipolar disorder was thought to be almost exclusively an adult disorder, and that its

earliest age of onset is the late teens (APA, 2013). However, beginning in the mid-1990s, clinical

theorists did an about-face, and a large number of them came to believe that many children

display bipolar disorder (Van Meter et al., 2016). Indeed, one review of national diagnostic

trends found that the number of children and adolescents diagnosed and treated for bipolar

disorder in the United States increased 40-fold from 1994 to 2003 (Moreno et al., 2007).

Moreover, this trend continued during the decade following that review (Mash & Wolfe, 2018;

Ryles et al., 2017).

During that period, some theorists came to suspect that such increases reflected not a rise in

the prevalence of bipolar disorders among children but rather a new—often inaccurate—

diagnostic trend (Van Meter et al., 2016). They believed that the diagnosis of bipolar disorder

was being overapplied to children and adolescents and being assigned to the majority of

extremely explosive, aggressive children. In support of these claims, studies revealed that

symptoms of rage and aggression, along with depression, were in fact dominating the clinical

picture of most children who were receiving a bipolar diagnosis (Hernandez et al., 2017; Ryles et

al., 2017). Many such children were not even displaying the symptoms of mania or the mood

swings that characterize adult bipolar disorder.

The task force of DSM-5 came to the same conclusion—that the childhood bipolar label had

been overapplied. In an attempt to 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, henceforth, most children with severe anger and temper

outbursts will receive this diagnosis and that the number of childhood bipolar disorder diagnoses

will decrease correspondingly.

disruptive mood dysregulation disorder

967

A childhood disorder marked by severe recurrent temper outbursts along with a persistent irritable or angry mood.

TABLE: 14-2 Dx Checklist Disruptive Mood Dysregulation Disorder

1. For at least a year, child frequently has severe outbursts of temper that are extremely out of proportion to triggering situations.

2. The outbursts occur in at least two settings (home, school, with peers).

3. Individual repeatedly is irritable or angry between the outbursts.

4. Individual receives initial diagnosis between 6 and 18 years of age.

Information from: APA, 2013.

This diagnostic issue is particularly important because the rise in diagnoses of bipolar disorder

has been accompanied by an increase in the number of children prescribed medications (Duffy &

Grof, 2018; Cervesi et al., 2017). Although several psychological approaches seem to be helpful

for children with a diagnosis of bipolar disorder, fully half of those in treatment receive an

antipsychotic drug, a third receive an antibipolar drug, and many others receive antidepressant or

stimulant drugs (Vallarino et al., 2015). Yet relatively few of these drugs or drug combinations

have been tested for such use with children.

SUMMING UP

CHILDHOOD ANXIETY, DEPRESSIVE, AND BIPOLAR DISORDERS Emotional and behavioral problems are common in childhood and adolescence, but in addition, at least 20 percent of

all children and adolescents in the United States have a diagnosable psychological disorder. A particular concern

among children is that of being bullied.

Anxiety disorders are particularly common among children and adolescents. This group of problems includes

adultlike disorders (such as generalized anxiety disorder and social anxiety disorder), the childhood form of separation

anxiety disorder, and selective mutism.

Two percent of children and 8 percent of adolescents experience depression. Childhood depression is often

characterized by such symptoms as irritability, headaches, stomach pain, and a disinterest in toys and games. In

addition, over the past two decades, there has also been 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.

968

969

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 oppositional defiant disorder or

conduct disorder. Those with oppositional defiant disorder are argumentative and defiant,

angry, and irritable, and in some cases, vindictive (Matthys & Lochman, 2017). 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, 2018, 2015). The disorder is more common in

boys than in girls before puberty but equal in both genders after puberty.

oppositional defiant disorder A disorder in which children are repeatedly argumentative, defiant, angry, irritable, and perhaps vindictive.

Children with conduct disorder, a more severe problem, repeatedly violate the basic rights of

others (APA, 2013). They are often aggressive and may be physically cruel to people or animals,

deliberately destroy other people’s property, steal or lie, skip school, 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 physical 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 electronics] 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)

970

conduct disorder A disorder in which children repeatedly violate the basic rights of others and display significant aggression.

TABLE: 14-3 Dx Checklist Conduct Disorder

1. Individual repeatedly violates the rights of others or ignores the norms or rules of society, beyond the violations displayed by most 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 Frequent provoking of physical fights Using dangerous weapons Physical cruelty to people Physical cruelty to animals Stealing during confrontations Forcing someone into sexual activity Firesetting Deliberately destroying others’ property Breaking into a house, building, or car Frequent lying Stealing under nonconfrontational circumstances Frequent staying out beyond curfews, starting before the age of 13 Running away from home overnight at least twice Frequent truancy, starting before adolescence.

3. Significant impairment.

Information from: APA, 2013.

Conduct disorder usually begins between 7 and 15 years of age (APA, 2013). Between 5 and

10 percent of children, three-quarters of them boys, qualify for this diagnosis (Matthys &

Lochman, 2017). 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,

another psychological problem, and/or a criminal lifestyle (Rivenbark et al., 2018; Dishion &

Patterson, 2016). Research indicates that more than 80 percent of those who develop conduct

disorder first display a pattern of oppositional defiant disorder (APA, 2013). More than one-third

of children with conduct disorder also display attention-deficit/hyperactivity disorder (ADHD), a

disorder that you will read about shortly, and a number experience depression and anxiety

(Wichstrom, Belsky, & Steinsbekk, 2017).

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 behaviors such as lying; (3) the covert-destructive pattern, characterized by

secretive destructive behaviors such as violating other people’s property, breaking and entering,

971

and setting fires; and (4) the covert-nondestructive pattern, in which individuals secretly commit

nonaggressive behaviors, such as being truant from school (Renk et al., 2017; McMahon &

Frick, 2007, 2005).

A number of researchers distinguish yet another pattern of aggression found in certain cases of

conduct disorder, relational aggression, in which the individual is socially isolated and primarily

performs social misdeeds such as slandering others, spreading rumors, and manipulating

friendships (Perry & Ostrov, 2018; Murray-Close et al., 2016). Relational aggression is more

common among girls than boys.

Antisocial behavior and the law Many children and adolescents with conduct disorder wind up incarcerated in juvenile

detention, or juvenile training, centers when their antisocial behaviors place them in conflict with the law. Here inmates at

one such center in Holland spend many hours sitting around, staring, and thinking—hardly a prescription for

improvements in their behaviors or mental health.

Many children with conduct disorder are suspended from school, placed in foster homes, or

incarcerated (Matthys & Lochman, 2017). When children between the ages of 8 and 18 break

972

#GenderGap Today, one of every five teens arrested for violent crimes is

female (DOJ, 2017).

the law, the legal system often labels them juvenile delinquents (Krisberg, 2018). Boys are much

more involved in juvenile crime than girls, although the gap between them is narrowing. It is

encouraging that the number of arrests of teenagers for serious crimes has fallen by one-third

since the turn of the century (DOJ, 2017, 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 (Matthys & Lochman, 2017). A number of cases have

also been tied to drug abuse, poverty, traumatic events, and exposure to violent peers or

community violence (McCloskey & Drabick, 2018; Wymbs et al., 2014). In addition, conduct

disorder is often related to troubled parent–child relationships, inadequate parenting, family

conflict, marital conflict, and family hostility (Mash & Wolfe, 2018; Dishion & Patterson,

2016). Children whose parents reject, leave, coerce, or abuse them or fail to provide appropriate

and consistent 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 (Wilson, 2017).

As they do with regard to other psychological disorders, developmental psychopathologists

explain conduct disorder by pointing to interactions between these various factors (Fonagy &

Luyten, 2018; Holz et al., 2018). Research shows, for example, that some, but not all, children

who are maltreated go on to develop conduct disorder. Why only some? According to several

studies, maltreated individuals are especially likely to develop conduct problems if they were also

born with a particular variation of a gene called the MAOA gene (nicknamed the “human warrior

gene”) (Byrd et al., 2018; Taylor & Kim-Cohen, 2007). On the other hand, children who are

similarly maltreated but who do not carry this particular genetic vulnerability are not nearly as

likely to develop conduct disorder. And, finally, unless they are maltreated, people with this

genetic variability do not have a particularly high risk for developing conduct disorder. In short,

children with a problematic variation of the MAOA gene and a childhood filled with

maltreatment are at high risk for conduct disorder, but children with only one of these factors are

significantly less likely to develop the disorder.

How Do Clinicians Treat Conduct Disorder? Because aggressive behaviors become

more locked in with age, treatments for

conduct disorder are generally most

973

Why might some children show more positive

improvements when their therapist uses technology to treat

them in their own homes?

effective with children younger than age

13 (Cornacchio et al., 2017; Comer et al., 2013). Several different treatments have had moderate

success, but no one of them alone appears to be the answer for this difficult problem (Bakker et

al., 2017). Today’s clinicians are increasingly combining several such approaches into a wide-

ranging treatment program.

Parent Management Training Given the importance of family factors in conduct disorder, many therapists use a combination

of family and cognitive-behavioral interventions, collectively known as parent management

training, to help improve family functioning and help parents deal with their children more

effectively (He et al., 2018; Kaminski & Claussen, 2017). Parent management training takes

various forms, depending on the age of the child with conduct problems.

parent management training A treatment approach for conduct disorder in which therapists combine family and cognitive-behavioral interventions to help improve family functioning and help parents deal with their children more effectively.

One form of parent management training, used with preschoolers, is called parent−child

interaction therapy (Elkins et al., 2017; Hembree-Kigin & McNeil, 2013). Here therapists teach

parents to work with their child positively, set appropriate limits, act consistently, be fair and

structured in their discipline, and establish appropriate expectations regarding the child. Ideally,

these efforts strengthen the parent−child relationship, improve the parents’ attitudes, increase

parental control, promote a consistent home environment, and produce improvements in the

child’s behavior. A related family intervention for preschoolers, video modeling, uses video tools to

help achieve the same goals (Webster-Stratton, 2016).

In recent years, researchers have

successfully used videoconferencing

technology to offer parent−child

interaction therapy in the actual homes of

children with severe conduct problems.

Using webcams, parents stream their home family interactions in real-time to a therapist located

elsewhere, and the therapist, in turn, coaches the parents through a Bluetooth earpiece. Research

suggests that this videoconferencing technique may lead to even more positive child

improvements than those seen in parent−child interaction therapy delivered in a clinic (Comer et

al., 2017, 2015).

If children with conduct problems are of school age, therapists may further engage the parents

974

and child in family therapy (Vuori et al., 2017, 2015; Kazdin, 2012, 2010, 2002). They may

guide the family to identify behaviors that are in need of change and then—with the aid of

written manuals, rehearsals, practice, and homework—teach the parents how to stop rewarding

unwanted behaviors and consistently reward proper behaviors. Like parent management training

for preschoolers with conduct disorder, this enhanced approach for school-age children has often

achieved a measure of success (Kaminski & Claussen, 2017; Forgatch & Patterson, 2010).

Many therapists further supplement parent management training with interventions in the

children’s schools, social lives, and the broader community—a combination of interventions

called multisystemic therapy. Multisystemic therapists not only treat family dynamics; they also

work to increase the amount of time children spend with positive children and role models

instead of delinquent peers. Treatment goals may include improving grades or helping the child

develop vocational skills, as well as promoting the child’s participation in positive and structured

activities, such as sports, school clubs, or neighborhood organizations. Although multisystemic

therapy is typically applied to severe and complex cases of conduct disorder, research finds that

this integrative approach often results in small but long-lasting positive effects (Bakker et al.,

2017; Tan & Fajardo, 2017).

“Is this the story you want to tell on your college application?”

975

Child-Focused Treatments Treatments that focus primarily on the child with conduct disorder, particularly cognitive-

behavioral interventions, have sometimes been helpful (Bakker et al., 2017; Kaminski &

Claussen, 2017). In an approach called problem-solving skills training, therapists combine

modeling, practice, role-playing, and systematic rewards to teach children constructive thinking

and positive social behaviors. The therapists may play games and solve tasks with the children,

and later help them apply the lessons and skills derived from the games and tasks to real-life

situations.

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 bombing in 2013. It turns out that their disorders were

triggered not only by witnessing (in person 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 et al., 2019, 2014). Here a

woman carries her child from their home as a SWAT team enters to conduct one such search.

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 this kind of approach does indeed help

976

How might juvenile training centers themselves contribute

to the high recidivism rate among teenage criminal

offenders?

#HelpNeeded Around 70 percent of children and teens in the juvenile justice

system have at least one mental health condition (NAMI,

2018).

reduce aggressive behaviors and prevent substance use in adolescence (Helander et al., 2018;

Powell et al., 2017).

Drug therapy has also been used for some children with conduct disorder. Stimulant drugs

may help reduce their aggressive behaviors at home and at school, particularly if the children’s

symptoms further include impulsivity and overactivity (Balia et al., 2018; Haggerty, 2017).

Residential Treatment

Residential treatment in the community

has also helped some children. 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 (Sinclair et al., 2016; Henggeler & Sheidow,

2012). While there, the children, foster parents, and birth parents all receive training and

treatment interventions, including family therapy with both sets of parents, individual treatment

for the child, and meetings with the school and with parole and probation officers. In addition,

the children and their parents continue to receive treatment and support after the children leave

foster care. In contrast to this form of residential treatment, 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.

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 (CDC, 2018;

Toth et al., 2016). These programs try to

change unfavorable social conditions before a conduct disorder is able to develop. Typically, the

programs offer training opportunities for young people, recreational facilities, and health care.

They may also seek to ease the stresses of poverty, promote more positive school environments,

and improve parents’ child-rearing skills. All such approaches work best when they educate and

involve the family.

977

978

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 wetting of one’s

clothes. It typically occurs at night during sleep but may also occur during the day. Children

must be at least 5 years of age to receive this diagnosis (Tu, Baskin, & Arnhym, 2017; APA,

2013). The problem may be triggered by stressful events, such as a hospitalization, entrance into

school, or family problems.

enuresis A childhood disorder marked by repeated bed-wetting or wetting of one’s clothes.

The prevalence of enuresis decreases with age. As many as 33 percent of 5-year-old children

have some bed-wetting and 16 percent meet the criteria for enuresis; in contrast, 5 percent of 10-

year-olds and less than 2 percent of 15-year-olds have enuresis (Kosilov et al., 2018; Tu et al.,

2017). Boys with the disorder outnumber girls by 2 to 1. Those with enuresis typically have a

close relative (parent, sibling) who has had or will have the same disorder.

The Bedwetter Outrageous comedian Sarah Silverman holds up a copy of her best-selling 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.

979

Theorists have proposed a range of possible causes for enuresis, but none of them has received

strong research support (Tu et al., 2017; Kim et al., 2014). Most cases of the disorder correct

themselves even without treatment. However, treatments, particularly cognitive-behavioral

therapy, can speed up the process (Tu & Baskin, 2018). In a widely used classical conditioning

approach, the bell-and-battery technique, a bell and a battery are wired to a pad consisting of two

metallic foil sheets, and the entire apparatus is placed under the child at bedtime (Kosilov et al.,

2018; 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 cognitive-behavioral treatment method is dry-bed training. In this approach

children receive training in retention control, are awakened periodically during the night,

practice getting out of bed and going to the bathroom, and are appropriately rewarded. Like the

bell-and-battery technique, this behavioral approach is often effective.

Encopresis Children with encopresis, also called soiling, repeatedly defecate into their clothing. The

disorder is less common than enuresis, and it is also less well researched (Mash & Wolfe, 2018;

Sood, 2018). 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 4 percent of all children (see Table 14-4). The

disorder is much more common in boys than in girls.

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

Selective mutism

2−4 years 1% Females Yes Often

Conduct disorder

7−15 years 5%−10% Males Yes Often

Enuresis 5−8 years 7% Males Yes Usually

Encopresis After 4 years 1.5%−4% Males Unclear Usually

ADHD Before 12 years 7% Males Yes Often

Autism spectrum disorder

0−3 years 2% Males Yes Sometimes

Specific learning 6−9 years 5%–10% Males Yes Often

980

disorder

Intellectual disability

Before 10 years 1%−3% Males Unclear Sometimes

Information from: AAIDD, 2018; Augustyn, 2018; CDC, 2018, 2017; Hamilton, 2018, 2017; Hannesdottir, 2018; Krull,

2018; Lerner et al., 2018; Pivalizza & Lalani, 2018; SMA, 2018; Sood, 2018; von Hahn, 2018, 2017; Matthys & Lochman,

2017; Tu et al., 2017; APA, 2013.

encopresis A childhood disorder characterized by repeated defecating in inappropriate places, such as one’s clothing.

Encopresis causes intense social problems, shame, and embarrassment (Sood, 2018; NLM,

2015). 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 biological

factors such as constipation, stress, improper toilet training, or a combination of these factors

(Sood, 2018). Constipation, by far the most common cause, is a factor in 80 percent of cases.

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 cognitive-behavioral and

medical approaches or a combination of the two (Sood, 2018; Call et al., 2017). Treatment may

include interventions to eliminate the children’s constipation; biofeedback (see pages 259–260)

to help the children better detect when their bowels are full; and the stimulation of regular bowel

functioning with high-fiber diets, mineral oil, laxatives, and lubricants. Family therapy has also

proved helpful.

SUMMING UP

OPPOSITIONAL DEFIANT, CONDUCT, AND ELIMINATION DISORDERS Children 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 of rule breaking and

aggressiveness, repeatedly violate the basic rights of others. These latter children often are violent and cruel and may

deliberately destroy property, steal, and run away from home. Several kinds of conduct disorders have been identified,

including an overt-destructive pattern, overt-nondestructive pattern, covert-destructive pattern, covert-nondestructive

pattern, and relational aggression pattern. Clinicians have treated children with conduct disorder by using approaches

such as parent management training (including parent–child interaction therapy), multisystemic therapy, problem-

solving skills training, the Coping Power Program, and treatment foster care. A number of prevention programs have

also been developed.

Children with an elimination disorder—enuresis or encopresis—repeatedly urinate or pass feces in inappropriate

places. Cognitive-behavioral approaches, such as the bell-and-battery technique, are effective treatments for enuresis.

981

982

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 individual’s behavior, memory,

concentration, and/or ability to learn. As you read at the beginning of this chapter, some

disorders first displayed during childhood subside as the person ages. However, the

neurodevelopmental disorders often have a significant impact throughout the person’s life.

neurodevelopmental disorders A group of disabilities—including ADHD, autism spectrum disorder, and intellectual disability—in the functioning of the brain that emerge at birth or during very early childhood and affect one’s behavior, memory, concentration, or ability to learn.

Three of the most prominent neurodevelopmental disorders are attention-deficit/hyperactivity

disorder, autism spectrum disorder, and intellectual disability. Each of these problems has been

studied 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 the disorders.

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). 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

periodically. 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 always 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.

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)

983

#SchoolPerformance More than 90 percent of children with ADHD underachieve

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.

attention-deficit/hyperactivity disorder (ADHD) A disorder marked by the inability to focus attention, or by overactive and impulsive behavior, or both.

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, 2018). The children may also have

great difficulty controlling their emotions, and some have anxiety or mood problems (Musser &

Nigg, 2018).

Around 7 percent of all children

display ADHD at any given time, as

984

scholastically.

Between 23 and 32 percent of children with ADHD do not

complete high school.

(ADDitude, 2017; Dendy, 2016; Rapport et al., 2008)

many as 70 percent of them boys (Krull,

2018; APA, 2013). Those whose parents

have had ADHD are more likely than

others to develop it. The disorder usually

persists throughout childhood. Many

children show a lessening of symptoms as

they move into mid-adolescence, but as many as 60 percent of them, particularly those with

more severe symptoms, continue to have ADHD as adults (Bukstein, 2018; APA, 2013). The

symptoms of restlessness and overactivity are not usually as pronounced in adult cases.

ADHD is difficult to assess properly (Sibley, Campez, & Raiker, 2018). 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 (APA, 2013). A range of diagnostic interviews, ratings scales, and

psychological tests should be used, but many children receive their diagnosis from pediatricians

or family physicians rather than from a systematic mental health assessment. At most one-third of

ADHD diagnoses are based on psychological or educational testing (Mattingly, Wilson, &

Rostain, 2017; Millichap, 2010). Extensive studies indicate that ADHD is, in fact,

overdiagnosed in the United States (Krull, 2018; Rydell et al., 2018).

“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.

985

What Are the Causes of ADHD? Most of today’s clinicians consider ADHD to result from several interacting causes. Biological

factors have, for example, been identified in many cases (Baykal et al., 2019; Krull, 2018). To

appreciate the brain factors that may contribute to ADHD, it is necessary to first understand

normal human attention. There are two complementary processes that make up our moment-to-

moment attention (Nigg, 2017, 2016). Type 1 attention processes are beyond our voluntary

control and focus our attention on unexpected things that occur in our surroundings, such as

sudden sounds or startling information. In contrast, Type 2 attention processes are mental activities

that we control, and they involve our effortful focus of attention. In order to attend to our

environment properly, we must have an appropriate interplay between our Type 1 and Type 2

attention processes. In many situations, for example, it is important that our Type 2 attention

processes suppress our Type 1 attention alerts so that we can achieve our goals. If you were

reading a book and suddenly there was lightning and thunder outside, your Type 1 attention

processes might automatically reorient your focus momentarily to the unanticipated sight and

sound. In order to resume reading, however, you would need to engage your Type 2 attention

processes to consciously divert your attention from the distracting weather outside back to your

book.

The symptoms of poor attention found in ADHD are commonly understood as a breakdown

in the balance between Type 1 and Type 2 attention processes (Nigg, 2017, 2016). Children

with ADHD have particular difficulty engaging Type 2 attention processes to override Type 1

“emergency alarms,” and as a result they have trouble deliberately refocusing their attention to

successfully function at home, at school, and in social situations.

986

Competition of another kind Simone Biles, the most decorated American gymnast in history, performs in the balance

beam competition at the 2016 Olympic Games at the age of 19. After hackers revealed her medical records, Biles proudly

announced that she suffers from ADHD and has received an exemption from the World Anti-Doping Association (WADA)

to take methylphenidate for her condition. She tweeted: “Having ADHD and taking medicine for it is nothing to be

ashamed of.”

Brain scan studies have identified an attention circuit—a number of structures that work

together throughout the brain to bring about attention and to maintain a proper balance between

Type I and Type 2 attention processes. You have read about some of the brain structures in this

circuit (the prefrontal cortex, anterior cingulate, and striatum, for example) in our earlier

discussions of other brain circuits. Other structures in the attention circuit, such as the corona

radiata and the longitudinal fasciculus, are new to your reading. Research on the possible ties

between the attention circuit and ADHD is still unfolding, but indications are that individuals

with ADHD have a dysfunctional attention circuit, marked by poor communication (faulty

interconnectivity) between the structures in this circuit, as well as by abnormal activity of the

neurotransmitter dopamine throughout the circuit (Gehricke et al., 2017; Nigg, 2017, 2016).

Given the dysfunctional attention circuit of these individuals, their Type 2 attention processes

are, more often than not, simply unable to override their Type 1 attention processes.

In addition to biological factors, ADHD has been linked to high levels of stress and to family

dysfunction (Krull, 2018). In fact, some studies suggest that these negative factors interfere with

the development of effective Type 2 attention processes (Nigg, 2017, 2016). In addition,

987

Why has there been a sizable increase in the diagnosis and

treatment of ADHD over the past few decades?

sociocultural theorists have noted that ADHD symptoms and a diagnosis of ADHD may

themselves create interpersonal problems and produce further symptoms in the child. That is,

children who are hyperactive tend to be viewed negatively by their peers and parents, have

impaired peer relationships, and, in turn, come to view themselves negatively (Ros & Graziano,

2018).

How Is ADHD Treated? Almost 80 percent of all children and adolescents with ADHD receive treatment (CDC, 2018).

The most commonly used approaches are drug therapy, cognitive-behavioral therapy, or a

combination of the two (Krull, 2018).

Millions of children and adults with

ADHD are currently treated with

methylphenidate, a stimulant drug that

actually has been available for decades, or

with certain other stimulants. Although a variety of manufacturers now produce

methylphenidate, the drug is often known to the public by its famous trade names, Ritalin or

Concerta. As researchers have confirmed methylphenidate’s quieting effects on children with

ADHD and its ability to help them focus, solve complex tasks, perform better at school, and

control aggression, use of the drug has increased enormously—according to some estimates, at

least a threefold increase since 1990 alone (Hawk et al., 2018; Krull, 2018). Around 2.2 million

children in the United States, 3 percent of all schoolchildren, regularly take methylphenidate for

ADHD, a number that keeps rising (Bachmann et al., 2017; Olfson et al., 2016). It is now the

most common treatment for the disorder, although amphetamines such as Adderall are being

increasingly prescribed for children with ADHD (Safer, 2016).

methylphenidate A stimulant drug, better known by the trade names Ritalin or Concerta, commonly used to treat ADHD.

Although widely used, methylphenidate has raised certain concerns. First, many clinicians

worry about the possible long-term effects of these various stimulants, and others question

whether the favorable findings of the drug studies (most of which have been done on non-

Hispanic white American children) are applicable to children from minority groups (Ji et al.,

2018; Cummings et al., 2017). Second, because ADHD is overdiagnosed in the United States,

many children who are receiving stimulants may in fact have been inaccurately diagnosed (Rydell

et al., 2018; Merten et al., 2017). Third, although stimulant medication can improve children’s

attention and behavioral control in the short term, studies do not always find that such treatment

988

#TheirWords “I want to thank my mom and my dad up in heaven for

disobeying the doctor’s orders and not medicating their

hyperactive girl and finding out what she was into instead.”

Audra McDonald, Tony Award–winning actress and singer

leads to meaningful long-term improvements or to positive changes in peer relationships or

family dynamics (Rajeh et al., 2017).

Cognitive-behavioral therapy is often

used for individuals with ADHD. In

many cases, parents and teachers are

taught how to apply the principles of

operant conditioning—systematically

rewarding the children for attentiveness or

self-control. They may, for example, set up a token economy program in which the children receive

tokens whenever they attend and respond appropriately—tokens that can later be exchanged for

rewards of various kinds (Krull, 2018). Many children with ADHD also participate in eight-

week therapeutic summer camps that provide systematic cognitive-behavioral interventions in

classroom-like formats (Sibley et al., 2018; Evans, Owens, & Bunford, 2014).

Parents of children with ADHD may also receive parent management training, in which

cognitive-behavioral techniques are combined with family interventions to help them deal with

their children more effectively, similar to the training received by parents of children with

conduct disorder. Moreover, parent management training and operant techniques may be

combined with school interventions (Sanchez et al., 2018). In one such combination program, the

Daily Report Card (DRC), a child’s target behaviors—staying in his or her classroom seat, raising

a hand to speak, and using an “inside voice”—are carefully evaluated, recorded on a DRC, and

reinforced by teachers throughout the school day. At the end of the day, the teacher further

provides the report card for the parents to see, and, if a sufficient number of target behaviors had

been performed satisfactorily that day, the child is also given rewards at home (Cornacchio et al.,

2017).

989

Cognitive-behavioral interventions Educational programs often use operant conditioning principles that clearly spell out

targeted behaviors and rewards and systematically reinforce appropriate behaviors. Such programs can be particularly helpful

for children with ADHD.

Research suggests that children with ADHD may improve most when they receive a

combination of stimulant drug therapy and the cognitive-behavioral treatments we have been

discussing (Kemper et al., 2018; Pelham et al., 2016). Combining drug therapies and cognitive-

behavioral therapy 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 undesired effects (Page et al., 2016).

Multicultural Factors and ADHD Throughout this book, you have seen that race and ethnicity often affect how people are

diagnosed and treated for various psychological disorders. Thus, you should not be totally

surprised that race and ethnicity also seem important 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 non-Hispanic white American

children with similar symptoms to be assessed for ADHD or receive a diagnosis of ADHD

(Coker et al., 2016; Morgan & Farkas, 2016). Moreover, among those who do receive an

ADHD diagnosis, children from racial/ethnic minorities are less likely than non-Hispanic white

American children to be treated with stimulant drugs or a combination of stimulants and

cognitive-behavioral therapy—the interventions that seem to be of most help to individuals with

990

ADHD (Ji et al., 2018; Pham et al., 2010). They are also less likely to receive adequate follow-up

care to monitor their medication responses (Cummings et al., 2017).

In part, these racial and ethnic 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/ethnic minority families have, on

average, lower incomes and weaker insurance coverage. Some clinical theorists further believe

that social bias and stereotyping may contribute to the racial and ethnic differences in diagnosis

and treatment. They argue that our society often views the symptoms of ADHD as medical

problems when exhibited by non-Hispanic 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 finding that, all symptoms being equal, teachers and parents

are more likely to conclude that overactive non-Hispanic white American children have ADHD,

but that overactive African American or Hispanic American children have other kinds of

difficulties (Alvarado & Modesto-Lowe, 2017; Hillemeier et al., 2007).

Whatever the precise reasons may be, it appears that children from racial and ethnic minority

groups are less likely to receive a proper ADHD diagnosis and treatment. While many of today’s

clinical theorists correctly alert us to the possibility that ADHD may be generally overdiagnosed

and overtreated, it is important to also recognize that children from minority backgrounds may,

in fact, be underdiagnosed and undertreated.

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 communication 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 two 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 50 children display this pattern (Augustyn, 2018). Jennie is one such

child:

Ms. D’Angelo [a special education teacher] first observed Jennie in a small classroom over a 5-day period. 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

991

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 accomplish this in less than

two seconds. … Ms. D’Angelo noticed that Jennie was most aggressive when introduced to something or someone new. …

Ms. D’Angelo noticed that Jennie did not speak and vocalized only when making her soft sounds. . . [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” and gave examples of her early impairment. 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)

TABLE: 14-6 Dx Checklist Autism Spectrum Disorder

1. Individual displays continual deficiencies in various areas of communication and social interaction, 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, movements, or object use Inflexible demand for same routines, statements, and behaviors Highly restricted, fixated, and overly intense interests Over- or underreactions to sensory input from the environment.

3. Individual develops symptoms by early childhood.

4. Individual experiences impaired functioning.

Information from: APA, 2013.

autism spectrum disorder A developmental disorder marked by extreme unresponsiveness to others, severe communication deficits, and highly repetitive and rigid behaviors, interests, and activities.

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

enormous difficulty maintaining employment, performing household tasks, and leading

independent lives (Lerner et al., 2018). Even the highest-functioning adults with autism typically

have problems with closeness and empathy and have restricted interests and activities.

992

#StunningNumbers Approximately 100 individuals are diagnosed with autism every

day in the United States.

Each year, more children are diagnosed with autism than with

cancer, diabetes, and AIDS combined.

(Information from: TACA, 2017)

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 this disorder 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, children with autism

typically do not include others in their play and do not represent social experiences when they are

playing; they often fail to see themselves as others see them and have no desire to imitate or be

like others (Augustyn, 2017).

Communication problems take various forms in autism spectrum disorder (Shire et al., 2018).

Many people with the disorder have great difficulty understanding speech or using language for

conversational purposes. In fact, like Jennie, at least a third fail to speak or develop language skills

(Autism Speaks, 2018). 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 with the same accent or inflection, but with no sign of

understanding or intent of communicating. 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. They may display

few or no facial expressions or body gestures. And they may be incapable of maintaining proper

eye contact during interactions. Recall, for example, that Jennie “rarely made eye contact with

anyone.”

People with autism also display a wide range of highly rigid and repetitive behaviors, interests,

and activities that extend beyond speech patterns (Lerner et al., 2018). Typically they become

very upset at minor changes in objects, persons, or routines and resist any efforts to change their

own repetitive behaviors. Jennie’s special education teacher noticed that she was most aggressive

when introduced to something or someone new.

993

Blocking out the world An 8-year-old child with autism spectrum disorder peers vacantly through a hole in the netting of a

baseball batting cage, seemingly unaware of other children and activities at the playground.

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.

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 individuals with the disorder also

perform self-injurious behaviors, such as repeatedly lunging into or banging their head against a

wall, pulling their hair, or biting themselves (Oliver et al., 2017).

The symptoms of autism spectrum disorder suggest a very disturbed and contradictory

pattern of reactions to stimuli. 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 understimulated 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.

994

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 the disorder.

SOCIOCULTURAL CAUSES At first, theorists thought that family dysfunction was the primary cause 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

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 (Lerner et al., 2018; Sicile-Kira, 2014).

PSYCHOLOGICAL CAUSES According to certain theorists, people with autism spectrum disorder have a central 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 (Jones et al., 2018; Mazza et al., 2017).

(You may notice that theory of mind is similar to mentalization, which was discussed on page

413 in Chapter 13).

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.

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 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. A child with autism would not. He or she would

expect Jessica to look in the nearby room because that is where the marble actually is. Jessica’s

995

own mental processes would be unimportant to the child.

The iPad breakthrough A child with autism works on an iPad as his teacher looks on. Electronic tablets provide enormous

cognitive stimulation and pleasure for people with this disorder and often serve as helpful communication devices.

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 (Jones et al.,

2018). 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.

People with autism also display deficiencies in joint attention, a cognitive limitation that is

probably related to their theory of mind deficiency. They have great difficulty sharing focus with

other people on items and events in their immediate surroundings, through mutual eye-gazing,

making reference to observed objects, pointing, or other such acts (Mundy, 2018; Van Hecke,

Oswald, & Mundy, 2016). When individuals with severe autism are around other people, they

simply are not having a “shared” experience. Deficiencies in joint attention can greatly impair

proper language development, since a core function of language is to direct someone else’s

attention.

joint attention Sharing focus with other people on items or events in one’s immediate surroundings, whether through shared eye-gazing, pointing, referencing, or other verbal or nonverbal indications that one is paying attention to the same object.

Why do people with autism have these cognitive limitations? Most theorists point to

996

biological factors that prevent proper cognitive development and functioning.

Autistic and artistic High school student Austin Morrison (standing) rehearses for the play Nerdicus (My Brother with

Autism). Morrison, who himself has autism, stars in the play, which is about a child whose intellectual, adaptive, and

language skills remain relatively strong despite his severe social interaction deficits and his highly rigid and repetitive

behaviors. This higher-functioning pattern of autism was previously called Asperger’s disorder, but it is now classified as

autism spectrum disorder along with lower-functioning patterns.

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 promising leads. First, examinations

of the relatives of people with autism keep suggesting a genetic factor in this disorder. The

prevalence of autism among their siblings, for example, is 10 to 20 percent, a rate much higher

than the general population’s (Autism Speaks, 2018). Moreover, the prevalence of autism among

the identical twins of people with the disorder is 60 percent. Genetic studies are increasingly

identifying specific genes that, in combination, increase the likelihood of developing autism

spectrum disorder (Fakhoury, 2018).

Some studies have also linked autism spectrum disorder to prenatal difficulties or birth

997

#FamilyCost

On average, the lifetime cost of rearing an individual with

autism ranges from $3.5 million to $5 million—at least 3 times

the cost of rearing a nonautistic individual (Autism Speaks,

2018; NAN, 2017).

#TheirWords

“The one common denominator for all of the young children

[with autism] is that early intervention does work, and it seems

to improve the prognosis.”

Temple Grandin, professor and individual with autism

complications (Hisle-Gorman et al., 2018; Bernier & Dawson, 2016). For example, the chances

of developing the disorder are higher when the mother had rubella (German measles) during

pregnancy, was exposed to toxic chemicals before or during pregnancy, or had complications

during labor or delivery.

In addition, researchers have identified

specific biological factors that may

contribute to autism spectrum disorder.

Initially, investigators believed that the

abnormal activity or anatomy of a single

brain structure, the cerebellum, might be

responsible for the disorder, partly because this structure helps control a person’s ability to

rapidly shift attention (Bernier & Dawson, 2016). Cerebellum abnormalities are still considered

a possible factor in the development of autism spectrum disorder, but research over the past two

decades has also tied the disorder to other brain structures, including the corpus callosum,

prefrontal cortex, amygdala, orbitofrontal cortex, cingulate cortex, striatum, and thalamus (Mundy,

2018; Kim et al., 2016). Dysfunction by any of these brain structures may contribute to the

disorder. However, in line with scientists’ growing appreciation of the importance of brain

circuits, a growing number of theorists believe that flawed communication (flawed

interconnectivity) among these and perhaps other brain structures may be the key to autism

spectrum disorder. In support of this belief, many studies of people with autism and of animals

that display autistic-like behavior indicate poor interconnectivity—sometimes hyperconnectivity

and sometimes hypoconnectivity—between these various structures (Xu et al., 2018; Fingher et

al., 2017). It is tempting to conclude from such findings that there is an autism-related brain

circuit whose dysfunction is the key to autism spectrum disorder, but research has yet to establish

the existence or nature of such a circuit (Muhle et al., 2018; Twining et al., 2017).

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). Specifically, the researchers thought that for certain children, this vaccine, which is

998

Why do many people still believe that the MMR vaccine

causes autism spectrum disorder, despite so much evidence

to the contrary?

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.

However, virtually all research

conducted since 1998 has argued against

this theory (Drutz, 2017; Taylor,

Swerdfeger, & Eslick, 2014). For

example, epidemiological studies

repeatedly 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. Moreover, careful

reexaminations of the original study have indicated that it was methodologically flawed, perhaps

even manipulated, and that it 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 very 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 (Weissman & Bridgemohan, 2018).

999

Learning to communicate Cognitive-behavioral clinicians and educators have had success teaching many children with

autism spectrum disorder to communicate. Here a speech language specialist combines cognitive-behavioral techniques with

the use of a communication board to teach a 3-year-old child how to express herself better and understand others.

COGNITIVE-BEHAVIORAL THERAPY For more than 50 years, cognitive-behavioral approaches have been used in cases of autism,

particularly behavior-focused interventions that teach the individuals new, appropriate behaviors

—including speech, social skills, classroom skills, and self-help skills—while seeking to reduce

their negative, dysfunctional behaviors. Using the principles of modeling, therapists often

demonstrate desired behaviors and guide the persons with autism to imitate them. Using the

principles of operant conditioning, the clinicians 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 consistently. 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). Nineteen received the

treatments described above, and 19 served as a control group. Treatment began when the

children were 3 years old and continued until they were 7. By the age of 7, the group that

received behavior-focused interventions 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 intensive behavior-focused programs

1000

to be the preferred treatment for autism spectrum disorder (Rivard et al., 2018; Weissman &

Bridgemohan, 2018, 2017).

Therapies for individuals with this disorder tend to provide the most benefit when they are

started early in life (Green & Garg, 2018; Landa, 2018). Very young children with autism often

begin with services at home, but ideally, by the age of 3 they attend special programs outside the

home. Typically, services are provided by education, health, or social service agencies until the

children reach 3; then the department of education for each state determines which specific

services the children will receive.

Given the recent increases in the prevalence of this disorder, many school districts are now

trying to provide education and training for the children in special classes that operate at the

district’s own facilities (Smith et al., 2017; Iadarola et al., 2015). However, most school districts

remain ill-equipped to meet the profound needs of students with autism. The most fortunate of

these 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, behaviors, and interactions with the world. Higher-functioning students with autism may

eventually spend at least part of their school day returning to standard classrooms in their own

school district (Weissman & Bridgemohan, 2018, 2017).

COMMUNICATION TRAINING As you read earlier, even when given intensive treatment, at least a third of 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 (Weissman & Bridgemohan, 2018). A child may point to a picture of

a fork to give the message “I am hungry,” 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.

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, letters, or words on a communication board or computer.

Some autism programs further try to improve language and communication skills by working

on the individual’s capacity for joint attention, the cognitive ability that you read about above.

The clinician teaches the individual to gaze into the eyes of others, make reference to observed

1001

objects, point at objects, and perform other “sharing” behaviors when he or she is involved in

joint activities with other people. Studies have found that treating joint attention deficiencies

during the preschool years can have a positive impact on communication and language

development as well as other features of autism (Shire et al., 2017).

Animal connection At the National Aquarium in Havana, Cuba, therapists host regular sessions of stroking and touching

dolphins, sea tortoises, and sea lions for children. These sessions have helped many children with autism spectrum disorder

and others with intellectual disability to become more spontaneous, independent, and sociable.

PARENT TRAINING Today’s treatment programs for autism spectrum disorder involve parents in a variety of ways.

Cognitive-behavioral programs, for example, often train parents so that they can apply

conditioning and skill-building techniques at home (Smith et al., 2017; Ginn et al., 2017).

Instruction manuals for parents and home visits by teachers and other professionals are typically

included in such programs. Research consistently has demonstrated that the improvements in

behavior 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 children with autism deal with their own emotions and

1002

needs (Da Paz & Wallander, 2017). A number of parent associations and lobbies also offer

emotional support and practical help.

A special bond Given the hard road they must travel together, the bond between children with autism and their parents is

often especially close and intense. Here Gordy Baylinson, who has autism and is nonverbal, reaches back to caress the face of

his father during a therapy session at Growing Kids Therapy Center in Herndon, Virginia.

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 adults with autism. These

and related programs help the individuals 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 intellectually disabled or, as it was

called in his day, “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

1003

retarded by looking at them. If you think 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 considered intellectually disabled and was educated and cared for in

special institutions. During his adult years, clinicians discovered that Ed’s intellectual ability was

in fact higher than had been assumed. In the meantime, however, he had lived the childhood and

adolescence of an intellectually disabled person, and his statement reveals the kinds of difficulties

often faced by people with this disability.

Normal needs People with intellectual disability have normal interpersonal and sexual needs—needs for which they may

receive training and supervision in various clinical programs. Here a couple with Down syndrome twirl each other on the

dance floor during the Night to Shine—a dance party in Portland, Maine, for people with special needs.

In DSM-5, the term “mental retardation” has been replaced by intellectual disability. 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 jobs that are modestly demanding. As many as 3 of every

100 people meet the criteria for this diagnosis (Baldor, 2018). Around three-fifths of them are

male, and the vast majority display a mild level of the disability.

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 intellectual

1004

Are there other kinds of intelligence that IQ tests might fail

to assess? What might that suggest about the validity and

usefulness of these tests?

disability 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).

TABLE: 14-7 Dx Checklist Intellectual Disability

1. Individual displays deficient intellectual functioning, as 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 of most similarly aged persons and necessitate ongoing support at school or work, or with independent living.

3. The deficits begin during the developmental period (before the age of 18).

Information from: APA, 2013.

intellectual disability (ID) A disorder marked by intellectual functioning and adaptive behavior that are well below average. Previously called mental retardation.

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). It is an individual’s overall test score, or intelligence quotient (IQ), that is thought

to indicate general intellectual ability.

intelligence quotient (IQ) A score derived from intelligence tests that theoretically represents a person’s overall intellectual capacity.

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 performance is

rather high—around .50—indicating that many children with lower IQs do, as one might

expect, perform 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

1005

disability (AAIDD, 2018).

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 for survival by people who live in

poor, crime-ridden areas—a kind of know-how that certainly requires intellectual 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 accurately 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.

PSYCHWATCH

Reading and ’Riting and ’Rithmetic

Around 15 to 20 percent of all children, boys more often than girls, develop particularly slowly and

function poorly in a single area such as learning, communication, or motor coordination (Poletti et al., 2018; CDC, 2017).

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 interactions. Similar difficulties may be seen in the

children’s close biological relatives (von Hahn, 2017, 2016). According to DSM-5, many of these children are suffering

from a specific learning disorder, communication disorder, or developmental coordination disorder—each a kind of

neurodevelopmental disorder.

Children with a specific learning disorder have significant difficulties acquiring reading, writing, arithmetic, or

mathematical reasoning skills (Poletti et al., 2018). Across the United States, children with such problems comprise the

largest subgroup of those placed in special education classes (von Hahn, 2017). Some of these children read slowly or

inaccurately or have difficulty understanding the meaning of what they are reading, difficulties also known as dyslexia

(Hamilton, 2018). Others spell or write very poorly. And still others have great trouble remembering number facts,

performing calculations, or reasoning mathematically.

1006

A special pair of glasses One of several explanations for dyslexia is that some people with this disorder have a

significant visual processing problem. Thus various kinds of special 3D glasses, modeled here by this child, have been

developed to help diagnose and treat the disorder.

The communication disorders include language disorder, speech sound disorder, and childhood-onset fluency disorder

(stuttering) (Lieberman, 2018; APA, 2013; Gillam & Petersen, 2011). Children with language disorder may have persistent

trouble using language to express themselves, struggle at learning new words, or confine their speech to short simple

sentences. Children with speech sound disorder may have persistent difficulties in speech production or speech fluency.

Some, for example, cannot make correct speech sounds at an appropriate age, resulting in speech that sounds like baby talk.

People who display stuttering may frequently repeat, prolong, or interject sounds when they speak, pause before finishing a

word, or experience excessive tension in the muscles they use for speech.

Finally, children with developmental coordination disorder perform coordinated motor activities at a level well below that

of others their age (Hamilton, 2017; APA, 2013). Younger children with this disorder are clumsy and slow to master skills

such as tying shoelaces, buttoning shirts, and zipping pants. Older children with the disorder may have great difficulty

assembling puzzles, building models, playing ball, and printing or writing.

Studies have linked these various disorders to genetic factors, brain abnormalities, birth injuries, lead poisoning,

inappropriate diet, sensory or perceptual dysfunction, and poor teaching (Hamilton, 2018, 2017; von Hahn, 2018, 2017,

2016). Some of the disorders respond to special treatment approaches. 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 disorders often disappear before adulthood, even without any treatment.

1007

#TheirWords “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

Assessing Adaptive Functioning Diagnosticians 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. Jeffrey’s

limitations, however, are pervasive. In

addition to his low IQ score, Jeffrey has

difficulty meeting 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 consistent feature of intellectual disability is that the person learns very slowly

(AAIDD, 2018; Sturmey & Didden, 2014). Other areas of difficulty are attention, short-term

1008

memory, planning, and language (Burack et al., 2016). Those who are institutionalized with this

disability are particularly likely to have these limitations. It may be that the 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. These children demonstrate rather typical language,

social, and play skills, but they need assistance when under stress (Pivalizza & Lalani, 2018). 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). Their jobs tend to be unskilled or semiskilled.

Breaking the barrier Thirty-one-year-old Noelia Garella (center) reads a book to her preschool students in Cordoba,

Argentina. She is one of but a few persons in the world with intellectual disability who work as public school teachers.

When she was a child, a nursery school rejected her as “a monster.”

1009

#TheirWords “Intelligence is the ability to adapt to change.”

Stephen Hawking, physicist

Research has often linked mild ID to sociocultural and psychological causes, particularly poor

and unstimulating environments during a child’s early years, inadequate parent–child

interactions, and insufficient learning experiences (Pivalizza & Lalani, 2018). These relationships

have been observed in studies comparing deprived and enriched environments. In fact, some

community programs 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, 2018; Ramey & Ramey, 2007, 2004).

Although sociocultural and psychological factors seem to be key 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 pregnancy may lower her child’s intellectual

potential (CDC, 2017; Popova et al., 2017). Malnourishment 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 typically 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, 2018).

Approximately 3 to 4 percent of

people with intellectual disability display

severe ID (IQ 20–34). They typically

demonstrate basic motor and

communication 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 careful supervision, profit somewhat from vocational training, and can

perform only basic work tasks in structured and sheltered settings. Their understanding of

communication is usually better than their speech. Most are able to function well in the

1010

#SexChromosomes

community if they live in group homes, in community nursing homes, or with their families

(AAIDD, 2018).

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, 2018). Profound (and severe) levels of intellectual disability often appear as part of

larger syndromes that include severe physical handicaps.

What Are the Biological Causes of Intellectual Disability? As you read earlier, the primary causes of mild ID are environmental, although biological factors

may also be operating in many cases. In contrast, the main causes of moderate, severe, and

profound ID are biological, although people who function at these levels also are strongly

affected by their family and social environment (Mary et al., 2018; Reichenberg et al., 2016).

The biological causes include chromosomal abnormalities, metabolic disorders, prenatal

problems, birth complications, 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 fewer than 1 of every 1,000 live births, but the rate increases significantly

when the mother’s age is 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.

Down syndrome A form of intellectual disability caused by an abnormality in the 21st chromosome.

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

1011

The 23rd chromosome, whose abnormality causes fragile X

syndrome, is the smallest chromosome.

The 23rd chromosome determines a person’s sex and so 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.

abnormalities may cause Down

syndrome. The most common type (94

percent of cases) is trisomy 21, in which

the person has three free-floating 21st

chromosomes instead of two

(Weremowicz, 2018). 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 (Ostermaier, 2018). It appears 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 (Hithersay et al., 2017).

Fragile X syndrome is the second most common chromosomal cause of intellectual disability.

Children born with a fragile X chromosome (that is, an X chromosome with a genetic

abnormality that leaves it prone to breakage and loss) generally display mild to moderate degrees

of intellectual dysfunction, language impairments, and in some cases, behavioral problems

(Dahlhaus, 2018). 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 development 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.

1012

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 syndrome, 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.

The most common metabolic disorder to cause intellectual disability is phenylketonuria

(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. Today infants can be screened for PKU, and if started on a special diet before 3

months of age, they may develop normal intelligence (van Spronsen et al., 2017).

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, 2018). 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.

1013

Other prenatal problems may also cause intellectual disability. As you read 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 that includes mild to severe ID (CDC,

2018; Popova et al., 2017). It is estimated that 120,000 children are born with fetal alcohol

syndrome each year (Popova et al., 2017). 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.

fetal alcohol syndrome A group of problems in a child, including lower intellectual functioning, low birth weight, and irregularities in the hands and face, that result from excessive alcohol intake by the mother during pregnancy.

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 (Oudgenoeg-Paz et al., 2017).

CHILDHOOD PROBLEMS After birth, particularly up to age 6, certain injuries and accidents can affect intellectual function

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, 2018; Kirkham, 2017). For example, a serious case of lead poisoning, from

eating 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, 2018; Khandaker et al., 2016).

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.

1014

WHAT IS THE PROPER RESIDENCE? Until recent decades, parents of children with intellectual 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.

state school A state-supported institution for people with intellectual disability.

The power of mainstreaming The goal of mainstreaming, or inclusion, programs—in which children with intellectual

disability are placed in regular classes with the general school population—is apparent in this photo. Here, Nandor Szecsi

(front), who has Down syndrome and is mainstreamed, is hugged lovingly by his primary school classmate in Budapest,

Hungary.

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 without 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 institutionalized

once again.

Since that time, reforms have led to the creation of small institutions and other community

residences that teach self-sufficiency, devote more staff time to patient care, and offer educational

1015

What might be the benefits of mainstreaming compared

with special education classes, and vice versa?

and medical services. The community residences range from fully supervised group homes to

semi-independent residences to local branches of larger institutions. Many of these settings follow

the principles of normalization first started in Denmark and Sweden—they attempt to provide

living conditions similar to those enjoyed by the rest of society; flexible routines; and normal

developmental experiences, including opportunities for self-determination, sexual fulfillment,

and economic freedom (Pivalizza, 2017).

normalization The principle that institutions and community residences for people with intellectual disability should provide living conditions and opportunities similar to those enjoyed by the rest of society.

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 community residence (NCD, 2018; Sturmey & Didden, 2014).

WHICH EDUCATIONAL PROGRAMS WORK BEST? Because early intervention seems to offer such great promise, educational programs for people

with intellectual disability 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 (Malki & Einat, 2017; Bouck &

Park, 2016). 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 special classes are better for others.

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.

Teachers who work with students with

intellectual disability often use operant

conditioning principles to improve their

students’ self-help, communication,

1016

#WorstWord

Surveys of the general population earlier this century found

“retarded” to be the single most offensive disability-related

word. Thus in 2010, Congress passed Rosa’s Law, which ruled

that the term “intellectual disability” must replace “mental

retardation” in many areas of government. DSM-5 followed

suit with this label change in 2013.

social, and academic skills (Mader, 2017; Pivalizza, 2017). 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 children with ADHD and

institutionalized patients who have schizophrenia.

WHEN IS THERAPY NEEDED? Like anyone else, people with intellectual disability sometimes have emotional and behavioral

problems (Sutton & Gates, 2019). Around 30 percent or more have a psychological disorder

other than intellectual disability (Bratek, Krysta, & Kucia, 2017; 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 (Cooney et al., 2018). Large numbers of people with intellectual disability also take

psychotropic medications (Bowring et al., 2017). Many clinicians argue, however, that too often

the medications are used simply for the purpose of making the individuals easier to manage.

PROMOTING PERSONAL, SOCIAL, AND OCCUPATIONAL GROWTH

People need to feel effective and

competent in order to move forward in

life. Those with intellectual disability are

most likely to feel 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

Olympics 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 (Tint et al., 2017;

Crawford et al., 2015).

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 (Gil-Llario et al., 2018). National advocacy

organizations and a number of clinicians currently offer guidance in these matters, and some have

1017

developed dating skills programs (AAIDD, 2018).

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

(McConnell et al., 2017).

Finally, adults with intellectual disability—whatever the severity—need the personal and

financial rewards that come with holding a job (AAIDD, 2018; Park & Bouck, 2018). 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, a number of people 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 40 years, there are too few of

them. Additional programs are required so that more people with intellectual disability may

achieve their full potential, as workers and as human beings.

Working for money, independence, and self-respect Simone Ippoliti pours a beer for a patron at Locanda dei Sunflowers,

a restaurant in Rome. The restaurant promotes the employment of individuals with intellectual disability, like Simone—

providing them with job opportunities and dignity through training and placement.

1018

SUMMING UP

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 person’s behavior, memory, concentration, and/or ability to learn.

Children with attention-deficit/hyperactivity disorder (ADHD) attend poorly to tasks, behave overactively and

impulsively, or both. Many of the attention difficulties seen in ADHD may be associated with a dysfunctional

attention brain circuit whose structures display problematic interconnectivity. Drug therapy—methylphenidate,

amphetamine, or other stimulant drugs—and cognitive-behavioral programs can be effective treatments.

People with autism spectrum disorder are extremely unresponsive to others, have severe communication deficits,

and display very rigid and repetitive behaviors, interests, and activities. The leading explanations of this disorder point

to cognitive deficits, such as failure to develop a theory of mind and joint attention skills, and biological

abnormalities, including, perhaps, a dysfunctional brain circuit. 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 intelligence and adaptive ability. Mild ID, by

far the most common level of intellectual disability, has often been linked to environmental factors such as

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. The leading

biological causes of intellectual disability are chromosomal abnormalities, metabolic disorders, prenatal problems,

birth complications, and childhood diseases and injuries.

Today’s intervention programs for people with intellectual disability typically emphasize the importance of a

comfortable and stimulating residence—either the family home, a small institution or group home, or a semi-

independent residence—that follows the principles of normalization. Other important interventions include proper

education, therapy for psychological problems, and programs offering training in socializing, sex, marriage, parenting,

and occupational skills. A key debate centers on whether people with intellectual disability profit more from special

classes or from mainstreaming.

1019

CLINICAL CHOICES 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.

Clinicians Discover Childhood and Adolescence Early in the twentieth century, mental health professionals virtually ignored children. At best,

they viewed them as small adults and treated their psychological disorders as they would adult

problems. Today the problems and needs of young people have caught the attention of

researchers and clinicians.

This increased attention has zeroed in

on the importance of the family. 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

disability, and other problems of childhood and adolescence 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 problems. 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.

The increased clinical focus on the young has also been accompanied by more attention to

young people’s human and legal rights. More and more clinicians 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 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.

1020

1021

Chapter 14 Review

Key Terms

bullying

separation anxiety disorder

selective mutism

play therapy

disruptive mood dysregulation disorder

oppositional defiant disorder

conduct disorder

parent management training

parent–child interaction therapy

multisystemic therapy

enuresis

encopresis

neurodevelopmental disorders

ADHD

Type 1 attention processes

Type 2 attention processes

attention circuit

methylphenidate

autism spectrum disorder

echolalia

theory of mind

joint attention

1022

augmentative communication system

intellectual disability (ID)

intelligence quotient (IQ)

mild ID

moderate ID

severe ID

profound ID

Down syndrome

fragile X syndrome

recessive genes

phenylketonuria (PKU)

fetal alcohol syndrome

state school

normalization

special education

mainstreaming

sheltered workshop

Quick Quiz

1. What are the prevalence rates and gender ratios for the various disorders common among children and adolescents? pp. 436–468

2. What are the different kinds of childhood anxiety and depressive disorders? What are today’s leading explanations and treatments for these disorders? pp. 438–443

3. What is disruptive mood dysregulation disorder, and why might DSM-5’s addition of this new category affect diagnoses of childhood bipolar disorder? p. 443

4. Describe oppositional defiant disorder and conduct disorder. What factors help cause

1023

conduct disorder, and how is this disorder treated? pp. 444–448

5. What are enuresis and encopresis? How are these disorders treated? pp. 448–449

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. 450–454

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. 454–460

8. Describe the different levels of intellectual disability. pp. 460–464

9. What are the leading environmental and biological causes of intellectual disability? pp. 462–466

10. What kinds of residences, educational programs, treatments, and community programs are helpful to persons with intellectual disability? pp. 466–468

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

1024

CHAPTER 15 Disorders of Aging and Cognition

TOPIC OVERVIEW

1025

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

Clinicians Discover the Elderly

Harry 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 working 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 problem 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 watching 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

1026

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 volunteers, 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 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 neurocognitive disorder. There are many types of

neurocognitive disorders listed in DSM-5 (APA, 2013). Alzheimer’s disease is the most common

one (Wolk & Dickerson, 2017).

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.

1027

Old Age and Stress Old age is usually defined in our society as the years past age 65. By this account, around 46

million people in the United States are “old,” representing 14.5 percent of the total population;

this is a 15-fold increase since 1900 (U.S. Census Bureau, 2018, 2016; Mather, 2016). It has also

been estimated that there will be 70 million elderly people in the United States by the year 2030

—21 percent of the population. 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.

Like childhood, old age brings special pressures, unique upsets, and major biological changes

(Heflin, 2018). People become more prone to illness and injury as they age. About half of adults

over 65 have two or three chronic illnesses, and 15 percent have four or more. And at least half of

elderly people have some measure of insomnia or other sleep problems (APA, 2018, 2017;

Winkelman, 2018). 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. Many lose their sense of purpose after they retire. Some also have to adjust to the loss of

favored pets and possessions.

1028

What kinds of attitudes and activities might help people

enter old age with peace of mind and positive anticipation?

#PovertyPressure

10% Percentage of elderly non-Hispanic white Americans who live below the poverty line

21% Percentage of elderly Hispanic Americans who live below the poverty line

24% Percentage of elderly African Americans who live below the poverty line

(Information from: Heflin, 2018)

Making a difference To help prevent feelings 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. This elderly man,

who volunteers regularly at an elementary school, is teaching math to a first-grader.

The stresses of aging need not

necessarily cause psychological problems

(see PsychWatch). 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 (Espinoza & Unützer, 2017). For example,

two-thirds of elderly people now use the Internet to connect with people of similar ages and

interests, a 16-fold increase since the year 2000 (Pew Research Center, 2017; Oinas-Kukkonen

& Mantila, 2010). Indeed, 34 percent of persons over age 65 use social media. 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, 2018, 2017). Geropsychology, the field of psychology

dedicated to the mental health of elderly people, has developed almost entirely within the last

four decades, and at present only 4.2 percent of clinicians work primarily with elderly persons

(APA, 2018, 2017).

geropsychology The field of psychology concerned with the mental health of elderly people.

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 depressive,

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 abnormalities. 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

1029

problems often display other such problems. For example, many who suffer from neurocognitive

disorders also deal with depression and anxiety (APA, 2018).

PSYCHWATCH

The Oldest Old

Clinicians suggest that aging need not inevitably lead to psychological problems. Nor apparently does it

always lead to physical problems.

There are currently 72,000 centenarians in the United States—people who are 100 years old or older. When researchers

have studied these people—often called the “oldest old”—they have been surprised to learn that centenarians are on average

more healthy, positive, clearheaded, and agile than those in their 80s and early 90s (Etxeberria et al., 2017; Rea, 2017).

Although some certainly experience 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 some studies, many people in their 90s and older fear the prospect of mental

deterioration more than they fear death (Arosio et al., 2017; Boeve et al., 2003).

Dream of a (long) lifetime Since 2008, it had been 107-year-old Virginia McLaurin’s dream to meet President

Barack Obama. That wish came true in 2016 when the centenarian was invited to a reception at the White House

celebrating African American History Month. McLaurin not only met with then-President Obama but got to dance

1030

with then-First Lady Michelle Obama.

Some scientists believe that people who live this long carry “longevity” genes that make them resistant to disabling or

terminal infections (Grossi et al., 2018; Hao et al., 2018). Research also points to engaged lifestyles and “robust”

personalities that help the oldest old meet life’s challenges with optimism and a sense of challenge (Etxeberria et al., 2017;

da Rosa et al., 2014). The centenarians themselves often credit a good frame of mind or regular behaviors that they have

maintained for many years—for example, eating healthful food, getting regular exercise, and not smoking (da Silva et al.,

2018; Rea, 2017). Said one very elderly retired math and science teacher, “You can’t sit. … You have to keep moving”

(Duenwald, 2003).

1031

#SpousalLoss

9.0 million Number of widows in the U.S.

2.1 million Number of widowers in the U.S.

(Information from: U.S. Census Bureau, 2018, 2017)

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, including feelings of profound

sadness and emptiness; low self-esteem, guilt, and pessimism; and loss of appetite and sleep

disturbances. Depression is particularly common 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

(APA, 2018; Espinoza & Unützer, 2017).

[Oscar] was an 83-year-old married man with an episode of major depressive disorder. … 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 relationships 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, 2018). 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. However, it climbs much

higher (32 percent or more) among aged people who live in nursing homes, as opposed to those

in the community (Espinoza & Unützer, 2017; Seitz et al., 2010).

Several studies suggest that depression

raises an elderly person’s chances of

developing significant medical problems

(Heflin, 2018; Taylor, 2014). 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

1032

Is it more likely that positive thinking leads to good health

or that good health produces positive thinking? condition. 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 depression are tied to increases in the death rate.

As you read in Chapter 7, elderly people are also more likely to die from suicide than young

people, and often their suicides are related to depression (APA, 2018). The overall rate of suicide

in the United States is 12.6 per 100,000 people; among those over 65 years of age, it is more

than 16 per 100,000, and among those over 75, it is more than 24 per 100,000 (CDC, 2017,

2016; WHO, 2017).

Racing to mental health Gerontologists propose that elderly people need to pursue pleasurable and personally meaningful

activities. The elderly women on the left compete in a race at the National Senior Games. In contrast, the elderly gentleman

on the right, also interested in racing, watches a competition 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?

Like younger adults, older people who are depressed may be helped by cognitive-behavioral

therapy, interpersonal psychotherapy, antidepressant medications, or a combination of these

approaches (Espinoza & Unützer, 2017). 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 antidepressant drugs effectively and safely

because the body breaks the drugs down differently in later life (Rochon, 2018). 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

1033

elderly people who are severely depressed and have not been helped by other approaches (Kellner,

2018).

Some elderly people experience depression as part of a bipolar disorder rather than a unipolar

type of depressive disorder (Sajatovic & Chen, 2017). Around 1 percent of all persons over 65

years of age display a bipolar disorder in any given year. Usually, the disorder began well before

they reached old age. In most cases, the individuals receive the kinds of treatment that younger

individuals with bipolar disorder receive—mood-stabilizing medications and adjunctive

psychotherapy.

1034

Anxiety Disorders in Later Life Anxiety is also common among elderly people (APA, 2018, 2017). At any given time, as many as

11 percent of elderly individuals in the United States experience at least one of the anxiety

disorders (ADAA, 2017; Zhang et al., 2015). Surveys indicate that generalized anxiety disorder is

particularly common (Baldwin, 2018). The prevalence 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 tends to be

underreported (APA, 2018). Both the elderly patient and the clinician may interpret physical

symptoms of anxiety, such as heart palpitations and perspiring, as symptoms of a medical

condition.

“All of a sudden, everyone seems younger than I am.”

There are many things about aging that may heighten the anxiety levels of certain people

(APA, 2018; Bower et al., 2015). 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).

Older adults with anxiety disorders have been treated with psychotherapy of various kinds,

particularly cognitive-behavioral therapy (APA, 2017; Hui & Zhihui, 2017). Many also receive

1035

benzodiazepines or other antianxiety medications, just as younger sufferers do. And a number are

treated with serotonin-enhancing antidepressant drugs. Again, however, all such drugs must be

used cautiously with older people (Rochon, 2018).

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

particular attention to aging-related issues in healthcare, housing, the economy, and other such

realms. In particular, as the number and proportion of elderly people increases, so too do the

number and proportion of the population who experience aging-related psychological difficulties.

1036

1037

#LateLifeMeds

66% Percentage of elderly persons who take blood pressure drugs

47% Percentage of elderly persons who take cholesterol drugs

19% Percentage of elderly persons who take diabetes drugs

17% Percentage of elderly persons who take antidepressant drugs

9% Percentage of elderly persons who take antianxiety drugs

(Information from: Kantor et al., 2015)

What changes in medical practice, patient education, or

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 (APA, 2018, 2017; Li & Caltabiano,

2017). 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 (APA, 2018; Li & Caltabiano, 2017). 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 are at least 15

percent, and estimates of alcohol-related problems among patients in nursing homes are as high

as 50 percent (Li & Caltabiano, 2017; McConnaughey, 2014).

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”). The latter group

typically begins abusive drinking as a

reaction to the negative events and

pressures of growing 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, and cognitive-behavioral

therapy (APA, 2017).

A leading substance problem in the

1038

family interactions might address the problem of

prescription drug misuse by the elderly? elderly is the misuse of prescription drugs

(APA, 2018; Rochon, 2018). Most often

the misuse is unintentional. In the United

States, people over the age of 65 buy more than one-third of all prescription drugs (NIDA,

2016). At any given time, elderly people are taking, on average, three to five prescription drugs

and two over-the-counter drugs (Heflin, 2018; NCHS, 2014). Thus their risk of confusing

medications or skipping doses is high. To help address this problem, physicians and pharmacists

often try to simplify medications, educate older patients about their prescriptions, clarify

directions, and teach patients 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 (Rochon, 2018).

Yet another drug-related problem, apparently on the increase, is the misuse of powerful

medications at nursing homes. Research indicates 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 (HRW, 2018; Rochon,

2018). Apparently, these powerful and (for some elderly patients) dangerous drugs are often

given to sedate and manage the patients. Indeed, research suggests that 17 percent of new nursing

home patients who have never before taken an antipsychotic drug are administered such drugs

within 100 days of admission (Rochon, 2018; Bronskill et al., 2004).

1039

Psychotic Disorders in Later Life Elderly people have a higher rate of psychotic symptoms than younger people (Soares et al.,

2017). Among aged people, these symptoms are usually 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, one of the

other schizophrenia spectrum disorders.

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 schizophrenia 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. It is uncommon for new cases of schizophrenia to emerge in late life (Feki et al.,

2017).

Another kind of psychotic disorder found among the elderly is delusional disorder, in which

people develop beliefs that are false but not bizarre (Jagsch et al., 2018; APA, 2013). This

disorder, which you read about in Chapter 12, is rare in most age groups—around 2 of every

1,000 persons—but its prevalence appears to increase in the elderly population. 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, the social isolation,

the greater stress, or the 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 services, yet fewer than 20

percent receive them. Depressive and anxiety disorders are common mental health problems among those in this age

group. Between 3 and 7 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.

1040

1041

Disorders of Cognition Most of us worry from time to time that we are losing our memory and other mental abilities.

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). Sometimes, however, people have memory and other cognitive changes that are

far more extensive and problematic.

Affection is not forgotten Clinicians have found that elderly people in senior care facilities are uplifted and stimulated by

interactions with cats, dogs, parakeets, and other pets. In apparent agreement with Sigmund Freud’s declaration that “time

spent with cats is never wasted,” Edith Ehninger, age 95, talks to her regular visitor Mogli. Ehninger has a neurocognitive

disorder.

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, cognitive

problems do have organic roots, particularly when they appear late in life. The leading such

disorders among the elderly are delirium, major neurocognitive disorder, and mild neurocognitive

disorder.

MINDTECH

Remember to Tweet; Tweet to Remember

Social media sites, and the Internet in general, are often thought of as the province of the young. However, elderly

1042

What other factors might help explain the link between

social networking and better coping, social functioning, and

emotions among the elderly?

people are also going online and joining social networking sites at increasing rates. Two-thirds of people over age 65 now

use the Internet, and 62 percent of those users are Facebook members (Pew Research Center, 2017; Wayne, 2017).

A new world A young volunteer teaches this elderly man how to use modern communication devices such as

computers and smartphones.

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 (GCBH, 2017; Wayne, 2017). In one study, for example, researchers

recruited 42 adults, aged 68 to 91, and trained 14 of them on Facebook. 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 (Piatt, 2013; Wohltmann, 2013).

Clinical theorists have offered several

explanations for the positive effects of social media

on elderly people. It may be, for example, that the

cognitive stimulation derived from Internet use

activates memory and other cognitive faculties or

that the engagement with the world and family provided by the Internet directly satisfies social and emotional needs.

Whatever the reason, more and more studies indicate that elderly people who are online often function and feel better than

those who do not pursue online activities.

Because older persons often find it intimidating to go online, many elderly people resist the Internet and social

networking, saying things like “It’s not for me,” “It overwhelms me,” or “You can’t teach an old dog new tricks” (Tsai et

al., 2017). However, the growing body of research suggests that they may want to embrace social networking and the

Internet for better functioning and for better mental health.

1043

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 difficulty concentrating and

thinking in an organized way, leading to misinterpretations, illusions, and on occasion,

hallucinations. 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.

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 concentrate and think in a clear and organized manner

This state of massive confusion typically develops over a short period of time, usually hours or

days. Delirium may occur in any age group, including children, but is most common in elderly

people (Grover & Avasthi, 2018). 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 (Hshieh, Inouye, & Oh, 2018; Tune & DeWitt, 2011). When elderly

people enter a hospital—which represents a major change in their environment and routine—to

be treated for a general medical condition, 10 percent of them show the symptoms of delirium

(Blazer, 2018; Grover & Avasthi, 2018). At least another 10 to 20 percent develop delirium

during their stay in the hospital (Blazer, 2018; Francis & Young, 2014). Around 17 percent of

elderly patients admitted for surgery develop delirium (Wang et al., 2017; de Castro et al., 2014).

That number rises to 23 percent among those admitted suddenly for acute surgery. Between 18

and 50 percent of elderly nursing home residents have some delirium (Blazer, 2018; Forsberg,

2017).

Fever, certain diseases and infections, poor nutrition, head injuries, strokes, and stress

(including the trauma of surgery) may all cause delirium (Magny et al., 2018; Paulo et al., 2017).

So may intoxication by certain substances, such as prescription 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 identifies delirium, it can often be relatively easy to correct—by treating the

1044

underlying infection, for example, or changing the patient’s drug prescription (Hshieh et al.,

2018). However, the syndrome typically fails to be recognized for what it is (Baten et al., 2018).

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 (Grover & Avasthi,

2018).

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, 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.

neurocognitive disorder A disorder marked by a significant decline in cognitive functioning.

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 functioning, the appropriate diagnosis is mild

neurocognitive disorder (see Table 15-2).

major neurocognitive disorder A neurocognitive disorder in which the cognitive decline is substantial and interferes with one’s independence. mild neurocognitive disorder A neurocognitive disorder in which the cognitive decline is modest and does not interfere with one’s independence.

TABLE: 15-2 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.

Neurocognitive Disorder Due to Alzheimer’s Disease

1. Individual displays the features of major or mild neurocognitive disorder.

1045

#CostlyDisease In the U.S., the total annual cost for Alzheimer’s disease and

other neurocognitive disorders is $236 billion (Alzheimer’s

Association, 2018, 2017).

2. Memory impairment is a prominent feature, and genetic indications often underscore diagnosis.

3. Symptoms are not due to other types of disorders or medical problems.

Information from: APA, 2013.

There are currently 47 million people with neurocognitive disorders around the world, with

4.6 million new cases emerging each year (Keene, Montine, & Kuller, 2018). The number of

cases is expected to reach 135 million by 2050 unless a cure is found. The occurrence of

neurocognitive disorders is closely related to age (see Figure 15-1). Among people 65 years of

age, the prevalence is around 1 to 2 percent, increasing to as much as 50 percent for those over

the age of 85 (Heflin, 2018).

FIGURE 15-1

Neurocognitive Disorders and Age

Fewer than 1 percent of 60-year-olds have neurocognitive disorders, compared with as many as 50 percent of those who are

85. (Information from: Heflin, 2018; Keene et al., 2018.)

As you read earlier, Alzheimer’s

disease is the most common type of

neurocognitive disorder, accounting for at

least two-thirds of all cases. Around 5.4

million people in the United States

currently have this disease, a number that is expected to triple by the year 2050 (Alzheimer’s

1046

Association, 2018, 2017; Wolk & Dickerson, 2017). Alzheimer’s disease sometimes appears in

middle age, but in the vast majority of cases it occurs after the age of 65, and its prevalence

increases markedly among people in their late 70s. Altogether, 11 percent of all people over 65

have Alzheimer’s disease.

Alzheimer’s disease The most common type of neurocognitive disorder, marked most prominently by memory impairment.

African Americans and Hispanic Americans are twice as likely as non-Hispanic white

Americans to develop this disease (Alzheimer’s Association, 2018, 2017). The reasons for this

significant difference are not known (Keene et al., 2018).

Alzheimer’s disease is a gradually progressive disease in which memory impairment is, by far,

the most prominent cognitive dysfunction. Technically, sufferers 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 15-2 again).

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 Epileptics, 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?”

1047

(She seems to be trying to remember.)

Three weeks.

It was her second day in the hospital. Dr. Alzheimer, a thirty-seven-year-old neuropathologist and clinician, … observed in

his new patient a remarkable cluster of symptoms: severe disorientation, reduced comprehension, aphasia (language impairment),

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 ensure 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 bedridden, 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)

Although some people with Alzheimer’s disease may survive for as many as 20 years, the time

between onset and death is typically 3 to 8 years (Wolk & Dickerson, 2017). 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.

1048

Slipping away Because of their short-term memory problems, people with advanced cases of Alzheimer’s disease are often

unable to easily draw or paint or do simple tasks. In addition, their long-term memory deficits may prevent them from

recognizing even close relatives or friends.

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. At least 17

percent of them develop major depressive disorder (APA, 2018; Chi et al., 2014). 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)

1049

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, speak little, and show very poor

judgment (Wolk & Dickerson, 2017). 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 (Neikrug & Ancoli-Israel, 2017). 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 serious infections

such as pneumonia, which can result in death (Mitchell, 2018). Alzheimer’s disease is currently

responsible for almost 94,000 deaths each year in the United States, a number more than 40

percent higher than it was a decade ago (CDC, 2017, 2015). It is the sixth leading cause of death

in the country, the third leading cause among the elderly.

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 neurofibrillary 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 neurons in the hippocampus, cerebral

cortex, and certain other brain structures, 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 (Keene et al., 2018). Neurofibrillary tangles, twisted protein fibers found within the

neurons of the hippocampus and certain other brain structures, also occur in all people as they

age, but, again, people with Alzheimer’s disease form an extraordinary number of them.

senile plaques Sphere-shaped deposits of beta-amyloid protein that form in the spaces between certain neurons and in certain blood vessels of the brain as people age. People with Alzheimer’s disease have an excessive number of such plaques. neurofibrillary tangles Twisted protein fibers that form within certain neurons as people age. People with Alzheimer’s disease have an excessive number of such tangles.

1050

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).

Scientists do not fully understand what role excessive numbers of plaques and tangles play in

Alzheimer’s disease, but most agree that they both do their ultimate damage by contributing to

the death of neurons. The plaques (which occur between neurons) accomplish this by interfering

with neuron-to-neuron communications, while the tangles (which occur inside neurons)

accomplish it by blocking the transportation of essential molecules within neurons (Alzheimer’s

Association, 2018, 2017). Today’s leading explanations for Alzheimer’s disease center on plaques

and tangles and on the various factors that may contribute to their formation and excessive

buildup.

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, including, of course,

brain cells. They are large molecules made up of chains of carbon, hydrogen, oxygen, nitrogen,

1051

and sulfur. There are many different kinds of proteins, each with a different function.

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 you just read, 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 also cause tau proteins

within neurons to start breaking down, resulting in tangles and the death of many neurons

(Keene et al., 2018; Hughes, 2011).

What causes this chain of events? Genetic factors are a major culprit (Sweeney et al., 2019).

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 Alzheimer’s disease occurs before the age of 65 in fewer than 1 percent of cases. This relatively

rare form of the disorder typically runs in families. Researchers have learned that it is caused by

abnormalities in 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 (Sherva & Kowall, 2018).

1052

An early good-bye Lyndon Blackbird (left) takes a leave of absence from work to spend what he suspects will be the last

summer with his 54-year-old wife, Evelyn Davis. Davis suffers from early-onset Alzheimer’s disease, a relatively uncommon

form of this neurocognitive disorder.

LATE-ONSET ALZHEIMER’S DISEASE The vast majority of Alzheimer cases develop after the age of 65 and do not typically run in

families (Wolk & Dickerson, 2017). This late-onset form of the disease appears to result from a

combination of genetic, environmental, and lifestyle factors. However, the genetic factors at play

in late-onset Alzheimer’s disease are different from those involved in early-onset Alzheimer’s

disease. The genetic factor that has received the most attention from clinical theorists and

researchers is a gene called the apolipoprotein E (ApoE) gene.

The ApoE gene, located on chromosome 19, 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 (Keene et al., 2018; Sherva &

Kowall, 2018). Apparently, this 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, ultimately, the

1053

#EarlyDebut People with early-onset Alzheimer’s disease may develop

symptoms as early as 30 years of age (Alzheimer’s Association,

2018).

onset of Alzheimer’s disease.

Although the ApoE-4 gene form appears to be a major contributor to the development 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 (Alzheimer’s

Association, 2018, 2017).

AN ALTERNATIVE GENETIC THEORY OF ALZHEIMER’S DISEASE As you have just read, a number of genetic theories of Alzheimer’s disease point to gene forms—

most often ApoE-4—that produce abnormal beta-amyloid protein buildups and plaque

formations. These gene forms, 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 (DeVos et al., 2018; Smolek et al., 2018). These researchers have identified other gene

forms in Alzheimer’s patients that seem to be directly associated with tau protein abnormalities

and tangle formations within neurons. Thus it may be that there are multiple genetic causes for

the formation of numerous tangle formations 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 Does Brain Structure Relate to Alzheimer’s Disease?

Granting that genetic factors may

predispose people to Alzheimer’s disease,

we still need to know what abnormalities

in brain structure eventually 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. Among the most important

structures in transforming short-term memory into long-term memory are the temporal lobes

(which include the hippocampus and amygdala) and the diencephalon (which includes the

1054

mammillary bodies, thalamus, and hypothalamus). Research indicates that Alzheimer’s disease

involves improper functioning of one or more of these brain structures (Giraldo et al., 2018;

Wolk & Dickerson, 2017) (see Figure 15-2).

FIGURE 15-2

The Aging Brain

In old age, the brain undergoes changes that affect cognitive functions such as memory, learning, and reasoning to some

degree. The same changes occur to an excessive degree in people with Alzheimer’s disease. (Information from: Bauer,

Cabral, & Killiany, 2018; Zheng et al. 2018; Mu et al., 2017; Nomi et al., 2017; Selkoe, 2011, 1992.)

What Biochemical Changes in the Brain Relate to Alzheimer’s Disease? In order for new information to be acquired and remembered, certain proteins must be produced

in key brain cells. Several brain chemicals—for example, acetylcholine, glutamate, RNA

1055

#BusyBrains 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 stimulating settings (Li et

al., 2017; Lazarov et al., 2005).

(ribonucleic acid), and calcium—are responsible for the production of the memory-linked

proteins. If the activity of any of these chemicals is disturbed, the proper production of proteins

may be prevented and the formation of memories interrupted (Gallegos et al., 2018; More et al.,

2018). Correspondingly, researchers have found that abnormal activity by these may contribute

to the symptoms of Alzheimer’s disease (Hoshi et al., 2018; Sabri et al., 2018).

Other Explanations of Alzheimer’s Disease Several lines of investigation 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 (Lee et al.,

2018). 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.

Still other studies suggest that the

environmental toxin lead may contribute

to the development of Alzheimer’s disease

(Lee, Peterson, & Freeman, 2017; Lee &

Freeman, 2016, 2014). Many of today’s

elderly were exposed to high levels of lead

in the 1960s and 1970s, regularly

inhaling air pollution from vehicle exhausts. 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 (Walton, 2018). 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. To date, however, no such virus has been detected in the brains of

Alzheimer’s victims (Zafar et al., 2017).

1056

Would people be better off knowing that they will

eventually develop a disease that has no known cure?

More than a dance Carmen Dunkelmann, who suffers from an advanced neurocognitive disorder, dances with her

husband, Peter, at the “dance cafe” of her treatment center. The couple always loved dancing and, as Carmen’s memories

and abilities slip away all too fast, this is an activity and form of intimacy they can still share. In addition, the exercise,

stimulation, and joy that accompany dancing are thought to be helpful in Carmen’s struggle against her progressive

disorder.

Assessing and Predicting Alzheimer’s Disease As you read earlier, cases of Alzheimer’s disease can be diagnosed with absolute certainty only

after death, when an autopsy is performed. However, by using a battery of assessment tools—

including neuropsychological tests (tests that measure a person’s cognitive, perceptual, and motor

performances on certain tasks), brain scans, blood tests and other laboratory work, and careful

history taking—diagnosticians are usually able to build a very strong circumstantial case and

arrive at an accurate diagnosis (Knezevic & Mizrahi, 2018; Larson, 2018).

When diagnosticians administer brain

scans, laboratory tests, and other

biological tests, they are looking for

biomarkers—biochemical, molecular,

genetic, or structural characteristics that usually accompany Alzheimer’s disease (Blennow &

Zetterberg, 2018). It turns out that many of these biomarkers appear in the brain long before the

obvious onset of Alzheimer’s disease. Thus many researchers have tried to determine whether

1057

certain combinations of biomarkers might be able to predict cases of Alzheimer’s disease and

other neurocognitive disorders—perhaps even years before the onset of symptoms (Perpetuini et

al., 2018; Sheng et al., 2018). One promising line of work comes from the laboratory of

neuroscientist Lisa Mosconi and her colleagues (Mosconi et al., 2018, 2014, 2010, 2008). Using

brain scans and other biological tests, this research team measured a combination of biomarkers

in dozens of elderly research participants—all of them seemingly healthy—and then conducted

follow-up studies of them for up to 24 years. 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 disorders had displayed more biomarker

abnormalities on their initial brain tests than the participants who remained healthy. Overall, the

biomarker tests, administered years before the onset of symptoms, predicted mild neurocognitive

impairment with an accuracy rate of 71 percent and major neurocognitive impairment with an

accuracy rate of 83 percent.

biomarkers Biochemical, molecular, genetic, or structural characteristics that usually accompany a disease.

Other Types of Neurocognitive Disorders There are a number of neurocognitive disorders in addition to Alzheimer’s disease (APA, 2013).

Vascular neurocognitive disorder follows a cerebrovascular accident, or stroke, during which blood

flow to specific areas of the brain was cut off, thus damaging the areas (Wright, 2017).

Frontotemporal neurocognitive disorder, also known as Pick’s disease, affects the frontal and

temporal lobes (Che et al., 2018). 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 caused by a virus that may live in the body for years before the disease develops.

Neurocognitive disorder due to Huntington’s disease is an inherited progressive syndrome in which

memory problems, along with personality changes, mood difficulties, and severe twitching and

spasms, worsen over time (Suchowersky, 2018). Parkinson’s disease, the slowly progressive

neurological disorder marked by tremors, rigidity, and unsteadiness, can result in neurocognitive

disorder due to Parkinson’s disease, particularly in older people or those whose cases are advanced

(Rodnitzky, 2018). Neurocognitive disorder due to Lewy body disease involves the buildup of

clumps of protein deposits, called Lewy bodies, within many neurons (Farlow, 2018). Finally, 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 (Price, 2018, 2017)

(see Trending).

TRENDING

1058

Damaging the Brain: Football and CTE

Tens of millions of people in the United States build their Sunday schedules around professional football. They

watch their favorite National Football League (NFL) teams go “head-to-head” in what has arguably become America’s

favorite viewer pastime. For years it was generally believed that the obvious dangers of this sport were outweighed by the

enjoyment it brought to so many and the riches it offered the players. But that thinking has changed dramatically over the

past decade. The reason? The discovery that chronic traumatic encephalopathy (CTE), a degenerative brain disease, is suffered

by many NFL players, largely as a result of the repeated head blows they receive over the course of their years in the game

(Solomon, 2018; Rabinovici, 2017).

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 a major neurocognitive disorder, apparently caused by repeated sports injuries to his

head. The link between football and such disorders was implicitly acknowledged by the NFL with their

implementation of the “88 Plan” (named after Mackey’s jersey number), which helps pay the cost of care for football

veterans with such problems.

Research has clarified that, like various other neurocognitive disorders, CTE features excessive formations of tangles—

produced by the tau protein—in neurons throughout the brain (Lepage et al., 2018; Ling, 2018). These tangles, along with

related abnormalities in brain structures such as the hippocampus, thalamus, substantia nigra, and amygdala, produce a

range of neurocognitive symptoms that unfold over a period of years—disorientation, memory loss, erratic behavior,

personality changes, progressive cognitive decline, suicidal thinking, and death (Larson, 2018; Brosch & Farlow, 2017).

CTE and its lethal impact were not identified until 2005 when neuropathologist Bennet Omalu was conducting an

autopsy on former NFL player Mike Webster and discovered indications of this “new” disease in Webster’s brain. Webster

had displayed severe cognitive, behavioral, and emotional deterioration prior to his death, but his symptoms had been a

mystery to medical professionals. Since Omalu’s breakthrough discovery, CTE has been identified in the autopsied brains

of many dozens of former football, hockey, soccer, and rugby players, as well as boxers, wrestlers, martial artists, and

military personnel (Solomon, 2018; Lindsley, 2017).

The recognition of CTE and its impact unfolded slowly for several reasons (Lee et al., 2018; Mez et al., 2017). One, it

1059

is caused by multiple relatively mild concussions and mild blows to the head, rather than by one obvious episode of major

brain trauma. Two, brain scans of living persons cannot detect the disease in progress because mild concussions do not

result in bleeding or obvious brain structure damage. Like Alzheimer’s disease, a definitive diagnosis of CTE can be made

only when the brain is examined after death. However, what is clear while the sufferers are still alive is that something

profoundly wrong is happening to them.

Now that CTE is “on the map,” a growing number of precautions and actions are being taken—by individuals and

officials alike (Oliver et al., 2018; Lindsley, 2017). For example, the NFL has changed its “return-to-play” procedures,

making sure that players fully recover from all symptoms of even mild concussions before they resume playing. The league

has also reduced the number of “contact” practice sessions a team may conduct. Moreover, the NFL has created a

multimillion-dollar CTE compensation fund from which former players and their families can collect as their symptoms

unfold and/or after their deaths. Changes of this kind did not necessarily come about easily or cooperatively—multiple

lawsuits and collective bargaining pressures preceded them. Nevertheless, they and other such improvements are now

unfolding.

In the meantime, we are reminded all too often that neurocognitive disorders are not only the result of genetic and/or

lifestyle factors. They can also be brought about by head injuries—even seemingly mild ones—or, for that matter, by drugs,

brain surgery, or factors yet to be determined.

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-behavioral interventions, support for caregivers, and

sociocultural approaches. None of these interventions stops the progression of the disorder (Wolk

& Dickerson, 2017).

1060

A therapeutic environment In this long-term care 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.

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 (Reminyl), and memantine (Namenda).

The short-term memory 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 (Press &

Alexander, 2018). Although the benefits of the drugs are limited and their side effects can be

problematic, they have been approved by the FDA. Clinicians believe that they may be of

greatest use to people in the early, mild stage of Alzheimer’s disease. There is a popular belief that

another approach, taking vitamin E, either alone or in combination with one of these drugs, will

help slow down some of the cognitive difficulties experienced by people in the mild stage of

Alzheimer’s disease; however, as it turns out, this notion is, at best, modestly supported by

various studies (Press & Alexander, 2018).

The drugs just discussed are each prescribed after a person has developed Alzheimer’s disease.

In contrast, studies suggest that certain substances now available 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

1061

menopause cut their risk of developing Alzheimer’s disease in half (Grodstein, 2018; Li et al.,

2017, 2014). 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 (Press & Alexander, 2018).

COGNITIVE-BEHAVIORAL TECHNIQUES Cognitive-behavioral treatments have been used in cases of Alzheimer’s disease, with some degree

of success. In Japan, for example, a number of people with the disease meet regularly in classes,

performing simple calculations and reading essays and novels aloud. Similarly, research suggests

that cognitive activities, including computer-based cognitive stimulation programs, sometimes

help prevent or delay the onset of Alzheimer’s disease (Ko et al., 2018; Press & Alexander, 2018).

For example, 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 (Arfanakis et al., 2016; Wilson et al., 2012,

2007).

Fitness of all kinds Clinicians have stressed the value of cognitive fitness to help prevent or slow down the cognitive decline

seen in old age and/or neurocognitive disorders. Thus, many senior community programs now include facilities (left) where

elderly people can work on cognitive computer programs. Research further suggests that physical exercise may be even more

effective at slowing cognitive decline. Thus, the elderly identical twins on the right, both of whom have Alzheimer’s disease,

participate regularly in a physical exercise program.

Interestingly, cognitive-behavioral strategies that focus primarily on behaviors rather than on

cognitions seem to be even more useful in preventing and managing this disease. It has become

clear across many studies that physical exercise helps improve cognitive functioning—for people

1062

#GenderPressure

Two-thirds of caregivers for Alzheimer sufferers are women.

One-third of the caregivers are daughters.

Daughters provide an average of 102 caregiving hours per

month for their parents with Alzheimer’s disease. Sons provide

of all ages and states of health (Mandolesi et al., 2018; McDade & Petersen, 2018). There is

evidence that regular physical exercise may also help reduce the risk of developing Alzheimer’s

disease and other neurocognitive disorders (Keene et al., 2018; Press & Alexander, 2018). Thus

physical exercise is often a part of treatment programs for people with the disorders.

Behavior-focused 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 (Press & Alexander, 2018,

2017; Lancioni et al., 2011). The 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.

Rejoining the world Virtual reality technology can help improve the cognitive and physical functioning of elderly people

and Alzheimer’s sufferers. Here a retirement home resident takes a virtual bike ride through various environments and

performs valuable exercise (she’s also on a stationary bike).

SUPPORT FOR CAREGIVERS Caregiving can take a heavy toll on the close relatives of people with Alzheimer’s disease and

other neurocognitive disorders (Alzheimer’s Association, 2018, 2017). Almost 90 percent of all

people with Alzheimer’s disease are cared for by their relatives, usually their adult children or

spouses. 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.

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

1063

80 hours per month.

(Information from: Alzheimer’s Association, 2018, 2017)

If Alzheimer’s disease is a cognitive disorder, and

biologically caused, why would increasing patients’ comfort

levels make a difference?

difficulties of keeping them at home

(Alzheimer’s Association, 2018, 2017; Di

Rosa et al., 2011). Many caregivers

experience anger and depression, and

their own physical and mental health often declines (Kang et al., 2014). A number of them are,

in fact, “sandwich generation” caregivers, meaning they must care not only for their parents with

Alzheimer’s disease but also for their teenage children. 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, including their needs for regular

time out, education about the disease, and psychotherapy (Merlo et al., 2018; Piersol et al.,

2017). Some clinicians also provide caregiver support groups.

Toll on caregivers A woman comforts her twin sister, who suffers from Alzheimer’s disease. The psychological and physical

burdens of caring for close relatives with neurocognitive disorders typically take a heavy toll on caregivers.

SOCIOCULTURAL APPROACHES

Sociocultural approaches play an

important role in treatment (Alzheimer’s

Association, 2018, 2017). A number of

1064

#NormalDecline?

DSM-5 has added the category mild neurocognitive disorder in

order to help clinicians detect individuals in the early stages of

major neurocognitive disorder (e.g., Alzheimer’s disease). Critics

worry, however, that many people who display normal

forgetfulness and other normal features of aging will incorrectly

receive a diagnosis of mild neurocognitive disorder.

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 cheerful apartments, receive needed supervision, and take part in stimulating activities. These

apartments are typically designed to meet the special needs of the residents—providing more

light, for example, or enclosing gardens with circular paths so the residents can go for strolls

alone without getting lost. Studies suggest that such facilities bring some degree of improvement

to the cognitive deficits 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 (Jensen & Padilla, 2017; Press & Alexander, 2017).

Given the progress now unfolding in

the understanding and treatment of

Alzheimer’s disease and other

neurocognitive disorders, researchers are

looking forward to life-changing 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.

SUMMING UP

DISORDERS OF COGNITION

Older people have an increased risk for experiencing delirium, a disturbance marked by major disturbances in

attention and orientation.

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

disease. This disease has been linked to an unusually high number of senile plaques and neurofibrillary tangles in the

brain. According to a leading explanation of late-onset Alzheimer’s disease, people who inherit ApoE-4, a particular

form of the apolipoprotein E (ApoE) gene, are particularly vulnerable to Alzheimer’s disease.

A number of other causes have also been proposed for this disease, including 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 disease and other neurocognitive

disorders and even at identifying those who will develop these disorders. Drug therapy and cognitive-behavioral

1065

therapies have been used to treat Alzheimer’s disease, with limited success. Addressing the needs of caregivers is a key

part of treatment. In addition, sociocultural approaches such as day-care facilities are on the rise.

1066

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 special 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 (Heflin, 2018; Ng et al., 2014) (see Figure 15-

3).

FIGURE 15-3

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 non-Hispanic white Americans. By 2060, non-Hispanic white Americans will comprise only

55 percent of the elderly. (Information from: Frey, 2018; Mather, 2016; PRB, 2015.)

Some elderly people in minority groups face language barriers that interfere with their medical

and mental health care. Others may hold cultural beliefs that prevent 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 (Lines & Wiener, 2014). As a result, it is common for elderly members of racial

1067

and ethnic minority groups to rely largely on family members or friends for remedies and health

care. Today, around 20 percent of all elderly people live with their children or other relatives,

usually because of increasing health problems (Pew Research Center, 2017; Keefer, 2015). In the

United States, this living arrangement is more common for families from racial and ethnic

minority groups.

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 apartment, a senior housing

complex for mildly impaired elderly persons, or a nursing home where skilled medical and

nursing care is available around the clock. The quality of care in such residences varies widely.

First things first Self-care and self-concern may decline over the course of a major neurocognitive disorder. Thus these

elderly women at a treatment facility in Japan are receiving hygiene and make-up lessons, part of their “cosmetic therapy

program.”

At any given time in the United States, only about 4 percent of the entire elderly population

1068

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, 2017). Thus many older

adults live in fear of being “put away.” They 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. The average

cost for a private room in a nursing home in the United States is over $90,000 per year; for a

semi-private room it is over $80,000 (Alzheimer’s Association, 2018, 2017). Most health

insurance plans available today do not adequately cover the costs of long-term or permanent

placement. Worry over these issues can greatly harm the mental health and/or family harmony of

older adults.

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 (Heflin, 2018;

Libman et al., 2017). 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. 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.

Every little bit helps In line with findings that all kinds of physical exercise may help improve cognitive functioning and/or

slow down cognitive decline, these elderly persons participate in an “armchair” exercise program at a community center in

England.

1069

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.

1070

CLINICAL CHOICES Now that you’ve read about disorders of aging and cognition,

try the interactive case study for this chapter. 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.

Clinicians Discover the Elderly Just a half century ago, mental health professionals focused relatively 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 understand and treat the psychological problems of

the elderly. No longer do clinicians simply accept depression or anxiety in older 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.

As the elderly population lives longer

and grows ever larger, the needs of people

in this age group are becoming more

visible. Particularly urgent is

neurocognitive impairment and its

devastating impact on the elderly and

their families. 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 the disorders, but the disorders have such a powerful impact on patients and

their families that psychological and sociocultural investigations are also now growing by leaps

and bounds.

1071

Chapter 15 Review

Key Terms

geropsychology

delirium

neurocognitive disorder

major neurocognitive disorder

mild neurocognitive disorder

Alzheimer’s disease

senile plaques

beta-amyloid protein

neurofibrillary tangles

tau protein

early-onset Alzheimer’s disease

beta-amyloid precursor protein

presenilin protein

late-onset Alzheimer’s disease

apolipoprotein E (ApoE) gene

ApoE-4

prefrontal cortex

temporal lobes

diencephalon

acetylcholine

glutamate

ribonucleic acid (RNA)

1072

calcium

zinc

lead

autoimmune theory

viral theory

Creutzfeldt-Jakob disease

biomarkers

vascular neurocognitive disorder

Huntington’s disease

Lewy body disease

donepezil

rivastigmine

galantamine

memantine

vitamin E

day-care facilities

assisted-living facilities

discrimination

long-term care

health-maintenance approach

Quick Quiz

1. What is geropsychology? What kinds of special pressures and upsets are faced by elderly persons? pp. 472–474

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. 474–475

1073

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? pp. 475–476

4. Describe and explain the kinds of substance misuse patterns that sometimes emerge among the elderly. pp. 476–478

5. What kinds of psychotic disorders may be experienced by elderly persons? p. 478

6. What is delirium? p. 479

7. How common are neurocognitive disorders among the elderly? Describe the clinical features and course of Alzheimer’s disease. pp. 480–483

8. What are the possible causes of Alzheimer’s disease? pp. 483–486

9. Can Alzheimer’s disease be predicted? What kinds of interventions are applied in cases of this and other neurocognitive disorders? pp. 486–490

10. What issues regarding aging have raised particular concern among clinicians? pp. 491– 492

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

1074

CHAPTER 16 Law, Society, and the Mental Health Profession

TOPIC OVERVIEW

1075

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

Within a Larger System

Dear 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 his

Secret Service detail pushed Reagan into the limousine, a police officer, the president’s press

secretary, and a Secret Service agent 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 of an individual does

1076

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

deinstitutionalization, 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—for

clinicians, it is the system that defines and often regulates their professional responsibilities. 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.

1077

#TheirWords “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, 2003

Law and Mental Health Two social institutions have a particularly

strong impact on the mental health

profession: 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 professionals 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 legislative and judicial systems act upon the clinical field, regulating certain aspects of mental

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 (Neal, 2018). 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.

forensic psychology The branch of psychology concerned with intersections between psychological practice and research and the judicial system. Also related to the field of forensic psychiatry.

How Do Clinicians Influence the Criminal Justice System?

1078

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 themselves 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.

criminal commitment A legal process by which people accused of a crime are instead 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.

In a second form of criminal commitment, people are judged mentally unstable at the time of

their trial and so are considered unable to understand the trial procedures and to 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 system that allow criminals to escape proper

punishment for wrongdoing. Others argue that a legal system simply cannot be just unless it

allows for extenuating circumstances, such as mental instability. The practice of criminal

commitment differs from country to country. In this chapter you will see primarily how it

operates in the United States. Although the specific principles and procedures of each country

may differ, most countries grapple with the same issues, concerns, and decisions that you will

read about here.

Criminal Commitment and Insanity During

1079

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, fifteen months after

he shot four men in the nation’s capital, a jury pronounced 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 (Brown, 2018; Hallevy, 2017). 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 definition 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 insanity 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.

M’Naghten test A legal test 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.

1080

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.

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.

irresistible impulse test A legal test 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.”

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 (Covey, 2017).

Durham test A legal test that holds people to be insane at the time they committed a crime if their act was the result of a mental disorder.

In 1955 the American Law Institute (ALI) formulated 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 to 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.

American Law Institute test A 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 right from wrong or could not resist an uncontrollable impulse to act.

Partly in response to this uproar, the American Psychiatric Association recommended in 1983

that people should be found not guilty by reason of insanity only if they did not know right from

1081

wrong at the time of the crime; an inability to control themselves and to follow the law should

no longer be sufficient grounds for a judgment of insanity. In short, the association was calling

for a return to the M’Naghten test. This test is now 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 confusion is a major feature may not

be able to tell right from wrong or to control their behavior. It is therefore not surprising that

more than 80 percent of defendants who are acquitted of a crime by reason of insanity qualify for

a diagnosis of schizophrenia or another form of psychosis (Melton et al., 2017, 2007). The

majority of these acquitted defendants 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 70 percent are violent crimes of some sort. At least 15 percent of those

acquitted are accused specifically of murder (see Figure 16-1).

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 acquitted on this basis had been charged

with a violent crime. (Information from: Melton et al., 2017, 2007; Perlin, 2017; Steadman et al., 1993; Callahan et al.,

1991.)

WHAT CONCERNS ARE RAISED BY THE INSANITY

1082

DEFENSE? Despite the changes in the insanity criteria, criticism of the insanity defense continues (Krauss et

al., 2018; Perlin, 2017). One concern is the fundamental difference between the law and the

science of human behavior. The law assumes that individuals 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 (Krauss et al., 2018). 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. 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 (Brown, 2018; Melton et al.,

2017, 2007).

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 defendant’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 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 (MHA,

2018; Melton et al., 2017, 2007; 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 (see

PsychWatch). It is also worth noting that in 80 percent of those cases in which defendants are

acquitted by reason of insanity, the prosecution has agreed to the appropriateness of the plea

(Gardner, Murrie, & Torres, 2018; MHA, 2018).

1083

PSYCHWATCH

Famous Insanity Defense Cases

Although the plea of not guilty by reason of insanity is used infrequently, some of the most famous cases

in history have featured this defense strategy. You have already read about the cases of John Hinckley and Andrea Yates.

Here are some other famous insanity defense cases:

1977 In Michigan, Francine Hughes poured gasoline around the bed where her husband 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 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 psychiatrists 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 multiple 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 and compared himself with Moses. Chapman was convicted of murder.

1992 Jeffrey Dahmer, a 31-year-old mass murderer in Milwaukee, was tried for the killings of 15 young men. Dahmer

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, twenty-four-year-old Lorena Bobbitt cut off her husband’s penis with a 12-inch kitchen knife

while he slept. During her trial, 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 raped her. In 1994, the jury found

her not guilty by reason of insanity. She was committed to a state mental hospital and released a few months later.

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 pleaded not guilty by reason of insanity in

2010, saying that he was acting out delusions (“revelations from God”) when he committed this crime. The jury found him

guilty of kidnapping in 2011 and sentenced him to life in prison without parole.

2015 In 2012, James Holmes, a 25-year-old neuroscience doctoral student, entered a cinema in Aurora, Colorado, and

opened fire on the moviegoers, killing 12 and wounding 20. In the months after his arrest, Holmes, who had no prior

criminal record, tried to kill himself three times. Holmes pleaded not guilty by reason of insanity, but a jury found him

guilty of murder in 2015 and sentenced him to life in prison without parole.

1084

After patients have been criminally committed to

institutions, why might clinicians be hesitant to later declare

them unlikely to commit the same crime again?

#TheAftermath

Daniel M’Naghten Judged not guilty by reason of insanity in

1843, M’Naghten lived in a mental hospital until his death 22

years later.

John Hinckley Judged not guilty by reason of insanity in

1982, Hinckley lived in a mental hospital until his release by a

federal judge in 2016.

Plea rejected James Holmes sits in a courtroom in Colorado in 2012, a few days after killing 12 moviegoers and

wounding 20 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.

2017 In 2014 two 12-year-old girls stabbed a classmate multiple times, saying they were trying to appease and impress

Slender Man, a mythical “boogie man” whom a number of Internet users report seeing and fearing in their everyday lives.

In separate 2017 trials, each of the assailants pleaded guilty to attempted intentional homicide, but in each case they were

further deemed to have been mentally ill at the time of the attack and were assigned to extended treatment in a mental

hospital rather than imprisonment.

During most of U.S. history, a

successful insanity plea amounted to the

equivalent of a long-term prison sentence.

In fact, on average, treatment in a mental

hospital resulted in confinement that was

twice as long as imprisonment for the same crime would have brought (Perlin, 2017). 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

released from mental hospitals earlier and

earlier. This trend is the result of the

increasing effectiveness of drug therapy

and other treatments in institutions, the

growing reaction against extended

1085

institutionalization, and more emphasis

on patients’ rights (Gowensmith et al., 2017). 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. Adopting a procedure called “outpatient

commitment,” the states may insist on community treatment, monitor the patients closely, and

rehospitalize them if necessary (Corring et al., 2018; Gowensmith et al., 2017).

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 recommendation that they also undergo

treatment if necessary.

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.

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 (MHA, 2018; 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.

1086

“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.

Some states allow still another kind of defense, guilty with diminished capacity, in which a

defendant’s mental dysfunction 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 (ABA, 2018,

2017; Slovenko, 2011). The defense lawyer argues that because of mental dysfunction, 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.

1087

Defense attorney Douglas Schmidt argued that a patriotic, civic-minded man like Dan White—high school athlete,

decorated war veteran, former fireman, policeman, 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 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 psychiatry 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)

1088

#FollowUp

Released from prison in 1984, Dan White died by suicide in

1985.

Justice served? People held mass protests in San Francisco after Dan White was convicted of voluntary manslaughter rather

than premeditated murder in the 1978 killings of Mayor George Moscone and Supervisor Harvey Milk, who was one of the

nation’s leading gay activists. The verdict highlighted the serious pitfalls of the “diminished capacity” defense and has led to

a significant decrease in its use.

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 (MHA, 2018).

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 (Lewis & Dwyer, 2018; Sanders, 2016). 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.

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

1089

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 abolishing 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 declare that in order to be classified as a

mentally disordered sex offender, the person must be a good candidate for treatment, another

judgment that is difficult for clinicians to make, especially for this population (Marshall &

Marshall, 2016; 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

non-Hispanic white Americans much more often than to members of racial and ethnic minority

groups. Non-Hispanic white Americans are twice as likely as African 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

(Feldman, 2017), 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) (MHA, 2018). These

relatively 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 committed

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”

(MHA, 2018). That is, in contrast to the mentally disordered sex offender laws, which call for

sex offenders to receive treatment instead of imprisonment, the sexually violent predator laws

require certain sex offenders to receive imprisonment and then, in addition, be committed 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 Regardless 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

1090

understand the charges they are facing and can work with their lawyers to prepare and conduct

an adequate defense (Reisner & Piel, 2018). This minimum standard of competence was

specified by the Supreme Court in the case of Dusky v. United States (1960).

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.

Incompetent to stand trial In 2014, Alton Nolen beheaded a co-worker and tried to behead another at a food plant in

Oklahoma. The defendant was ruled incompetent to stand trial until 2017, at which time he pled guilty and requested to

receive the death penalty.

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 (Judd & Parker,

1091

2018; Reisner & Piel, 2018). 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 (Faubion, 2016; Bartol &

Bartol, 2015). Approximately 20 to 25 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.

TABLE: 16-1 Race and Forensic Psychology Racial/Ethnic Minority Individuals Non-Hispanic White Individuals

Psychologically disturbed law breakers more likely to be sent to prison. Defendants more likely to be judged incompetent to stand trial. Individuals more likely to be ordered into involuntary mental hospital commitment. Individuals more likely to be ordered into involuntary outpatient commitment.

Psychologically disturbed law breakers more likely to be sent to mental health facilities. Defendants less likely to be judged incompetent to stand trial. Individuals less likely to be ordered into involuntary mental hospital commitment. Individuals less likely to be ordered into involuntary outpatient commitment.

Information from: Judd & Parker, 2018; APA, 2017; Kisely & Xiao, 2017; Fraser, 2016; NCBH, 2015; Zaejian, 2014;

Swanson et al., 2009; Haroules, 2007; Pinals et al., 2004.

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 in Tucson, Arizona, and

opened fire on 20 persons. Six people 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 (Kaneya, 2017; Roesch, 2016). However, the

majority of criminals currently institutionalized for psychological 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 (Ollove, 2017; Fazel et al., 2016) (see Figure 16-2).

1092

FIGURE 16-2

Prison and Mental Health

According to studies in several Western countries, psychological disorders are much more prevalent in prison populations

than in the general population. For example, schizophrenia and personality disorders (particularly antisocial personality

disorder) are each four times more common among prisoners than among nonprisoners. (Information from: Stürup-Toft,

O’Moore, & Plugge, 2018; NIMH, 2017; Bukstein, 2016; Fazel et al., 2016.)

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

awaiting 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 incompetent 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 community for mental health care

1093

(Boutros, Kang, & Boutros, 2018).

SUMMING UP

HOW DO CLINICIANS INFLUENCE THE CRIMINAL JUSTICE SYSTEM?

Mental health professionals may help assess the mental stability of people accused of crimes. 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, which holds that defendants were insane at the time of a

criminal act if they did not know the nature or quality of the act or did not know right from wrong at the time they

committed it. 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. Depending on state laws, it is also

the case that sex offenders may receive treatment as mentally disordered sex offenders, or, more commonly, under the

state’s sexually violent predator law.

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 understanding the charges or legal proceedings that confront them. These

defendants are commonly 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.

civil commitment A legal process by which a person can be forced to undergo mental health treatment.

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 treatment voluntarily, even on an outpatient

basis.

Civil Commitment

1094

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 46 states also

have some form of outpatient civil commitment laws that allow patients to be forced into

community treatment programs (Tabas et al., 2017; TAC, 2017). Canada and Great Britain

have similar laws. Civil commitments have long caused controversy and debate. In some ways the

law provides more protection for people suspected of being criminals than for people suspected

of being psychotic.

WHY COMMIT? Generally our legal system permits involuntary commitment of individuals 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.

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

straightforward. 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.

1095

“The Taser solution” Police often use Tasers—stun guns that affect neuromuscular control and temporarily incapacitate

individuals—to subdue people with mental disorders. To help officers appreciate the impact of this weapon, the Los Angeles

Police Department has new recruits—such as Officer Vanessa Lopez—receive a Taser charge during training. Mental health

advocates view Tasers as an inhumane intervention when dealing with extremely confused or frightened people.

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. That is, whatever the state’s criteria, clinicians must offer clear and

convincing proof that the person meets those criteria (Hille, 2017). 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

1096

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

patients makes them dangerous to themselves or others. By tradition, the certifications are often

referred to 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 (Frances & Ruffalo, 2018; Hedman et

al., 2016). Should clinicians come to believe that a longer stay is necessary, formal commitment

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.

Dangerous to oneself There are various ways that people may be dangerous to themselves, in need of treatment, and subject

1097

#BetterInterventions

Many police now receive Crisis Intervention Team (CIT)

training to help them respond more knowledgeably and

effectively when dealing with people who have mental

disorders. The police undergo 40 hours of intensive training

regarding mental conditions, medications, and community

resources, and they develop skills at verbal de-escalation. There

are now 2,800 CIT programs across the United States—offered

in 15 percent of all police jurisdictions (NAMI, 2018; Lucas,

2016).

to civil commitment. 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.

It is important to be clear that, according to research, the vast majority of people with mental

disorders (90 percent) are in no way violent or dangerous, and only a small percentage of all

violent acts (3 percent) are committed by people with mental disorders (HHS, 2017; Frances,

2016). That said, recent studies do suggest that people with severe mental disorders are

somewhat more likely than the general population to perform violent behaviors (Dai et al.,

2017). The disorders with the strongest relationships to violence are severe substance use

disorder, impulse control disorder, antisocial personality disorder, and psychotic disorders

(Bonnet et al., 2017; Moore & Pfaff, 2017). 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 determination 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

(Galán et al., 2018; Miller & Hanson,

2016). Most often they overestimate the

likelihood that a patient will eventually be violent. Their short-term predictions—that is,

predictions of imminent violence—tend to be more accurate (Fazel et al., 2017). 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 (Ramesh et al., 2018).

WHAT ARE THE PROBLEMS WITH CIVIL COMMITMENT? Civil commitment has been criticized on several grounds (Jain, Christopher, & Appelbaum,

2018; Miller & Hanson, 2016). First is the difficulty of assessing a person’s dangerousness. If

judgments of dangerousness 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.

1098

How are people who have been institutionalized viewed and

treated by other people in society today?

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 is often done in countries ruled by authoritarian governments, where

mental hospitals house people with unpopular political views. A third problem is the sometimes

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 substance use disorders might violate the Constitution’s ban on cruel and unusual

punishment, and it recommended involuntary civil commitment to a mental hospital as a more

reasonable 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 hospital commitment, and, as

mentioned earlier, many launched outpatient commitment programs in which courts may order

people with severe mental disorders into community treatment (Corring et al., 2018). In turn,

rates of involuntary hospital commitment 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 (Tingle, 2018; Miller & Hanson, 2016).

1099

Hospital neglect While some countries increasingly have attended to the rights of patients, including their rights to

treatment and to humane treatment conditions, other countries, especially poor ones, have lagged behind. For example,

although the government of Indonesia banned pasung—the chaining or close-quarter confinement of mentally ill persons—

back in 1977, the practice apparently continues today. This scene inside a center for mental patients in Jakarta underscores

the point.

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 the patients’ 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.

right to treatment The legal right of patients, particularly those who are involuntarily committed, to receive adequate treatment.

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. Donaldson repeatedly had sought release and had been

1100

overruled by the institution’s psychiatrists. 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 dangerous 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 U.S. territories and gave public advocates who worked for patients the power to investigate

possible abuse and neglect and to correct those problems legally.

In more 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 communities ill-equipped to care for them. Many such people have

no place to go and are unable to care for themselves, often winding up homeless or in prisons

(Allison et al., 2017; MIP, 2017). A number of advocates are now suing 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

institutions, have the right to refuse treatment. 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.

right to refuse treatment The legal right of patients to refuse certain forms of treatment.

1101

Prisoners also have a right to treatment These prisoners, all military veterans, at the San Diego County jail are receiving

day-long classes on subjects like anger management and PTSD. Many prisoners in the United States have psychological

disorders, and the Supreme Court has upheld their right to receive treatment during their incarceration. However, prison

systems are often ill-equipped to provide proper care.

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, but it can cause great upset and can also be misused. Today

many states grant patients—particularly voluntary patients—the right to refuse ECT (NARPA,

2018; OPA, 2016). 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.

1102

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 produce effects that are

unwanted and dangerous. As these harmful effects have become more apparent, some states have

granted patients the right to refuse medication (Virdi & Weiss, 2017; OPA, 2016). 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 medications 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 being cleared?

1103

Executing the mentally ill Charles Singleton, a man who killed a store clerk in Arkansas, was sentenced to death in 1979,

and then he developed schizophrenia at some point after the trial. Since the United States does not allow executions if

persons cannot understand why they are being executed, state officials wanted Singleton to take medications to clear up his

psychosis. Eventually, Singleton chose to take medications voluntarily, showed psychological improvement, and was

executed by lethal injection in 2004.

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’ overriding 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.

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 involuntary commitment of people considered to be in need of treatment and dangerous

to themselves or others. Laws governing civil commitment procedures vary from state to state, but the Supreme Court

has ruled that in order for individuals to be committed there must be clear and convincing proof that they are

1104

#FamousCase After shooting and killing two men on a busy street in 1995,

delusional law student Wendell Williamson was found not

guilty by reason of insanity and institutionalized for treatment.

He later sued the psychiatrist who had been treating him before

the killings, contending that the therapist had made an

incorrect diagnosis and failed to arrange follow-up services

when therapy ended. In 1998 a jury awarded Williamson a

judgment of $500,000.

mentally ill and meet their state’s criteria for involuntary commitment. In addition to mental hospital commitment,

many states have established outpatient civil commitment programs.

The courts and legislatures significantly affect the mental health profession by specifying legal rights to which

patients are entitled, including 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 consultation, 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 (Reuveni et al., 2017; Pope & Vasquez, 2016). Studies suggest that malpractice

suits, or the fear of them, can have significant effects on clinical decisions and practice, for better

or for worse.

malpractice suit A lawsuit charging a therapist with improper conduct in the course of treatment.

Professional Boundaries

Over the past 25 years, the legislative and

judicial systems have helped change the

boundaries that distinguish one clinical

profession from another. In particular,

they have given more authority to

psychologists and blurred the lines that

once separated psychiatry from

psychology. A growing number of states,

for example, are ruling that psychologists

can admit patients to hospitals, a power previously held only by psychiatrists.

1105

Most psychiatrists oppose the idea of prescription rights for

psychologists. Why do some psychologists also oppose the

idea?

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 previously 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 pursue extensive educational and training

programs in prescription services and receive certification to prescribe medications if they pass.

New Mexico, Louisiana, Illinois, Iowa, Idaho, and the U.S. territory of Guam now do grant

prescription privileges to psychologists who receive special pharmacology training (APA, 2018,

2017).

Jury Consultation During the past 30 years, more and more lawyers have turned to clinicians for psychological

advice in conducting trials (Kovera, 2017; Gomez, 2016). 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 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 simulations 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 70 percent of such

wrongful convictions were based in large part on mistaken eyewitness testimony (Innocence

1106

#TVProfilers

Criminal Minds (current)

Mindhunter (current)

Project, 2017).

Most eyewitnesses undoubtedly try to tell the truth about what or whom they saw. Yet

research indicates that eyewitness testimony can be highly unreliable, partly because eyewitnesses

sometimes hold subtle biases and partly because most crimes are unexpected and fleeting and

therefore not the sort of events remembered well (Carpenter & Krendl, 2018; Wade, Nash, &

Lindsay, 2018). 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.

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 identified man was released. In the meantime, however, he had served 11 years of a life sentence in

prison.

In laboratory studies, researchers have found it easy to fool participants who are trying to

recall the details of an observed event simply by introducing misinformation (Loftus, 2017;

Rindal et al., 2017). 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.

In addition, laboratory studies indicate that persons who are highly suggestible have the poorest

recall of observed events (Liebman et al., 2002).

As for identifying actual perpetrators,

research has found that accuracy is heavily

influenced by the method used in

1107

Killing Eve (current)

Luther (current)

Law and Order: SVU (current)

The Mentalist (recent)

Psych (recent)

identification (Smith et al., 2018; Wixted

& Wells, 2017). For example, police

lineups, particularly ones conducted

poorly, are not always reliable, and the

errors that witnesses make when looking

at lineups tend to stick (Taubert, van

Golde, & Verstraten, 2017; Wells et al.,

2015, 2011). Researchers have also

learned that the confidence of witnesses is not consistently related to accuracy (Wixted & Wells,

2017). 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 (Loftus & Greenspan, 2017).

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. Instructions to

jurors about the accuracy of eyewitness confidence may now be included in eyewitness cases

(Cash & Lane, 2017). In addition, studies of hypnosis and of its ability to create false memories

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 thirties, 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 in recent decades; however, it is not nearly as revealing or influential as the media and

the arts would have us believe (Keatley et al., 2018; Kapardis, 2017).

On the positive side, researchers have gathered information about the psychological 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 profile information to a particular crime can be wrong and misleading

(Fox, Levin, & Fridel, 2018). Increasingly, police are consulting psychological profilers, and this

1108

practice appears to be helpful as long as the limitations of profiling are recognized.

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

non-Hispanic 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.

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. As it

turned out, psychological profiling in this famous case offered little help and even misled the police.

PSYCHWATCH

Serial Murderers: Madness or Badness?

On April 24, 2018, police arrested former police officer Joseph James DeAngelo outside his home near

Sacramento, California. Based on DNA evidence, they accused DeAngelo of being the so-called Golden State Killer, a

murderer of at least 12 people in separate incidents during a crime spree that terrorized Californians from 1974 to 1986. If

convicted, DeAngelo would join a growing list of serial killers who have fascinated and horrified the public over the years:

1109

Bruce Ivins (“anthrax killer”), Theodore Kaczynski (“Unabomber”), Ted Bundy, David Berkowitz (“Son of Sam”), Albert

DeSalvo (“Boston Strangler”), John Wayne Gacy (“Killer Clown”), Jeffrey Dahmer (“Milwaukee Cannibal”), Dennis Rader

(“BTK killer”), and more.

Serial sentences for serial murders During a trial in 2016, court deputies watch over Charles Severance, an eccentric

history buff accused of killing three people in Alexandria, Virginia, between 2003 and 2014 simply because they were

relatively affluent. Severance was found guilty for his serial killings and given three consecutive life sentences.

By definition, serial killers commit a series of murders (3 or more) in separate incidents over an extended period of

time. They are different from mass killers, whom you read about in Chapter 13—individuals who murder four or more

people at a single time, usually in a single location (see page 408).

The FBI estimates that there are between 25 and 50 serial killers at large in the United States at any given time (FBI,

2017, 2014). Worldwide, 4,500 such killers have been identified since the year 1900 (Aamodt, 2016, 2014).

Each serial killer follows his or her own pattern, but many of them appear to have certain characteristics in common

(Fox et al., 2018; Johnston, 2017). The majority—but certainly not all—are non-Hispanic white males between 30 and 45

years old, of average to high intelligence, seemingly clean-cut, smooth-talking, attractive, and skillful manipulators.

Close to half of serial killers seem to have severe personality disorders (Fox et al., 2018; FBI, 2017, 2014). Lack of

conscience and an utter disregard for people and the rules of society—key features of antisocial personality disorder—are

typical. Narcissistic thinking is quite common as well. Feelings of being special may even give the killers an unrealistic belief

that they will not get caught (Fox et al., 2018; Kocsis, 2008). Often it is this sense of invincibility that leads to their

capture.

Sexual dysfunctions, paraphilic disorders, and fantasies also seem to play a part (Fox et al., 2018; FBI, 2017, 2014).

1110

Studies have found that vivid fantasies, often sexual and sadistic, may help drive the killer’s behavior. Some clinicians also

believe that the killers may be trying to overcome general feelings of powerlessness by controlling, hurting, or eliminating

those who are momentarily weaker. A number of the killers were abused as children—physically, sexually, and/or

emotionally (Keatley et al., 2018).

Law enforcement agencies and behavioral researchers have gathered an impressive body of statistical information about

serial killings and killers in recent years. This data is often of help to criminal investigators as they seek to capture these

repeat perpetrators of particularly heinous acts. At the same time, it would be inaccurate to say that clinical theorists

understand why serial killers behave as they do.

SUMMING UP

OTHER CLINICAL–LEGAL INTERACTIONS Mental health and legal professionals 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 mental health professionals regarding the selection of jurors and case strategies.

Fourth, psychologists may investigate legal phenomena such as eyewitness testimony and patterns of criminality.

1111

What Ethical Principles Guide Mental Health Professionals? Discussions of the legal and mental health systems may sometimes give the impression 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 clinicians care greatly about their clients

and strive to help them while at the same time respecting their rights and dignity (Mazulla &

LiVecchi, 2018; Pope & Vasquez, 2016, 2011). In fact, clinicians do not rely exclusively on the

legislative and court systems to ensure proper and effective clinical practice. They also regulate

themselves by continually developing and revising ethical 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.

The ethics of giving professional advice Today’s psychologists are bound by the field’s ethics code to base their advice on

psychological 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 judgment when giving advice on television and in books.

Each profession within the mental health field has its own code of ethics. The code of the

American Psychological Association (2017, 2010, 2002) is typical. This code, highly respected by

1112

other mental health professionals and public officials, includes specific guidelines:

1. Psychologists are permitted to offer advice online, in self-help books, on DVDs, on television and radio programs, in newspapers and magazines, through mailed material, and in other places, provided they do so responsibly and professionally and base their advice on appropriate psychological literature and practices. Of these, Internet-based professional advice has proved particularly difficult to regulate, because the number of online clinical offerings keeps getting larger and larger and so many advice-givers do not appear to have any professional training or credentials.

2. Psychologists may not conduct fraudulent research, plagiarize the work of others, or publish false data. During the past 30 years, cases of scientific fraud or misconduct have been discovered in all of the sciences, including psychology. These acts have led to misunderstandings 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 knowledgeable 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 individual in question is not possible, psychologists must make clear the limited nature of their testimony.

5. Psychologists may not participate or assist in torture—acts in which severe pain, suffering, or degradation is intentionally inflicted on people. This guideline was added to the code of ethics in 2017, a year after an APA-sponsored evaluation revealed that, over a period of several years, the APA had aided and advised the Department of Defense and the Central Intelligence Agency in the development of “enhanced interrogation” techniques (that is, torture-based questioning) and had adjusted professional guidelines to allow psychologist involvement in such interrogations (see Trending).

6. Psychologists may not take advantage of clients and students, sexually or otherwise. This guideline relates to the widespread 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 permitted only in “the

1113

Can you think of other instances in which the principle of

therapy confidentiality should be broken?

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 & Wedding, 2019; Pope & Vasquez, 2016, 2011).

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 & Wedding, 2019; Pope & Vasquez, 2016, 2011). 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.

7. Psychologists must follow the principle of confidentiality. All of the state and federal courts have upheld laws protecting therapy confidentiality (Ashton & Sullivan, 2018; Skodol & Bender, 2018). 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 confidentiality must be compromised (Pope & Wedding, 2019; Middleman & Olson, 2017). 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.

A second exception arises in cases

of outpatients who are clearly

dangerous. 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.

1114

#LegalKnowledge 75% Percentage of psychologists who are misinformed about

their legal responsibilities regarding potentially dangerous clients.

90% Percentage of same psychologists who feel confident that their legal knowledge in this realm is accurate.

(Information from: Thomas, 2014)

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 without 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 (Adi & Mathbout, 2018; Middleman &

Olson, 2017).

code of ethics A body of principles and rules for ethical behavior, designed to guide decisions and actions by members of a profession. confidentiality The principle that certain professionals will not divulge the information they obtain from a client. 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.

TRENDING

Doctor, Do No Harm

The Hippocratic Oath requires that doctors, first and foremost, “do no harm”—a principle also embraced by the

code of ethics for each mental health profession. However, recent developments suggest that in the realm of torture, some

psychologists have indeed done harm to individuals.

A 2014 book entitled Pay Any Price, a 2015 Senate Select Committee investigation, a 2015 report called the Hoffman

Report, and a 2017 lawsuit have collectively indicated that certain psychologists and, indeed, the American Psychological

Association (APA) participated for several years in the Central Intelligence Agency’s program of enhanced interrogation, or

torture-based questioning, to obtain information from suspected terrorists (Wise, 2018; APA, 2017; Bailey, 2017; Fink &

Risen, 2017; Melechi, 2016; Patel & Elkin, 2015). Here are key events revealed by these sources:

1115

No place for psychologists Protestors at an APA conference rally against psychologist involvement in CIA enhanced

interrogation programs.

In 2002, shortly after the September 11, 2001 terrorist attacks in New York City and Washington, DC, the White

House gave approval to a CIA program of “enhanced interrogation” of national security prisoners, or “detainees.” In a

series of so-called torture memos, it stated that enhanced interrogations could indeed proceed if consulting mental health

experts indicated the procedures were not causing or likely to cause significant physical injury or severe mental distress.

Later in 2002, two psychologists, commissioned by the CIA, developed a package of enhanced interrogation

procedures (including sleep deprivation, repeated waterboarding, physical assault, binding in stressful positions, deafening

noise, and imprisonment in a box), and the CIA tested those procedures on a prisoner with possible ties to the terrorist

organization Al Qaeda. Officials declared the test a success and, from that point forward, enhanced interrogations became

an accepted national security policy. The two psychologists continued to serve as major advisers for the CIA program.

In order for the enhanced interrogation program to proceed, the CIA needed a number of psychologists to observe the

interrogations and declare them acceptable, as well as ongoing advice and input from various psychologists to further

develop the program. As a result, the CIA and key administrators at the APA developed a cooperative relationship that

continued for several years. Although the APA did not participate in the actual administration of torture procedures, some

of its administrators did have a series of communications, discussions, and brainstorming sessions with the CIA about the

enhanced interrogation program and the possible role of psychologists.

Perhaps most damning, certain APA administrators manipulated the language of the organization’s code of ethics,

apparently to allow individual psychologists to participate in the enhanced interrogation program without fear of being

accused of professional wrongdoing. After all, psychologists could not work with the program if that meant they were

violating their profession’s ethical standards. This concern disappeared in 2005 when the APA’s “Presidential Task Force

on Ethics and National Security” (PENS) ruled, in subtle language, that psychologists are not violating their “do no harm”

obligation if they do not break any laws in their work, including possible work in the realm of enhanced interrogations.

That is, even if their enhanced interrogation involvement contributed to the development of PTSD, anxiety disorders,

depression, or the like, the psychologists would not be violating their profession’s ethical principles.

Some members of the APA recognized that the subtly worded PENS ruling allowed psychologists to participate in the

1116

CIA torture-based program, and, in the ensuing years, as the relationship between certain APA officials and the CIA

continued and while the APA continued to deny the organization’s involvement in or endorsement of the torture-based

program, these astute APA members protested the APA’s likely involvement with the CIA.

All this came to a head in 2014, when the stunning developments mentioned earlier began to unfold in quick

succession. Since those revelations, several of the APA administrators linked to the enhanced interrogation discussions have

resigned. (In 2017, those former administrators sued the authors of the Hoffman Report for incorrectly characterizing their

actions and for defaming them.) Also in 2017, the two psychologists who initiated and implemented the CIA’s enhanced

interrogation program beginning back in 2002 reached a court settlement with three tortured national security prisoners

who had sued them.

Finally, the APA, with its members now fully informed about what had unfolded, sought to end this ugly episode and

to ensure that it would not occur again. Most importantly, the entire APA membership voted to bar psychologists from

direct and indirect involvement in any national security interrogations—both enhanced and noncoercive. In so doing, it

was reaffirming that, even in a complex and dangerous world, a primary obligation of psychologists is to “do no harm” of

any kind to individuals.

1117

Mental Health, Business, and Economics The legislative and judicial systems are not the only social institutions with which mental health

professionals interact. 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 According to numerous surveys, work is by far the leading source of stress for people (APA,

2018; AIS, 2017). Over 40 percent of workers find their jobs very stressful and believe them to

be bad for their mental health and general health (AIS, 2017; HSPH, 2016). Stressed-out

workers report that the primary causes of their upsets are excessive workload (46 percent of

workers), people and personnel issues (28 percent), difficulties balancing work with home life (20

percent), and lack of job security (6 percent) (APA, 2018; AIS, 2017).

“My life has become a tangled web of fictitious user names and fiendishly clever passwords.”

All this stress not only affects the home life and personal functioning of employees. It also

impairs performance in the workplace. Indeed, 60 percent of absences from work can be traced,

directly or indirectly, to stress and related mental health issues (APA, 2018; HSPH, 2016).

Furthermore, studies find that stress at work contributes to poorer productivity and more

1118

accidents, employee mistakes, employee departures, insurance costs, and worker compensation

expenses (AIS, 2017; White, 2015).

For both humane and financial reasons, many employers try to address the work-related stress

and other mental health needs of their employees. Two common approaches, provided by about

half of employers, are employee assistance programs and stress reduction programs (McRee, 2017;

HSPH, 2016). Employee assistance programs are mental health services made available by a

place of business. They are run either by mental health professionals who work directly for a

company or by outside mental health agencies. Stress-reduction and problem-solving programs

are workshops or group sessions in which mental health professionals teach employees techniques

for coping, solving problems, and handling and reducing stress. As you read in Chapter 2, one of

today’s most common such techniques is mindfulness training, offered by around one-third of

employers (see pages 53–54). Businesses believe that employee assistance and stress reduction

programs save them money in the long run by preventing psychological problems from

interfering with work performance and by reducing employee insurance claims, a notion that has

been supported in various studies (Richmond et al., 2017). And, for their part, at least half of

workers agree that they need help learning how to manage stress (AIS, 2017).

employee assistance program A mental health program offered by a business to its employees. stress-reduction and problem-solving program 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.

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 consideration in the country’s

deinstitutionalization movement, which contributed to 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 $152

billion today (SAMHSA, 2017, 2014). Around 28 percent 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. The result is that government funding for

mental health services is, in fact, insufficient. People with severe mental disorders are hit hardest

1119

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, and that number has increased still more over

the past decade, according to individual state reports (Morris, 2017; NCBH, 2017).

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 residents with severe

mental disorders losing their group homes and having nowhere to live.

Government funding currently covers 63 percent of all mental health services, leaving a

mental health expense of tens of billions of dollars for individual patients and their private

insurance companies (SAMHSA, 2017, 2014). 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 insurance company determines which therapists clients

may choose from, the cost of sessions, and the number of sessions for which a client may be

reimbursed (Bowers et al., 2017, 2016). These and other insurance plans may also control

expenses through the use of peer review systems, in which clinicians who work for the insurance

company periodically 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.

1120

What are the costs to clients and practitioners when

insurance companies make decisions about the methods,

frequency, and duration of treatment?

#InsuranceRejection

55% Percentage of psychiatrists willing to accept insurance payments.

93% Percentage of all other kinds of physicians who accept insurance payments.

(Information from: Pettypiece, 2015; Pear, 2013)

managed care program An insurance program in which the insurance company decides the cost, method, provider, and length of treatment. peer review system A system by which clinicians paid by an insurance company may periodically review a patient’s progress and recommend the continuation or termination of insurance benefits.

As you also read in Chapter 1, many

therapists and clients dislike managed care

programs and peer reviews (Kornack,

Herscovich, & Williams, 2017; Decker,

2016). 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 (Bowers et al., 2017, 2016). As in the

medical field, there are disturbing stories about patients who are prematurely cut off from mental

health services by their managed care programs.

Yet another major problem with

insurance coverage in the United States—

whether managed care or other kinds of

insurance programs—is that

reimbursements for mental disorders are,

on average, lower than those for physical

disorders, placing people with

psychological difficulties at a significant

disadvantage (Thalmayer et al., 2018). As you have read, the federal government tried to address

this problem from 2008 through 2016 (see page 18). In 2008 Congress passed a parity law that

mandated equal insurance coverage for mental and physical problems, and in 2014 the mental

health provisions of the Affordable Care Act (“Obamacare”) expanded the reach of the earlier

bill. If, however, efforts in Congress to change or repeal the Affordable Care Act eventually

succeed, it is possible that the federal mandates for parity in mental health insurance coverage

will, likewise, be discontinued.

1121

1122

Technology and Mental Health As you have seen throughout this book, today’s ever-changing technology has had significant

effects—both positive and negative—on the mental health field, and it will undoubtedly affect

the field even more in the coming years.

Our digital world provides new triggers for the expression of abnormal behavior. The

maladaptive functioning of many persons with gambling disorder, for example, has been

exacerbated by the ready availability of Internet gambling (see page 325). Similarly, the Internet,

texting, and social networking are now used frequently by those who wish to stalk or bully

others, express sexual exhibitionism, pursue pedophilic desires, or satisfy other paraphilic

disorders (see pages 348, 437). And, in the opinion of many clinicians, constant texting,

tweeting, and Internet browsing may help shorten people’s attention spans and establish a

foundation for attention problems.

Beyond providing new triggers for abnormal behavior, research indicates that today’s

technology also is helping to produce new psychological disorders. As you read in Chapter 10,

one such pattern is Internet use disorder, a problem marked by excessive and dysfunctional levels

of texting, tweeting, networking, Internet browsing, e-mailing, blogging, online shopping, or

online pornographic use (Lindenberg et al., 2018) (see page 326). The framers of DSM-5 have

suggested that this disorder be considered for possible inclusion in future revisions of the DSM.

Similarly, the Internet has brought a new exhibitionistic feature to certain kinds of abnormal

behavior. For example, as you read in Chapter 7, a growing number of people now use social

networking to post videos of themselves engaging in self-cutting or suicidal acts, acts that

traditionally had been conducted in private (see pages 214–216).

There is also a growing recognition among clinical practitioners and researchers that even

everyday social networking can contribute to psychological dysfunction. In addition to its many

virtues, social networking may, according to research, provide a new venue for peer pressure and

social anxiety in some adolescents (Gao et al., 2018; Levula et al., 2018). It may, for example,

cause some people to develop fears that others in their network will exclude them socially.

Similarly, clinicians worry that social networking may lead shy or socially anxious people to

withdraw from valuable face-to-face relationships.

As you have read throughout this textbook, the face of clinical treatment has also expanded in

our fast-moving digital world. Telemental health, the use of various technologies to deliver mental

health services without the therapist being physically present, is now common (Comer et al.,

1123

2019, 2017; Adams et al., 2018). It takes such forms as long-distance therapy between clients

and therapists using videoconferencing (see page 446), therapy offered by computer programs,

treatment enhanced by the use of video game–like avatars and other virtual reality experiences

(see pages 63, 118, 155), and Internet-based support groups (see pages 20, 63). In addition, of

the hundreds of thousands of new apps created over the past five years, a number are devoted to

helping people relax, cheer up, or track their shifting moods and thoughts (see pages 193–194).

And many computer exercise programs—cognitive and physical—have been developed with the

goal of improving both mental health (particularly, cognitive functioning and mood) and

physical health (see page 489).

Extending psychology’s reach A child meets with a psychologist (left on screen) and physician (right) located several towns

away. Long-distance therapy by videoconferencing is an increasingly used form of telemental health.

Similarly, numerous Web sites now offer useful mental health information, enabling people to

better inform themselves, their friends, and their family members about psychological problems

and treatment options (see page 20). Unfortunately, along with this wealth of online information

comes considerable misinformation about psychological problems and their treatments, offered

by persons and sites that are far from knowledgeable or noble. The issue of quality control is also

a major problem for Internet-based therapy, support groups, and the like, and there are now

numerous antitreatment networks, such as the pro-suicide and pro-Ana networks you read about

in Chapters 7 and 9, that try to guide people away from seeking help for their psychological

problems (see pages 216, 277).

1124

What ethical concerns or problems might emerge as a result

of the mental health field’s increasing use of new

technologies?

Clearly, the growing impact of

technological change on the mental health

field presents formidable challenges for

clinicians and researchers alike. Few of the

technological applications discussed

throughout this book are well understood, and few have been subjected to comprehensive

research. Yet, as we mentioned earlier, the relationship between technology and mental health is

growing precipitously. It behooves everyone in the field to understand this growth and its

implications.

1125

#TheirWords “Relativity applies to physics, not ethics.”

Albert Einstein, physicist, Theory of Relativity

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). 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.

INFOCENTRAL PERSONAL AND PROFESSIONAL ISSUES

Like everyone else, clinicians have personal needs, perspectives, goals, and problems, each of

which may affect their work. Therapists 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 influence how clinicians deal with clients.

1126

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, 2019; Pope & Vasquez, 2016). Their

reasons are largely the same as those of other clients, with relationship problems, depression, and

anxiety topping the list. And, like other people, therapists often are reluctant to acknowledge

their psychological problems.

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

1127

#TheirWords “After doing psychology for half a century, my passion for all

of it is greater than ever.”

Phillip Zimbardo, influential psychologist, Stanford Prison

Experiment

burnout (Hammond, Crowther, & Drummond, 2018). 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, clinicians 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, 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?

“Oops! I just deleted all your files. Can you repeat everything you’ve ever told me?”

1128

SUMMING UP

ETHICAL, ECONOMIC, TECHNOLOGICAL, AND PERSONAL FACTORS Each clinical profession has a code of ethics. The psychologists’ code includes prohibitions against engaging in

fraudulent research, taking advantage of clients and students (sexually or otherwise), and participating or assisting in

enhanced interrogation programs. It also establishes guidelines for respecting patient confidentiality. The case of

Tarasoff v. Regents of the University of California helped determine the circumstances in which therapists have a duty

to protect the client or others from harm and must break confidentiality.

Clinical practice and study also intersect with the business and economic worlds. Clinicians may be called upon

to address psychological problems in the workplace. In addition, private insurance companies often set up managed

care programs whose procedures influence—sometimes adversely—the length, focus, confidentiality, and quality of

therapy.

The technological advances of recent times have affected the mental health field by contributing to new triggers

for psychopathology, new forms of psychopathology, and various kinds of telemental health.

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 direction and even quality of their work.

1129

#TheirWords “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

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 positive or

negative, like a family’s impact on each of its members. When the system protects 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

knowledge, especially during the past

several decades. What mental health professionals 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 unfolding.

1130

1131

Chapter 16 Review

Key Terms

forensic psychology

criminal commitment

not guilty by reason of insanity (NGRI)

M’Naghten test

irresistible impulse test

Durham test

American Law Institute (ALI) test

guilty but mentally ill

guilty with diminished capacity

mentally disordered sex offenders

sexually violent predator laws

mental incompetence

civil commitment

outpatient civil commitment

two-physician certificate (2 PC)

dangerousness

right to treatment

right to refuse treatment

malpractice suit

professional boundaries

jury consultation

eyewitness testimony

1132

psychological profiles

code of ethics

enhanced interrogation

confidentiality

duty to protect

employee assistance programs

stress-reduction and problem-solving programs

managed care program

peer review system

telemental health

Quick Quiz

1. Briefly explain the M’Naghten, irresistible impulse, Durham, and ALI tests of insanity. Which tests are used today to determine whether defendants are not guilty by reason of insanity? pp. 496–498

2. Explain the guilty but mentally ill, diminished capacity, mentally disordered sex offender, and sexually violent predator verdicts and laws. pp. 501–502

3. What are the reasons behind and the procedures for determining whether defendants are mentally incompetent to stand trial? pp. 502–503

4. What are the reasons for civil commitment, and how is it carried out? What criticisms have been made of civil commitment? pp. 504–506

5. What rights have court rulings and legislation guaranteed to patients with psychological disorders? pp. 506–508

6. How do the legislative and judicial systems affect the issue of professional boundaries of clinical practice? p. 509

7. What have clinical researchers learned about eyewitness memories and about patterns of criminality? How accurate and influential is the practice of psychological profiling in criminal cases? pp. 509–511

1133

8. What key issues are covered by the psychologist’s code of ethics? Under what conditions must therapists break the principle of confidentiality? pp. 512–513

9. What kinds of programs for the prevention 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. 515–516

10. Describe how the mental health field has been affected by and dealt with the technological advances of recent years. pp. 516–518

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

1134

GLOSSARY 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 treatment 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 (ACT) 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 characterized 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 posthospitalization 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 difficult (or embarrassing) or help unavailable if panic-like symptoms were to occur.

Agranulocytosis A life-threatening drop in white blood cells. This condition is sometimes produced by the second-generation antipsychotic 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 content; 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.

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.

1135

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.

Amphetamines Stimulant drugs that are manufactured in the laboratory.

Amphetamine psychosis A syndrome characterized by psychotic symptoms brought on by high doses of amphetamines. Similar to cocaine psychosis.

Amygdala A structure in the brain that plays a key role in emotion and memory.

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 participants and then conducts experiments on the participants.

Anal stage In psychoanalytic theory, the second 18 months of life, during which the child’s focus of pleasure shifts to the anus.

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 correct grossly confused or distorted thinking.

Antisocial personality disorder A personality disorder marked by a general pattern of disregard for and violation of other people’s rights.

1136

Anxiety The central nervous system’s physiological 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 illogically, and interpret them as harmful.

Anxiolytics Drugs that reduce anxiety.

ApoE-4 gene One form of the ApoE gene that is inherited by about 30 percent of the population. Those people may be particularly vulnerable to the development of - Alzheimer’s disease.

Arbitrary inference An error in logic in which a person draws negative conclusions on the basis of little or even contrary evidence.

Aripiprazole A second-generation antipsychotic drug whose brand name is Abilify.

Asperger’s disorder The term previously applied to persons with autism spectrum disorder who display profound social impairment yet maintain 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 narrowing 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 disorders. Most became virtual prisons.

Attention circuit A number of brain structures that work together to bring about attention and to maintain a proper balance between Type 1 and Type 2 attention processes.

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.

Auditory hallucination A hallucination in which a person hears sounds or voices that are not actually present.

Augmentative communication system A method for enhancing the communication skills of people with autism spectrum disorder, 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 developmental disorder marked by extreme unresponsiveness to others, severe communication 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.

Autogenic mass killing Mass murder in which an individual kills people indiscriminately to fulfill a personal agenda.

1137

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 personality 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 reduces anxiety and helps 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 activation A therapy for depression in which the client is guided to systematically increase the number of constructive and pleasurable activities and events in his or her life.

Behavioral medicine A field that combines psychological and physical interventions to treat or prevent medical problems.

Behavior-focused therapy A therapeutic approach that seeks to identify problem-causing behaviors and change them. Also known as behavior modification.

Behaviors The responses an organism makes to its environment.

Bender Visual-Motor Gestalt Test A neuropsychological 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, extroversion, agreeableness, and neuroticism.

Binge An episode of uncontrollable eating during which a person ingests a very large quantity of food.

Binge drinking

1138

A pattern of alcohol consumption in which a person consumes 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 perform some other potentially panic-inducing task in the presence of a researcher or therapist.

Biological model The theoretical perspective that points to biological processes as the key to human behavior.

Biological therapy The use of physical and chemical procedures to help people overcome psychological problems.

Biomarkers Biochemical, molecular, genetic, or structural characteristics that usually accompany a disease.

Biopsychosocial theories Explanations that attribute the cause of abnormality to an interaction of genetic, biological, developmental, 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.

Bipolar II disorder A type of bipolar disorder marked by mild manic (hypomanic) 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 participants do not know whether they are in the experimental or the control condition. Also known as masked design, now the preferred term.

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 preoccupied with the belief that they have certain defects or flaws in their physical appearance. The perceived defects or flaws are imagined or greatly exaggerated.

Body shaming The practice of criticizing people publicly for being overweight, or, less frequently, underweight.

Borderline personality disorder A personality disorder characterized by repeated instability in interpersonal relationships, self-image, and mood, and by impulsive behavior.

Brain circuit A network of particular brain structures that work together, triggering each other into action to produce a distinct kind of behavioral, cognitive, or emotional reaction.

Brain stimulation Interventions that directly or indirectly stimulate the brain in order to bring about psychological improvement.

Brain structure

1139

A distinct area or region 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 disrupted 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. Also called the subgenual cingulate.

Bulimia nervosa A disorder marked by frequent eating binges that are followed by forced vomiting or other extreme compensatory behaviors to avoid gaining weight. Also known as binge-purge syndrome.

Buprenorpine An opioid substitute drug that is administered as a form of maintenance therapy for substance use disorder.

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 disorders, including therapy, advice, medication, guidance, and protection of patients’ rights.

Case study A detailed account of a person’s life and psychological problems.

Catatonia A pattern of extreme psychomotor symptoms, found in some forms of schizophrenia, that may include catatonic stupor, rigidity, or posturing.

Catatonic excitement A form of catatonia in which a person moves excitedly, sometimes 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 feelings in order to settle internal conflicts and overcome problems.

Caudate nuclei Structures in the brain, within the region known as the basal ganglia, that help convert sensory information into thoughts and actions.

Central nervous system The brain and spinal cord.

Cerebellum An area of the brain that coordinates 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 excessive 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

1140

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.

Chronic traumatic encephalopathy (CTE) A degenerative brain disease that is suffered by many NFL players, among others, that is caused by repeated head blows over the course of time.

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 and guidelines for making appropriate diagnoses.

Cleaning compulsion A common compulsion 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 conveying 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 professional who has earned a doctorate in clinical psychology.

Clinical psychology The study, assessment, treatment, and prevention of abnormal behavior.

Clinical social worker A mental health specialist who is qualified to conduct psychotherapy upon earning a master’s degree or doctorate in social work.

Clitoris The female sex organ located in front of the urinary and vaginal openings. It becomes enlarged during sexual arousal.

Clozapine A commonly prescribed second-generation 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-behavioral model A theoretical perspective that emphasizes both behavior and the process and content of thinking as causes of psychological problems.

Cognitive-behavioral therapies Therapy approaches that seek to help clients change both counterproductive behaviors and dysfunctional ways of thinking.

1141

Cognitive processing therapy A cognitive-focused intervention for people with PTSD in which therapists guide individuals to examine and change the dysfunctional attitudes and styles of interpretation they have developed as a result of their traumatic experiences, thus enabling them to deal with difficult memories and feelings.

Cognitive remediation A treatment that focuses on the cognitive impairments that often characterize people with schizophrenia, particularly their difficulties in attention, planning, and memory.

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 psychological disorders.

Cognitive triad The three forms of negative 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 Neurodevelopmental disorders characterized by marked impairment in language and/or speech.

Community mental health center A treatment facility that provides medication, psychotherapy, and emergency care to patients, and coordinates treatment in the community.

Community mental health treatment A treatment approach that emphasizes community 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 elaborate, set of actions that a person often feels compelled to perform, always in an identical manner.

Computerized axial tomography (CT scan) A composite image of the brain created by compiling X-ray images taken from many angles.

Concerta A trade name of methylphenidate, a stimulant drug that is helpful in many cases of attention-deficit/hyperactivity disorder (ADHD).

Concordance A statistical measure of the frequency 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 unconditioned stimulus that comes to be produced by a conditioned stimulus.

Conditioned stimulus (CS) A previously neutral stimulus that comes to be associated with a nonneutral stimulus, and it 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 aggression, 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.

1142

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 research participant.

Confidentiality The principle that certain professionals will not divulge the information they obtain from a client.

Confound In an experiment, a variable other than the independent variable that is also acting on the dependent variable.

Contingency management An operant conditioning treatment program that offers clients incentives (such as vouchers, prizes, cash, or privileges) that are contingent on the submission of drug-free urine specimens.

Continuous amnesia An inability to recall newly occurring events as well as certain past events.

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, widely discredited, that attempts to change the sexual orientation of a person from homosexual or bisexual to heterosexual. Also called reparative therapy.

Convulsion A brain seizure.

Coronary arteries Blood vessels that surround the heart and are responsible for carrying 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 magnitude 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.

Cortico-striato-thalamo-cortical brain circuit A brain circuit that includes such brain structures as the orbitofrontal cortex (just above each eye), cingulate cortex, striatum (including the caudate nucleus and putamen, two other structures at the back of the striatum), and thalamus. The circuit is hyperactive in people with obsessive-compulsive disorder, making it difficult for them to turn off or dismiss their various impulses, needs, and related thoughts.

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 a therapist’s own feelings, history, and values subtly influence the way he or she interprets a patient’s problems.

Couple therapy A therapy format in which the therapist works with two people who share a long-term relationship.

1143

Covert desensitization Desensitization that focuses on imagining confrontations with frightening objects or situations while in a state of relaxation.

Covert sensitization A treatment 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 mother’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.

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 constructively, 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 regularly 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.

Cyclothymic disorder A disorder marked by numerous periods of hypomanic symptoms and mild depressive symptoms.

Daily Report Card (DRC) A treatment for ADHD in which a child’s target classroom behaviors—staying in his or her classroom seat, raising a hand to speak, and using an “inside voice”— are carefully evaluated, recorded on a DRC, and reinforced by teachers throughout the school day. At the end of the day, the teacher further provides the report card for the parents to see, and, if a sufficient number of target behaviors had been performed satisfactorily that day, the child is also given rewards at home.

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 suicide 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 suicide attempt.

Deep brain stimulation (DBS) A treatment procedure for depression in which a pacemaker powers electrodes that have been implanted in the subgenual cingulate, thus stimulating that brain

1144

structure.

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 previously seen or experienced a new scene or situation.

Delayed ejaculation A male sexual dysfunction characterized by persistent inability to ejaculate or very delayed ejaculations during sexual activity with a partner.

Delirium A rapidly developing, acute disturbance 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 personality 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 significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms.

Depression-related brain circuit A brain circuit whose dysfunction contributes to unipolar depression. It includes the prefrontal cortex, hippocampus, amygdala, and subgenual cingulate (also called Brodmann Area 25), among other structures.

Depressive disorders The group of disorders marked by unipolar depression.

1145

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.

Detoxification Systematic and medically supervised withdrawal from a drug.

Developmental coordination disorder Neurodevelopmental disorder characterized by marked impairment in the development and performance of coordinated motor activities.

Developmental psychopathology A perspective that uses a developmental framework to understand how factors and principles from the various models may intersect at points throughout the life span to help produce both normal and abnormal functioning.

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 classification system for mental disorders developed by the American Psychiatric Association.

Dialectical behavior therapy (DBT) A comprehensive treatment approach developed by psychologist Marsha Linehan, applied particularly in cases of borderline personality disorder and/or suicidal intent. The approach includes both individual therapy sessions and group sessions and features cognitive-behavioral techniques, social skill building, and 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 immediate 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 hypothalamus) 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 a 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 separated, from other parts of one’s memory or identity.

1146

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.

Dissociative identity disorder A disorder in which a person develops two or more distinct personalities. Previously 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-masked design Experimental procedure 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 21st 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 therapists 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 impairment 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 depressive disorder that is chronic but less severe and less disabling than repeated episodes of major depression.

Early-onset Alzheimer’s disease A relatively rare form of Alzheimer’s disease that occurs before the age of 65. It typically runs in families.

Eccentric A person who deviates from conventional norms in odd, irregular, or even bizarre ways, but who is not displaying a psychological disorder.

Echolalia A symptom of autism or schizophrenia in which a person responds to statements by repeating the other person’s words.

Ecstasy (MDMA)

1147

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.

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 treatment for depression in which electrodes attached to a patient’s head send an electrical 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 muscular tension in the body.

Emergency commitment The temporary 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 guidelines, 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 control important activities such as growth and sexual activity.

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 tension. They are sometimes referred to as the body’s own opioids.

Enhanced interrogation program A torture-based form of questioning that has been used to try to obtain information from suspected terrorists.

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.

Equifinality The principle that a number of different developmental pathways can lead to the same psychological disorder.

Erectile disorder

1148

A sexual dysfunction in which a man persistently fails to attain or maintain an erection during sexual activity.

Ergot alkaloid A naturally occurring compound from which LSD is derived.

Erotomanic delusions Delusional beliefs held by some individuals that they are loved by and in a relationship with a person on whom they focus their attention (for example, a celebrity), a person with whom they have no relationship.

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 patterns 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 significant 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 perspective 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 encourages 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.

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 independent variable under investigation.

Exposure and response prevention A 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 exposure and ritual prevention.

Exposure therapy A behavior-focused intervention in which fearful persons are repeatedly exposed to the objects or situations they dread.

Expressed emotion The general level of criticism, disapproval, hostility, and intrusiveness expressed in a family. People recovering 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

1149

Unwanted movements—such as severe shaking, bizarre-looking grimaces, twisting of the body, and extreme restlessness—sometimes produced by 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, typically 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 disorder have the same disorder.

Family systems theory A theory that views the family as a system of interacting parts whose interactions exhibit consistent patterns 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 therapeutic ways.

Fantasy An ego defense mechanism in which a person uses imaginary events to satisfy unacceptable impulses.

Fear The central nervous system’s physiological and emotional response to a serious threat to one’s well-being.

Fear brain circuit The brain circuit that produces and manages fear reactions. Generalized anxiety disorder is related to dysfunction in this circuit, which includes such brain structures as the prefrontal cortex, anterior cingulate cortex, insula, and amygdala.

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 systematic desensitization.

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 persistent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensations during sexual activity.

Fentanyl A powerful opioid pain relief drug that is 50 to 100 times more powerful than morphine and 20 to 35 times more powerful than heroin. It is by far the painkiller most commonly linked to overdose deaths.

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 excessive 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.

First-generation antipsychotic drugs A group of drugs, including phenothiazines, that comprised the first wave of antipsychotic drugs and are still in use today.

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 posttraumatic stress disorder, the reexperiencing of past traumatic events.

Flat affect A symptom of schizophrenia in which the person shows almost no emotion at all.

Flooding

1150

An exposure therapy in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.

Forensic psychology The branch of psychology 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 technique 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 persistent feelings of anxiety that are not clearly attached to a specific, identifiable threat.

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 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-change surgery A surgical procedure that changes a person’s sex organs and gender features. Also known as gender reassignment surgery, gender confirmation surgery, and gender- affirming surgery.

Gender dysphoria A disorder in which a transgender individual persistently experiences clinically significant distress or impairment due to his or her assigned gender.

Gender reassignment surgery A surgical procedure that changes a person’s sex organs and gender features. Also known as gender change surgery, gender confirmation surgery, and gender-affirming surgery.

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 psychological 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 feelings of anxiety and worry about numerous events and activities.

Generic drug A marketed drug that is comparable to a trade-named drug in dosage form, strength, and performance.

1151

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 pleasure 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 clinicians actively move clients toward self-recognition and self-acceptance by using 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 technique 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 dysfunction, 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 powerful changes, primarily in sensory perception, 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.

1152

High The pleasant feeling of relaxation and euphoria that follows the rush from certain recreational drugs.

Hippocampus A brain structure located below the cerebral cortex that is involved in memory.

Histrionic personality disorder A personality 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 accumulation of items and possessions.

Hopelessness A pessimistic belief that one’s present circumstances, problems, or mood will never change.

Hormones The chemicals released by endocrine glands into the bloodstream.

Humanistic model The theoretical perspective that human beings are born with a natural inclination to be friendly, cooperative, 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, that results in a 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 forgotten events, or to forget remembered events.

Hypnotic amnesia Loss of memory produced 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 disorder in which people mistakenly fear that minor changes in their physical functioning indicate 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.

Hypothalamic-pituitary-adrenal (HPA) pathway One of the two major routes by which the brain and body produce arousal and fear.

Hypothalamus A brain structure that helps maintain various bodily functions, including eating and hunger.

Hypothesis

1153

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, somatic symptom disorder, and illness anxiety disorder.

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 understanding 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 psychological problems.

Immune system The body’s network of activities and cells that identify and destroy antigens and cancer cells.

Inappropriate affect Display of emotions that are unsuited to the situation; a symptom of schizophrenia.

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 determine whether it has an effect on another variable.

Individual therapy A therapeutic approach in which a therapist sees a client alone for sessions that may last from 15 minutes to 2 hours.

Informed consent The requirement that researchers provide sufficient information to participants about the purpose, procedure, 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

1154

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 excessive Internet gaming activity. Recommended for further study by the DSM-5 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.

Interpersonal theory of suicide A theory asserting that people with perceived burdensomeness, thwarted belongingness, and a psychological capability to carry out suicide are the most likely to attempt suicide. Also called interpersonal-psychological theory.

Interrater reliability A measure of the reliability of a test or of research results in which the consistency of evaluations across different judges is assessed. Also called interjudge reliability.

Intolerance of uncertainty theory An explanation for generalized anxiety disorder that states that certain individuals cannot tolerate the knowledge that negative events may occur, even if the possibility of occurrence is very small.

Intoxication A cluster of undesirable behavioral or psychological changes, such as slurred speech or mood changes, that may develop during or shortly after the ingestion 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.

Jail diversion An arrangement in which mentally disturbed criminal defendants are treated for their disorders on an outpatient basis. That is, they are diverted from jail to the community for mental health care.

Joint attention Sharing focus with other people on items or events in one’s immediate surroundings, through shared eye-gazing, pointing, referencing, or other verbal or nonverbal indications that one is paying attention to the same object.

Korsakoff’s syndrome An alcohol-related disorder marked by extreme confusion, memory impairment, and other neurological symptoms.

Late-onset Alzheimer’s disease

1155

By far, the most common form of Alzheimer’s disease, developing after the age of 65 and not typically running in families.

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 Parkinson’s disease, a disease in which dopamine is low.

Learned helplessness The perception, based on past experiences, that one has no control over one’s reinforcements.

Lewy body disease A type of neurocognitive disorder that involves a buildup of clumps of protein deposits, called Lewy bodies, within many neurons. In addition to progressive cognitive problems, this disease features significant movement difficulties.

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 affective 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 surgeon 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 brain structure that seems to be active in the regulation 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 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 disturbance 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 persons believe themselves to be possessed by wolves or other animals.

Lymphocytes White blood cells that circulate 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.

1156

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 neurocognitive 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 therapist with improper conduct or decision making in the course of treatment.

Managed care program A system of health care coverage in which the insurance company largely controls the nature, scope, and cost of medical or psychological services.

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.

Manifest content The consciously remembered 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 monoamine oxidase.

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.

Masked design An experiment in which participants do not know whether they are in the experimental or the control condition. Previously called a blind design.

Masturbation Self-stimulation of the genitals to achieve sexual arousal.

Masturbatory satiation A behavioral treatment 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.

Matched design A research design that matches the experimental participants with control participants who are similar on key characteristics.

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 physicians 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 proceedings they are facing and unable to prepare an adequate defense with their attorney.

1157

Mentalization The capacity to understand one’s own mental states and those of other people.

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 use disorder. Also called dual-diagnosis patients.

Mesmerism The method employed by Austrian physician F. A. Mesmer to treat hysterical disorders; a precursor of hypnotism.

Meta-analysis A statistical method that combines 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 organism’s biochemical transformation of various substances, as when the liver breaks down alcohol into acetylaldehyde.

Metacognitive theory A theory suggesting that people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying.

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 opioid-centered substance use in which clients are given legally and medically supervised doses of a substitute drug, methadone.

Methamphetamine A powerful amphetamine 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 names Ritalin and Concerta, 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 sometimes accompanied by dizziness, nausea, or vomiting.

Mild intellectual disability A level of intellectual disability (IQ between 50 and 70) at which people can benefit from education and can support themselves as adults.

Mild neurocognitive disorder Neurocognitive disorder in which the decline in cognitive 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 The position advocated by the seventeenth-century French philosopher René Descartes that the mind is separate from the body.

Mindfulness-based cognitive-behavioral 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 meditation in which people are mindful of (just notice) the various thoughts, emotions, sensations, and other private experiences that pass through their minds and bodies.

Minnesota Multiphasic Personality Inventory (MMPI) A widely used personality inventory consisting of a large number of statements that subjects mark as being true or false for them.

Mixed design

1158

A research design that intermixes elements of both experimental and correlational studies. Also known as quasi-experimental design.

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 observations. 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 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 norepinephrine 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 suffering from a bipolar 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.

Motivational interviewing A treatment intervention that uses a mixture of empathy and inquiring review to help motivate clients to recognize they have a serious psychological problem and to commit to making constructive choices and behavior changes.

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 influence 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.

Multifinality The principle that persons with a similar developmental history may nevertheless react to similar current situations in very different ways.

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 factitious disorder in which parents make up or produce physical illnesses in their children.

Muscle contraction headache A headache caused by the narrowing of muscles surrounding the skull. Also known as tension headache.

Muscle dysmorphia Disorder in which people become obsessed with the incorrect belief that they are not muscular enough.

Naloxone One of the most widely used opioid antagonist drugs.

1159

Narcissistic personality disorder A personality disorder marked by a broad pattern of grandiosity, need for admiration, and lack of empathy.

Narcolepsy A sleep-wake disorder characterized by a repeated sudden and irrepressible need to sleep during waking hours.

Narcotic Any natural or synthetic opioid-like drug.

National Alliance on Mental Illness (NAMI) A nationwide grassroots organization that provides support, education, advocacy, and research for people with severe mental disorders and their families.

National interest groups Groups and organizations such as NAMI that have formed in countries around the world to push for better community treatment.

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 relationship in which the value of one variable increases while the other variable decreases.

Negative symptoms Symptoms of schizophrenia 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 disorders—including ADHD, autism spectrum disorder, and intellectual disability—in the functioning of the brain that emerge at birth or during very early childhood and that 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 first-generation antipsychotic drugs, so called because they often produce undesired effects similar to the symptoms of neurological disorders.

Neuroleptic malignant syndrome A severe, potentially fatal reaction to antipsychotic 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 measures brain structure or activity.

Neuromodulator A neurotransmitter that helps modify or regulate the effect of other neurotransmitters.

Neuron A nerve cell.

Neuropsychological test A test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.

1160

Neurosis Freud’s term for disorders characterized by intense anxiety, attributed to failure of a person’s ego defense mechanisms 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.

New wave cognitive-behavioral therapies A group of relatively new approaches, including acceptance and commitment therapy (ACT), that help clients to accept many of their problematic thoughts rather than judge them, act on them, or try fruitlessly to change them.

Nicotine An alkaloid (nitrogen-containing chemical) derived from tobacco or produced in the laboratory.

Nicotine patch A patch attached to the skin like a Band-Aid, with nicotine content that is absorbed through the skin; it may ease the withdrawal reaction of an individual who has quit cigarette smoking.

Nightmare disorder A parasomnia characterized 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 functioning, 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 1-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 with 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.

Nutritional rehabilitation An initial phase of treatment in a number of cases of anorexia nervosa that includes supportive nursing care, day-to-day increased caloric intake, nutrition counseling, support, and, in some programs, motivational interviewing.

Object relations theory The psychodynamic 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.

Obsession A persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.

Obsessive-compulsive disorder (OCD) A disorder in which a person has recurrent and unwanted thoughts and/or a need to perform repetitive and rigid actions.

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.

1161

Obsessive-compulsive-related disorders A group of disorders in which obsessive-like concerns drive people to repeatedly and excessively perform specific patterns 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 A second-generation 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, drugs derived from opium, and similar synthetic drugs. Also known collectively as narcotics.

Opioid antagonist A substance that attaches to opioid receptors in the brain and, in turn, blocks the effects of opioids.

Opium A highly addictive substance made from the sap of the opium poppy seed.

Oppositional defiant disorder A disorder in which children are repeatedly argumentative and defiant, angry and irritable, and, in some cases, vindictive.

Oral stage The earliest developmental stage in Freud’s conceptualization of psychosexual development, during which the infant’s main gratification comes from feeding and from the body parts involved in feeding.

Orbitofrontal cortex A brain structure in which impulses involving excretion, sexuality, violence, and other primitive activities normally arise.

Orgasm A peaking of sexual pleasure, consisting 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.

Outpatient A person who receives a diagnosis or treatment in a clinic, hospital, or therapist’s office but is not hospitalized overnight.

Outpatient civil commitment program A legal process in which courts order people with severe mental disorders into community treatment.

Oxycodone The key ingredient in OxyContin and Percocet, medical opioids prescribed to relieve pain.

Panic attacks Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.

Panic brain circuit The brain circuit that helps produce panic reactions, consisting of structures such as the amygdala, hippocampus, ventromedial nucleus of the hypothalamus, central gray matter, and locus coeruleus.

Panic disorder An anxiety disorder marked by recurrent and unpredictable panic attacks.

Paranoid personality disorder A personality 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 experiences of suffering or humiliation.

1162

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.

Parent management training A treatment approach for conduct disorder in which therapists combine family and cognitive-behavioral interventions to improve family functioning and help parents deal with their children more effectively.

Parity laws Laws that direct insurance companies to provide equal coverage for mental and physical problems.

Parkinsonian symptoms Symptoms similar to those found in Parkinson’s disease. Patients with schizophrenia who take 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 a neurocognitive disorder.

Participant An individual chosen to participate in a study. Also called a subject.

Participant modeling A behavioral treatment 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 clinicians paid by an insurance company may periodically review a patient’s progress and recommend the continuation or termination of insurance benefits.

Penile prosthesis A surgical implant consisting of a semirigid rod that produces an artificial erection.

Performance anxiety The fear of performing inadequately and a related tension experienced during sex.

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 significant impairment in functioning as a result of one or more very problematic traits.

1163

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 effective antipsychotic medications.

Phenylketonuria (PKU) A metabolic disorder 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 childhood disorders that helps children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories.

Pleasure principle The pursuit of gratification that characterizes id functioning.

Plethysmograph A device used to measure sexual arousal.

Polygraph test A test that seeks to determine 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.

Polysubstance use The use of two or more substances at the same time.

Positive correlation A statistical relationship 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 schizophrenia that seem to be excesses of or bizarre additions to normal thoughts, emotions, 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 psychosis 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 symptoms 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

1164

The ability of a test or other assessment tools to predict future characteristics or behaviors.

Predisposition An inborn or acquired vulnerability for developing certain symptoms or disorders.

Prefrontal lobes Structures 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 beginning sexual activity with a partner and before he wishes to. Also called early or rapid ejaculation.

Premenstrual dysphoric disorder A disorder marked by repeated experiences of significant depression and related symptoms during the week before menstruation.

Premenstrual syndrome (PMS) A common and normal cluster of psychological 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 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 interventions 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 environment 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 ambiguous material that people interpret or respond to.

Prolonged exposure An exposure treatment in which clients confront not only trauma-related objects and situations but also their painful memories of traumatic experiences.

Protection and advocacy system The system by which lawyers and advocates who work for patients may investigate the patients’ treatments and protect their rights.

Prozac

1165

The trade name for fluoxetine, a second-generation antidepressant.

Pseudocommando mass killing Mass murder in which an individual kills in public, often during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. The killer has no escape planned and expects to be killed during the incident.

Psychedelic drugs Substances such as LSD that cause profound perceptual changes. Also called hallucinogenic drugs.

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.

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 incident stress debriefing.

Psychological profile A method of suspect identification that seeks to predict an unknown criminal’s psychological, emotional, and personality characteristics based on the individual’s pattern of criminal behavior and on research into the psychological 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 disorders 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 sociocultural factors interact to cause or worsen a physical illness. Also known as psychological factors affecting other medical conditions.

Psychophysiological test A test that measures 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

1166

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 dysfunction.

Quasi-experimental design A research design that fails to include key elements of a “pure” experiment and/or intermixes elements of both experimental and correlational studies. Also called a mixed design.

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 nonconsenting 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, indicating 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-behavioral 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 mechanism whereby a person counters an unacceptable 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 undesirable 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 discussions with patients.

1167

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 environment. Also called a therapeutic community.

Resilience The ability to avoid or recover from the effects of negative circumstances.

Resistance An unconscious refusal to participate 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.

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 experimental design in which behavior is measured to provide a baseline (A), then again after the treatment has been applied (B), then again after the conditions during baseline have been reintroduced (A), and then once again after the treatment is reintroduced (B). Also known as ABAB design.

Reward A pleasurable stimulus given to an organism that encourages a specific behavior.

Reward circuit A dopamine-rich circuit 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 circuit 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.

Right to treatment The legal right of patients, particularly those who are involuntarily committed, to receive adequate treatment.

Risperidone A commonly prescribed second-generation antipsychotic drug.

Ritalin A trade name of methylphenidate, a stimulant drug that is helpful in many cases of attention-deficit/hyperactivity disorder (ADHD).

Role-playing A therapy technique in which clients 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.

1168

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 with significant intellectual deficits who has some extraordinary ability despite the disorder or deficits.

Schizoaffective disorder A disorder in which symptoms of both schizophrenia and a mood disorder are prominent.

Schizoid personality disorder A personality 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.

Schizophrenia-related brain circuit A brain circuit whose dysfunction contributes to schizophrenia. It includes the prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and substantia nigra, among other brain structures.

Schizophreniform disorder A disorder in which all of the key features of schizophrenia 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 personality disorder characterized by extreme discomfort in close relationships, odd forms of thinking and perceiving, and behavioral eccentricities.

School refusal A pattern in which children fear going to school and often stay home for a long period of time. Also called school phobia.

Scientific method The process of systematically 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.

Second-generation antidepressant drugs 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 first-generation 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 interventions that are designed to address disorders quickly, before they become more serious problems.

Sedative-hypnotic drugs Drugs used in low doses to calm people and in higher doses to help people sleep.

Selective amnesia An inability to recall some of the events that occurred over a limited period of time.

Selective mutism A disorder marked by failure to speak in certain social situations when speech is expected, despite an ability to speak in other situations.

Selective serotonin reuptake inhibitors (SSRIs)

1169

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 support one another without the direct leadership of a clinician. Also called a mutual help group.

Self-hypnosis The process of hypnotizing oneself, sometimes for the purpose of forgetting unpleasant events.

Self-Injury Implicit Association Test A cognitive test used to help assess suicidal risk. Rather than asking people if they plan to attempt suicide, this test instructs them to pair various suicide-related words (for example, “dead,” “lifeless,” “suicide”) with words that are personally relevant (“I,” “myself,” “mine”) and with words that are not personally relevant (“they,” “them,” “other”).

Self-instruction training A treatment 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 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 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 disorders 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 three 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 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.

Sexting The sending of sexually explicit material—particularly photos or text messages—between cell phones or other digital devices.

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 behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer, accompanied by clinically significant distress or impairment.

1170

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 disorder 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 individuals 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 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 workplace 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 a shock.

Sildenafil A drug used to treat erectile disorder 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 participant is observed and measured both before and after the manipulation of an independent variable.

Sleep apnea disorder A sleep-wake disorder 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 persistent fear of social or performance situations in which embarrassment may occur.

Social communication disorder A disorder 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 spectrum 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 making, memory enhancement, development of social skills, and management of medications. Also known as personal therapy.

Sociocultural model The theoretical perspective 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 forgotten events.

Sodium pentobarbital (Pentothal) A drug used to put people into a near-sleep state during which some can better recall forgotten events.

Somatic symptom disorder

1171

A disorder in which people become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing, with their lives greatly and disproportionately disrupted by the symptoms.

Somatogenic perspective The view that abnormal psychological functioning has physical causes.

Special education An approach to educating children with intellectual disability in which they are grouped together and given a separate, specially designed education.

Specific learning disorder A neurodevelopmental 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, in which they focus 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 standard 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 principles 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 experimental manipulation.

Stimulant drug A substance that increases the activity of the central nervous system.

Stimulus generalization A phenomenon in which responses to one stimulus are also produced by similar stimuli.

Stress brain circuit The brain circuit whose dysfunction contributes to PTSD. It includes such brain structures as the amygdala, prefrontal cortex, anterior cingulate cortex, insula, and hippocampus, among others.

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 programs Workshops or group sessions offered by a business, in which mental health professionals teach employees techniques for coping, solving problems, and handling and reducing stress.

Stress response A person’s particular reactions to stress.

Structured interview An interview format in which the clinician asks prepared questions.

Subgenual cingulate A brain structure whose abnormal activity has been linked to depression. Also called Brodmann Area 25.

1172

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 personally 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 substance, 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 individuals have tried to die by suicide within the last two years.

Suicide A self-inflicted death in which the person acted intentionally, directly, and consciously.

Suicide education programs Suicide prevention programs that usually take place in schools and concentrate on students and their teachers. There are also a growing number of online sites that provide education about suicide—targeting troubled persons, their family members, and friends.

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 psychological force that represents a person’s values and ideals.

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.

Sympathetic nervous system The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal and fear. One of the two major routes by which the brain and body produce 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 usually 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 perceptions. For example, a loud sound may be seen or a color may be felt.

Systematic desensitization An exposure therapy 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 antipsychotic drugs for an extended time.

1173

Telemental health The use of digital technologies to deliver mental health services without the therapist being physically present.

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 interventions 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 psychological 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 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 problems. Therapy consists of a client (patient), a trained therapist, and a series of contacts between them.

Token economy program A behavior-focused 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.

Tranquilizer A drug that reduces anxiety.

Transcranial magnetic stimulation (TMS) A treatment procedure for depression and certain other disorders 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 psychotherapist of feelings associated with important figures in a patient’s life, now or in the past.

Transgender Individuals who have a strong sense that their gender identity is different from their birth anatomy.

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 distress or impairment. Also known as transvestism or cross-dressing.

1174

Treatment A systematic procedure designed to help change abnormal behavior into more normal behavior. Also called therapy.

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 condition becomes life-threatening.

Type A personality style A personality pattern characterized by hostility, cynicism, drivenness, impatience, competitiveness, and ambition.

Type B personality style A personality pattern 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 dangerously. 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 stimulus 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 an unacceptable desire or act by performing another act.

Unipolar depression Depression without a history of mania.

Unstructured interview An interview format in which the clinician asks spontaneous 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 regular 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 antianxiety drug.

1175

Variable Any characteristic or event that can vary across time, locations, or persons.

Ventromedial hypothalamus (VMH) A brain region that depresses hunger when activated.

Virtual reality treatment Cognitive-behavioral intervention that uses virtual reality—3D computer graphics that simulate real-world objects and situations—as an exposure tool.

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 individuals or experiences clinically significant distress or impairment.

Weight set point The weight level that a person is predisposed to maintain, controlled in part by the hypothalamus.

Withdrawal Unpleasant, sometimes dangerous 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, reinterpreting feelings, and overcoming one’s problems.

1176

References AA World Services. (2017, April). Estimated worldwide A.A. individual and group membership

(SM F-132). A.A. Retrieved from http://www.aa.org/assets.

AA World Services. (2018, April). Estimated worldwide A.A. individual and group membership (SMF-132). A.A. Retrieved from http://www.aa.org/assets.

AAC (American Addiction Centers). (2018). Dangers of snorting, smoking, or injecting cocaine. Brentwood, TN: AAC.

AAFPRS (American Academy of Facial Plastic and Reconstructive Surgery). (2017, January 26). AAFPRS Annual Survey unveils rising trends in facial plastic surgery. Retrieved from http://www.aafprs.org/media/stats_polls/m_stats.html.

AAIDD (American Association of Intellectual and Developmental Disabilities). (2018). Definition of intellectual disability. AAIDD. Retrieved from http://www.aaidd.org.

Aalami, M., Jafarnejad, F., & Modarres Gharavi, M. (2016). The effects of progressive muscular relaxation and breathing control technique on blood pressure during pregnancy. Iranian Journal of Nursing and Midwifery Research, 21(3), 331–336.

AAMFT (American Association of Marriage and Family Therapy). (2018). Rape trauma. Alexandria, VA: AAMFT

Aamodt, M. G. (2014, September 6). Serial killer statistics. Retrieved from Aamodt website: http://maamodt.asp.radford.edu/serial_killer_information_center/project_description.htm.

Aamodt, M. G. (2016, September 4). Serial killer statistics. Retrieved from http://maamodt.asp.radford.edu/serial_killer_information_center/project_description.htm.

Aaronson, S. T., Sears, P., Ruvunaq, F., Bunker, M., Conway, C. R., Dougherty, D. D., . . . Zajecka, J. M. (2017). A 5-year observational study of patients with treatment-resistant depression treated with vagus nerve stimulation or treatment as usual: Comparison of response, remission, and suicidality. American Journal of Psychiatry, 174, 640–648.

ABA (American Bar Association). (2017). Court cases by diminished capacity/guilt. Washington, DC: ABA (Center on Children and the Law).

ABA (American Bar Association). (2018). Rule 1.14: Client with diminished capacity. Chicago, IL: ABA.

Abbey, A. (2002). Alcohol-related sexual assault: A common problem among college students. Journal of Studies on Alcohol, 14, 118–128.

1177

http://www.aa.org/assets

http://www.aafprs.org/media/stats_polls/m_stats.html

http://www.aaidd.org

http://maamodt.asp.radford.edu/serial_killer_information_center/project_description.htm

Abbey, S. E. (2005). Somatization and somatoform disorders. In J. L. Levenson (Ed.), The American Psychiatric Publishing textbook of psychosomatic medicine (pp. 271–296). Washington, DC: American Psychiatric Publishing.

Abdel-Hamid, I. A., & Ali, O. I. (2018). Delayed ejaculation: Pathophysiology, diagnosis, and treatment. World Journal of Men’s Health, 36(1), 22–40.

Abe, K. (2017). What is a serial killer? What is a mass murderer? How do they differ? European Journal of Academic Essays, 4(4), 187–198.

Abel, G. G., Jordan, A., Hand, C. G., Holland, L. A., & Phipps, A. (2001). Classification models of child molesters utilizing the Abel Assessment for child sexual abuse interest. Child Abuse and Neglect, 25(5), 703–718.

Abma, J. C., & Martinez, G. M. (2017, June 22). Sexual activity and contraceptive use among teenagers in the United States, 2011–2015. Atlanta, GA: CDC, National Health Statistics Report, No. 104.

Abraham, K. (1911). Notes on the psychoanalytic investigation and treatment of manic- depressive insanity and allied conditions. In Selected papers on psychoanalysis (pp. 137–156). New York: Basic Books. [Work republished 1960.]

Abraham, K. (1916). The first pregenital stage of the libido. In Selected papers on psychoanalysis (pp. 248–279). New York: Basic Books. [Work republished 1960.]

Abraham, K. M., Yosef, M., Resnick, S. G., & Zivin, K. (2017). Competitive employment outcomes among veterans in VHA therapeutic and supported employment services programs. Psychiatry Services, 68(9), 938–946.

Abramowitz, J. (2017, October 23). Psychotherapy for obsessive-compulsive disorders in adults. UpToDate. Retrieved from http://www.uptodate.com.

Abramowitz, J. S., & Braddock, A. E. (2011). Hypochondriasis and health anxiety. Advances in psychotherapy—Evidence-based practice. Cambridge, MA: Hogrefe Publishing.

Abramson, L. Y., Alloy, L. B., Hankin, B. L., Haeffel, G. J., MacCoon, D. G., & Gibb, B. E. (2002). Cognitive vulnerability—Stress models of depression in a self-regulatory and psychobiological context. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 268–294). New York: Guilford Press.

Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory- based subtype of depression. Psychological Review, 96(2), 358–372.

Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans:

1178

http://www.uptodate.com

Critique and reformulation. Journal of Abnormal Psychology, 87(1), 49–74.

Abulizi, X., Pryor, L., Michel, G., Melchior, M., van der Waerden, J., & EDEN Mother– Child Cohort Study Group. (2017). Temperament in infancy and behavioral and emotional problems at age 5.5: The EDEN mother-child cohort. PLoS ONE, 12(2), e0171971.

à Campo, J. M. L. G., & Nijman, H. (2016). Gender dysphoria and psychiatric symptoms. Journal of Nervous & Mental Disease, 204(7), 558.

Achalia, R. M., Chaturvedi, S. K., Desai, G., Rao, G. N., & Prakash, O. (2014). Prevalence and risk factors associated with tardive dyskinesia among Indian patients with schizophrenia. Asian Journal of Psychiatry, 9, 31–35.

Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., . . . Foa, E. B. (2017). A non-inferiority trial of prolonged exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behaviour Research and Therapy, 89, 57–65.

Ackerman, C. (2017, January 18). 22 mindfulness exercises, techniques & activities for adults (+PDF’s). Positive Psychology Program. Retrieved from https://positivepsychologyprogram.com.

Ackland, G. L., Whittle, J., Toner, A., Machhada, A., Del Arroyo, A. G., Sciuso, A., . . . Gourine, A. V. (2016). Molecular mechanisms linking autonomic dysfunction and impaired cardiac contractility in critical illness. Critical Care Medicine, 44(8), e614–e624.

ACOG (American Congress of Obstetricians and Gynecologists). (2016). Committee opinion: Concerns regarding social media and health issues in adolescents and young adults (No. 653). Washington, DC: ACOG.

ADAA (Anxiety and Depression Association of America). (2017). About ADA: Facts & statistics. Silver Springs, MD: ADAA.

Adam, K. S., Bouckoms, A., & Streiner, D. (1982). Parental loss and family stability in attempted suicide. Archives of General Psychiatry, 39(9), 1081–1085.

Adamowicz, M. W. (2016). Psychological Testing. Mentalhelp.net

Adams, C. E., Awad, G. A., Rathbone, J., Thornley, B., & Soares-Weiser, K. (2014). Chlorpromazine versus placebo for schizophrenia. Cochrane Database of Systematic Reviews, 1, CD000284.

Adams, J. G. (2013). Sexual assault (Chap. 128). In J. G. Adams (Ed.), Emergency medicine: Clinical essentials (2nd ed.). Elsevier Health Services. [Kindle edition]

1179

https://positivepsychologyprogram.com

Adams, R. E., & Boscarino, J. A. (2005). Stress and well-being in the aftermath of the World Trade Center attack: The continuing effects of a communitywide disaster. Journal of Community Psychology, 33(2), 175–190.

Adams, S. M., Rice, M. J., Jones, S. L., Herzog, E., Mackenzie, L. J., & Oleck, L. G. (2018, March 1). Telemental health standards: Standards, reimbursement, and interstate practice. Journal of the American Psychiatric Nurses Association. [Epub ahead of print]

Addington, J., Heinssen, R. K., Robinson, D. G., Schooler, N. R., Marcy, P., Brunette, M. F., . . . Kane, J. M. (2015). Duration of untreated psychosis in community treatment settings in the United States. Psychiatric Services (Washington, D.C.), 66(7), 753–756.

ADDitude. (2017). ADHD, by the numbers. ADDitude Magazine.

Adebäck, P., Schulman, A., & Nilsson, D. (2018). Children exposed to a natural disaster: Psychological consequences eight years after 2004 tsunami. Nordic Journal of Psychiatry, 72(1), 75–81.

Adi, A., & Mathbout, M. (2018, April). The duty to protect: Four decades after Tarasoff. Psychiatry Online (American Psychiatric Association). Retrieved from https://ajp.psychiatryonline.org.

AFA (Alzheimer’s Foundation of America). (2014). About dementia. New York: AFA.

Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, 186(9), E324–E332.

AFSP (American Foundation for Suicide Prevention). (2014). Facts and figures for 2010: Suicide deaths. Retrieved from https://www.afsp.org/understanding-suicide/facts-and-figures.

AFSP (American Foundation for Suicide Prevention). (2014). Facts and figures for 2011: Suicide deaths. Retrieved from https://www.afsp.org/understanding-suicide/facts-and-figures.

AFSP (American Foundation for Suicide Prevention). (2017). Suicide statistics. Retrieved from https://www.afsp.org/about-suicide/suicide-statistics/.

AFSP (American Foundation for Suicide Prevention). (2018). Suicide prevention in schools. New York: AFSP.

AFSP (American Foundation for Suicide Prevention). (2018). Suicide statistics. Retrieved from https://www.afsp.org/about-suicide/suicide-statistics/.

AFSP (American Foundation for Suicide Prevention). (2018). Suicide statistics. New York:

1180

https://ajp.psychiatryonline.org

https://www.afsp.org/understanding-suicide/facts-and-figures

https://www.afsp.org/about-suicide/suicide-statistics/

AFSP.

Aggarwal, N. K. (2017). Culture, communication, and DSM-5 diagnostic reliability. Journal of the National Medical Association, 109(3), 150–152.

Agha, M., Nisar, A., Liaqat, H., Choudry, U. K., Choudry, A. K., & Shoaib, M. (2017). Neurophysiological perspectives of borderline personality disorders. Acta Psychopathologica, 3(3), 21.

Aghajani, M., Klapwijk, E. T., van der Wee, N. J., Veer, I. M., Rombouts, S. A. R. B., Boon, A. E., . . . Colins, O. F. (2017). Disorganized amygdala networks in conduct-disordered juvenile offenders with callous-unemotional traits. Biological Psychiatry, 82(4), 283–293.

Agras, S. (1985). Panic: Facing fears, phobias, and anxiety. New York: W. H. Freeman.

Agras, W. S., Fitzsimmons-Craft, E. E., & Wilfley, D. E. (2017). Evolution of cognitive- behavioral therapy for eating disorders. Behaviour Research and Therapy, 88, 26–36.

Agrawal, A., Tillman, R., Grucza, R. A., Nelson, E. C., McCutcheon, V. V., Few, L., . . . Bucholz, K. K. (2017). Reciprocal relationships between substance use and disorders and suicidal ideation and suicide attempts in the Collaborative Study of the Genetics of Alcoholism. Journal of Affective Disorders, 213, 96–104.

Agronin, M. (2017, October 24). Sexual dysfunction in older adults. UpToDate. Retrieved from http://www.uptodate.com.

Aguilera, A., Bruehlman-Senecal, E., Demasi, O., & Avila, P. (2017). Automated text messaging as an adjunct to cognitive behavioral therapy for depression: A clinical trial. Journal of Medical Internet Research, 19(5), e148.

Aguilera, A., Garza, M. J., & Muñoz, R. F. (2010). Group cognitive-behavioral therapy for depression in Spanish: Culture-sensitive manualized treatment in practice. Journal of Clinical Psychology, 66(8), 857–867.

Ahmadi, K. (2016). What is a self-help group? Psych Central. Retrieved from https://psychcentral.com/lib.

Aiken, L. R. (1985). Psychological testing and assessment (5th ed.). Boston: Allyn & Bacon.

Aikin, K. J., Sullivan, H. W., Dolina, S., Lynch, M., & Squiers, L. B. (2017). Direct-to- consumer promotion of prescription drugs on mobile devices: Content analysis. Journal of Medical Internet Research, 19(7), e225.

AIS (American Institute of Stress). (2017). Transforming stress through awareness, education and

1181

http://www.uptodate.com

https://psychcentral.com/lib

collaboration. Fort Worth, TX: AIS.

Akhtar, S., Wig, N. H., Verma, V. K., Pershod, D., & Verma, S. K. (1975). A phenomenological analysis of symptoms in obsessive-compulsive neuroses. British Journal of Psychiatry, 127, 342–348.

Akin, O., Yesilkaya, E., Sari, E., Akar, C., Basbozkurt, G., Macit, E., . . . Gül, H. (2016). A rare reason of hyperinsulinism: Munchausen syndrome by proxy. Hormone Research in Paediatrics, 86(6), 416–419.

Akins, C. K. (2004). The role of Pavlovian conditioning in sexual behavior: A comparative analysis of human and nonhuman animals. International Journal of Comparative Psychology, 17(2–3), 241–262.

Albano, A. M., Comer, J. S., Compton, S. N., Piacentini, J., Kendall, P. C., Birmaher, B., . . . Sherrill, J. T. (2018). Secondary outcomes from the Child/Adolescent Anxiety Multimodal Study (CAMS): Implications for clinical practice. Evidence-Based Practice in Child and Adolescent Mental Health, 3(1), 30–41.

Alderson-Day, B., & Jones, N. (2018). Understanding AVATAR therapy: Who, or what, is changing? Lancet Psychiatry, 5(1), 2–3.

Alegría, M., Alvarez, K. Ishikawa, R. Z., DiMarzio, K., & McPeck, S. (2016). Removing obstacles to eliminating racial and ethnic disparities in behavioral health care. Health Affairs, 35(6), 991–999.

Alegría, M., Nakash, O., & NeMoyer, A. (2018). Increasing equity in access to mental health care: A critical first step in improving service quality. World Psychiatry, 17(1), 43–44.

Alegría, M., Atkins, M., Farmer, E., Slaton, E., & Stelk, W. (2010). One size does not fit all: Taking diversity, culture and context seriously. Administration and Policy in Mental Health and Mental Health Service Research, 37(1-2), 48–60.

Alegría, M., Fortuna, L. R., Lin, J. Y., Norris, F. H., Gao, S., Takeuchi, D. T., . . . Valentine, A. (2013). Prevalence, risk, and correlates of posttraumatic stress disorder across ethnic and racial minority groups in the United States. Medical Care, 51(12), 1114–1123.

Alegría, M., Molina, K. M., & Chen, C. (2014). Neighborhood characteristics and differential risk for depressive and anxiety disorders across racial/ethnic groups in the United States. Depression and Anxiety, 31(1), 27–37.

Alexander, J. R., Houghton, D. C., Twohig, M. P., Franklin, M. E., Saunders, S. M., Neal- Barnett, A. M., . . . Woods, D. W. (2017). Clarifying the relationship between

1182

trichotillomania and anxiety. Journal of Obsessive-Compulsive and Related Disorders, 13, 30– 34.

Ålgars, M., Santtila, P., Jern, P., Johansson, A., Westerlund, M., & Sandnabba, N. K. (2011). Sexual body image and its correlates: A population-based study of Finnish women and men. International Journal of Sexual Health, 23(1), 26–34.

Ali, M. M., Dwyer, D. S., & Rizzo, J. A. (2011). The social contagion effect of suicidal behavior in adolescents: Does it really exist? Journal of Mental Health Policy and Economics, 14(1), 3–12.

Allara, E., Ferri, M., Bo, A., Gasparrini, A., Faggiano, F. (2014). Are mass-media campaigns effective in preventing drug use: A Cochrane systematic review and meta-analysis. BMJ. Retrieved from http://bmjopen.bmj.com.

Allderidge, P. (1979). Hospitals, madhouses and asylums: Cycles in the care of the insane. British Journal of Psychiatry, 134, 321–334.

Allen, A. P., Curran, E. A., Duggan, A., Cryan, J. F., Chorcoráin, A. N., Dinan, T. G., . . . Clarke, G. (2017). A systematic review of the psychobiological burden of informal caregiving for patients with dementia: Focus on cognitive and biological markers of chronic stress. Neuroscience & Biobehavioral Reviews, 73, 123–164.

Allen, D. F. (Ed.). (1985). The cocaine crisis. Plenum Press: New York.

Allen, M. T., Jameson, M. M., & Myers, C. E. (2017). Beyond behavioral inhibition: A computer avatar task designed to assess behavioral inhibition extends to harm avoidance. Frontiers in Pharmacology, 8, 1560.

Allison, S., Bastiampillai, T., & Fuller, D. A. (2017). Mass incarceration and severe mental illness in the USA. The Lancet, 390(1009), 25.

Allison, S., Bastiampillai, T., Licinio, J., Fuller, D. A., Bidargaddi, N., & Sharfstein, S. S. (2018). When should governments increase the supply of psychiatric beds? Molecular Psychiatry, 23(4), 796–800.

Alloway, T. P. (2014, May 11). Selfies, Facebook, and narcissism: What’s the link? Psychology Today.

Alloway, T. P., Runac, R., Qureshi, M., & Kemp, G. (2014). Is Facebook linked to selfishness? Investigating the relationships among social media use, empathy, and narcissism. Social Networking, 3(3), 150–158.

Alridge, J. (2012, May 17). How many people commit suicide due to depression? Examiner.com.

1183

http://bmjopen.bmj.com

Al-Shaqi, R., Mourshed, M., & Rezgui, Y. (2016). Progress in ambient assisted systems for independent living by the elderly. Springerplus, 5, 624.

Althof, S. E., & Needle, R. B. (2017). Treating low sexual desire in men. In Z. D. Peterson, The Wiley-Blackwell handbook of sex therapy (Chap. 3, pp. 32–39). Hoboken, NJ: Wiley- Blackwell.

Althof, S. E. (2007). Treatment of rapid ejaculation: Psychotherapy, pharmacotherapy, and combined therapy. In S. R. Leiblum, Principles and practice of sex therapy (4th ed., pp. 212– 240). New York: Guilford Press.

Altinay, M., Karne, H., & Anand, A. (2018). Lithium monotherapy associated clinical improvement effects on amygdala-ventromedial prefrontal cortex resting state connectivity in bipolar disorder. Journal of Affective Disorders, 225, 4–12.

Altszyler, E., Ribeiro, S., Sigman, M., & Fernández Slezak, D. (2017). The interpretation of dream meaning: Resolving ambiguity using Latent Semantic Analysis in a small corpus of text. Consciousness and Cognition, 56, 178–187.

Alvarado, C., & Modesto-Lowe, V. (2017). Improving treatment in minority children with attention deficit/hyperactivity disorder. Clinical Pediatrics, 56, 171–176.

Alzheimer’s Association. (2017). 2017 Alzheimer’s disease facts and figures. Chicago, IL: Alzheimer’s Association.

Alzheimer’s Association. (2018). 2018 Alzheimer’s disease facts and figures. Chicago, IL: Alzheimer’s Association.

AMA (American Medical Association). (2015). AMA calls for ban on DTC ads of prescription drugs and medical devices. Washington, DC: Author

Amad, A., Ramoz, N., Thomas, P., Jardri, R., & Gorwood, P. (2014). Genetics of borderline personality disorder: Systematic review and proposal of an integrative model. Neuroscience and Biobehavioral Reviews, 40, 6–19.

Amadeo, K. (2017, July 11). Deinstitutionalization: How does it affect you today? Retrieved from https://www.thebalance.com/deinstitutionalization-3306067.

Amirkhan, J. H., Urizar, G. G., & Clark, S. (2015). Criterion validation of a stress measure: The Stress Overload Scale. Psychological Assessment, 27(3), 985–996.

Amore, M., Innamorati, M., Vittorio, C. D., Weinberg, I., Turecki, G., Sher, L., . . . Pompili, M. (2014). Suicide attempts in major depressed patients with personality disorder. Suicide and Life-Threatening Behavior, 44(2), 155–166.

1184

https://www.thebalance.com/deinstitutionalization-3306067

Amsel, T. T. (2017). Practicing polygraph: Best practice guide. CreateSpace.

an der Heiden, W., & Häfner, H. (2011). Course and outcomes. In D. R. Weinberg & P. Harrison (Eds.), Schizophrenia (pp. 104–141). Hoboken, NJ: Wiley-Blackwell.

ANAD (National Association of Anorexia Nervosa and Associated Disorders). (2018). Eating disorder types and symptoms. Chicago, IL: ANAD. Retrieved from http://www.anad.org/education-and-awareness.

ANAD (National Association of Anorexia Nervosa and Associated Disorders). (2014). Binge eating disorder: The “new” eating disorder: Binge eating disorder (BED). Retrieved from http://www.anad.org/get-information/get-informationbinge-eating.

Anderson, A. P. A., Feldman, M. D., & Bryce, J. (2018). Munchausen by proxy: A qualitative investigation into online perceptions of medical child abuse. Journal of Forensic Science, 63(3), 771–775.

Anderson, J. L., Sellbomn, M., & Salekin, R. T. (2016, November 7). Utility of the personality inventory for DSM-5 Brief Form (PID-5-BF) in the measurement of maladaptive personality and psychopathology. Assessment. [Epub ahead of print]

Anderson, G. (2018). Linking the biological underpinnings of depression: Role of mitochondria interactions with melatonin, inflammation, sirtuins, tryptophan catabolites, DNA repair and oxidative and nitrosative stress, with consequences for classification and cognition. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 80(Pt C), 255–266.

Anderson, J. L., Sellbom, M., & Shealy, R. C. (2017). Clinician perspectives of antisocial and borderline personality disorders using DSM-5 Section III dimensional personality traits. Journal of Personality Disorders, 31, 1–15.

Anderson, J. L., Wood, M. E., Tarescavage, A. M., Burchett, D., & Glassmire, D. M. (2018). The role of dimensional personality psychopathology in a forensic inpatient psychiatric setting. Journal of Personality Disorders. [Manuscript in press]

Anderson, J., Snider, S., Sellbom, M., Krueger, R., & Hopwood, C. (2014). A comparison of the DSM-5 Section II and Section III personality disorder structures. Psychiatry Research, 216(3), 363–372.

Andrade, C. (2016). Antipsychotic drugs in schizophrenia: Relative effects in patients with and without treatment resistance. Journal of Clinical Psychiatry, 77(12), e1656–e1660.

Andrews, B., & Brewin, C.R. (2017). False memories and free speech: Is scientific debate being suppressed? Applied Cognitive Psychology, 31(1), 45–49.

1185

http://www.anad.org/education-and-awareness

http://www.anad.org/get-information/get-informationbinge-eating

Andrews, V. (1998, December 14). Abducted by aliens? Or just a little schizoid? HealthScout.

Anestis, M. D., & Houtsma, C. (2018). The association between gun ownership and statewide overall suicide rates. Suicide and Life-Threatening Behavior. [Manuscript in press]

Angier, N. (2010, April 5). Even among animals: Leaders, followers and schmoozers. New York Times.

Anheyer, D., Haller, H., Barth, J., Lauche, R., Dobos, G., & Cramer, H. (2017, April 25). Mindfulness-based stress reduction for treating low back pain: A systematic review and meta- analysis. Annals of Internal Medicine, 1–9. [Epub ahead of print]

Anonymous. (1996). First person account: Social, economic, and medical effects of schizophrenia. Schizophrenia Bulletin, 22(1), 183.

Anonymous. (2006). On madness: A personal account of rapid cycling bipolar disorder. British Journal of General Practice, 56(530), 726–728.

Anson, P. (2017, February 9). Sex, poverty and education linked to chronic pain. Pain News Network. Retrieved from https://www.painnewsnetwork.org.

Antal, H., Hossain, M. J., Hassink, S., Henry, S., Fuzzell, L., Taylor, A., & Wysocki, T. (2015). Audio-video recording of health care encounters for pediatric chronic conditions: Observational reactivity and its correlates. Journal of Pediatric Psychology, 40(1), 144–153.

Antfolk, J. (2017, January 25). Age limits. Evolutionary Psychology, 15(1).

Antony, M. M. (2019). Behavior therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., Ch. 6). Independence, KY: Cengage Publications.

Anupama, M., Gangadhar, K. H., Shetty, V. B., & Dip, P. B. (2016). Transvestism as a symptom: A case series. Indian Journal of Psychological Medicine, 38(1), 78–80.

APA (American Psychiatric Association). (2000). DSM-IV text revision. Washington, DC: Author.

APA (American Psychiatric Association). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

APA (American Psychiatric Association). (2013). The people behind DSM-5. Washington, DC: Author.

APA (American Psychiatric Association). (2013, May 13). DSM-5 field trials. Washington, DC: Author.

1186

https://www.painnewsnetwork.org

APA (American Psychiatric Association). (2017). DSM history. Arlington, VA: APA.

APA (American Psychological Association). (2002). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

APA (American Psychological Association). (2010). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

APA (American Psychological Association). (2014). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

APA (American Psychological Association). (2014). Mental and behavioral health and older Americans. Washington, DC: American Psychiatric Publishing, Inc. Retrieved from http://www.apa.org/about/gr/issues/aging/mental-health.aspx.

APA (American Psychological Association). (2014, July/August). How many psychology doctorates are awarded by U.S. institutions? Monitor, 45(7), 13.

APA (American Psychological Association). (2015). 2005–13: Demographics of the U.S. psychology workforce. Washington, DC: American Psychological Association.

APA (American Psychological Association). (2016). Data on behavioral health in the United States. Washington, DC: American Psychological Association.

APA (American Psychological Association). (2016, September). 2015 APA survey of psychology health service providers. Times Higher Education. Retrieved from https://www.timeshighereducation.com.

APA (American Psychological Association). (2017). Depression. Washington, DC: Author.

APA (American Psychological Association). (2017). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

APA (American Psychological Association). (2017). Ethnic and racial minorities & socioeconomic status. Washington, DC: Author.

APA (American Psychological Association). (2017). Mental and behavioral health and older Americans. Washington, DC: APA.

APA (American Psychological Association). (2017, April 5). Idaho becomes fifth state to allow psychologists to prescribe medications. Washington, DC: Author.

APA (American Psychological Association). (2017, August 17). APA reaction to settlement of torture case against psychologists Mitchell, Jessen. Washington, DC: APA.

1187

http://www.apa.org/about/gr/issues/aging/mental-health.aspx

https://www.timeshighereducation.com

APA (American Psychological Association). (2017, January 1). Introduction and applicability (Amendment). Washington, DC: Author.

APA (American Psychological Association). (2017, January 30). School bullying linked to lower academic achievement, research finds. Retrieved from http://www.apa.org/news/press/releases.

APA (American Psychological Association). (2017, November 1). Stress in America: State of our nation. Washington, DC: Author.

APA (American Psychological Association). (2018). Coping with stress at work. Washington, DC: APA.

APA (American Psychological Association). (2018). Growing mental and behavioral health concerns facing older Americans. Washington, DC: APA.

APA (American Psychological Association). (2018). Higher stress among minority and low- income populations can lead to health disparities, says report. Washington, DC: Author.

APA (American Psychological Association). (2018, June 4). Prescriptive authority. Washington, DC: APA. Retrieved from http://www.apapracticecentral.org/advocacy.

APA (American Psychological Association). (2015, February 4). Stress in America: Paying with our health. Washington, DC: Author.

Apter, A., & Wasserman, D. (2007). Suicide in psychiatric disorders during adolescence. In R. Tatarelli, M. Pompili, & P. Girardi (Eds.), Suicide in psychiatric disorders. New York: Nova Science Publishers.

Archer, D. (2013). Reading between the (head)lines: Smartphone addiction. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/reading-between-the- headlines/201307/smartphone-addiction.

Arfanakis, K., Wilson, R. S., Barth, C. M., Capuano, A. W., Vasireddi, A., Zhang, S., . . . Bennett, D. A. (2016). Cognitive activity, cognitive function, and brain diffusion characteristics in old age. Brain Imaging and Behavior, 10(2), 455–463.

Arie, S. (2016, September 21). Beyond Bedlam. BMJ, 354:i5115.

Arieti, S. (1974). Interpretation of schizophrenia. New York: Basic Books.

Arieti, S., & Bemporad, J. R. (1978). Severe and mild depression: The psychotherapeutic approach. New York: Basic Books.

Aring, C. D. (1974). The Gheel experience: Eternal spirit of the chainless mind! Journal of the American Medical Association, 230(7), 998–1001.

1188

http://www.apa.org/news/press/releases

http://www.apapracticecentral.org/advocacy

https://www.psychologytoday.com/us/blog/reading-between-the-headlines/201307/smartphone-addiction

Aring, C. D. (1975). Gheel: The town that cares. Family Health, 7(4), 54–55, 58, 60.

Arnold, T. C., & Ryan, M. L. (2017, November 6). Acute amphetamine and synthetic cathinone (“bath salt”) intoxication. UpToDate. Retrieved from http://www.uptodate.com.

Aronson, M. D. (2017, June 22). Psychosocial treatment of alcohol use disorder. UpToDate. Retrieved from http://www.uptodate.com.

Arosio, B., Ostan, R., Mari, D., Damanti, S., Ronchetti, F., Arcudi, S., . . . Monti, D. (2017). Cognitive status in the oldest old and centenarians: A condition crucial for quality of life methodologically difficult to assess. Mechanisms of Ageing and Development, 165(Part B), 185–194.

Arseneault, L. (2017). The long-term impact of bullying victimization on mental health. World Psychiatry, 16, 27–28.

ASA (American Sleep Association). (2017). Sleep and sleep disorder statistics. Sleep Association. Retrieved from https://www.sleepassociation.org/sleep/sleep-statistics.

Asarnow, J. R., Hughes, J. L., Babeva, K., & Sugar, C. A. (2017). Cognitive-behavioral family treatment for suicide attempt prevention: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 56(6), 506–514.

ASCA (American School Counselor Association). (2016). Student-to-school-counselor ratio 2013–2014. Alexandria, VA: ASCA.

ASCA (American School Counselor Association). (2017). Student-to-school-counselor ratio. Alexandria, VA: ASCA.

Ascoli, M., Lee, T., Warfa, N., Mairura, J., Persaud, A., & Bhui, K. (2017, March 31). Race, culture, ethnicity and personality disorder: Group Careif position paper. Psycheblog. Retrieved from http://psycheblog.uk.

Ash, R. (2001). The top 10 of everything 2002 (American ed.). New York: DK Publishing.

Ashford, M. T., Olander, E. K., Rowe, H., Fisher, J. R. W., & Ayers, S. (2017). Internet- based interventions for postpartum anxiety: Exploring health visitors’ views. Journal of Reproductive and Infant Psychology, 35(3), 298–308.

Ashraf, N., & Thevasagayam, M. S. (2014). Munchausen syndrome by proxy presenting as hearing loss., Journal of Laryngology and Otology, 128(6), 540–542.

Ashton, K., & Sullivan, A. (2018, February 15). Ethics and confidentiality for psychologists in academic health centers. Journal of Clinical Psychology in Medical Settings. [Epub ahead of

1189

http://www.uptodate.com

https://www.sleepassociation.org/sleep/sleep-statistics

http://psycheblog.uk

print]

Asimov, I. (1997). Isaac Asimov’s book of facts. New York: Random House (Wings Books).

ASPS (American Society of Plastic Surgeons). (2017). 2016 plastic surgery statistics. Retrieved from https://www.plasticsurgery.org/news.

ASPS (American Society of Plastic Surgeons). (2017, May 22). Gender confirmation surgeries rise 20% in first ever report. Retrieved from https://www.plasticsurgery.org/news/press- releases.

Assari, S. (2017). Social determinants of depression: The intersections of race, gender, and socioeconomic status. Brain Sciences, 7(12), 156.

Asselmann, E., Stender, J., Grabe, H. J., König, J., Schmidt, C. O., Hamm, A. O., & Pané- Farré, C. A. (2018). Assessing the interplay of childhood adversities with more recent stressful life events and conditions in predicting panic pathology among adults from the general population. Journal of Affective Disorders, 225, 715–722.

Augustyn, M. (2017, March 7). Autism spectrum disorder: Terminology, epidemiology, and pathogenesis. UpToDate. Retrieved from http://www.uptodate.com.

Augustyn, M. (2017, March 8). Autism spectrum disorder: Clinical features. UpToDate. Retrieved from http://www.uptodate.com.

Augustyn, M. (2018, January 4). Autism spectrum disorder: Clinical features. UpToDate. Retrieved from http://www.uptodate.com.

Augustyn, M. (2018, May 8). Autism spectrum disorder: Terminology, epidemiology, and pathogenesis. UpToDate. Retrieved from http://www.uptodate.com.

Austen, I. (2017, April 13). Trudeau unveils bill legalizing recreational marijuana in Canada. New York Times.

Austin, J. (2015). More than half of Britons claim to have had contact with ghosts. The Independent. Retrieved from http://www.theindependentbd.com.

Autism Speaks. (2018). Facts about autism. New York: Autism Speaks.

Autism Speaks. (2018). Increased risk of autism in siblings news coverage. New York: Autism Speaks.

Autism Speaks. (2018). What is autism? New York: Autism Speaks.

Avenevoli, S., Swendsen, J., He, J. P., Burstein, M., & Merikangas, K. R. (2015). Major

1190

https://www.plasticsurgery.org/news

https://www.plasticsurgery.org/news/press-releases

http://www.uptodate.com

http://www.theindependentbd.com

depression in the National Comorbidity Survey-Adolescent Supplement: Prevalence, correlates, and treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 37–44.

Avery-Clark, C., & Weiner, L. (2017). A traditional Masters and Johnson behavioral approach to sex therapy. In Z. D. Peterson, The Wiley-Blackwell handbook of sex therapy (Chap. 11, pp. 165–189). Hoboken, NJ: Wiley-Blackwell.

Avraham, Y., Hants, Y., Vorobeiv, L., Staum, M., Abu Ahmad, W., Mankuta, D., . . . Arbel- Alon, S. (2017). Brain neurotransmitters in an animal model with postpartum depressive-like behavior. Behavioural Brain Research, 326, 307–321.

Ayd, F. J., Jr. (1956). A clinical evaluation of Frenquel. Journal of Nervous and Mental Disease, 124, 507–509.

Ayhan, G., Arnal, R., Basurko, C., About, V., Pastre, A., Pinganaud, E., . . . Nacher, M. (2017). Suicide risk among prisoners in French Guiana: Prevalence and predictive factors. BMC Psychiatry, 17(1), 156.

Ayllon, T. (1963). Intensive treatment of psychotic behavior by stimulus satiation and food reinforcement. Behavioral Research and Therapy, 1, 53–62.

Ayllon, T., & Michael, J. (1959). The psychiatric nurse as a behavioural engineer. Journal of Experimental Analytical Behavior, 2, 323–334.

Ayoub, C. C. (2006). Munchausen by proxy. In T. G. Plante (Ed.), Mental disorders of the new millenium: Biology and function (Vol. 3, pp. 173–193). Westport, CT: Praeger Publishers/Greenwood Publishing.

Ayoub, C. C. (2010). Munchausen by proxy. In J. M. Brown & E. A. Campbell (Eds.), The Cambridge handbook of forensic psychology (pp. 690–699). New York: Cambridge University Press.

Azevedo, J. C., Pais-Ribeiro, J. L., Coelho, R., & Figueiredo-Braga, M. (2018). Validation of the Portuguese version of impulsive-premeditated aggression scale in an inmate population. Frontiers in Psychiatry, 9, 10.

BAAM (British Association of Anger Management). (2016). Mental health organization: Boiling point report 2008. BAAM. Retrieved from https://www.angermanage.co.uk/anger- statistics.

BAAM (British Association of Anger Management). (2017). Mental health organization: Boiling point report 2008. BAAM. Retrieved from https://www.angermanage.co.uk/anger-

1191

https://www.angermanage.co.uk/anger-statistics

statistics.

Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–2013. American Journal of Public Health, 106, 686–688.

Bachmann, C. J., Wijilaars, L. P., Kalverdijk, L. J., Burcu, M., Glaeske, G., Schuiling- Beninga, C. C. M., Hoffmann, F., Aagaard, L., & Zito, J. M. (2017). Trends in ADHD medication use in children and adolescents in five western countries, 2005–2012. European Neuropsychopharmacology, 27, 484–493.

Bademli, K., & Duman, Z. C. (2016). Emotions, ideas and experiences of caregivers of patients with schizophrenia about “family to family support program.” Archives of Psychiatric Nursing, 30(3), 329–333.

Badoud, D., Prada, P., Nicastro, R., Germond, C., Luyten, P., Perroud, N., & Debbane, M. (2018). Attachment and reflective functioning in women with borderline personality disorder. Journal of Personality Disorders. [Manuscript in press]

Badr, L. K. (2018). Is the effect of postpartum depression on mother-infant bonding universal? Infant Behavior and Development, 51, 15–23.

Bagayogo, I. P., Interian, A., & Escobar, J. I. (2013). Transcultural aspects of somatic symptoms in the context of depressive disorders. Advances in Psychosomatic Medicine, 33, 64– 74.

Bagby, E. (1922). The etiology of phobias. Journal of Abnormal Psychology, 17, 16–18.

Bagot, R. C., Cates, H. M., Purushothaman, I., Lorsch, Z. S., Walker, D. M., Wang, J., . . . Nestler, E. J. (2016). Circuit-wide transcriptional profiling reveals brain region-specific gene networks regulating depression susceptibility. Neuron, 90(5), 969–983.

Bailey, L. (2017, February 21). Psychologists refute report on collusion with Feds. Courthouse News. Retrieved from https://www.courthousenews.com.

Bakalar, N. (2013, July 31). Moon phases tied to sleep cycles. New York Times.

Bakker, M. J., Greven, C. U., Buitelaar, J. K., & Glennon, J. C. (2017). Practitioner review: Psychological treatments for children and adolescents with conduct disorder problems: A systematic review and meta-analysis. Journal of Child Psychology and Psychiatry, 58(1), 4–18.

Balassone, M., (2011). Jails, prisons increasingly taking care of mentally ill. Washington Post, 134(49).

1192

https://www.courthousenews.com

Baldor, R. (2018, January 16). Primary care of the adult with intellectual and developmental disabilities. UpToDate. Retrieved from http://www.uptodate.com.

Baldwin, D. (2018, April 3). Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Baldwin, D. S., Gordon, R., Abelli, M., & Pini, S. (2016). The separation of adult separation anxiety disorder. CNS Spectrums, 21(4), 289–294.

Bales, D. L., Timman, R., Andrea, H., Busschbach, J. V., Verheul, R., & Kamphuis, J. H. (2014). Effectiveness of day hospital mentalization-based treatment for patients with severe borderline personality disorder: A matched control study. Clinical Psychology and Psychotherapy. [Advance online publication]

Balia, C., Carucci, S., Coghill, D., & Zuddas, A. (2018). The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous-unemotional traits modulate the efficacy of medication? Neuroscience & Biobehavioral Reviews, 91, 218–238.

Balmer, A. (2018). Lie detection and the law: Torture, technology and truth (law, science and society). New York: Routledge.

Bancroft, J., Loftus, J., & Long, J. S. (2003). Distress about sex: A national survey of women in heterosexual relationships. Archives of Sexual Behavior, 32(3), 193–208.

Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 17, 327–335.

Bandura, A. (1971). Psychotherapy based upon modeling principles. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215.

Bandura, A. (2011). But what about that gigantic elephant in the room? In R. M. Arkin (Ed.), Most underappreciated: 50 prominent social psychologists describe their most unloved work (pp. 51–59). New York: Oxford University Press.

Bandura, A., & Rosenthal, T. (1966). Vicarious classical conditioning as a function of arousal level. Journal of Personality and Social Psychology, 3, 54–62.

Bandura, A., Adams, N. E., & Beyer, J. (1977). Cognitive processes mediating behavioral change. Journal of Personality and Social Psychology, 35(3), 125–139.

1193

http://www.uptodate.com

Barbieri, R. I. (2017, October 3). Differential diagnosis of sexual pain in women. UpToDate. Retrieved from http://www.uptodate.com.

Bareggi, S. R., Bianchi, L., Cavallaro, R., Gervasoni, M., Siliprandi, F., & Bellodi, L. (2004). Citalopram concentrations and response in obsessive-compulsive disorder: Preliminary results. CNS Drugs, 18(5), 329–335.

Bari, A. A., Mikell, C. B., Abosch, A., Ben-Haim, S., Buchanan, R. J., Burton, A. W., . . . Sheth, S. A. (2018, January 25). Charting the road forward in psychiatric neurosurgery: Proceedings of the 2016 American Society for Stereotactic and Functional Neurosurgery workshop on neuromodulation for psychiatric disorders. Journal of Neurology, Neurosurgery & Psychiatry. [Epub ahead of print]

Barker, E. D. (2018). Epigenetics, early adversity and child and adolescent mental health. Psychopathology, 51(2), 71–75.

Barlow, M. R. (2011). Memory for complex emotional material in dissociative identity disorder. Journal of Trauma & Dissociation, 12(1), 53–66.

Barnes, A. (2004). Race, schizophrenia, and admission to state psychiatric hospitals. Administration and Policy in Mental Health, 31(3), 241–252.

Barnes, M. (2017, March 14). Mom thought daughter’s Facebook suicide was fake, posts cruel comment. Rolling Out. Retrieved from http://rollingout.com.

Barnes, N., Hattan, P., Black, D. S., & Schuman-Olivier, Z. (2016). An examination of mindfulness-based programs in US medical schools. Biomind. Retrieved from http://www.biomind.usc.edu.

Barnes, S. M., Bahraini, N. H., Forster, J. E., Stearns-Yoder, K. A., Hostetter, T. A. Smith, G., . . . Nock, M. K. (2017). Moving beyond self-report: Implicit associations about death/life prospectively predict suicidal behavior among veterans. Suicide and Life-Threatening Behavior, 47(1), 67–77.

Barnett, J. E. (2018). Integrating spirituality and religion into psychotherapy practice. Society for the Advancement of Psychotherapy, Division 29 of the American Psychological Association. (Web article.)

Barrera, T. L., Wilson, K. P., & Norton, P. J. (2010). The experience of panic symptoms across racial groups in a student sample. Journal of Anxiety Disorders, 24(8), 873–878.

Barsky, A. J. (2016). Assessing the new DSM-5 diagnosis of somatic symptom disorder. Psychosomatic Medicine, 78(1), 2–4.

1194

http://www.uptodate.com

http://rollingout.com

http://www.biomind.usc.edu

Bartholomew, R. (2014). Mass hysteria in schools: Worldwide since 1566. Jefferson, NC: McFarland.

Bartlett, S. C. (2017). A path towards abuse—the decline of moral treatment in the Utica Lunatic Asylum. Global Tides, 11(1).

Bartol, C. R., & Bartol, A. M. (2015). Psychology and law: Research and practice. Los Angeles: Sage Publications.

Bartoli, F., Pompili, M., Lillia, N., Crocamo, C., Salemi, G., Clerici, M., Carrà, G. (2017). Rates and correlates of suicidal ideation among stroke survivors: A meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry, 88, 498–504.

Bartz, J., Kaplan, A., & Hollander, E. (2007). Obsessive-compulsive personality disorder. In W. O’Donohue, K. A. Fowler, S. O. Lilienfeld (Eds.). Personality disorders: Toward the DSM- V. Los Angeles: Sage Publications.

Basile, J., & Bloch, M. J. (2018, January 18). Overview of hypertension in adults. UpToDate. Retrieved from http://www.uptodate.com.

Basoglu, M., Jaranson, J. M., Mollica, R., & Kastrup, M. (2001). Torture and mental health: A research overview. In E. Gerrity, T. M. Keane, & F. Tuma (Eds.), The mental health consequences of torture (pp. 35–62). New York: Kluwer Academic/Plenum Publishers.

Bass, C., & Glaser, D. (2014). Early recognition and management of fabricated or induced illness in children. Lancet, 383(9926), 1412–1421.

Bassir Nia, A., Eveleth, M. C., Gabbay, J. M., Hassan, Y. J., Zhang, B., & Perez-Rodriguez, M. M. (2018). Past, present, and future of genetic research in borderline personality disorder. Current Opinion in Psychology, 21, 60–68.

Basso, J. C., McHale, A., Ende, V., Oberlin, D. J., & Suzuki, W. A. (2019). Brief, daily meditation enhances attention, memory, mood, and emotional regulation in non-experienced meditators. Behavioural Brain Research, 356, 208–220.

Basson, R. (2007). Sexual desire/arousal disorders in women. In S. R. Leiblum (Ed.), Principles and practice of sex therapy (4th ed., pp. 25–53). New York: Guilford Press.

Bateman, A. W., Fonagy, P., & Campbell, C. (2018). Mentalization-based treatment. In W. J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., Ch. 30). New York: Guilford Press.

Bateman, A. W. (2011). Borderline personality disorder. In J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (2nd ed., pp. 588–

1195

http://www.uptodate.com

600). Washington, DC: American Psychological Association.

Baten, V., Busch, H. J., Busche, C., Schmid, B., Heupel-Reuter, M., Perlov, E., . . . Klöppel, S. (2018, May 8). Validation of the brief confusion assessment method for screening delirium in elderly medical patients in a German emergency department. Academic Emergency Medicine. [Epub ahead of print]

Bates, C. K. (2017, April 6). Evaluation and management of adult and adolescent sexual assault victims. UpToDate. Retrieved from http://www.uptodate.com.

Bates, G. W., Thompson, J. C., & Flanagan, C. (1999). The effectiveness of individual versus group induction of depressed mood. Journal of Psychology, 133(3), 245–252.

Baucom, B. R., Atkins, D. C., Rowe, L. S., Doss, B. D., & Christensen, A. (2015). Prediction of treatment response at 5-year follow-up in a randomized clinical trial of behaviorally based couple therapies. Journal of Consulting and Clinical Psychology, 83(1), 103–114.

Baucom, D. H., Fischer, M. S., Worrell, M., Corrie, S., Belus, J. M., Molyva, E., & Boeding, S. E. (2018). Couple-based intervention for depression: An effectiveness study in the National Health Service in England. Family Process, 57(2), 275–292.

Baucom, D. H., Epstein, N. B., Kirby, J. S., & LaTaillade, J. J. (2010). Cognitive-behavioral couple therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 411–444). New York: Guilford Press.

Bauer, C. M., Cabral, H. J., & Killiany, R. J. (2018). Multimodal discrimination between normal aging, mild cognitive impairment and Alzheimer’s disease and prediction of cognitive decline. Diagnostics (Basel), 8(1).

Bauer, S. M., Schanda, H., Karakula, H., Olajossy-Hilkesberger, L., Rudaleviciene, P., Okribelashvili, N., . . . Stompe, T. (2011). Culture and the prevalence of hallucinations in schizophrenia. Comprehensive Psychiatry, 52(3), 319–325.

Baum, A., Trevino, L. A., & Dougall, A. L. (2011). Stress and the cancers. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science: Biology, psychology, and health (pp. 411–423). New York: Springer Publishing.

Baune, B. T., Malhi, G. S., Morris, G., Outhred, T., Hamilton, A., Das, P., . . . Singh, A. B. (2018). Cognition in depression: Can we THINC-it better? Journal of Affective Disorders, 225, 559–562.

Baykal, S., Batar, B., Nalbantoglu, A., Albayrak, Y., Hanci, H., Potas, N., . . . Beyanzyüz, M. (2019). Altered methyltetrahydrofolate reductase gene polymorphism in mothers of children

1196

http://www.uptodate.com

with attention deficit and hyperactivity disorder. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 88, 215–221.

Bearse, J. L., McMinn, M. R., Seegobin, W., & Free, K. (2014). Healing thyself: What barriers do psychologists face when considering personal psychotherapy and how can they be overcome? APA, 45(49), 62.

Beasley, L. O., Silovsky, J. F., Owora, A., Burris, L., Hecht, D., DeMoraes-Huffine, P., . . . Tolma, E. (2014). Mixed-methods feasibility study on the cultural adaptation of a child abuse prevention model. Child Abuse and Neglect. [Electronic publication]

Beatty Moody, D. L., Waldstein, S. R., Tobin, J. N., Cassells, A., Schwartz, J. C., & Brondolo, E. (2016). Lifetime racial/ethnic discrimination and ambulatory blood pressure: The moderating effect of age. Health Psychology, 35(4), 333–342.

Beblo, T., Kater, L., Baetge, S., Driessen, M., & Piefke, M. (2017). Memory performance of patients with major depression in an everyday life situation. Psychiatry Research, 248, 28–34.

Bechtel, K., & Bennett, B. L. (2017, March 15). Evaluation of sexual abuse in children and adolescents. UpToDate. Retrieved from http://www.uptodate.com.

Beck, A. T. (2016). Cognitive therapy: Nature and relation to behavior therapy (Republished article). Behavior Therapy, 47(6), 776–784.

Beck, A. T., & Weishaar, M. E. (2019). Cognitive therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., Ch. 7). Independence, KY: Cengage Publications.

Beck, A. T., Davis, D. D., & Freeman, A. (Eds.). (2015). Cognitive therapy of personality disorders (3rd ed.). New York: Guilford Press.

Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row.

Beck, A. T. (2002). Cognitive models of depression. In R. L. Leahy & E. T. Dowd (Eds.), Clinical advances in cognitive psychotherapy: Theory and application (pp. 29–61). New York: Springer.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. (1962). Reliability of psychiatric diagnosis: 2. A study of consistency of clinical judgments and ratings. American Journal of Psychiatry, 119, 351–357.

1197

http://www.uptodate.com

Becker, C. B., Perez, M., Kilpela, L. S., Diedrichs, P. C., Trujillo, E., & Stice, E. (2017). Engaging stakeholder communities as body image intervention partners: The Body Project as a case example. Eating Behaviors, 25, 62–67.

Becker, P. M. (2015). Hypnosis in the management of sleep disorders. Sleep Medicine Clinics, 10(1), 85–92.

Becker, W. C., & Starrels, J. L. (2018, January 4). Prescription drug misuse: Epidemiology, prevention, identification, and management. UpToDate. Retrieved from http://www.uptodate.com.

Beckman, K., Lindh, A. U., Waern, M., Stromsten, L., Renberg, E. S., Runeson, B., & Dahlin, M. (2019). Impulsive suicide attempts among young people: A prospective multicentre cohort study in Sweden. Journal of Affective Disorders, 243, 421–426.

Beelmann, A., Malti, T., Noam, G. G., & Sommer, S. (2018, January 25). Innovation and integrity: Desiderata and future directions for prevention and intervention science. Prevention Science. [Epub ahead of print]

Beeney, J. E., Wright, A. G. C., Stepp, S. D., Hallquist, M. N., Lazarus, S. A., Beeney, J. R. S., . . . Pilkonis, P. A. (2017). Disorganized attachment and personality functioning in adults: A latent class analysis. Personality Disorders, 8(3), 206–216.

Beidel, D. C., Alfano, C. A., Kofler, M. J., Rao, P. A., Scharfstein, L., & Wong Sarver, N. (2014). The impact of social skills training for social anxiety disorder: A randomized controlled trial. Journal of Anxiety Disorders, 28(8), 908–918.

Beier, E. G., & Young, D. M. (1984). The silent language of psychotherapy: Social reinforcement of the unconscious processes (2nd ed.). Hawthorne, New York: Aldine.

Bekker, J. (2017, October 6). 28 percent of mass shooting survivors experience PTSD. Las Vegas Review-Journal.

Belendiuk, K. A., & Riggs, P. (2014). Treatment of adolescent substance use disorders. Current Treatment Options in Psychiatry, 1(2), 175–188.

Beletsky, L., & Davis, C. S. (2017). Today’s fentanyl crisis: Prohibition’s iron law, revisited. International Journal of Drug Policy, 46, 156–159.

Bemporad, J. R. (1992). Psychoanalytically orientated psychotherapy. In E. S. Paykel (Ed.), Handbook of affective disorders. New York: Guilford Press.

Ben-Ezra, M., Leshem, E., & Goodwin, R. (2015). In the wake of national trauma: Psychological reactions following the Charlie Hebdo attack. American Journal of Psychiatry,

1198

http://www.uptodate.com

172(8), 795–796.

Ben-Natan, M., Sharon, I., Barbashov, P., Minasyan, Y., Hanukayev, I., Kajdan, D., & Klein-Kremer, A. (2014). Risk factors for child abuse: Quantitative correlational design. Journal of Pediatric Nursing, 29(3), 220–227.

Bennett, M. P. (1998). The effect of mirthful laughter on stress and natural killer cell cytotoxicity. Dissertation Abstracts International: Section B: The Sciences and Engineering, 58(7– B), 3553.

Bennett, S., & Walkup, J. T. (2018, June 5). Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course. UpToDate. Retrieved from http://www.uptodate.com.

Ben-Shakhar, G., & Bar, M. (2019). The lying machine: Mysticism and pseudo-science in personality assessment and prediction. New York: Routledge.

Bergink, V., Bouvy, P. F., Vervoort, J. P., Koorengevel, K. M., Steegers, E. P., & Kushner, S. A. (2012). Prevention of postpartum psychosis and mania in women at high risk. American Journal of Psychiatry, 169(6), 609–615.

Bergman, H., Rathbone, J., Agarwal, V., & Soares-Weiser, K. (2018). Antipsychotic reduction and/or cessation and antipsychotics as specific treatments for tardive dyskinesia. Cochrane Database of Systematic Reviews, 2, CD000459.

Bergner, R. M., & Bunford, N. (2017). Mental disorder is a disability concept, not a behavioral one. Philosophy, Psychiatry, & Psychology, 24(1), 25–40.

Bergner, R. M., & Bunford, N. (2014). Mental disorder is a disability concept, not a behavioral one: An empirical investigation. Athens, OH: Ohio University.

Berk, S. N., & Efran, J. S. (1983). Some recent developments in the treatment of neurosis. In C. E. Walker (Ed.), The handbook of clinical psychology: Theory, research, and practice (Vol. 2). Homewood, IL: Dow Jones-Irwin.

Berman, A. L. (2018). Risk factors proximate to suicide and suicide risk assessment in the context of denied suicide ideation. Suicide and Life-Threatening Behavior. [Manuscript in press]

Berman, A. L. (1986). Helping suicidal adolescents: Needs and responses. In C. A. Corr & J. N. McNeil (Eds.), Adolescence and death. New York: Springer.

Berman, E. (2017). An inclusive psychoanalyst: Sidney Blatt’s contribution in perspective. Journal of the American Psychoanalytic Association, 65(3), 525–533.

1199

http://www.uptodate.com

Bernecker, S. L., Coyne, A. E., Constantino, M. J., & Ravitz, P. (2017). For whom does interpersonal psychotherapy work? A systematic review. Clinical Psychology Review, 56, 82–93.

Bernier, R., & Dawson, G. (2016). Autism spectrum disorders. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed.). New York: Wiley.

Bernstein, L. (2017, February 14). Poll: Mainstream media continues to lose the public’s trust. WJLA.

Berry, M. D., & Berry, P. D. (2013). Contemporary treatment of sexual dysfunction: Reexamining the biopsychosocial model. Journal of Sexual Medicine, 10, 2627–2643.

Bertozzi, S., Londero, A. P., Fruscalzo, A., Driul, L., & Marchesoni, D. (2010). Prevalence and risk factors for dyspareunia and unsatisfying sexual relationships in a cohort of primiparous and secondiparous women after 12 months postpartum. International Journal of Sexual Health, 22(1), 47–53.

Best, D. (2017). Why the mechanisms of 12-step behaviour change should matter to clinicians. Addiction, 112(6), 938–939.

Beutler, L. E., Williams, R. E., Wakefield, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50(12), 984–994.

Bever, L. (2017, June 6). The disturbing trend of live-streamed suicides. Chicago Tribune.

BGS (British Geriatrics Society). (2016, February). Acute confusion/delirium. BGS. Retrieved from bgs.org.uk.

Bhatia, T., Gettig, E. A., Gottesman, I. I., Berliner, J., Mishra, N. N., Nimgaonkar, V. L., & Deshpande, S. N. (2016). Stratifying empiric risk of schizophrenia among first degree relatives using multiple predictors in two independent Indian samples. Asian Journal of Psychiatry, 24, 79–84.

Bhattacharya, R., Cross, S., & Bhugra, D. (Eds). (2010). Clinical topics in cultural psychiatry. London: Royal College of Psychiatrists.

Bigdeli, T. B., Maher, B. S., Zhao, Z., Sun, J., Medeiros, H., Akula, N., . . . Fanous, A. H. (2013). Association study of 83 candidate genes for bipolar disorder in chromosome 6q selected using an evidence-based prioritization algorithm. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics, 162B(8), 898–906.

Billard, T. J. (2018). Attitudes toward transgender men and women: Development and validation of a new measure. Frontiers in Psychology, 9, 387.

1200

Bills, C. B., & Li, G. (2005). Correlating homicide and suicide. International Journal of Epidemiology, 34(4), 837–845.

Bina, R., & Glasser, S. (2017, December 27). Factors associated with attitudes toward seeking mental health treatment postpartum. Women’s Health. [Epub ahead of print]

Binet, A., & Simon, T. (1916). The development of intelligence in children (The Binet-Simon Scale). Baltimore: Williams & Wilkins.

Binswanger, I., & Elmore, J. G. (2018, April 23). Clinical care of incarcerated adults. UpToDate. Retrieved from http://www.uptodate.com.

BJS (Bureau of Justice Statistics). (2013, March 7). Female victims of sexual violence, 1994–2010 (NCJ 240655). Retrieved from http://www.bjs.gov/index.cfm?tv=pbdetail&iid=4594.

BJS (Bureau of Justice Statistics). (2016). Data collection: National Crime Victimization Survey (NCVS). Washington, DC: Author.

BJS (Bureau of Justice Statistics). (2016, April). Assessing inmate cause of death: Deaths in Custody Reporting Program and National Death Index (NCJ 249568). Retrieved from http://www.bjs.gov.

BJS (Bureau of Justice Statistics). (2016, October). Criminal victimization, 2015 (NCJ 250180). Washington, DC: BJS.

BJS (Bureau of Justice Statistics). (2017). Victims and offenders. Washington, DC: Author.

BJS (Bureau of Justice Statistics). (2017, December 7). Criminal victimization, 2016. Retrieved from https://www.bjs.gov/index.

BJS (Bureau of Justice Statistics). (2017, December). Criminal victimization, 2016. Washington, DC: BJS.

BJS (Bureau of Justice Statistics). (2018, May). Mortality in correctional institutes. Retrieved from https://www.bjs.gov.

Black Youth Project. (2011). The attitudes and behavior of young Black Americans: Research summary. Retrieved from Black Youth Project website: www.blackyouthproject.com/survey/findings.

Black Youth Project. (2016). About us. Chicago, IL: Author.

Black Youth Project. (2018). Discrimination archives. Chicago, IL: Author.

Black, D. W. (2017, April 20). Treatment of antisocial personality disorder. UpToDate.

1201

http://www.uptodate.com

http://www.bjs.gov/index.cfm?tv=pbdetail&iid=4594

http://www.bjs.gov

https://www.bjs.gov/index

https://www.bjs.gov

Retrieved from http://www.uptodate.com.

Black, D. W. (2017, September 15). Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., . . . Stevens, M. R. (2011) The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, CDC.

Blagov, P. S., Fowler K. A., & Lilienfeld, S. O. (2007). Histrionic personality disorder. In W. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.). Personality disorders: Toward the DSM- V. Los Angeles: Sage Publications.

Blair, J., Mitchell, D., & Blair, K. (2005). The psychopath: Emotion and the brain. Malden, MA: Blackwell Publishing.

Blanchard, J. J., Bradshaw, K. R., Garcia, C. P., Nasrallah, H. A., Harvey, P. D., Casey, D., . . . O’Gorman, C. (2017). Examining the reliability and validity of the Clinical Assessment Interview for Negative Symptoms within the Management of Schizophrenia in Clinical Practice (MOSAIC) multisite national study. Schizophrenia Research, 185, 137–143.

Blashfield, R. K., Keele, J. W., Flanagan, E. H., & Miles, S. R. (2014). The cycle of classification: DSM-I through DSM-5. Annual Review of Clinical Psychology, 10, 25–51.

Blass, R.B. (2015). Conceptualizing splitting: On the different meanings of splitting and their implications for the understanding of the person and the analytic process. International Journal of Psychoanalysis, 96(1), 123–139.

Blaxton, J. M., & Bergeman, C. S. (2017). A process-oriented perspective examining the relationships among daily coping, stress, and affect. Personality and Individual Differences, 104, 357–361.

Blazer, D. G. (2018). Advancing our diagnostic tools and treatment options for delirium. International Psychogeriatrics, 30(4), 447–449.

Blennow, K., & Zetterberg, H. (2018). The past and the future of Alzheimer’s disease fluid biomarkers. Journal of Alzheimer’s Disease, 62(3), 1125–1140.

Bliss, E. L. (1980). Multiple personality, allied disorders and hypnosis. New York: Oxford University Press.

Block, J. (2015). Shortage of psychiatrists only getting worse. Psychiatry Advisor. Retrieved from http://www.psychiatryadvisor.com/shortage-of-psychiatrists-only-getting-

1202

http://www.uptodate.com

http://www.psychiatryadvisor.com/shortage-of-psychiatrists-only-getting-worse/printarticle/437233

worse/printarticle/437233.

Bloom, B. L. (1984). Community mental health: A general introduction (2nd ed.). Monterey, CA: Brooks/Cole.

BLS (Bureau of Labor Statistics). (2015). Economic News Release. Table A-3. Employment status of the Hispanic or Latino population by sex and age. Retrieved from http://www.bls.gov/news.release.empsit.t03.htm.

BLS (Bureau of Labor Statistics). (2016). Occupational employment statistics. Occupational employment and wages, May 2015: 21-1014 Mental health counselors. Retrieved from https://data.bls.gov/cgi-bin/print.pl/oes/current/oes211014.htm.

BLS (Bureau of Labor Statistics). (2016). Occupational employment statistics. Occupational employment and wages, May 2015. 29-1066 Psychiatrists. Retrieved from https://www.bls.gov/oes/current/oes291066.htm.

BLS (Bureau of Labor Statistics). (2016). Occupational outlook handbook, 2016–17 edition: Psychologists. Washington, DC: U.S. Department of Labor. Retrieved from https://www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm.

BLS (Bureau of Labor Statistics). (2016). Occupational outlook handbook, 2016–17 edition: Social workers. Washington, DC: U.S. Department of Labor. Retrieved from https://www.bls.gov/ooh/community-and-social-service/social-workers.htm.

BLS (Bureau of Labor Statistics). (2017, March 31). Occupational employment statistics. Occupational employment and wages, May 2016 29-1066 psychiatrists. Retrieved from https://www.bls.gov/oes/current/oes291066.htm.

BLS (Bureau of Labor Statistics). (2017, October 24). Occupational outlook handbook. Woodworkers. Retrieved from https://www.bls.gov/ooh/.

Blum, K., Chen, A. L. C., Thanos, P. K., Febo, M., Demetrovics, Z., Dushaj, K., . . . Badgaiyan, R. D. (2018). Genetic addiction risk score (GARS)™, a predictor of vulnerability to opioid dependence. Frontiers in Bioscience (Elite Edition), 10, 175–196.

Blum, K., Febo, M., & Badgaiyan, R. D. (2016, October 12). Fifty years in the development of a glutaminergic-dopaminergic optimization complex (KB220) to balance brain reward circuitry in reward deficiency syndrome: A pictorial. Austin Addiction Science, 1(2).

Blum, K., Simpatico, T., Badgaiyan, R. D., Demetrovics, Z., Fratantonio, J., Agan, C., . . . Gold, M. S. (2015). Coupling neurogenetics (GARS) and a nutrigenomic-based dopaminergic agonist to treat Reward Deficiency Syndrome (RDS): Targeting polymorphic

1203

http://www.bls.gov/news.release.empsit.t03.htm

https://data.bls.gov/cgi-bin/print.pl/oes/current/oes211014.htm

https://www.bls.gov/oes/current/oes291066.htm

https://www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm

https://www.bls.gov/ooh/community-and-social-service/social-workers.htm

https://www.bls.gov/oes/current/oes291066.htm

https://www.bls.gov/ooh/

reward genes for carbohydrate addiction algorithms. Journal of Reward Deficiency Syndrome, 1(2), 75–80.

Blum, K., Braverman, E. R., Holder, J. M., Lubar, J. F., Monastra, V. J., Miller, D., & Comings, D. E. (2000). Reward deficiency syndrome: A biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors. Journal of Psychoactive Drugs, 32(Suppl.), 1–68.

Blum, K., Noble, E. P., Sheridan, P. J., Montgomery, A., Ritchie, T., Jagadeeswaran, P., . . . Cohn, J. B. (1990). Allelic association of human dopamine D2 receptor gene in alcoholism. Journal of the American Medical Association, 263(15), 2055–2060.

Bock, C., Bukh, J. D., Vinberg, M., Gether, U., & Kessing, L. V. (2010). The influence of comorbid personality disorder and neuroticism on treatment outcome in first episode depression. Psychopathology, 43(3), 197–204.

Bodnar, A., Krzywotulski, M., Lewandowska, A., Chlopocka-Wozniak, M., Bartkowska- Sniatkowska, A., Michalak, M., & Rybakowski, J. K. (2016). Electroconvulsive therapy and cognitive functions in treatment-resistant depression. 17(2), 159–164.

Boepple, L., & Thompson, J. K. (2016). A content analytic comparison of fitspiration and thinspiration websites. International Journal of Eating Disorders, 49(1), 98–101.

Boeve, B., McCormick, J., Smith, G., Ferman, T., Rummans, T., Carpenter, T., . . . Petersen, R. (2003). Mild cognitive impairment in the oldest old. Neurology, 60(3), 477–480.

Bogdan, R., & Taylor, S. (1976, January). The judged, not the judges: An insider’s view of mental retardation. American Psychologist, 31(1), 47–52.

Bohnert, K. M., Ilgen, M. A., Louzon, S., McCarthy, J. F., & Katz, I. R. (2017). Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Addiction, 112, 1193–1201.

Boissoneault, L. (2017, March 6). How a soap opera virus felled hundreds of students in Portugal. Smithsonian Magazine.

Bole, C. B., Pislar, M., Sen, M., Tavcar, R., & Mrhar, A. (2017). Original research paper. Switching antipsychotics: Results of 16-month non-interventional, prospective, observational clinical research of inpatients with schizophrenia spectrum disorders. Acta Pharmaceutica, 67(1), 99–112.

Bond, B., Wright, J., & Bacon, A. (2017, August 31). What helps in self-help? A qualitative exploration of interactions within a borderline personality disorder self-help group. Journal of

1204

Mental Health. [Epub ahead of print]

Bonn, S. (2015, March 9). The history and rise of mass public shootings. Psychology Today.

Bonn, S. A. (2017, January 1). Why psychopaths are effective killers: Psychopaths are cold- blooded and calculating. Psychology Today.

Bonnet, M. H., & Arand, D. L. (2017, May 11). Treatment of insomnia in adults. UpToDate. Retrieved from www.uptodate.com.

Bonnet, M. H., & Arand, D. L. (2018, January 12). Clinical features and diagnosis of insomnia in adults. UpToDate. Retrieved from http://www.uptodate.com.

Bonnet, M. H., & Arand, L. D. (2017, November 1). Overview of insomnia in adults. UpToDate. Retrieved from http://www.uptodate.com.

Bonnet, S., Lacambre, M., Schandrin, A., Capdevielle, D., & Courtet, P. (2017). Insight and psychiatric dangerousness: A review of the literature. Encephale, 43(2), 146–153.

Bonsack, C., Golay, P., Gibellini Manetti, S., Gebel, S., Ferrari, P., Besse, C., . . . Morandi, S. (2016). Linking primary and secondary care after psychiatric hospitalization: Comparison between transitional case management setting and routine care for common mental disorders. Frontiers in Psychiatry, 7, 96.

Boos, S. C. (2017, August 7). Physical child abuse: Diagnostic evaluation and management. UpToDate. Retrieved from http://www.uptodate.com.

Boos, S. C. (2017, February 15). Physical child abuse: Recognition. UpToDate. Retrieved from http://www.uptodate.com.

Borden, K. A. (2017). Contemporary assessment practices. Part 1: General and diversity issues. Professional Psychology: Research and Practice, 48(2), 71–72.

Borge, F., Hoffart, A., Sexton, H., Martinsen, E., Gude, T., Hedley, L. M., & Abrahamsen, G. (2010). Pre-treatment predictors and in-treatment factors associated with change in avoidant and dependent personality disorder traits among patients with social phobia. Clinical Psychology and Psychotherapy, 17(2), 87–99.

Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 77–108). New York: Guilford Press.

Bornstein, R. F. (2016). Toward a firmer foundation for ICD-11: On the conceptualization and

1205

http://www.uptodate.com

assessment of personality pathology. Personality and Mental Health, 10(2), 123–126.

Bornstein, R. F. (2005). Psychodynamic theory and personality disorders. In S. Strack (Ed.), Handbook of personality and psychopathology (pp. 164–180). Hoboken, NJ: Wiley.

Bornstein, R. F. (2007). Dependent personality disorder. In W. O’Donohue, K. A. Fowler, S. O. Lilienfeld (Eds.). Personality disorders: Toward the DSM-V. Los Angeles: Sage Publications.

Bornstein, R. F. (2007). Might the Rorschach be a projective test after all: Social projection of an undesired trait alters Rorschach oral dependency scores. Journal of Personality Assessment, 88(3), 354–367.

Bornstein, R. F. (2012). Illuminating a neglected clinical issue: Societal costs of interpersonal dependency and dependent personality disorder. Journal of Clinical Psychology, 68(7), 766– 781.

Both, S., Schultz, W. W., & Laan, E. (2017). Treating women’s sexual desire and arousal problems. In Z. D. Peterson, The Wiley-Blackwell handbook of sex therapy (Chap. 2, pp. 11– 31). Hoboken, NJ: Wiley-Blackwell.

Bott, E. (1928). Teaching of psychology in the medical course. Bulletin of the Association of American Medical Colleges, 3, 289–304.

Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, E., Forget, H., . . .Roucaut, F. X. (2017). Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: A three-arm randomised controlled trial. British Journal of Psychiatry, 210(4), 276– 283.

Bouck, E. C., & Park, J. (2016). Inclusion and students with an intellectual disability. In J. P. Bakken & F. E. Obiakor (Eds), General and special education inclusion in an age of change: Impact on students with disabilities (Advances in special education, Vol. 31). West Yorkshire, UK: Emerald Publishing Limited.

Boudewyn, M. A. (2017). Understanding working memory and attentional control impairments in schizophrenia. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2(3), 212– 213.

Bouman, T. K., Mulkens, S., & van der Lei, B. (2017). Cosmetic professionals’ awareness of body dysmorphic disorder. Plastic and Reconstructive Surgery, 139(2), 336–342.

Bouras, N., & Holt, G. (Eds.). (2010). Mental health services for adults with intellectual disability: Strategies and solutions. The Maudsley Series. New York, Psychology Press.

Bourin, M., Malinge, M., & Guitton, B. (1995). Provocative agents in panic disorder. Therapie

1206

50(4), 301–306. [French].

Boutros, A., Kang, S. S., & Boutros, N. N. (2018). A cyclical path to recovery: Calling into question the wisdom of incarceration after restoration. International Journal of Law and Psychiatry, 57, 100–105.

Bowden, S. C., Saklofske, D. H., & Weiss, L. G. (2011). Invariance of the measurement model underlying the Wechsler Adult Intelligence Scale-IV in the United States and Canada. Educational and Psychological Measurement, 71(1), 186–199.

Bower, E. S., Wetherell, J. L., Mon, T., & Lenze, E. J. (2015). Treating anxiety disorders in older adults: Current treatments and future directions. Harvard Review of Psychiatry, 23(5), 329–342.

Bower, G. H. (1981). Mood and memory. American Psychologist, 36(2), 129–148.

Bowerman, M. (2016, October 12). Survey reveals what Americans fear the most. USA Today.

Bowers, A., Owen, R., & Heller, T. (2016). Care coordination experiences of people with disabilities enrolled in Medicaid managed care. Disability and Rehabilitation. Retrieved from http://www.tandfonline.com.

Bowers, A., Owen, R., & Heller, T. (2017). Care coordination experiences of people with disabilities enrolled in Medicaid managed care. Disability and Rehabilitation, 39(21), 2207– 2214.

Bowler, R. M., Adams, S. W., Schwarzer, R., Gocheva, V. V., Roels, H. A., Kim, Y., . . . Lobdell, D. T. (2018). Validity of self-reported concentration and memory problems: Relationship with neuropsychological assessment and depression. Journal of Clinical and Experimental Neuropsychology, 1–11.

Bowring, D. L., Totsika, V., Hastings, R. P., Toogood, S., & McMahon, M. (2017). Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study. Journal of Intellectual Disability Research, 61, 604–617.

Boyer, E. W., Siefert, S. A., & Hernon, C. (2017, April 6). Methamphetamine: Acute intoxication. UpToDate. Retrieved from http://www.uptodate.com.

Boysen, G. A., & VanBergen, A. (2013). A review of published research on adult dissociative identity disorder: 2000–2010. The Journal of Nervous and Mental Disease, 201(1), 5–11.

Boysen, G. A., & VanBergen, A. (2014). Simulation of multiple personalities: A review of research comparing diagnosed and simulated dissociative identity disorder. Clinical Psychology

1207

http://www.tandfonline.com

http://www.uptodate.com

Review, 34(1), 14–28.

Bradford, A. (2017, July 5). Female orgasmic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Bradford, A. (2017, July 6). Treatment of female orgasmic disorder. UpToDate. Retrieved from http://www.uptodate.com.

Brady, J. E., & Li, G. (2014). Trends in alcohol and other drugs detected in fatally injured drivers in the United States, 1999–2010. American Journal of Epidemiology, 179(6), 1093.

Braham, M. Y., Jedidi, M., Chkirbene, Y., Hmila, I., El Khai, M. C., Souguir, M. K., & Ben Dhiab, M. (2017). Caregiver-fabricated illness in a child: A case report of three siblings. Journal of Forensic Nursing, 13(1), 39–42.

Brakoulias, V., Starcevic, V., Belloch, A., Brown, C., Ferrao, Y. A., Fontenelle, L. F., . . . Viswasam, K. (2017). Comorbidity, age of onset and suicidality in obsessive-compulsive disorder (OCD): An international collaboration. Comprehensive Psychiatry, 76, 79–86.

Bram, A. D. (2017). Reviving and refining psychodynamic interpretation of the Wechsler Intelligence Tests: The verbal comprehension subtests. Journal of Personality Assessment, 99(3), 324–333.

Brand, B. L., Loewenstein, R. J., & Spiegel, D. (2014). Dispelling myths about dissociative identity disorder treatment: An empirically based approach. Psychiatry, 77(2), 169–189.

Branley, D. B., & Covey, J. (2017). Pro-ana versus Pro-recovery: A content analytic comparison of social media users’ communication about eating disorders on Twitter and Tumblr. Frontiers in Psychology, 8, 1356.

Brannon, G. E. (2016). History and mental status examination. Retrieved from http://emedicine.medscape.com/article/293402–overview.

Bratek, A., Krysta, K., & Kucia, K. (2017). Psychiatric comorbidity in older adults with intellectual disability. Psychiatria Danubina, 29(Suppl. 3), 590–593.

Bratskeir, K. (2013, September 16). The habits of supremely happy people. Huffington Post.

Braun, D. L. (1996, July 28). Interview. In S. Gilbert, More men may seek eating-disorder help. New York Times.

Braverman, D. W., Marcus, B. S., Wakim, P. G., Mercurio, M. R., & Kopf, G. S. (2017). Healthcare professionals’ attitudes about physician-assisted death: an analysis of their

1208

http://www.uptodate.com

http://emedicine.medscape.com/article/293402–overview

justifications and the role of terminology and patient competency. Journal of Pain and Symptom Management, 54, 538–545.

Braxton, L. E., Calhoun, P. S., Williams, J. E., & Boggs, C. D. (2007). Validity rates of the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory-2 in a VA medical center setting. Journal of Personality Assessment, 88(1), 5–15.

Bremner, J. D. (2016). Traumatic stress from a multilevel developmental psychopathology perspective. In D. Cicchetti (Ed.), Developmental psychopathology, maladaptation and psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed., Chap. 9, pp. 1–39). New York: Wiley.

Bremner, J. D. (2002). Does stress damage the brain? Understanding trauma-related disorders from a mind-body perspective. New York: Norton.

Bremner, J. D., & Charney, D. S. (2010). Neural circuits in fear and anxiety. In D. J. Stein, E. Hollander & B. O. Rothbaum (Eds.), Textbook of anxiety disorders (2nd ed., pp. 55–71). Arlington, VA: American Psychiatric Publishing.

Brenner, I. (2018). Catching a wave: The hypnosis-sensitive transference-based treatment of dissociative identity disorder (DID). American Journal of Clinical Hypnosis, 60(3), 279–295.

Breslau, J., Gilman, S. E., Stein, B. D., Ruder, T., Gmelin, T., & Miller, E. (2017). Sex differences in recent first-onset depression in an epidemiological sample of adolescents. Translational Psychiatry, 7, e1139.

Bressert, S. (2016) Antisocial personality disorder treatment. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2016). Histrionic personality disorder treatment. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2016). Obsessive-compulsive personality disorder treatment. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2016). Schizotypal personality disorder. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2016, May 17). Facts about shyness. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2016, May 18). Dependent personality disorder treatment. Psych Central. Retrieved from https://psychcentral.com.

1209

https://psychcentral.com

Bressert, S. (2017). Avoidant personality disorder symptoms. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2017). Dependent personality disorder treatment. Psych Central. Retrieved from https://psychcentral.com.

Bressert, S. (2017). Dissociative identity disorder treatment. Psych Central. Retrieved from https://psychcentral.com/disorders.

Bressert, S. (2017). Fetishistic disorder symptoms. Psych Central. Retrieved from https://psychcentral.com/disorders/fetishism-symptoms.

Bressert, S. (2018). Who gets bipolar disorder? PsychCentral. Retrieved on april 26, 2018, from https://psychcentral.com/lib/who-gets-bipolar-disorder/.

Brewer, J. (2014). Mindfulness in the military. American Journal of Psychiatry, 171, 803–806.

Brewis, A., SturtzSreetharan, C., & Wutich, A. (2018, February 13). Obesity stigma as a globalizing health challenge. Global Health Hub, 14(1), 20.

Bridler, R., Häberle, A., Müller, S. T., Cattapan, K., Grohmann, R., Toto, S., . . . Greil, W. (2015). Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: A comparison with other psychiatric disorders. European Neuropsychopharmacology, 25(6), 763–772.

Briggs, S., Slater, T., & Bowley, J. (2017). Practitioners’ experiences of adolescent suicidal behaviour in peer groups. Journal of Psychiatric and Mental Health Nursing, 24, 293–301.

Britt, R. R. (2005, January 6). The odds of dying. LiveScience.com.

Brodeur, M. (2016, December 21). 10 negative body image thoughts you need to stop right now. Verily Magazine.

Bronskill, S. E., Anderson, G. M., Sykora, K., Wodchis, W. P., Gill, S., Shulman, K. I., & Rochon, P. A. (2004). Neuroleptic drug therapy in older adults newly admitted to nursing homes: Incidence, dose, and specialist contact. Journal of the American Geriatrics Society, 52(5), 749.

Brooks, A. C. (2013, December 14). A formula for happiness. New York Times.

Brooks, F., Michaelson, V., King, N., Inchley, J., & Pickett, W. (2018). Spirituality as a protective health asset for young people: An international comparative analysis from three countries. International Journal of Public Health, 63(3), 387–395.

Brooks, G. R., & Richardson, F. C. (1980). Emotional skills training: A treatment program for

1210

https://psychcentral.com

https://psychcentral.com/disorders

https://psychcentral.com/disorders/fetishism-symptoms

https://psychcentral.com/lib/who-gets-bipolar-disorder/

duodenal ulcer. Behavior Therapist, 11(2), 198–207.

Brosch, J. R., & Farlow, M. R. (2017, May 30). Early-onset dementia in adults. UpToDate. Retrieved from http://www.uptodate.com.

Brouwer, M. E., Williams, A. D., Forand, N. R., DeRubeis, R. J., & Bockting, C. L. H. (2019). Dysfunctional attitudes or extreme response style as predictors of depressive relapse and recurrence after mobile cognitive therapy for recurrent depression. Journal of Affective Disorders, 243, 48–54.

Brown, A. (2012, April 27). Chronic pain rates shoot up until Americans reach late 50s: Low- income and obese Americans more likely to have chronic pain. Retrieved from Gallup website: http://www.gallup.com/poll/154169.

Brown, C. A., & Weisman de Mamani, A. (2018). The mediating effect of family cohesion in reducing patient symptoms and family distress in a culturally informed family therapy for schizophrenia: A parallel-process latent-growth model. Journal of Consulting and Clinical Psychology, 86(1), 1–14.

Brown, E. M. (2018). François Leuret: The last moral therapist. History of Psychiatry, 29(1), 38– 48.

Brown, G. R. (2017, September). Exhibitionistic disorder (exhibitionism). Merck Manual. Retrieved from https://www.merckmanuals.com/professional/psychiatric-disorders/sexuality,- gender-dysphoria,-and-paraphilias.

Brown, G. R. (2017, September). Pedophilic disorder (pedophilia). Merck Manual. Retrieved from https://www.merckmanuals.com/professional/psychiatric-disorders/sexuality,-gender- dysphoria,-and-paraphilias.

Brown, G. R. (2017, September). Transvestism (transvestic disorder). Merck Manual. Retrieved from https://www.merckmanuals.com/home/mental-health-disorders/sexuality.

Brown, G. R. (2017, September). Voyeuristic disorder (voyeurism). Merck Manual. Retrieved from https://www.merckmanuals.com/professional/psychiatric-disorders/sexuality,-gender- dysphoria,-and-paraphilias.

Brown, G. W. (2002). Social roles, context and evolution in the origins of depression. Journal of Health and Social Behavior, 43(3), 255–276.

Brown, G. W., & Harris, T. O. (1978). Social origins of depression: A study of psychiatric disorder in women. London: Tavistock.

Brown, J. L. (2017). Physician exposure to direct-to-consumer pharmaceutical marketing:

1211

http://www.uptodate.com

http://www.gallup.com/poll/154169

https://www.merckmanuals.com/professional/psychiatric-disorders/sexuality,-gender-dysphoria,-and-paraphilias

https://www.merckmanuals.com/home/mental-health-disorders/sexuality

https://www.merckmanuals.com/professional/psychiatric-disorders/sexuality,-gender-dysphoria,-and-paraphilias

Potential for creating prescribing bias. American Journal of Medicine, 130(6), e247–e248.

Brown, K. P. (2018, April 20). Insanity defense typology. Behavioral Sciences & the Law. [Epub ahead of print]

Brown, L., Beutler, L. E., Patterson, J. H., Bongar, B., & Holleran, L. (2016). Psychotherapy with people exposed to mass casualty events: Theory and practice. In A. J. Consoli, L. E. Beutler, & B. Bongar, Comprehensive textbook of psychotherapy: theory and practice: Part II: Psychotherapy by modalities and populations (2nd ed., Chap. 27). New York: Oxford University Press.

Brown, N. W. (2017). Group therapy. CreateSpace Independent Publishing Platform.

Brown, R. C., & Plener, P. L. (2017). Non-suicidal self-injury in adolescence. Current Psychiatry Reports, 19(3), 20.

Brownley, K. A., Peat, C. M., La Via, M., & Bulik, C. M. (2015). Pharmacological approaches to the management of binge eating disorder. Drugs, 75(1), 9–32.

Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 24, 187–194.

Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa and the person within. New York: Basic Books.

Bruch, H. (1978). The golden cage: The enigma of anorexia nervosa. Cambridge, MA: Harvard University Press.

Bruch, H. (1991). The sleeping beauty: Escape from change. In S. I. Greenspan & G. H. Pollock (Eds.), The course of life, Vol. 4: Adolescence. Madison, CT: International Universities Press.

Bruch, H. (2001). The golden cage: The enigma of anorexia nervosa. Cambridge, MA: Harvard University Press.

Brühl, A. B., Delsignore, A., Komossa, K., & Weidt, S. (2014). Neuroimaging in social anxiety disorder—A meta-analytic review resulting in a new neurofunctional model. Neuroscience & Biobehavioral Reviews, 47, 260–280.

Brunet, K., & Birchwood, M. (2010). Duration of untreated psychosis and pathways to care. In P. French, J. Smith, D. Shiers, M. Reed, & M. Rayne (Eds.), Promoting recovery in early psychosis: A practice manual (pp. 9–16). Hoboken, NJ: Wiley-Blackwell.

Bryant, R. (2017, February 17). Acute stress disorder in adults: Epidemiology, pathogenesis,

1212

clinical manifestations, course, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Bryant, R. (2018, February 27). Treatment of acute stress disorder in adults. UpToDate. Retrieved from http://www.uptodate.com.

Bryman, A. (2016). Social research methods (5th ed.). New York: Oxford University Press.

Bryner, J. (2011). Close friends less common today, study finds. Live Science. Retrieved from http://www.livescience.com/16879.

BSA (Boy Scouts of America). (2017). Bullying awareness. Retrieved from http://www.scouting.org/training/YouthProtection/bullying.aspx.

BSA (Bullying Statistics in America). (2014). A 2014 presentation of statistics and graphs on bullying.

BSA (Bullying Statistics in America). (2017). A 2017 presentation of statistics and graphs on bullying.

Buchman-Schmitt, J. M., Chu, C., Michaels, M. S., Hames, J. L., Silva, C., Hagan, C. R., . . . Joiner, T. E., Jr. (2017). The role of stressful life events preceding death by suicide: Evidence from two samples of suicide decedents. Psychiatry Research, 256, 345–352.

Buckley, L., Bonar, E. E., Walton, M. A., Carter, P. M., Voloshyna, D., Ehrlich, P. F., & Cunningham, R. M. (2017). Marijuana and other substance use among male and female underage drinkers who drive after drinking and ride with those who drive after drinking. Addictive Behaviors, 71, 7–11.

Buckner, J. D., Lemke, A. W., Jeffries, E. R., & Shah, S. M. (2017). Social anxiety and suicidal ideation: Test of the utility of the Interpersonal-Psychological Theory of Suicide. Journal of Anxiety Disorders, 45, 60–63.

Bucsek, M. J., Giridharan, T., MacDonald, C. R., Hylander, B. L., & Repasky, E. A. (2018). An overview of the role of sympathetic regulation of immune responses in infectious disease and autoimmunity. International Journal of Hyperthermia, 34(2), 135–143.

Budhwani, H., Hearld, K. R., & Chavez-Yenter, D. (2015). Generalized anxiety disorder in racial and ethnic minorities: A case of nativity and contextual factors. Journal of Affective Disorders, 175, 275–280.

Buehler, S. (2017). Treating sexual problems in clients with mental illness. In Z. D. Peterson, The Wiley-Blackwell handbook of sex therapy (Chap. 22, pp. 359–368). Hoboken, NJ: Wiley- Blackwell.

1213

http://www.uptodate.com

http://www.livescience.com/16879

http://www.scouting.org/training/YouthProtection/bullying.aspx

Bukalo, O., Pinard, C. R., & Holmes, A. (2014). Mechanisms to medicines: Elucidating neural and molecular substrates of fear extinction to identify novel treatments for anxiety disorders. British Journal of Pharmacology, 171(20), 4690–4718.

Bukstein, O. (2016, November 3). Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Bukstein, O. (2018, April 23). Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Bulik, B. S. (2017). The top 10 most-advertised prescription drug brands. FiercePharma.

Bulik, C. M., Kleiman, S. C., & Yilmaz, Z. (2016). Genetic epidemiology of eating disorders. Current Opinion in Psychiatry, 29(6), 383–388.

Burack, J. A., Russo, N., Green, C. G., Landry, O., & Iarocci, G. (2016). Developments in the developmental approach to intellectual disability. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed.). New York: Wiley.

Burch, R., Rizzoli, P., & Loder, E. (2018). The prevalence and impact of migraine and severe headache in the United States: Figures and trends from government health studies. Headache: The Journal of Head and Face Pain, 58(4), 496–505.

Burg, M. M. (2017, December 18). Psychological treatment of cardiac patients. Clinical Health Psychology. Washington, DC: APA.

Burke, K. (2016, May 24). 63 texting statistics that answer all your questions. Text request. Retrieved from https://www.textrequest.com.

Burke, S. M., Cohen-Kettenis, P. T., Veltman, D. J., Klink, D. T., & Bakker, J. (2014). Hypothalamic response to the chemo-signal androstadienone in gender dysphoric children and adolescents. Frontiers in Endocrinology, 5, 60.

Burke, S. M., Kreukels, B. P., Cohen-Kettenis, P. T., Veltman, D. J., Klink, D. T., & Bakker, J. (2016). Male-typical visuospatial functioning in gynephilic girls with gender dysphoria: Organizational and activational effects of testosterone. Journal of Psychiatry & Neuroscience, 41(6), 395–404.

Burke, S. M., Manzouri, A. H., Dheine, C., Bergström, K., Arver, S., Feusner, J. D., & Savic-Berglund, I. (2018). Testosterone effects on the brain in transgender men. Cerebral Cortex, 28(5), 1582–1596.

1214

http://www.uptodate.com

https://www.textrequest.com

Burke, T. A., Jacobucci, R., Ammerman, B. A., Piccirillo, M., McCloskey, M. S., Heimberg, R. G., & Alloy, L. B. (2018). Identifying the relative importance of non-suicidal self-injury features in classifying suicide ideation, plans, and behavior using exploratory data mining. Psychiatry Research, 262, 175–183.

Burke, K., & Riley, J. (2010). Coronary artery disease. In C. Margereson & S. Trenoweth (Eds.), Developing holistic care for long-term conditions (pp. 255–273). New York: Routledge/Taylor & Francis Group.

Burns, T. (2010). Modern community care strategies for schizophrenia care: Impacts on outcome. In W. F. Gattaz & G. Busatto (Eds.), Advances in schizophrenia research 2009 (pp. 417–427). New York: Springer Science + Business Media.

Burns, T., & Drake, B. (2011). Mental health services and patients with schizophrenia. In D. R. Weinberg & P. Harrison (Eds.), Schizophrenia (pp. 625–643). Hoboken, NJ: Wiley- Blackwell.

Burnsed, B. (2014, July 22). Rates of excessive drinking among student-athletes falling. NCAA. Retrieved from http://www.ncaa.org.

Burrell, L. V., Mehlum, L., & Qin, P. (2018). Sudden parental death from external causes and risk of suicide in the bereaved offspring: A national study. Journal of Psychiatric Research, 96, 49–56.

Burt, K. B., Coatsworth, J. D., & Masten, A. S. (2016). Competence and psychopathology in development. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 4: Risk, resilience, and intervention (3rd ed.). New York: Wiley.

Burta˘verde, V., Chraif, M., Anit¸ei, M., & Miha˘ila˘, T. (2016). The incremental validity of the Dark Triad in predicting driving aggression. Accident Analysis and Prevention, 96, 1–11.

Busch, A. C., Denduluri, M., Glass, J., Hetzel, S., Gugnani, S. P., Gassman, M., . . . Brown, R. (2017). Predischarge injectable versus oral Naltrexone to improve postdischarge treatment engagement among hospitalized veterans with alcohol use disorder: A randomized pilot proof- of-concept study. Alcoholism: Clinical and Experimental Research, 41, 1352–1360.

Busch, A. M., Ciccolo, J. T., Puspitasari, A. J., Nosrat, S., Whitworth, J. W., & Stults- Kolehmainen, M. (2017). Preferences for exercise as a treatment for depression. Mental Health and Physical Activity, 10, 68–72.

Busch, F. N., Milrod, B. L., & Shear, K. (2010). Psychodynamic concepts of anxiety. In D. J. Stein, E. Hollander, & B. O. Rothbaum (Eds.), Textbook of anxiety disorders (2nd ed., pp. 117–128). Arlington, VA: American Psychiatric Publishing.

1215

http://www.ncaa.org

Busch, F. N., Rudden, M. G., & Shapiro, T. (2004). Psychodynamic treatment of depression. Washington, DC: American Psychiatric Publishing.

Bushman, B. J., Baumeister, R. F., & Stack, A. D. (1999). Catharsis, aggression, and persuasive influence: Self-fulfilling or self-defeating prophecies? Journal of Personality and Social Psychology, 76(3), 367–376.

Bustillo, J., & Weil, E. (2018, August 11). Psychosocial interventions for schizophrenia. UpToDate. Retrieved from http://www.uptodate.com.

Bustillo, J., & Weil, E. (2018, June 3). Psychosocial interventions for severe mental illness. UpToDate. Retrieved from http://www.uptodate.com.

Buzzell, G. A., Troller-Renfree, S. V., Barker, T. V., Bowman, L. C., Chronis-Tuscano, A., Henderson, H. A., . . . Fox, N. A. (2017). A neurobehavioral mechanism linking behaviorally inhibited temperament and later adolescent social anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 56(12), 1097–1105.

Byers, A. L., Covinsky, K. E., Neylan, T. C., & Yaffe, K. (2014). Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA Psychiatry, 71(5), 540–546.

Byrd, A. L., Manuck, S. B., Hawes, S. W., Vebares, T. J., Nimgaonkar, V., Chowdari, K. V., . . . Stepp, S. D. (2018, February 22). The interaction between monoamine oxidase A (MAOA) and childhood maltreatment as a predictor of personality pathology in females: Emotional reactivity as a potential mediating mechanism. Development and Psychopathology. [Epub ahead of print]

Byrne, K. A., Patrick, C. J., & Worthy, D. A. (2016). Striatal dopamine, externalizing proneness, and substance abuse: Effects on wanting and learning during reward-based decision making. Clinical Psychological Science, 4(5), 760–774.

Bystritsky, A. (2018, January 17). Pharmacotherapy for generalized anxiety disorder in adults. UpToDate. Retrieved from http://www.uptodate.com.

Cable, A. (2008, November 14). Divorced from reality: All three accounts of the Second Life love triangle that saw a woman separate from her husband for having a cyber-affair. Daily Mail, UK.

Cabrera, F. J. P., Herrera, A. R. C., Rubalcava, S. J. A., & Martinez, K. I. M. (2017, June 2). Behavior patterns of antisocial teenagers interacting with parents and peers: A longitudinal study. Frontiers in Psychology, 8, 757.

Cachelin, F. M., Phinney, J. S., Schug, R. A., & Striegel-Moore, R. M. (2006). Acculturation

1216

http://www.uptodate.com

and eating disorders in a Mexican American community sample. Psychology of Women Quarterly, 30(4), 340–347.

Cacioppo, C. N., Conway, L. J., Mehta, D., Krantz, I. D., & Noon, S. E. (2016). Attitudes about the use of internet support groups and the impact among parents of children with Cornelia de Lange syndrome. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 172(2), 229–236.

Cacioppo, J., & Freberg, L. (2016). Discovering pychology: The science of mind (2nd edition). Boston: Cengage Learning.

Cagle, J. (2018, April 11). Mariah Carey on why she kept her bipolar disorder hidden for years: Lived in denial and isolation. People.com.

Calarco, M. (2017). Does depression turn self-medication into addiction? Psych Central. Retrieved from https://psychcentral.com/blog/archives/2016/10/15/does-depression-turn-self- medication-into-addiction/.

Caldwell, C. (2017, April). American carnage: The new landscape of opioid addiction. First Things.

Calhoun, B. H., Maggs, J. L., & Loken, E. (2018). Change in college students’ perceived parental permissibility of alcohol use and its relation to college drinking. Addictive Behaviors, 76, 275–280.

Caligor, E., & Petrini, M. J. (2018, March 21). Narcissistic personality disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Caligor, E., & Petrini, M. J. (2018, March 21). Treatment of narcissistic personality disorder. UpToDate. Retrieved from http://www.uptodate.com.

Caligor, E., Kernberg, O. F., Clarkin, J. F., & Yeomans, F. E. (Eds.). (2018). Psychodynamic therapy for personality pathology: Treating self and interpersonal functioning (1st ed.). Washington, DC: American Psychiatric Publishing.

Caligor, E., & Clarkin, J. F. (2010). An object relations model of personality and personality pathology. In J. F. Clarkin, P. Fonagy, & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for personality disorders: A clinical handbook (pp. 3–36). Arlington, VA: American Psychiatric Publishing.

Call, N. A., Mevers, J. L., McElhanon, B. O., & Scheithauer, M. C. (2017). A multidisciplinary treatment for encopresis in children with developmental disabilities. Journal

1217

https://psychcentral.com/blog/archives/2016/10/15/does-depression-turn-self-medication-into-addiction/

http://www.uptodate.com

of Applied Behavior Analysis, 50(2), 332–344.

Callahan, L. A., Steadman, H. J., McGreevy, M. A., & Robbins, P. C. (1991). The volume and characteristics of insanity defense pleas: An eight-state study. Bulletin of the American Academy of Psychiatry Law, 19(4), 331–338.

Calzada, E., Barajas-Gonzalez, R. G., Huang, K. Y., & Brotman, L. (2017). Early childhood internalizing problems in Mexican- and Dominican-origin children: The role of cultural socialization and parenting practices. Journal of Clinical Child & Adolescent Psychology, 46(4), 551–562.

Cameron, D. J., Thomas, R. I., Mulvihill, M., & Bronheim, H. (1987). Delirium: A test of the Diagnostic and Statistical Manual III criteria on medical inpatients. Journal of the American Geriatrics Society, 35, 1007–1010.

Cameron, E. E., Hunter, D., Sedov, I. D., & Tomfohr-Madsen, L. M. (2017). What do dads want? Treatment preferences for paternal postpartum depression. Journal of Affective Disorders, 215, 62–70.

Campbell, D., & Hale, R. (2017). Working in the dark: Understanding the pre-suicide state of mind. New York: Routledge.

Campbell, E. C., Caroff, S. N., & Mann, S. C. (2017, September 15). Co-occurring schizophrenia and substance use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Campbell, E. C., Caroff, S. N., & Mann, S. C. (2018, February 5). Pharmacotherapy for co- occurring schizophrenia and substance use disorder. UpToDate. Retrieved from http://www.uptodate.com.

Campbell, E. C., Caroff, S. N., & Mann, S. C. (2018, February 5). Psychosocial interventions for co-occurring schizophrenia and substance use disorder.

Campbell, K. (2016, March 23). The pitfalls of direct-to-consumer advertising in medicine. U.S. News & World Report. Health Care.

Campos, R. C., Holden, R. R., & Santos, S. (2018). Exposure to suicide in the family: Suicide risk and psychache in individuals who have lost a family member by suicide. Journal of Clinical Psychology, 74(3), 407–417.

Canat, L., Degirmentepe, R. B., Atalay, H. A., Aikan, I., Özbir, S., Culha, M. G., & Ötünçtemur, A. (2018). The relationship between female sexual function index domains and

1218

http://www.uptodate.com

premature ejaculation. International Urology and Nephrology, 50(4), 633–637.

Canetta, S., Sourander, A., Surcel, H., Hinkka-Yli-Salomäki, S., Leiviskä, J., Kellendonk, C., . . . Brown, A. S. (2014). Elevated maternal C-reactive protein and increased risk of schizophrenia in a national birth cohort. American Journal of Psychiatry, 171(9), 960–968.

Canner, J. K., Harfouch, O., Kodadek, L. M., Pelaez, D., Coon, D., Offodile, A. C., 2nd, . . . Lau, B. D. (2018, February 28). Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surgery. [Epub ahead of print]

Cao, H., Zhou, N., Fang, X., & Fine, M. (2017). Marital well-being and depression in Chinese marriage: Going beyond satisfaction and ruling out critical confounders. Journal of Family Psychology, 31, 775–784.

Capobianco, L., Morrison, A. P., & Wells, A. (2018). The effect of thought importance on stress responses: A test for the metacognitive model. Stress, 21(2), 128–135.

CareerBuilder. (2012, April 18). 37% of companies use social networks to research potential job candidates. CareerBuilder. Retrieved from http://www.careerbuilder.com/share/aboutus/pressreleasesdetail.

CareerBuilder. (2017). Number of employees using social media to screen candidates has increased 500 percent over the last decade. Chicago, IL: CareerBuilder. Retrieved from http://www.careerbuilder.com/share/aboutus/pressreleasedetail.

Carey, B. (2016, April 3). Investigating the minds of mass killers. New York Times.

Carey, B. (2017, August 30). The true story behind Sybil. Retrieved from http://www.cbc.ca/books/the-true-story-behind-sybil-and-her-multiple-personalities- 1.4268459.

Carpenter, A. C., & Krendl, A. C. (2018). Are eyewitness accounts biased? Evaluating false memories for crimes involving in-group or out-group conflict. Society for Neuroscience, 13(1), 74–93.

Carpenter, A. L., Pincus, D. B., Furr, J. M., & Comer, J. S. (2018). Working from home: An initial pilot examination of videoconferencing-based cognitive-behavioral therapy for anxious youth delivered to the home setting. Behavior Therapy, 49, 917–930.

Carpenter, K. M., Williams, K., & Worly, B. (2017). Treating women’s orgasmic difficulties. In Z. D. Peterson (Ed.), The Wiley-Blackwell handbook of sex therapy (Chap. 5, pp. 57–71). Hoboken, NJ: Wiley-Blackwell.

Carr, S. N., & Francis, A. J. P. (2010). Do early maladaptive schemas mediate the relationship

1219

http://www.careerbuilder.com/share/aboutus/pressreleasesdetail

http://www.careerbuilder.com/share/aboutus/pressreleasedetail

http://www.cbc.ca/books/the-true-story-behind-sybil-and-her-multiple-personalities-1.4268459

between childhood experiences and avoidant personality disorder features? A preliminary investigation in a non-clinical sample. Cognitive Therapy and Research, 34(4), 343–358.

Carroll, R. A. (2007). Gender dysphoria and transgender experiences. In S. R. Leiblum (Ed.), Principles and practice of sex therapy (4th ed., pp. 477–508). New York: Guilford Press.

Carroll, T. D., Currier, J. M., McCormick, W. H., & Drescher, K. D. (2017). Adverse childhood experiences and risk for suicidal behavior in male Iraq and Afghanistan veterans seeking PTSD treatment. Psychological Trauma. 9, 583–586.

Caruso, R. J., Nanni, M. G., Riba, M., Sabato, S., Mitchell, A. J., Croce, E., & Grassi, L. (2017). Depressive spectrum disorders in cancer: Prevalence, risk factors and screening for depression: A critical review. Acta Oncologica, 56(2), 146–155. DOI:10.1080/0284186X.2016.1266090.

Cash, D. K., & Lane, S. M. (2017). Context influences interpretation of eyewitness confidence statements. Law and Human Behavior, 41(2), 180–190.

Cash, T. F., & Henry, P. E. (1995). Women’s body images: The results of a national survey in the U. S. A. Sex Roles, 33(1/2), 19–28.

Catanesi, R., Martino, V., Candelli, C., Troccoli, G., Grattagliano, I., Di Vella, G., & Carabellese, F. (2013). Posttraumatic stress disorder: Protective and risk factors in 18 survivors of a plane crash. Journal of Forensic Sciences, 58(5), 1388–1392.

Cawley, R., Pontin, E. E., Touhey, J., Sheehy, K., & Taylor, P. J. (2019). What is the relationship between rejection and self-harm or suicidality in adulthood? Journal of Affective Disorders, 242, 123–134.

Cayman, S. (2014). Sex facts: 369 facts to blow you away. Chichester, UK: Summersdale.

CBC. (2008, May 13). The world’s worst natural disasters: Calamities of the 20th and 21st centuries. CBC News.

CDC (Centers for Disease Control and Prevention). (2010). Suicide rates among persons ages 10 years and older, by race/ethnicity and sex, United States, 2002–2006. National Suicide Statistics at a Glance. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2010, December 3). QuickStats: Percentage of adults who had migraines or severe headaches, pain in the neck, lower back, or face/jaw. by sex. National Health Interview Survey, 2009. Morbidity and Mortality Weekly Report, 59(47), 1557.

CDC (Centers for Disease Control and Prevention). (2011). High blood pressure facts.

1220

Retrieved from http://www.cdc.gov/bloodpressure/facts.htm.

CDC (Centers for Disease Control and Prevention). (2013). Suicide and self-inflicted injury. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2014). Data and statistics. Washington, DC: CDC.

CDC (Centers for Disease Control and Prevention). (2014). National suicide statistics at a glance. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2014). Older persons’ health. Washington, DC: CDC.

CDC (Centers for Disease Control and Prevention). (2015). Caloric intake from fast food among children and adolescents in the United States, 2011–2012. Data Brief 213. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2015). Table 41 (page 1 of 3). Severe headache or migraine, low back, and neck pain among adults aged 18 and over, by selected characteristics: United States, selected years 1997–2014. Retrieved from https://www.cdc.gov/nchs/data/hus/2015/041.pdf.

CDC (Centers for Disease Control and Prevention). (2015, March 17). High cholesterol facts. Retrieved from https://www.cdc.gov/cholesterol/facts.htm.

CDC (Centers for Disease Control and Prevention). (2016, April). Suicide rates for females and males by race and ethnicity: United States, 1999 and 2014. Hyattsville, MD: NCHS.

CDC (Centers for Disease Control and Prevention). (2016, January). Mortality among centenarians in the United States, 2000–2014. NCHS data brief No. 233. Hyattsville, MD: NCHS.

CDC (Centers for Disease Control and Prevention). (2016, June 16). Heart disease fact sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm.

CDC (Centers for Disease Control and Prevention). (2016, November 30). High blood pressure facts. Retrieved from https://www.cdc.gov/bloodpressurel/facts.htm.

CDC (Centers for Disease Control and Prevention). (2016, October 20). Fact sheets–Underage drinking. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). Data overview: Drug overdose. Atlanta, GA: CDC.

1221

http://www.cdc.gov/bloodpressure/facts.htm

https://www.cdc.gov/nchs/data/hus/2015/041.pdf

https://www.cdc.gov/cholesterol/facts.htm

https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

https://www.cdc.gov/bloodpressurel/facts.htm

CDC (Centers for Disease Control and Prevention). (2017). Economic trends in tobacco. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). Fact sheets—Binge drinking. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). Heroin overdose data. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). National Survey of Family Growth: Key statistics. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). Opioid data analysis. CDC. Retrieved from https://www.cdc.gov.

CDC (Centers for Disease Control and Prevention). (2017). QuickStats: Age-adjusted rate for suicide, by sex—National Vital Statistics System, United States, 1975–2015. Retrieved from https://www-cdc-gov.ezproxy.princeton.edu/mmwr/volumes/66/wr/mm6610a7.htm.

CDC (Centers for Disease Control and Prevention). (2017). Quitting smoking. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017). Sexual risk behaviors: HIV, STD, & teen pregnancy prevention Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, February 27). Most recent asthma data. Retrieved from https://www.cdc.gov/asthma/most_recent_data/htm.

CDC (Centers for Disease Control and Prevention). (2017, January 3). Learning disorder. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, January 19). Hypertension. Retrieved from https://www.cdc.gov/nchs/fastats/hypertension.htm.

CDC (Centers for Disease Control and Prevention). (2017, June 1). Adverse drug event monitoring. Hyattsville, MD: NCHS.

CDC (Centers for Disease Control and Prevention). (2017, June 16). Impaired driving: Get the facts. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, June 6). Data and statistics: FASDs. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, June 7). Binge drinking. Atlanta, GA: CDC.

1222

https://www.cdc.gov

https://www-cdc-gov.ezproxy.princeton.edu/mmwr/volumes/66/wr/mm6610a7.htm

https://www.cdc.gov/asthma/most_recent_data/htm

https://www.cdc.gov/nchs/fastats/hypertension.htm

CDC (Centers for Disease Control and Prevention). (2017, March 17). Leading causes of death. Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.

CDC (Centers for Disease Control and Prevention). (2017, March 17). Suicide and self- inflicted injury. Retrieved from https://www.cdc.gov/nchs/fastats/suicide.htm.

CDC (Centers for Disease Control and Prevention). (2017, March 6). America’s opioid epidemic is worsening. The Economist.

CDC (Centers for Disease Control and Prevention). (2017, May 12). Youth bullying: What does the research say? Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, May 17). Tobacco-related mortality. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_morta lity/index.htm.

CDC (Centers for Disease Control and Prevention). (2017, May 3). Data & statistics: Mental, behavioral, and developmental health of children aged 2–8 years. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2017, May 3). Life expectancy: 78.8 years. Retrieved from https://www.cdc.gov.

CDC (Centers for Disease Control and Prevention). (2017, November 28). Heart disease facts. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2018, April 20). Behavior or conduct problems. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2018, April 5). High blood pressure facts. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2018, June 14). Fewer U.S. high school students having sex, using drugs. Retrieved from https://www.cdc.gov/media/releases/2018/p0614-yrbs.html.

CDC (Centers for Disease Control and Prevention). (2018, March 20). Attention deficit/hyperactivity disorder: Data & statistics. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2018, March 27). Binge drinking. Atlanta, GA: CDC.

1223

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

https://www.cdc.gov/nchs/fastats/suicide.htm

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm

https://www.cdc.gov

https://www.cdc.gov/media/releases/2018/p0614-yrbs.html

CDC (Centers for Disease Control and Prevention). (2018, May 10). Fetal alcohol spectrum disorders: Basics about FASDs. Atlanta, GA: CDC.

CDC (Centers for Disease Control and Prevention). (2018, May 4). Economic trends in tobacco. Atlanta, GA: CDC.

CDC (Centers for Disease Control). (2015, November 5). Drowsy driving: Asleep at the wheel. Atlanta, GA: Author.

CDPS (Colorado Department of Public Safety). (2018). The use of polygraph in sex offender treatment. Denver, CO: Author.

Cerdá, M., Nandi, V., Frye, V., Egan, J. E., Rundle, A., Quinn, J.W., . . . Koblin, B. (2017, April 5). Neighborhood determinants of mood and anxiety disorders among men who have sex with men in New York City. Social Psychiatry and Psychiatric Epidemiology. [Epub ahead of print]

Cerniglia, L., Cimino, S., Tafa, M., Marzilli, E., Ballarotto, G., & Bracaglia, F. (2017). Family profiles in eating disorders: Family functioning and psychopathology. Psychology Research and Behavior Management, 10, 305–312.

Cervesi, C., Park, S. Y., Galling, B., Molteni, S., Masi, G., Gerhard, T., Olfson, M., & Correll, C. U. (2017). Extent, time course, and moderators of antipsychotic treatment in youth and mood disorders: Results of a meta-analysis and meta-regression analyses. Journal of Clinical Psychiatry, 78, 347–357.

Chadwick, P. K. (2014). Peer-professional first-person account: Before psychosis—schizoid personality from the inside. Schizophrenia Bulletin, 40(3), 483–486.

Chamberlain, S. R., Redden, S. A., Leppink, E., & Grant, J. E. (2017). Problematic internet use in gamblers: Impact on clinical and cognitive measures. CNS Spectrums, 22(6), 495–503.

Chambers, J. (2017). The neurobiology of attachment: From infancy to clinical outcomes. Psychodynamic Psychiatry, 45(4), 542–563.

Chan, A. T., Sun, G. Y., Tam, W. W., Tsoi, K. K., & Wong, S. Y. (2017). The effectiveness of group-based behavioral activation in the treatment of depression: An updated meta-analysis of randomized controlled trial. Journal of Affective Disorders, 208, 345–354.

Chan, C. C., Szeszko, P. R., Wong, E., Tang, C. Y., Kelliher, C., Penner, J. D., . . . Hazlett, E. A. (2018, February 14). Frontal and temporal cortical volume, white matter tract integrity, and hemispheric asymmetry in schizotypal personality disorder. Schizophrenia Research. [Epub ahead of print]

1224

Chandra, A., Mosher, W. D., & Copen, C. (2011). Sexual behavior, sexual attraction, and sexual identity in the United States: Data from the 2006–2008 national survey of family growth. National Health Statistics Reports, 36, March 3.

Chang, G. (2017, April 18). Substance misuse in pregnant women. UpToDate. Retrieved from http://www.uptodate.com.

Chang, G. (2018, February 15). Alcohol intake and pregnancy. UpToDate. Retrieved from http://www.uptodate.com.

Chang, J. S., Hsiao, J-R., & Chen, C-H. (2017). ALDH2 polymorphism and alcohol-related cancers in Asians: A public health perspective. Journal of Biomedical Science, 24, 19.

Chang, L. Y., Chang, H. Y., Lin, L. N., Wu, C. C., & Yen, L. L. (2017). Disentangling the effects of depression on trajectories of sleep problems from adolescence through young adulthood. Journal of Affective Disorders, 217, 48–54.

Chapman, B. P., Benedict, R. H., Lin, F., Roy, S., Federoff, H. J., & Mapstone, M. (2017). Personality and performance in specific neurocognitive domains among older persons. American Journal of Geriatric Psychiatry, 25(8), 900–908.

Chaput, J-P., Weippert, M., LeBlanc, A. G., Hjorth, M. F., Michaelsen, K. F., Katzmarzyk, P. T., . . . Sjödin, A. M. (2016). Are children like werewolves? Full moon and its association with sleep and activity behaviors in an international sample of children. Frontiers in Pediatrics, 4, 24.

Charney, A. W., Ruderfer, D. M., Stahl, E. A., Moran, J. L., Chambert, K., Belliveau, R. A., . . . Sklar, P. (2017). Evidence for genetic heterogeneity between clinical subtypes of bipolar disorder. Translational Psychiatry. 7(1), e993.

Charney, D. S., Woods, S. W., Goodman, W. K., & Heninger, G. R. (1987). Neurobiological mechanisms of panic anxiety: Biochemical and behavioral correlates of yohimbine-induced anxiety. American Journal of Psychiatry, 144(8), 1030–1036.

Charney, D. S., Woods, S. W., Price, L. H., Goodman, W. K., Glazer, W. M., & Heninger, G. R. (1990). Noradrenergic dysregulation in panic disorder. In J. C. Ballenger (Ed.), Neurobiology of panic disorder. New York: Wiley-Liss.

Chassin, L., Colder, C. R., Hussong, A., & Sher, K. J. (2016). Substance use and substance use disorders. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed., Chap. 19, pp. 833–897). Hoboken, NJ: John Wiley.

Chavira, D. A., Grilo, C. M., Shea, M. T., Yen, S., Gunderson, J. G., Morey, L. C., . . .

1225

http://www.uptodate.com

McGlashan, T. H. (2003). Ethnicity and four personality disorders. Comprehensive Psychiatry, 44(6), 483–491.

Che, X. Q., Song, N., Gao, Y., Ren, R. J., & Wang, G. (2018). Precision medicine of frontotemporal dementia: from genotype to phenotype. Frontiers in Bioscience (Landmark Edition), 23, 1144–1165.

Chefetz, R. A. (2017). Issues in consultation for treatments with distressed activated abuser/protector self-states in dissociative identity disorder. Journal of Trauma and Dissociation. 18(3): 465–475.

Chen, H., Wang, X., Huang, Y., Li, G., Liu, Z., Li, Y., & Geng, H. (2019). Prevalence, risk factors and multi-group latent class analysis of lifetime anxiety disorders comorbid depressive symptoms. Journal of Affective Disorders, 243, 360–365.

Chen, X., Jiang, Y., Chen, L., He, H., Dong, L., Hou, C., . . . Luo, C. (2017). Altered hippocampo-cerebello-cortical circuit in schizophrenia by a spatiotemporal consistency and causal connectivity analysis. Frontiers in Neuroscience, 11, 25.

Cheong, E. V., Sinnott, C., Dahly, D., & Kearney, P. M. (2017). Adverse childhood experiences (ACEs) and later-life depression: Perceived social support as a potential protective factor. BMJ Open, 7(9), e013228.

Cherry, K. (2017, April 25). 10 fascinating facts about personality. Verywell. Retrieved from https://www.verywell.com/facts-about-personality-2795436.

Cherry, K. (2018). 9 common dreams and what they supposedly mean: What do dreams really mean? Verywellmind. Retrieved from https://verywellmind.com/understanding-your-dreams.

Chesnes, M., & Jin, G. Z. (2016). Direct-to-consumer advertising and online search. Federal Trade Commission.

Cheung, G., & Sundram, F. (2017). Understanding the progression from physical illness to suicidal behavior: A case study based on a newly developed conceptual model. Clinical Gerontologist, 40(2), 124–129.

Chhabra, K. H., Adams, J. M., Jones, G. L., Yamashita, M., Schlapschy, M., Skerra, A., . . . Low, M. J. (2016). Reprogramming the body weight set point by a reciprocal interaction of hydrothalamic leptin sensitivity and Pomc gene expression reverts extreme obesity. Molecular Metabolism, 5(10), 869–881.

Chi, S., Yu, J., Tan, M., & Tan, L. (2014). Depression in Alzheimer’s disease: Epidemiology, mechanisms, and management. Journal of Alzheimer’s Disease, 42(3), 739–755.

1226

https://www.verywell.com/facts-about-personality-2795436

https://verywellmind.com/understanding-your-dreams

Choca, J. P., & Rossini, E. D. (2018). Assessment using the Rorschach inkblot test (Psychological Assessment Series). Washington, DC: American Psychological Association.

Choi, K. W., Na, E. J., Hong, J. P., Cho, M. J., Fava, M., Mischoulon, D., Cho, H., & Jeon, H. J. (2018). Alcohol-induced disinhibition is associated with impulsivity, depression, and suicide attempt: A nationwide community sample of Korean adults. Journal of Affective Disorders, 227, 323–329.

Choi, S. W., Shin, Y. C., Kim, D. J., Choi, J. S., Kim, S., Kim, S. H., & Youn, H. (2017). Treatment modalities for patients with gambling disorder. Annals of General Psychiatry, 16, 23.

Choi, Y. S., Lee, E. J., & Cho, Y. (2017). The effect of Korean-group cognitive behavioural therapy among patients with panic disorder in clinic settings. Journal of Psychiatric and Mental Health Nursing, 24(1), 28–40.

Chomet, N. (2018). Coping with body shaming. New York: Rosen Young Adult.

Chou, T., Carpenter, A., Kerns, C. E., Elkins, R. M., Green, J. G., & Comer, J. S. (2017). Disqualified qualifiers: Evaluating the utility of the revised DSM-5 definition of potentially traumatic events among area youth following the Boston Marathon bombing. Depression and Anxiety, 34, 367–373.

Chowdhary, N., Jotheeswaran, A. T., Nadkarni, A., Hollon, S. D., King, M., Jordans, M. J., . . . Patel, V. (2014). The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: A systematic review. Psychological Medicine, 44(6), 1131– 1146.

Christensen, A. (2017, January 10). Most selfie takers aren’t narcissists, study says. PhysicsForums. Retrieved from https://phys.org/news.

Christensen, A., & Doss, B. D. (2017). Integrative behavioral couple therapy. Current Opinion in Psychology, 13, 111–114.

Christensen, B. S., Gronbaek, M., Osler, M., Pedersen, B. V., Graugaard, C., & Frisch, M. (2011). Sexual dysfunctions and difficulties in Denmark: Prevalence and associated sociodemographic factors. Archives of Sexual Behavior, 40(1), 121–132.

Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78(2), 225–235.

Christensen, A., Doss, B. D., & Jacobson, N. S. (2014). Reconcilable differences: Rebuild your

1227

https://phys.org/news

relationship by rediscovering the partner you love—without losing yourself (2nd ed.). New York: Guilford Press.

Christian, C. (2017, October 13). Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children. UpToDate. Retrieved from http://www.uptodate.com.

Christiansen, E., Agerbo, E., Bilenberg, N., & Stenager, E. (2016). SSRIs and risk of suicide attempts in young people: A Danish observational register-based historical cohort study using propensity score. Nordic Journal of Psychiatry, 70(3), 167–175.

Chu, C. S., Stubbs, B., Chen, T. Y., Tang, C. H., Li, D. J., Yang, W. C., . . . Lin, P. Y. (2018). The effectiveness of adjunct mindfulness-based intervention in treatment of bipolar disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 225, 234–245.

Chu, J., Leino, A., Pflum, S., & Sue, S. (2016). Psychotherapy with racial/ethnic minority groups: Theory and practice. In A. J. Consoli, L. E. Beutler, & B. Bongar (Eds.), Comprehensive textbook of psychotherapy: Theory and practice (2nd ed., pp. 346–362). New York: Oxford University Press.

Chudal, R., Gissler, M., Sucksdorff, D., Lehti, V., Suominen, A., Kinkka-Yli-Salomaki, S., . . . Sourander, A. (2014). Parental age and the risk of bipolar disorders. Bipolar Disorders, 16, 624–632.

Cicchetti, D. (2016). Developmental psychopathology (3rd ed., 4 vols.). New York: Wiley.

Cicchetti, D. (2016). Developmental psychopathology, Vol. 1: Theory and method (3rd ed.). New York: Wiley.

Cicchetti, D. (2018). A multilevel developmental approach to the prevention of psychopathology in children and adolescents. In J. Butcher (Ed.-in-Chief), APA handbook of psychopathology, Vol. 2, Psychopathology in children and adolescents (Chap. 3). Washington, DC: APA.

Cicchetti, D. (Ed.) (2016). Developmental psychopathology, maladaptation and psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed.). New York: Wiley.

Cicchetti, D., & Toth, S. L. (2016). Child maltreatment and developmental psychopathology: A multilevel perspective. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed., pp. 457–512). New York: Wiley.

Ciliberti, M. G., Albenzio, M., Inghese, C., Santillo, A., Marino, R., Sevi, A., & Caroprese, M. (2017). Peripheral blood mononuclear cell proliferation and cytokine production in sheep

1228

http://www.uptodate.com

as affected by cortisol level and duration of stress. Journal of Dairy Science, 100(1), 750–756.

Cipolletta, S., Votadoro, R., & Faccio, E. (2017). Online support for transgender people: An analysis of forums and social networks. Health & Social Care in the Community, 25, 1542– 1551.

Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Frontiers in Psychology, 8, 1946.

Ciraulo, D. A., Shader, R. I., & Greenblatt, D. J. (2011). Clinical pharmacology and therapeutics of antidepressants. In D. A. Ciraulo & R. I. Shader (Eds.), Pharmacotherapy of depression (2nd ed., pp. 33–124). New York: Springer Science + Business Media.

Cirelli, C. (2016, December 8). Insufficient sleep: Definition, epidemiology, and adverse outcomes: UpToDate. Retrieved from http://www.uptodate.com.

CISCRP (Center for Information and Study on Clinical Research Participation). (2013). Clinical trial facts and figures for health professionals. Boston, MA: CISCRP.

Clark, D. A. (2018). The anxious thoughts workbook: Skills to overcome the unwanted intrusive thoughts that drive anxiety, obsessions, and depression. Oakland, CA: New Harbinger Publications.

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York: Guilford Press.

Clark, D. A., & Beck, A. T. (2012). The anxiety and worry workbook: The cognitive behavioral solution. New York: Guilford Press.

Clarke, J. C., & Saunders, J. B. (1988). Alcoholism and problem drinking: Theories and treatment. Sydney, Australia: Pergamon Press.

Clarkin, J. F., Cain, N., Lenzenweger, M. F., & Levy, K. N. (2018). Transference-focused psychotherapy. In W. J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., Ch. 32). New York: Guilford Press.

Clarkin, J. F., Livesley, W. J., & Meehan, K. B. (2018). Clinical assessment. In W. J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., Ch. 21). New York: Guilford Press.

Clausen, L., Rosenvinge J. H., Friborg, O., & Rokkedal, K. (2011). Validating the Eating Disorder Inventory-3 (EDI-3): A comparison between 561 female eating disorders patients and 878 females from the general population. Journal of Psychopathology and Behavioral Assessment, 33(1), 101–110.

1229

http://www.uptodate.com

CMSAC (Central MN Sexual Assault Center). (2017). Facts and statistics: Facts about sexual assault. St. Cloud, MN: CMSAC.

Coates, T. D. (2018, February 18). Drug-induced neutropenia and agranulocytosis. UpToDate. Retrieved from http://www.uptodate.com.

Coffey, M. J. (2017, November 22). Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis. UpToDate. Retrieved from http://www.uptodate.com.

Coffey, M. J. (2017, November 22). Catatonia: Treatment and prognosis. UpToDate. Retrieved from http://www.uptodate.com.

Coffin, P. (2017, April 10). Prevention of lethal opioid overdose in the community. UpToDate. Retrieved from http://www.uptodate.com.

Cohen, K. M., & Savin-Williams, R. C. (2017). Treating sexual problems in lesbian, gay, and bisexual clients. In Z. D. Peterson (Ed.), The Wiley-Blackwell handbook of sex therapy (Chap. 17, pp. 269–290). Hoboken, NJ: Wiley-Blackwell.

Cohen, N. (2009, July 28). “A Rorschach cheat sheet on Wikipedia?” New York Times, p. A1.

Coker, T. R., Elliott, M. N., Toomey, S. L., Schwebel, D. C., Cuccaro, P., Emery, S., . . . Schuster, M. A. (2016). Racial and ethnic disparities in ADHD diagnosis and treatment. Pediatrics, 138(3).

Colburn, D. (1996, November 19). Singer’s suicide doesn’t lead to “copycat” deaths. Washington Post Health, p. 5.

Cole, M. (2016, August 13). Aversion therapy and learning to overcome bad habits. Today’s Therapist.

Coleman, K. J., Stewart, C., Waitzfelder, B. E., Zeber, J. E., Morales, L. S., Ahmed, A. T., . . . Simon, G. E. (2016). Racial-ethnic differences in psychiatric diagnoses and treatment across 11 health care systems in the mental health research network. Psychiatry Services, 67(7), 749– 757.

Coleman, L. (1984). The reign of error: Psychiatry, authority, and law. Boston: Beacon.

Colen, C. G., Ramey, D. M., Cooksey, E. C., & Williams, D. R. (2018). Racial disparities in health among nonpoor African Americans and Hispanics: The role of acute and chronic discrimination. Social Science & Medicine, 199, 167–180.

Colletti, G., Lynn, S. J., & Laurence, J-R. (2010). Hypnosis and the treatment of dissociative identity disorder. In S. J. Lynn, J. W. Rhue, & I. Kirsch (Eds.), Handbook of clinical hypnosis

1230

http://www.uptodate.com

(2nd ed., pp. 433–451). Washington, DC: American Psychological Association.

Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry, 171(1), 102–108.

Collingwood, J. (2016). The link between bipolar disorder and creativity. Psych Central. Retrieved from https://psychcentral.com.

Collins, B. M., & Stam, H. J. (2015). Freeman’s transorbital lobotomy as an anomaly: A material culture examination of surgical instruments and operational spaces. History of Psychology, 18(2), 119–131.

Collins, J. L., Thompson, K., Sherry, S. B., Glowacka, M., & Stewart, S. H. (2018). Drinking to cope with depression mediates the relationship between social avoidance and alcohol problems: A 3-wave, 18-month longitudinal study. Addictive Behaviors, 76, 182–187.

Coluccia, A., Gabbrielli, M., Gualtieri, G., Ferretti, F., Pozza, A., & Fagiolini, A. (2016). Sexual masochism disorder in asphyxiophilia: A deadly yet underrecognized disease. Case Reports in Psychiatry, 2016, ID 5474862.

Comas-Díaz, L. (2019). Multicultural theories of psychotherapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., Ch. 15). Independence, KY: Cengage Publications.

Comer, J. S., & Bry, L. J. (2018). Research methodology in clinical child and adolescent psychology. In T. H. Ollendick, S. W. White, & B. A. White (Eds.), The Oxford handbook of clinical child and adolescent psychology (Chap. 8). NY: Oxford University Press.

Comer, J. S., Bry, L., Poznanski, B., & Golik, A. M. (2016). Children’s mental health in the context of terrorist attacks, ongoing threats, and possibilities of future terrorism. Current Psychiatry Reports, 18, 79.

Comer, J. S., Chow, C., Chan, P., Cooper-Vince, C., & Wilson, L. A. S. (2013). Psychosocial treatment efficacy for disruptive behavior problems in young children: A meta-analytic examination. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 26–36.

Comer, J. S., Dantowitz, A., Chou, T., Edison, A. L., Elkins, R. M., Kerns, C., Brown, B., & Green, J. G. (2014). Adjustment among area youth after the Boston Marathon bombing and subsequent manhunt, Pediatrics, 134(1), 7–14.

Comer, J. S., Del Busto, C., Dick, A. S., Furr, J. M., & Puliafico, A. C. (2019). Adapting PCIT to treat anxiety problems in young children: The PCIT CALM Program. In L. Niec (Ed.), Handbook of parent-child interaction therapy: Innovations and applications for research

1231

https://psychcentral.com

and practice. New York: Springer Publishing.

Comer, J. S., Furr, J. M., & Gurwitch, R. (2018). Terrorism exposure and the family: Where we are, and where we go next. In B. Fiese (Ed.), APA handbook of contemporary family psychology. Washington, DC: APA.

Comer, J. S., Furr, J. M., Cooper-Vince, C., Madigan, R. J., Chow, C., Chan, P. T., . . . Eyberg, S. M. (2015). Rationale and considerations for the Internet-based delivery of parent- child interaction therapy. Cognitive and Behavioral Practice, 22, 302–316.

Comer, J. S., Furr, J. M., Kerns, C. E., Miguel, E., Coxe, S., Elkins, R. M., . . . Freeman, J. B. (2017). Internet-delivered, family-based treatment for early-onset OCD: A pilot randomized trial. Journal of Consulting and Clinical Psychology, 85, 178–186.

Comer, J. S., Furr, J. M., Miguel, E., Cooper-Vince, C. E., Carpenter, A. L., Elkins, R. M., . . . Chase, R. (2017). Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered Parent-Child Interaction Therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85, 909–917.

Comer, J. S., Golik, A., & Martin, J. (2019). Learning from the past: Understanding children’s mental health after 9/11 and after the Boston Marathon bombing. In S. Tyano, C. W. Hoven, & L. Amsel (Eds.), Responses to children’s mental health needs after major disasters: An international perspective. New York: Springer.

Comer, J. S., Hong, N., Poznanski, B., Silva, K., & Wilson, M. (2019). Evidence base update on the treatment of early childhood anxiety and related problems. Journal of Clinical Child and Adolescent Psychology.

Comer, J. S., Mojtabai, R., & Olfson, M. (2011). National trends in the antipsychotic treatment of psychiatric outpatients with anxiety disorders. American Journal of Psychiatry, 168(10), 1057–1065.

Comer, J. S., Olfson, M., & Mojtabai, R. (2010). National trends in child and adolescent psychotropic polypharmacy in office-based practice, 1996–2007. Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 1001–1010.

Comer, R. (1973). Therapy interviews with a schizophrenic patient. Unpublished manuscript.

Compean, E., & Hamner, M. (2019). Posttraumatic stress disorders with secondary psychotic features (PTSD-SP): Diagnostic and treatment challenges. Progress in Neuro- Psychopharmacology & Biological Psychiatry, 88, 265–275.

Conrad, D., Wilker, S., Pfeiffer, A., Lingenfelder, B., Ebalu, T., Lanzinger, H., . . . Kolassa,

1232

S. (2017). Does trauma event type matter in the assessment of traumatic load? European Journal of Psychotraumatology, 8(1), 1344079.

Conradi, H. J., Kamphuis, J. H., & de Jonge, P. (2018). Adult attachment predicts the seven- year course of recurrent depression in primary care. Journal of Affective Disorders, 225, 160– 166.

Conti, A. A. (2014). Western medical rehabilitation through time: A historical and epistemological review. The Scientific World Journal, 2014, 432506.

Conti, C., Mennitto, C., De Francesco, G., Fraticelli, F., Vitacolonna, E., & Fulcheri, M. (2017). Clinical characteristics of diabetes mellitus and suicide risk. Frontiers in Psychiatry, 8, 40.

Cook, N., Ayers, S., & Horsch, A. (2018). Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. Journal of Affective Disorders, 225, 18–31.

Cooney, P., Jackman, C., Tunney, C., Coyle, D., & O’Reilly, G. (2018, May 3). Computer- assisted cognitive behavioural therapy: The experiences of adults who have an intellectual disability and anxiety or depression. Journal of Applied Research in Intellectual Disabilities. [Epub ahead of print]

Coons, P. M., & Bowman, E. S. (2001). Ten-year follow-up study of patients with dissociative identity disorder. Journal of Trauma and Dissociation, 2(1), 73–89.

Cooper, A. A., Kline, A. C., Graham, B., Bedard-Gilligan, M., Mello, P. G., Feeny, N. C., & Zoellner, L. A. (2017). Homework “dose,” type, and helpfulness as predictors of clinical outcomes in prolonged exposure for PTSD. Behavior Therapy, 48(2), 182–194.

Cooper, M. (2008). Essential research findings in counselling and psychotherapy: The facts are friendly. Los Angeles, CA: Sage Publications.

Cooper, M. (2016). Existential therapies (2nd ed.). Los Angeles: Sage Publications.

Cooper, R. (2014). On deciding to have a lobotomy: Either lobotomies were justified or decisions under risk should not always seek to maximize expected utility. Medicine, Health Care, and Philosophy, 17(1), 143–154.

Copen, C. (2017). Condom use during sexual intercourse among women and men aged 15–44 in the United States: 2011–2015 National Survey of Family Growth. Atlanta, GA: CDC, National Health Statistics Report, No. 105.

Copen, C. E., Chandra, A., & Febo-Vazquez, M. S. (2016, January 7). Sexual behavior, sexual

1233

attraction, and sexual orientation among adults aged 18–44 in the United States: Data from the 2011–2013 National Survey of Family Growth. Atlanta, GA: CDC, National Health Statistics Report, No. 88.

Corathers, S. D. (2018). Collaboration is key to developing effective hormonal treatment paradigms for transgender youth. Journal of Adolescent Health, 62(4), 361–362.

Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.). Independence, KY: Cengage Learning.

Cornacchio, D., Bry, L. J., Sanchez, A. L., Poznanski, B., & Comer, J. S. (2017). Psychosocial treatment and prevention of conduct problems in early childhood. In J. E. Lochman & W. Matthys (Eds.), The Wiley handbook of disruptive and impulse-control disorders. New York: Wiley.

Cornacchio, D., Crum, K. I., Coxe, S., Pincus, D. B., & Comer, J. S. (2016). Irritability and severity of anxious symptomatology among youth with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 55, 54–61.

Cornacchio, D., Sanchez, A. L., Chou, T., & Comer, J. S. (2017). Cognitive-behavioral therapy for children and adolescents. In S.G. Hofmann & G. Asmundson (Eds.), The science of cognitive behavioral therapy: From theory to therapy. New York: Elsevier.

Corral-Corral, I., & Corral-Corral, C. (2016). Tarantism in Spain in the eighteenth century: Latrodectism and suggestion. [Spanish] Revista de Neurologia, 63(8), 370–379.

Corrie, S., & Callanan, M. M. (2001). Therapists’ beliefs about research and the scientist- practitioner model in an evidence-based health care climate? A qualitative study. British Journal of Medical Psychology, 74(2), 135–149.

Corrigan, P. W., Schomerus, G., Shuman, V., Kraus, D., Perlick, D., Harnish, A., . . . Smelson, D. (2017). Developing a research agenda for reducing the stigma of addictions, Part II: Lessons from the mental health stigma literature. American Journal on Addictions, 26(1), 67–74.

Corring, D., O’Reilly, R. L., Sommerdyk, C., & Russell, E. (2018, April 26). What clinicians say about the experience of working with individuals on community treatment orders. Psychiatric Services. [Epub ahead of print]

Coryell, W. (2018, April 1). Unipolar depression in adults: Course of illness. UpToDate. Retrieved from http://www.uptodate.com.

Coskun, M., & Ozturk, M. (2013). Sexual fetishism in adolescence: Report of two cases.

1234

http://www.uptodate.com

Journal of Psychiatry and Neurological Sciences, 26, 199–205.

Costa, R. T. D., Carvalho, M. R., Ribeiro, P., & Nardi, A. E. (2018, February 15). Virtual reality exposure therapy for fear of driving: Analysis of clinical characteristics, psychological response, and sense of presence. Revista Brasileira de Psiquiatria. [Epub ahead of print]

Costantino, G., Litman, L., Waxman, R., Dupertuis, D., Pais, E., Rosenzweig, C., . . . Canales, M. M. F. (2014). Tell-me-a-story (TEMAS) assessment for culturally diverse children and adolescents. Rorschachiana, 35(2), 154–175.

Costantino, G., Dana, R. H., & Malgady, R. G. (2007). TEMAS (Tell-Me-A-Story) assessment in multicultural societies. Mahwah, NJ: Lawrence Erlbaum.

Costello, E. J., & Angold, A. (2016). Developmental epidemiology. In D. Cicchetti (Ed.), Developmental psychology, Vol. 1: Theory and Method (3rd ed.). New York: Wiley.

Cottle, J. (2016, March 15). Facebook and mental health: Is social media hurting or helping? MentalHelp.net.

Cottler, L. B., Hu, H., Smallwood, B. A., Anthony, J. C., Wu, L. T., & Eaton, W. W. (2016). Nonmedical opioid pain relievers and all-cause mortality: A 27-year follow-up from the Epidemiologic Catchment Area Study. American Journal of Public Health, 106(3), 509– 516.

Cottrell, D. B., & Williams, J. (2016). Eating disorders in men. Nurse Practitioner, 41(9), 49– 55.

Covey, R. D. (2017). The temporary insanity defense. In M. D. White (Ed.), The insanity defense: Multidisciplinary views on its history, trends, and controversies (Chap. 2, pp. 23–60). Westport, CT: Praeger.

Coyne, S. M., Padilla-Walker, L. M., & Holmgren, H. G. (2018). A six-year longitudinal study of texting trajectories during adolescence. Child Development, 89(1), 58–65.

Cozzi, G., Minute, M., Skabar, A., Pirrone, A., Jaber, M., Neri, E., . . . Barbi, E. (2017). Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain. Acta Paediatrica, 106(4), 586–593.

Crabtree, S. (2011). U.S. seniors maintain happiness highs with less social time (Gallup poll 151457). Gallup. Retrieved from http://www.gallup.com/poll/151457.

Craig, T. K., Rus-Calafell, M., Ward, T., Leff, J. P., Huckvale, M., Howarth, E., . . . Garety, P. A. (2018). AVATAR therapy for auditory verbal hallucinations in people with psychosis: A single-blind, randomised controlled trial. Lancet Psychiatry, 5(1), 31–40.

1235

http://www.gallup.com/poll/151457

Craig, T., Ward, T., & Rus-Calafell, M. (2016). AVATAR therapy for refractory auditory hallucinations. In B. Pradhan, N. Pinninti, & S. Rathod (Eds.), Brief interventions for psychosis: A clinical compendium (Chap. 4). London: Springer.

Craig, T., & Power, P. (2010). Inpatient provision in early psychosis. In P. French, J. Smith, D. Shiers, M. Reed, & M. Rayne (Eds.), Promoting recovery in early psychosis: A practice manual (pp. 17–26). Hoboken, NJ: Wiley-Blackwell.

Cramer, P. (2017), Defense mechanism card pull in TAT stories. Journal of Personality Assessment, 99(1), 15–24.

Crandall, M. (2018, February 28). Trends of gender-affirming surgery among transgender patients in the United States. JAMA Surgery. [Epub ahead of print]

Craske, C. M., & Barlow, D. H. (2014). Panic disorder and agoraphobia. In D. H. Barlow, Clinical handbook of psychological disorders (5th ed., pp. 1–61). New York: Guilford Press.

Craske, M. G. (2017). Cognitive-behavioral therapy. Washington, DC: American Psychological Association.

Craske, M. (2017, May 26). Psychotherapy for panic disorder with or without agoraphobia in adults. UpToDate. Retrieved from http://www.uptodate.com.

Craske, M. (2018, March 1). Psychotherapy for generalized anxiety disorder in adults. UpToDate. Retrieved from http://www.uptodate.com.

Craske, M., & Bystritsky, A. (2017, December 1). Approach to treating generalized anxiety disorder in adults. UpToDate. Retrieved from http://www.uptodate.com.

Crawford, C., Burns, J., & Fernie, B. A. (2015). Psychosocial impact of involvement in the Special Olympics. Research in Developmental Disabilities, 45-46, 93–102.

CRC (Cyberbullying Research Center). (2016, November 26). 2016 cyberbullying data. Retrieved from https://cyberbullying.org.

CRC (Cyberbullying Research Center). (2017, January 3). Millions of students skip school each year because of bullying. Retrieved from https://cyberbullying.org.

CRC (Cyberbullying Research Center). (2017, June 2). More on the link between bullying and suicide. Retrieved from https://cyberbullying.org.

CRCC (Cleveland Rape Crisis Center). (2014). Sexual violence on college campuses. Retrieved from CRCC website: http://www.clevelandrapecrisis.org/resources/statistics/sexual-violence- on-college-campuses.

1236

http://www.uptodate.com

https://cyberbullying.org

http://www.clevelandrapecrisis.org/resources/statistics/sexual-violence-on-college-campuses

Creswell, J. D. (2017). Mindfulness interventions. Annual Review of Psychology, 68, 491–516.

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta- analysis. JAMA Psychiatry, 74(4), 319–328.

Cronin, E., Brand, B. L., & Mattanah, J. F. (2014). The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. European Journal of Psychotraumatology, 5d, 22676.

Crow, S. J. (2017, July 17). Bulimia nervosa in adults: Pharmacotherapy. UpToDate. Retrieved from http://www.uptodate.com.

Crow, T. J. (1980). Positive and negative schizophrenic symptoms and the role of dopamine: II. British Journal of Psychiatry, 137, 383–386.

Crow, T. J. (1985). The two-syndrome concept: Origins and current status. Schizophrenia Bulletin, 11(3), 471–486.

Crow, T. J. (1995). Brain changes and negative symptoms in schizophrenia. Psychopathology, 28(1), 18–21.

Crow, T. J. (2008). The “big bang” theory of the origin of psychosis and the faculty of language. Schizophrenia Research, 102(1–3), 31–52.

CRS (Congressional Research Service). (2016, March 3). Heroin production in Mexico and U.S. policy. CRS. Retrieved from https://fas.org/sgp/crs/row/IN10456.pdf.

Crystal, S., Kleinhaus, K., Perrin, M., & Malaspina, D. (2012). Advancing paternal age and the risk of schizophrenia. In A. S. Brown & P. H. Patterson (Eds.), The origins of schizophrenia (pp. 140–155). New York: Columbia University Press.

CSP Daily News. (2017, March 7). E-cig sales to hit $27 billion by 2022: Study. Retrieved from http://www.cspdailynews.com.

Cui, L. B., Liu, K., Li, C., Wang, L. X., Guo, F., Tian, P., . . . Yin, H. Putamen-related regional and network functional deficits in first-episode schizophrenia with auditory verbal hallucinations. Schizophrenia Research, 173(1-2), 13–22.

Cui, Y., Liu, B., Song, M., Lipnicki, D. M., Li, J., Xie, S., . . . Jiang, T. (2018). Auditory verbal hallucinations are related to cortical thinning in the left middle temporal gyrus of patients with schizophrenia. Psychological Medicine, 48(1), 115–122.

Cuijpers, P., Centili, C., Banos, R. M., Garcia-Campayo, J., Botella, C., & Cristea, I. A.

1237

http://www.uptodate.com

https://fas.org/sgp/crs/row/IN10456.pdf

http://www.cspdailynews.com

(2016). Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis. Journal of Anxiety Disorders, 43, 79–89.

Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., Hollon, S. D., & van Straten, A. (2014). The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. Journal of Affective Disorders, 159, 118–126.

Culp, A. M., Clyman, M. M., & Culp, R. E. (1995). Adolescent depressed mood, reports of suicide attempts, and asking for help. Adolescence, 30(120), 827–837.

Culver, J. L., & Pratchett, L. C. (2010). Adjunctive psychosocial interventions in the management of bipolar disorders. In T. A. Ketter (Ed.), Handbook of diagnosis and treatment of bipolar disorders (pp. 661–676). Arlington, VA: American Psychiatric Publishing.

Cummings, J. R., Ji, X., Allen, L., Lally, C., & Druss, B. G. (2017). Racial and ethnic differences in ADHD treatment quality among Medicaid-enrolled youths. Pediatrics, 139(6), e20162444.

Cunningham, G. R., & Khera, M. (2018, January 31). Evaluation of male sexual dysfunction. UpToDate. Retrieved from http://www.uptodate.com.

Cunningham, G. R., & Rosen, R. C. (2018, April 18). Overview of male sexual dysfunction. UpToDate. Retrieved from http://www.uptodate.com.

Cunningham, K. C., LoSavio, S. T., Dennis, P. A., Farmer, C., Clancy, C. P., Hertzberg, M. A., . . . Beckham, J. C. (2019). Shame as a mediator between posttraumatic stress disorder symptoms and suicidal ideation among veterans. Journal of Affective Disorders, 243, 216–219.

Curtiss, J., Andrews, L., Davis, M., Smits, J., & Hofmann, S. G. (2017). A meta-analysis of pharmacotherapy for social anxiety disorder: An examination of efficacy, moderators, and mediators. Expert Opinion on Pharmacotherapy, 18(3), 243–251.

Cutler, D. M., Glaeser, E. L., & Norberg, K. E. (2001). Explaining the rise in youth suicide. In J. Gruber (Ed.), Risky behavior among youths: An economic analysis (pp. 219–269). Chicago: University of Chicago Press.

Cutrer, F. M., & Bajwa, Z. H. (2017, November 13). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. Retrieved from http://www.uptodate.com.

Cutright, P., & Fernquist, R. M. (2001). The relative gender gap in suicide: Societal integration, the culture of suicide and period effects in 20 developed countries, 1955–1994. Social Science Research, 30(1), 76–99.

1238

http://www.uptodate.com

Cutting, J. (2015). First rank symptoms of schizophrenia: Their nature and origin. History of Psychiatry, 26(2), 131–146.

Cuvelier, M. (2002). Victim, not villain. The mentally ill are six to seven times more likely to be murdered. Psychology Today, 35(3), 23.

Cynkar, A. (2007). The changing gender composition of psychology. The Monitor, 38(6), 46.

Da Paz, N. S., & Wallander, J. L. (2017). Interventions that target improvements in mental health for parents of children with autism spectrum disorders: A narrative review. Clinical Psychology Review, 51, 1–14.

da Rosa, G., Martin, P., Gondo, Y., Hirose, N., Ishioka, Y., & Poon, L. (2014). Examination of important life experiences of the oldest-old: Cross-cultural comparisons of U.S. and Japanese centenarians. Journal of Cross-Cultural Gerontology, 29(2), 109–130.

da Silva, A. P., Valente, A., Chaves, C., Matos, A., Gil, A., Santos, A. C., . . . Bicho, M. (2018, March 13). Characterization of Portuguese centenarian eating habits, nutritional biomarkers, and cardiovascular risk: A case control study. Oxidative Medicine and Cellular Longevity, 2018: 5296168.

Daalman, K., Boks, M. P., Diederen, K. M., de Weijer, A. D., Blom, J. D., Kahn, R. S., & Sommer, I. E. (2011). The same or different? A phenomenological comparison of auditory verbal hallucinations in healthy and psychotic individuals. Journal of Clinical Psychiatry, 72(3), 320–325.

Dahl, M. (2015, April 10). The more money you make, the more sleep you get. NY Magazine.

Dahlhaus, R. (2018). Of men and mice: Modeling the Fragile X Syndrome. Frontiers in Molecular Neuroscience, 11, 41.

Dahling, J. J., Whitaker, B. G., & Levy, P. E. (2008). The development and validation of a new Machiavellianism scale. Journal of Management, 35, 219–257.

Dahne, J., Lejuez, C. W., Kustanowitz, J., Felton, J. W., Diaz, V. A., Player, M. S., & Carpenter, M. J. (2017). Moodivate: A self-help behavioral activation mobile app for utilization in primary care: Development and clinical considerations. International Journal of Psychiatry in Medicine, 52(2), 160–175.

Dai, H. J., Su, E. C., Uddin, M., Jonnagaddala, J., Wu, C. S., & Syed-Abdul, S. (2017). Exploring associations of clinical and social parameters with violent behaviors among psychiatric patients. Journal of Biomedical Informatics, 75S, S149–S159.

Daigre, C., Rodríguez-Cintas, L., Tarifa, N., Rodríguez-Martos, L., Grau-Lopez, L.,

1239

Berenguer, M., . . . Roncero, C. (2015). History of sexual, emotional or physical abuse and psychiatric comorbidity in substance-dependent patients. Psychiatry Research, 229(3), 743– 749.

Dalsbø, T. K., Steiro, A., Strømme, H., & Reinar, L. M. (2017). Effectiveness of tapering from methadone or buprenorphine maintenance treatment compared to traditional maintenance treatment for people with opiate addiction: Systematic review. Folkehelseinsuttet. Retrieved from https://www.fhi.no/en.

Dana, R. H. (Ed.). (2015). Handbook of cross-cultural and multicultural personality assessment. New York: Routledge.

Dana, R. H. (2000). Culture and methodology in personality assessment. In I. Cuellar & F. A. Paniagua (Eds.), Handbook of multicultural mental health (pp. 97–120). San Diego, CA: Academic Press.

Dana, R. H. (2005). Multicultural assessment: Principles, applications, and examples. Mahwah, NJ: Lawrence Erlbaum.

Dando, C. (2017, January 26). I specialise in the psychology of torture, so I know the truth behind Trump’s claims that waterboarding works. The Independent Online. Retrieved from http://www.independent.co.uk.

Danquah, M. N-A. (1998). Willow weep for me: A black woman’s journey through depression. New York: W. W. Norton.

Dasgupta, P., Bhattacherjee, S., Dasgupta, S., Roy, J. K., Mukherjee, A., & Biswas, R. (2017). Nomophobic behaviors among smartphone using medical and engineering students in two colleges in West Bengal. Indian Journal of Public Health, 61(3), 199–204.

Daugherty, J. C., Puente, A. E., Fasfous, A. F., Hidalgo-Ruzzante, N., & Pérez-Garcia, M. (2017). Diagnostic mistakes of culturally diverse individuals when using North American neuropsychological tests. Applied Neuropsychology: Adult, 24(1), 16–33.

Daugherty, J., & Copen, C. (2016, March 17). Trends in attitudes about marriage, childbearing, and sexual behavior: United States, 2002, 2006–2010, and 2011–2013. Atlanta, GA: CDC, National Health Statistics Report, No. 92.

Davenport, L. (2017, August 30). Aerobic exercise improves cognition in depression. Medscape.

Davidson, K. M. (2018). Cognitive-behavioral therapy. In W. J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., Ch. 28). New York: Guilford Press.

1240

https://www.fhi.no/en

http://www.independent.co.uk

Davidson, L., & Chan, K. K. S. (2014). Common factors: Evidence-based practice and recovery. Psychiatric Services, 65(5), 675–677.

Davis, M. (1992). Analysis of aversive memories using the fear potentiated startle paradigm. In M. Butters & L. R. Squire (Eds.), The neuropaychology of memory (2nd ed.). New York: Guilford Press.

Davis, E., Burden, R., & Manning, R. (2010). Early intervention and vocational opportunities. In P. French, J. Smith, D. Shiers, M. Reed, & M. Rayne (Eds.), Promoting recovery in early psychosis: A practice manual (pp. 140–146). Hoboken, NJ: Wiley-Blackwell.

Dayan, J., Rauchs, G., & Guillery-Girard, B. (2017, February 1). Rhythms dysregulation: A new perspective for understanding PTSD? Journal of Physiology Paris. [Epub ahead of print]

de Beurs, D. P., Bosmans, J. E., de Groot, M. H., de Keijser, J., van Duijn, E., de Winter, R. P., & Kerkhof, A. M. (2015). Training mental health professionals in suicide practice guideline adherence: Cost-effectiveness analysis alongside a randomized controlled trial. Journal of Affective Disorders, 186, 203–210.

de Castro, S. M., Ünlü, Ç., Tuynman, J. B., Honig, A., van Wagensveld, B. A., Steller, E. P., & Vrouenraets, B. C. (2014). Incidence and risk factors of delirium in the elderly general surgical patient. American Journal of Surgery, 208(1), 26–32.

De Cort, K., Schroijen, M., Hurlemann, R., Claassen, S., Hoogenhout, J., Van den Bergh, O., . . . Schruers, K. (2017). Modeling the development of panic disorder with interoceptive conditioning. European Neuropsychopharmacology, 27(1), 59–69.

De Genna, N. M., & Feske, U. (2013). Phenomenology of borderline personality disorder: The role of race and socioeconomic status. The Journal of Nervous and Mental Disease, 201(12), 1027–1034.

de Jonge, P., Roest, A. M., Lim, C. C., Florescu, S. E., Bromet, E. J., Stein, D. J., . . . Scott, K. M. (2016). Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys. Depression and Anxiety, 33(12), 1155–1177.

de Leede-Smith, S., & Barkus, E. (2013). A comprehensive review of auditory verbal hallucinations: Lifetime prevalence, correlates, and mechanisms in healthy and clinical individuals. Frontiers in Human Neurosciences, 7, 367.

De Leo, D., & Evans, R. (2004). International suicide rates and prevention strategies. Cambridge, MA: Hogrefe & Huber.

De Nadia. A. S., Karver, M. S., Murphy, T. K., Cavitt, M. A., Alvaro, J. L., Bengtson, M., . .

1241

. Storch, E. A. (2017). Common factors in pediatric psychiatry: A review of essential and adjunctive mechanisms of treatment outcome. Journal of Child and Adolescent Psychopharmacology, 27(1), 10–18.

De Neve, J. E., & Ward, G. (2017) Happiness at work. In J. Helliwell, R. Layard, & J. Sacks (Ed.), World happiness report 2017. New York: Sustainable Development Solutions Network.

de Vries, R. E. (2018). Three nightmare traits in leaders. Frontiers in Psychology, (9), 871.

Deacon, B. J., & Spielmans, G. I. (2017). Is the efficacy of “antidepressant” medications overrated? In S. O. Lilienfeld and I. D. Waldman (Eds.), Psychological science under scrutiny: Recent challenges and proposed solutions (Chap. 13). New Jersey: John Wiley.

Decker, H. S. (2016). Cyclical swings: The bête noire of psychiatry. History of Psychology, 19(1), 52–56.

Deeley, Q. (2017). Hypnosis as therapy for functional neurologic disorders. Handbook of Clinical Neurology, 139, 585–595.

Dein, S. (2017). Recent work on culture and schizophrenia: Epidemiological and anthropological approaches. Global Journal of Archaeology & Anthropology, 1(3), 1–5.

Deitz, S. M. (1977). An analysis of programming DRL schedules in educational settings. Behavioral Research and Therapy, 15(1), 103–111.

Delgadillo, J., Asaria, M., Ali, S., & Gilbody, S. (2016). On poverty, politics and psychology: The socioeconomic gradient of mental healthcare utilisation and outcomes. British Journal of Psychiatry, 209(5), 429–430.

Delgado, D. (2018, June 4). 5 reasons eating disorders may flare up in summer months. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/eating- disorders/201806/5-reasons-eating-disorders-may-flare-in-summer-months.

Delgado, J. (2017, March 2). Intoxication from LSD and other common hallucinogens. UpToDate. Retrieved from http://www.uptodate.com.

Dell, P. F. (2010). Involuntariness in hypnotic responding and dissociative symptoms. Journal of Trauma & Dissociation, 11(1), 1–18.

Demory-Luce, D., & Motil, K. J. (2018, February 12). Adolescent eating habits. UpToDate. Retrieved from http://www.uptodate.com.

Dendy, C. A. Z. (2016, February 11). Impact of ADHD on school performance. HealthyPlace. Retrieved from https://www.healthyplace.com/adhd.

1242

https://www.psychologytoday.com/us/blog/eating-disorders/201806/5-reasons-eating-disorders-may-flare-in-summer-months

http://www.uptodate.com

https://www.healthyplace.com/adhd

Deng, Y., Hung, K. S. Y., Lui, S. S. Y., Chui, W. W. H., Lee, J. C. W., Wang, Y., . . . Cheung, E. F. C. (2019). Tractography-based classification in distinguishing patients with first-episode schizophrenia from healthy individuals. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 88, 66–73.

Dennhardt, A. A., Murphy, J. G., McDevitt-Murphy, M. E., & Williams, J. L. (2016). Drinking motives mediate the relationship between alcohol reward value and alcohol problems in military veterans. Psychology of Addictive Behaviors, 30(8), 819–826.

Dennis, J. P., & Brown, G. K. (2011). Suicidal older adults: Suicide risk assessments, safety planning, and cognitive behavioral therapy. In K. H. Sorocco & S. Lauderdale (Eds.), Cognitive behavior therapy with older adults: Innovations across care settings (pp. 95–123). New York: Springer Publishing.

Denno, D. W. (2017). Andrea Yates: A continuing story about insanity. In M. D. White (Ed.), The insanity defense: Multidisciplinary views on its history, trends, and controversies (Chap. 12). Westport, CT: Praeger Publishers.

DePaulo, B. M. (2013, April 5). On getting married and (not) getting happier: What we know. Retrieved from http://belladepaulo.com/2013/04/05/on-getting-married-and-not-getting- happpier.

DePaulo, B. M. (2013, March 15). Marriage and happiness: 18 long-term studies. Psychology Today.

DeVeaugh-Geiss, J., Moroz, G., Biederman, J., Cantwell, D. P., Fontaine, R., Griest, J. H., . . . Landau, P. (1992). Clomipramine hydrochloride in childhood and adolescent obsessive compulsive disorder. A multicenter trial. Journal of the American Academy of Child and Adolescent Psychiatry, 31(1), 45–49.

DeVos, S. L., Corjuc, B. T., Oakley, D. H., Nobuhara, C. K., Bannon, R. N., Chase, A., . . . Hyman, B. T. (2018). Synaptic tau seeding precedes tau pathology in human Alzheimer’s disease brain. Frontiers in Neuroscience, 12, 267.

Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Langström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS ONE, 6(2), e16885.

Di Florio, A., Jones, L., Forty, L., Gordon-Smith, K., Blackmore, E. R., Heron, J., . . . Jones, I. (2014). Mood disorders and parity: A clue to the aetiology of the postpartum trigger. Journal of Affective Disorders, 152–154, 334–339.

Di Rosa, M., Kofahl, C., McKee, K., Bien, B., Lamura, G., Prouskas, C., . . . Mnich, E.

1243

http://belladepaulo.com/2013/04/05/on-getting-married-and-not-getting-happpier

(2011). A typology of caregiving situations and service use in family careers of older people in six European countries: The EUROFAMCARE study. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 24(1), 5–18.

Diamond, D., & Meehan, K. B. (2013). Attachment and object relations in patients with narcissistic personality disorder: Implications for therapeutic process and outcome. Journal of Clinical Psychology, 69(11), 1148–1159.

Dickerson, C. (2017, November 13). After hurricane, signs of a mental health crisis haunt Puerto Rico. New York Times.

Dickerson, F., Schroeder, J., Stallings, C., Origoni, A., Katsafanas, E., Schwienfurth, L. A., . . . Yolken, R. (2014). A longitudinal study of cognitive functioning in schizophrenia: Clinical and biological predictors. Schizophrenia Research, 156(2/3), 248–253.

Diefenbach, S., & Christoforakos, L. (2017). The selfie paradox: Nobody seems to like them yet everyone has reasons to take them. An exploration of psychological functions of selfies in self-presentation. Frontiers in Psychology, 87, 7.

Dillard, D. A., Avey, J. P., Robinson, R. F., Smith, J. J., Beals, J., Manson, S. M., & Comtois, K. A. (2017). Demographic, clinical, and service utilization factors associated with suicide-related visits among Alaska native and American Indian adults. Suicide and Life- Threatening Behavior, 47(1), 27–37.

Dimidjian, S., Martell, C. R., Herman-Dunn, R., & Hubley, S. (2014). Behavioral activation for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (5th ed., Chap. 9). New York: Guilford Press.

Dimsdale, J. E., Sharma, N., & Sharpe, M. (2011). What do physicians think of somatoform disorders? Psychosomatics: Journal of Consultation Liaison Psychiatry, 52(2), 154–159.

Ding, J. M., & Kanaan, R. A. (2017). Conversion disorder: A systematic review of current terminology. General Hospital Psychiatry, 45, 51–55.

Dinger, U., Ehrenthal, J. C., Nikendei, C., & Schauenburg, H. (2017). Change in self-esteem predicts depressive symptoms at follow-up after intensive multimodular psychotherapy for major depression. Clinical Psychology & Psychotherapy, 24(5), 1040–1046.

Dishion, T. J., & Patterson, G. R. (2016). The development and ecology of antisocial behavior: Linking etiology, prevention, and treatment. In D. Cicchetti (Ed.), Developmental psychopathology, Vol. 3: Maladaptation and psychopathology (3rd ed.). New York: Wiley.

Dittrich, K., Fuchs, A., Bermpohl, F., Meyer, J., Führer, D., Reichl, C., . . . Resch, F.

1244

(2018). Effects of maternal history of depression and early life maltreatment on children’s health-related quality of life. Journal of Affective Disorders, 225, 280–288.

Dixon, L. B., & Schwarz, E. C. (2014). Fifty years of progress in community mental health in US: The growth of evidence–based practices. Epidemiology and Psychiatric Sciences, 23(1), 5– 9.

Dobson, D., & Dobson, K. S. (2017). Evidence-based practice of cognitive-behavioral therapy (2nd ed.). New York: Guilford Press.

Doctor, R. M., & Neff, B. (2001). Sexual disorders. In H. S. Friedman (Ed.), Specialty articles from the encyclopedia of mental health. San Diego: Academic Press.

Dodes, L. M., & Khantzian, E. J. (2016). Individual psychodynamic psychotherapy. In A. H. Mack, K. T. Brady, S. I. Miller, & R. J. Frances (Eds.). Clinical textbook of addictive disorders (4th ed., Ch. 26, pp. 548–562). New York: Guilford Press.

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., . . . Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: Randomised controlled trial. British Journal of Psychiatry, 196(5), 389–395.

Dohrmann, R. J., & Laskin, D. M. (1978). An evaluation of electromyographic feedback in the treatment of myofascial pain-dysfunction syndrome. Journal of the American Medical Association, 96, 656–666.

DOJ (U.S. Department of Justice). (2010). Arrests. Crime in the United States 2009. http://www.fbi.gov/ucr/cius2009/arrests/index.html.

DOJ (U.S. Department of Justice). (2014). Crime in the United States 2013. http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s./2013.

DOJ (U.S. Department of Justice). (2017, December 6). Statistical briefing book. Law enforcement & juvenile crime: Juvenile arrests. Washington, DC: OJJDP.

Dole, V. P., & Nyswander, M. (1965). A medical treatment for heroin addiction. Journal of the American Medical Association, 193, 646–650.

Dole, V. P., & Nyswander, M. (1967). Heroin addiction, a metabolic disease. Archives of Internal Medicine, 120, 19–24.

Dolezsar, C. M., McGrath, J. J., Herzig, A. M., & Miller, S. B. (2014). Perceived racial discrimination and hypertension: A comprehensive systematic review. Health Psychology, 33(1), 20–34.

1245

http://www.fbi.gov/ucr/cius2009/arrests/index.html

http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s./2013

Donnelly, B., Touyz, S., Hay, P., Burton, A., Russell, J., & Caterson, I. (2018). Neuroimaging in bulimia nervosa and binge eating disorder: a systematic review. Journal of Eating Disorders, 6(3).

Donohoue, P. A. (2017, December 6). Causes and clinical manifestations of primary adrenal insufficiency in children. UpToDate. Retrieved from http://www.uptodate.com.

Dorahy, M. J., Brand, B. L., Sar, V., Krüger, C., Stavropoulos, P., Martínez-Taboas, A., . . . Middleton, W. (2014). Dissociative identity disorder: An empirical overview. The Australian and New Zealand Journal of Psychiatry, 48(5), 402–417.

Dossat, A. M., Bodell, L. P., Williams, D. L., Eckel, L. A., & Keel, P. K. (2014). Preliminary examination of glucagon-like peptide-1 levels in women with purging disorder and bulimia nervosa. International Journal of Eating Disorders.

Dove. (2016). Dove global beauty and confidence report. Englewood Cliffs, NJ: Author.

DPE (Department for Professional Employees). (2016). Social service workers: An occupational overview. Fact sheet 2016. Washington, DC: DPE, AFL-CIO.

Drain, K. (2016, August 13). The top Google health searches of the last 4 years and how they’ve changed. MedicalDaily.com. Retrieved from http://medicaldaily.com.

Draper, B. M. (2014). Suicidal behaviour and suicide prevention in later life. Maturitas, 79(2), 179–183.

Dreisbach, S. (2011). Shocking body-image news: 97% of women will be cruel to their bodies today. Glamour. Retrieved from Glamour website: http://www.glamour.com/health- fitness/2011/02.

Drouin, M., Coupe, M., & Temple, J. R. (2017). Is sexting good for your relationship? It depends . . . Computers in Human Behavior, 75, 749–756.

Drouin, M., & Landgraff, C. (2012). Texting, sexting, attachment, and intimacy in college students’ romantic relationships. Computers in Human Behavior, 28, 444–449.

Drutz, J. E. (2017, April 14). Autism spectrum disorder and chronic disease: No evidence for vaccines or thimerosal as a contributing factor. UpToDate. Retrieved from http://www.uptodate.com.

DTL (Ditch the Label). (2017). The annual bullying survey 2017. Los Angeles: Ditch the Label.

Duan, W., Fei, Y., Zhao, J., & Guo, X. (2018, January 1). Incremental validity of the comprehensive inventory of thriving in predicting self-reporting mental and physical health

1246

http://www.uptodate.com

http://medicaldaily.com

http://www.glamour.com/health-fitness/2011/02

http://www.uptodate.com

among community populations. Journal of Health Psychology. [Epub ahead of print]

Dube, A., Moffatt, M., Davison, C., & Bartels, S. (2018). Health outcomes for children in Haiti since the 2010 earthquake: A systematic review. Prehospital and Disaster Medicine, 33(1), 77–88.

Ducharme, J. (2018, March 6). Kevin Love opens up about his first panic attack: ‘We’re all carrying around things that hurt’. Time. Retrieved from http://time.com/5187641/kevin- love-panic-attacks/.

Duenwald, M. (2003, March 18). “Oldest old” still show alertness. New York Times.

Duffy, A., & Grof, P. (2018, February 28). Lithium treatment in children and adolescents. Pharmacopsychiatry. [Epub ahead of print]

Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., . . . Gervais, N. J. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1), 46–58.

Dugas, M. J., Buhr, K., & Ladouceur, R. (2004). The role of intolerance of uncertainty in etiology and maintenance. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.)., Generalized anxiety disorder: Advances in research and practice (pp. 143–163). New York: Guilford Press.

Dugas, M. J., Laugesen, N., & Bukowski, W. M. (2012). Intolerance of uncertainty, fear of anxiety, and adolescent worry. Journal of Abnormal Child Psychology, 40(6), 863–870.

Dunbar, R. I. (2016). Do online social media cut through the constraints that limit the size of offline social networks? Royal Society Open Science, 3(1), 150292.

Dundas, I., Thorsheim, T., Hjeltnes, A., & Binder, P. E. (2016). Mindfulness-based stress reduction for academic evaluation anxiety: A naturalistic longitudinal study. Journal of College Student Psychotherapy, 30(2), 114–131.

Dunham, I. (2018, September 26). Human genes: Time to follow the roads less traveled? PLoS Biology, 16(9), e3000034.

Duperrouzel, J., Hawes, S., Lopez-Quintero, C., Pacheco-Colon, I., Comer, J. S., & Gonzalez, R. (2018). The association between adolescent cannabis use and anxiety: A parallel process analysis. Addictive Behaviors, 78, 107–113.

Durbin, A., Rudoler, D., Durbin, J., Laporte, A., & Callaghan, R. C. (2014). Examining patient race and area predictors of inpatient admission for schizophrenia among hospital users in California. Journal of Immigrant and Minority Health, 16(6), 1025–1034.

1247

http://time.com/5187641/kevin-love-panic-attacks/

Durkheim, E. (1897). Suicide. New York: Free Press. [Work republished 1951]

Durkin, K. F., & Hundersmarck, S. (2008). Pedophiles and child molesters. In E. Goode & D. A. Vail (Eds.), Extreme deviance. Los Angeles: Pine Forge Press.

Dusi, N., De Carlo, V., Delvecchio, G., Bellani, M., Soares, J. C., & Brambilla, P. (2019). MRI features of clinical outcome in bipolar disorder: A selected review: Special section on “Translational and neuroscience studies in affective disorders.” Journal of Affective Disorders, 243, 559–563.

Duval, E. R., Javanbakht, A., & Liberzon, I. (2015). Neural circuits in anxiety and stress disorders: A focused review. Therapeutics and Clinical Risk Management, 11, 115–126.

Duval-Harvey, J., & Rogers, K. M. (2010). Attention-deficit/hyperactivity disorder. In R. L. Hampton, T. P. Gullotta, & R. L. Crowel (Eds.), Handbook of African American health (pp. 375–418). New York: Guilford Press.

Dworkin, E. R., Wanklyn, S., Stasiewicz, P. R., & Coffey, S. F. (2018). PTSD symptom presentation among people with alcohol and drug use disorders: Comparisons by substance of abuse. Addictive Behaviors, 76, 188–194.

Dyl, J., Kittler, J., Phillips, K. A., & Hunt, J. I. (2006). Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: Prevalence and clinical characteristics. Child Psychiatry and Human Development, 36(4), 369–382.

Eastman, M., Foshee, V., Ennett, S., Sotres-Alvarez, D., Reyes, H. L. M., Faris, R., & North, K. (2018). Profiles of internalizing and externalizing symptoms associated with bullying victimization. Journal of Adolescence, 65, 101–110.

EBSCO. (2018). Mental measurements yearbook with tests in print internacional. Ipswich, MA: Author. Retrieved from https://www.ebsco.com/products/research-databases.

Eckler, P., Kalyango, Y., & Paasch, E. (2017). Facebook use and negative body image among U.S. college women. Women’s Health, 57(2), 249–267.

Economist, The. (2010, December 16). Age and happiness: The U-bend of life. The Economist. Retrieved from http://www.economist.com/node/17722567.

Ehnvall, A., Parker, G., Hadzi, P. D., & Malhi, G. (2008). Perception of rejecting and neglectful parenting in childhood relates to lifetime suicide attempts for females—but not for males. Acta Psychiatrica Scandinavica, 117(1), 50–56.

EIE (Enough Is Enough). (2017). Cyberbullying statistics. Retrieved from http://enough.org/stats_cyberbullying.

1248

https://www.ebsco.com/products/research-databases

http://www.economist.com/node/17722567

http://enough.org/stats_cyberbullying

Eisner, P., Klasen, M., Wolf, D., Zerres, K., Eggermann, T., Eisert, A., . . . Mathiak, K. (2017). Cortico-limbic connectivity in MAOA-L carriers is vulnerable to acute tryptophan depletion. Human Brain Mapping, 38(3), 1622–1635.

Eisold, K. (2013, December 21). Hidden motives: A look at the hidden factors that really drive our social interactions. Psychology Today.

Eker, C., Simsek, F., Yılmazer, E. E., Kitis, O., Cinar, C., Eker, O. D., . . . Gonul, A. S. (2014). Brain regions associated with risk and resistance for bipolar I disorder: A voxel-based MRI study of patients with bipolar disorder and their healthy siblings. Bipolar Disorders, 16(3), 249–261.

Ekern, J. (2014, April 28). Eating disorder statistics and research. Retrieved from http:www.eatingdisorderhope.com.

Ekern, J. (2018, February 14). Anorexia nervosa: Causes, symptoms, signs & treatment help. Retrieved from https://www.eatingdisorderhope.com/information/anorexia.

Elhai, J. D., Dvorak, R. D., Levine, J. C., & Hall, B. J. (2017). Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology. Journal of Affective Disorders, 207, 251–259.

Elkins, R. L., Richards, T. L., Nielsen, R., Repass, R., Stahlbrandt, H., & Hoffman, H. G. (2017). The neurobiological mechanism of chemical aversion (emetic) therapy for alcohol use disorder: An fMRI study. Frontiers in Behavioral Neuroscience, 11, 182.

Elkins, R. M., Mian, N. D., Comer, J. S., & Pincus, D. B. (2017). Parent-Child Interaction Therapy (PCIT) and its adaptations. In J. L. Luby (Ed.), Handbook of preschool mental health: Development, disorders, and treatment (2nd ed.). New York: Guilford Press.

Ellenberger, H. F. (1970). The discovery of the unconscious. New York: Basic Books.

Ellenberger, H. F. (1972). The story of “Anna O.”: A critical review with new data. Journal of the History of the Behavioral Sciences, 8, 267–279.

Elliott, E., & Vollm, B. (2016, October 17). The utility of post-conviction polygraph testing among sexual offenders. Sexual Abuse. [Epub ahead of print]

Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Lyle Stuart.

Ellis, A. (2016). How to stubbornly refuse to make yourself miserable about anything—Yes, anything! New York: Citadel Press.

Ellis, A., & Ellis, D. J. (2019). Rational emotive behavior therapy. In D. Wedding & R. J.

1249

http://www.eatingdisorderhope.com

https://www.eatingdisorderhope.com/information/anorexia

Corsini (Eds.), Current psychotherapies (11th ed., Ch. 5). Independence, KY: Cengage Publications.

Ellis, C. C., Peterson, M., Bufford, R., & Benson, J. (2014). The importance of group cohesion in inpatient treatment of combat-related PTSD. International Journal of Group Psychotherapy, 64(2), 208–226.

Ellis, H. (2015). Franz Mesmer: Pioneer in the treatment of functional disease or charlatan? British Journal of Hospital Medicine, 76(3), 170.

Elwood, C. E., Poythress, N. G., & Douglas, K. S. (2004). Evaluation of the Hare P-SCAN in a non-clinical population. Personality and Individual Differences, 36(4), 833–843.

Elzy, M., & Karver, M. (2018). Behaviour vs. perception: An investigation into the components of emotional invalidation. Personality and Mental Health, 12(1), 59–72.

Emanuel, E. (2017). Euthanasia and physician-assisted suicide: Focus on the data. Medical Journal of Australia, 206(8), 339–340.

Emanuel, E. J., Onwuteaka-Philipsen, B. D., Urwin, J. W., & Cohen, J. (2016). Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA, 316(1), 79.

Eme, R. (2017). Developmental psychopathology: A primer for clinical pediatrics. World Journal of Psychiatry, 7(3), 159–162.

Emmelkamp, P. M. (1982). Exposure in vivo treatments. In A. Goldstein & D. Chambless (Eds.), Agoraphobia: Multiple perspectives on theory and treatment. New York: Wiley.

Enatescu, V., Enatescu, I., Craina, M., Gluhovschi, A., Papava, I., Romosan, R., . . . Bernad, E. (2014). State and trait anxiety as a psychopathological phenomenon correlated with postpartum depression in a Romanian sample: A pilot study. Journal of Psychosomatic Obstetrics and Gynaecology, 35(2), 55–61.

Endom, E. E. (2017, March 22). Child neglect and emotional maltreatment. UpToDate. Retrieved from http://www.uptodate.com.

Engel, S., Steffen, K., & Mitchell, J. E. (2017, March 6). Bulimia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis. UpToDate. Retrieved from www.uptodate.com.

Englander, E., & McCoy, M. (2018). Sexting—Prevalence, age, sex, and outcomes. JAMA Pediatrics, 172(4), 317–318.

1250

http://www.uptodate.com

Englbrecht, M., Alten, R., Aringer, M., Baerwald, C. G., Burkhardt, H., Eby, N., . . . Wendler, J. (2017). Validation of standardized questionnaires evaluating symptoms of depression in rheumatoid arthritis patients: Approaches to screening for a frequent yet underrated challenge. Arthritis Care & Research, 69(1), 58–66.

Epstein, N. B., & Zheng, L. (2017). Cognitive-behavioral couple therapy. Current Opinion in Psychology, 13, 142–147.

Erikson, E. (1963). Childhood and society. New York: Norton.

Erkic, M., Bailer, J., Fenske, S. C., Schmidt, S. N. L., Trojan, J., Schröder, A., . . . Mier, D. (2018). Impaired emotion processing and a reduction in trust in patients with somatic symptom disorder. Clinical Psychology & Psychotherapy, 25(1), 163–172.

Erlangsen, A., Vach, W., & Jeune, B. (2005). The effect of hospitalization with medical illnesses on the suicide risk in the oldest old: A population-based register study. Journal of the American Geriatrics Society, 53(5), 771–776.

Ernst, E. (2017, August 13). Complementary and alternative therapies for cancer. UpToDate. Retrieved from http://www.uptodate.com.

Erving, C. L. (2017). Physical-psychiatric comorbidity: Implications for health measurement and the Hispanic epidemiological paradox. Social Science Research, 64, 197–213.

Espinoza, R. T., & Unützer, J. (2017, December 14). Diagnosis and management of late-life unipolar depression. UpToDate. Retrieved from http://www.uptodate.com.

Etgar, S., & Amichai-Hamburger, Y. (2017). Not all selfies took alike: Distinct selfie motivations are related to different personality characteristics. Frontiers in Psychology, 8, 842.

Etkin, A. (2010). Functional neuroanatomy of anxiety: A neural circuit perspective. In M. B. Stein & T. Steckler (Eds.), Behavioral neurobiology of anxiety and its treatment. Current topics in behavioral neurosciences (pp. 251–277). New York: Springer Science + Business Media.

Etxeberria, I., Etxebarria, I., & Irdaneta, E. (2017, February 17). Profiles in emotional aging: Does age matter? Aging & Mental Health. [Epub ahead of print]

Evans, S. W., Owens, J., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 43, 527–551.

Fábrega, H., Jr. (2010). Understanding the evolution of medical traditions: Brain/behavior influences, enculturation, and the study of sickness and healing. Neuropsychoanalysis, 12(1), 21–27.

1251

http://www.uptodate.com

Fairburn, C. G., Bailey-Straebler, S., Basden, S., Doll, H. A., Jones, R., Murphy, R., . . . Cooper, Z. (2015). A transdiagnostic comparison of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behavior Research and Therapy, 70, 64–71.

Fairburn, C. G., & Cooper, Z. (2014). Eating disorders: A transdiagnostic protocol. In D. H. Barlow, Clinical handbook of psychological disorders (5th ed., Chap. 17). New York: Guilford Press.

Fairburn, C. G., Cooper, Z., Shafran, R., & Wilson, G. T. (2008). Eating disorders: A transdiagnostic protocol. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). New York: Guilford Press.

Fakhoury, M. (2018). Imaging genetics in autism spectrum disorders: Linking genetics and brain imaging in the pursuit of the underlying neurobiological mechanisms. Progress in Neuro- Psychopharmacology and Biological Psychiatry, 80(Pt B), 101–114.

Falconer, C. J., Cutting, P., Bethan Davies, E., Hollis, C., Stallard, P., & Moran, P. (2017). Adjunctive avatar therapy for mentalization-based feasibility study. Evidence-Based Mental Health, 20(4), 123–127.

Fan, Q., Liao, L., & Pan, G. (2017). The application of cognitive remediation therapy in the treatment of mental disorders. Shanghai Archives of Psychiatry, 29(6), 373–375.

Fanelli, G., & Serretti, A. (2019). The influence of the serotonin transporter gene 5-HTTLPR polymorphism on suicidal behaviors: A meta-analysis. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 88, 375–387.

Fanta, C. H. (2017, March 6). Diagnosis of asthma in adolescents and adults. UpToDate. Retrieved from http://www.uptodate.com.

Farber, B. A., Manevich, I., Metzger, J., & Saypol, E. (2005). Choosing psychotherapy as a career: Why did we cross that road? Journal of Clinical Psychology, 61(8), 1009–1031.

Farberow, N. L., & Litman, R. E. (1970). A comprehensive suicide prevention program. Unpublished final report, Suicide Prevention Center of Los Angeles, Los Angeles.

Farchione, T. J., Boswell, J. F., & Wilner, J. G. (2017). Behavioral activation strategies for major depression in transdiagnostic cognitive-behavioral therapy: An evidence-based case study. Psychotherapy, 54(3), 225–230.

Fardouly, J., Pinkus, R. T., & Vartanian, L. R. (2017). The impact of appearance comparisons made through social media, traditional media, and in person in women’s everyday lives. Body

1252

http://www.uptodate.com

Image, 20, 31–39.

Farkas, M. (2013). Pedophilia. Psychiatria Hungarica: A Magyar Pszichiátriai Társaság Tudományos Folyóirata, 28(2), 180–188.

Farlow, M. R. (2018, June 22). Epidemiology, pathology, and pathogenesis of dementia with Lewy bodies. UpToDate. Retrieved from http://www.uptodate.com.

Farmer, R. F., & Chapman, A. L. (2015). Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action (2nd ed.). Washington, DC: APA Books.

Farmer, R. F., & Nelson-Gray, R. O. (2005). Behavioral treatment of personality disorders. In R. F. Farmer & R. O. Nelson-Gray (Eds.), Personality-guided behavior therapy (pp. 203–243). Washington, DC: American Psychological Association.

Farokhnia, M., Sheskier, M. B., Lee, M. R., Le, A. N., Singley, E., Bouhlal, S., . . . Leggio, L. (2018, April 14). Neuroendocrine response to GABA-B receptor agonism in alcohol- dependent individuals: Results from a combined outpatient and human laboratory experiment. Neuropharmacology. [Epub ahead of print]

Farrell, J. M., & Shaw, I. A. (2018). Experiencing schema therapy from the inside out: A self- practice/self-reflection workbook for therapists (Self-practice/self-reflection guides for psychotherapists). New York: Guilford Press.

Faubion, M. D. (2016, September-October). Evaluating defendants for competency and sanity. Austin, TX: Texas District & County Attorneys Association.

Faugere, M., Micoulaud-Franchi, J. A., Faget-Agius, C., Lançon, C., Cermolacce, M., & Richieri, R. (2018). High C-reactive protein levels are associated with depressive symptoms in schizophrenia. Journal of Affective Disorders, 225, 671–675.

Fay, B. P. (1995). The individual versus society: The cultural dynamics of criminalizing suicide. Hastings International and Comparative Law Review, 18, 591–615.

Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). The mental health of prisoners: A review of prevalence, adverse outcomes and interventions. Lancet Psychiatry, 3(9), 871–881.

Fazel, S., Wolf, A., Larsson, H., Lichtenstein, P., Mallett, S., & Fanshawe, T. R. (2017). Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): A derivation and validation study. Lancet Psychiatry, 4(6), 461–468.

FBI (Federal Bureau of Investigation). (2014) Ten-year arrest trends. Totals, 2003–2012.

1253

http://www.uptodate.com

Washington, DC: Department of Justice, Criminal Justice Information Services.

FBI (Federal Bureau of Investigation). (2016, November 14). Latest hate crime statistics released: Annual report sheds light on serious issue. FBI. Retrieved from https://www.fbi.gov/news/stories/2015.

FBI (Federal Bureau of Investigation). (2016, September 26). Latest crime statistics released: Increase in violent crime, decrease in property crime. Washington, DC: FBI.

FBI (Federal Bureau of Investigation). (2017). 2016 crime statistics released: Violent crime increases, property crime decreases. Retrieved from https://www.fbi.gov/news/stories.

FBI (Federal Bureau of Investigation). (2017). Active shooter resources. Washington DC: FBI.

FBI (Federal Bureau of Investigation). (2017). Resources: Reports and publications. Washington, DC: FBI.

FDA (U.S. Food and Drug Administration). (2014). Consumer update: Understanding antidepressant medications. Retrieved from http://www.fda.gov/forconsumers/consumerupdates/ucm095980.html.

FDA (Food and Drug Administration). (2015). The impact of direct-to-consumer advertising. Retrieved from https://www.fda.gov/drugs/ResourcesForYou/consumers/ucm143562.htm.

FDA (U.S. Food and Drug Administration). (2016). Keeping watch over direct-to-consumer ads. (last updated 6/14/2016). Washington, DC: U.S. Department of Health and Human Services.

FDA (U.S. Food and Drug Administration). (2016). The impact of direct-to-consumer advertising. Washington, DC: U.S. Department of Health and Human Services.

FDA (U.S. Food & Drug Administration). (2018, January 16). Development & approval process (drugs). Retrieved from https://www.fda.gov/Drugs/DevelopmentApprovalProcess/.

Federoff, J. P., & Marshall, W. L. (2010). Paraphilias. In D. McKay, J. S. Abramowitz, & S. Taylor (Eds.), Cognitive-behavioral therapy for refractory cases: Turning failure into success (pp. 369–384). Washington, DC: American Psychological Association.

Feki, I., Mdhaffar, K., Hentati, S., Sallemi, R., & Masmoudi, J. (2017). Depression in elderly patients with schizophrenia. European Psychiatry, 41(Suppl Apr), S654.

Feldman, N. (2017, January 4). Sex offender lockup should trouble court more. Bloomberg View.

Feldman, R., Bailey, R. A., Muller, J., Le, J., & Dirani, R. (2014). Cost of schizophrenia in

1254

https://www.fbi.gov/news/stories/2015

https://www.fbi.gov/news/stories

http://www.fda.gov/forconsumers/consumerupdates/ucm095980.html