psych case study & stat hw assignment due 12/1/12 by 4:30pm

Eating Disorders 283

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\\\nUir31( nU12 ,/, ' 1. What are the symptoms and main

features of anorexia nervosa? pp. 258-260

2. What are the symptoms and main features of bulimia nervosa? pp. 260-264

3. How are people with anorexia ner- vosa similar to those with bulimia nervosa? How are they different? pp. 264-265

4. Theorists usually apply a multi- dimensional risk perspective to explain the eating disorders. What does this mean? p. 265

5. 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. 265-266

6. How might a person's hypothala- mus and weight set point contribute to the development of an eating disorder? pp. 267-270

7. What evidence suggests that socio- cultural pressures and factors may set the stage for eating disorders? pp. 270-275

8. 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. 275-278

9. How well do people with anorexia nervosa recover from their disor- der? What factors affect a person's recovery? What risks and prob- lems may linger after recovery? pp. 278-279

10. What are the key goals and approaches used in the treatment of bulimia nervosa? How success- ful are they? What factors affect a person's recovery? What risks and problems may linger after recovery? pp. 279-281

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A Chapter 9 Video Cases Imprisoned by an Eating Disorder Anorexia Nervosa: Not for Women Only Weight Gain: A Surprise Factor

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SUBSTANCE-RELATED DISORDERS CHAPTER

66 am Duncan. l 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 1 had that first drink that everybody to ks about. And like so many of them . . . it was like a miracle. With a little beer in my gut, the world was transformed. l wasn't a weakling anymore, 1 could lick almost anybody on the block. And girls? Well, you can imagine how a couple of beers made me feel like l could have any girl I wanted.

"Though it's obvious to me now that my drinking even then, in high school, and after I got to college, was a problem, l didn't think so at the time. After oil, everybody was drinking and get- ting drunk and acting stupid, and I didn't really think l was different. . . . 1 guess the fact that 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 1 found myself drinking even more—and mare 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 whale 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 sow how shaky 1 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]ortly because l 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, l 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 responsibili- ties 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. 1 had a couple of wrecks, lost my license for two years because of one of them. Worst of all was when 1 tried to stop. By then I was totally hooked, so every time / 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 fie down. And that would go on for days at a time. . . .

TOPIC OVERVIEW Depressants Alcohol Sedative-Hypnotic Drugs Opioids

Stimulants Cocaine Amphetamines

Hallucinogens

Cannabis

Combinations of Substances

What Causes Substance-Related Disorders? Sociocultural Views Psychodynamic Views Cognitive-Behavioral Views Biological Views

How Are Substance-Related Disorders Treated? Psychodynamic Therapies Behavioral Therapies Cognitive-Behavioral Therapies

Biological Treatments Sociocultural Therapies

Putting It Together: New Wrinkles to a Familiar Story

292 ://CHAPTER 10

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2008). The rate may increase to as many as 29 of every 1,000 babies of women who are problem drinkers. In addition, heavy drinking early in pregnancy often leads to a miscarriage. According to surveys, around 11 percent of pregnant American women have drunk alcohol during the past month and 4.5 percent of pregnant women have had binge-drinking episodes (NSDUH, 2008).

Sedative-Hypnotic Drugs Sedative-hypnotic drugs, also called anxiolytic 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. The sedative-hypnotic drugs include bar- biturates and benzadiazepines.

Barbiturates First discovered in Germany more than 100 years ago, barbiturates were widely prescribed in the first half of the twentieth century to fight anxiety and to help people sleep. Although still prescribed by some physicians, these drugs have been largely replaced by benzodiazepines, which are generally safer drugs. Barbiturates can cause many problems, not the least of which are abuse and dependence. Several thousand deaths a year are caused by accidental or suicidal overdoses.

Barbiturates are usually taken in pill or capsule form. In low doses they reduce a per- son's level of excitement in the same way that alcohol does, by attaching to receptors on the neurons that receive the inhibitory neurotransmitter GABA and by helping GABA operate at those neurons (Ksir et al., 2008; Grilly, 2006). People can get intoxicated from large doses of barbiturates, just as they do from excessive alcohol.At too high a dose, the drugs can halt breathing, lower blood pressure, and lead to coma and death.

Repeated use of barbiturates can quickly result in a pattern of abuse (Dupont & Dupont, 2005). Users may spend much of the day intoxicated, irritable, and unable to do their work. Dependence can also result. The users organize their lives around the drug and need increasing amounts of it to calm down or fall asleep. A great danger of barbiturate dependence is that the lethal dose of the drug remains the same even while the body is building up a tolerance for its sedating effects. Once the prescribed dose stops reducing anxiety or inducing sleep, the user is all too likely to increase it without medical supervision and eventually may ingest a dose that proves fatal. Those caught in a pattern of barbiturate dependence may also experience withdrawal symptoms such as nausea, anxiety, and sleep problems. Barbiturate withdrawal is particularly dangerous because it can cause convulsions.

Risks and Consequences of Drug Misuse

Opioids ---------

Sedative-hypnotics Barbiturates Benzodiazepines

. -----------

Risk of Risk of Risk of Severe Organ Severe Social or Long-Lasting

Intoxication Dependency Damage or Economic Mental and Potential Potential or Death Consequences Behavioral Change High High Low High Low to moderate

Moderate

Moderate to high Moderate to high Moderate to high Low Moderate

Moderate Low Low Low

Stimulants (cocaine, amphetamines) High High Moderate Low to moderate Moderate to high

i Alcohol High Moderate High High High

Cannabis High Low to moderate Low Low to moderate Low

r Mixed drugs High High High High High

Source: Ksir et al., 2008; APA, 2000; Gold, 1986, p. 28.

Substance-Related Disorders :1/ 293

Benzodiazepines Chapter 4 described benzodiazepines, the antianxiety drugs developed in the 1950s, as the most popular sedative-hypnotic drugs available. Xanax, Ativan, and Valium are just three of the dozens of these drugs in clinical use. Altogether, about 100 million prescriptions are written each year for this group of drugs (Bisaga, 2008). 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 (Ksir et al., 2008). These drugs, however, 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 (Nishino et al., 1995).

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 abuse or dependence (Bisaga, 2008).As many as 1 percent of the adults in North America abuse or become physically dependent on these antianxiety drugs at some point in their lives (Sareen et al., 2004; Goodwin et al, 2002) and thus become subject to some of the same dangers that researchers have identified in barbiturate misuse.

Opioids Opioids include opium—taken from the sap of the opium poppy—and the drugs de- rived from it such as heroin, morphine, and codeine. Opium itself has been in use for thousands of years. In the past it was used widely in the treatment of medical disorders because of its ability to reduce both physical and emotional pain. Eventually, however, physicians discovered that the drug was physically addictive.

In 1804 a new substance, morphine, was derived from opium. Named after Mor- pheus, 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. So many wounded soldiers in the United States received morphine injections during the Civil War that morphine dependence became known as "soldiers' disease."

In 1898 morphine was converted into yet another new pain reliever, heroin. For several years heroin was viewed as a wonder drug and was used as a cough medicine and for other medical purposes. Eventually, however, physicians learned that heroin is even more addictive than the other opioids. By 1917 the U.S. Congress had concluded that all drugs derived from opium were addictive (see Table 10-3), and it passed a law making opioids illegal except for medical purposes.

Still other drugs have been derived from opium, and synthetic (laboratory-blended) opioids such as methadone have also been developed.All these opioid drugs—natural and synthetic—are known collectively as narcotics. Each drug has a different strength, speed of action, and tolerance level. Morphine and codeine are medical nar- cotics usually prescribed to relieve pain. Heroin is illegal in the United States in all circumstances.

Narcotics are smoked, inhaled, snorted, injected by needle just beneath the skin ("skin popped"), or injected directly into the blood- stream ("mainlined"). Injection seems to be the most common method of narcotic use, although the other techniques have been used increas- ingly in recent years (NSDUH, 2008). 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 (Kreek, 2008; Ksir et al., 2008). When neurons at these receptor sites

*sedative - hypnotic drugeA drug used in low doses to reduce anxiety and in higher doses fo help people sleep. Also called anxiolytic drug.

obarbiturateseAddictive sedative- hypnotic drugs that reduce anxiety and help produce sleep.

obenzadiazepineseThe most com- mon group of antianxiety drugs, which includes Valium and Xanax.

QopioidoOpium or any of the drugs derived from opium, including morphine, heroin, and codeine.

eopiumoA highly addictive substance made from the sap of the opium poppy.

0morphine0A highly addictive sub- stance derived from opium that is particularly effective in relieving pain.

oheroinoOne of the most addictive substances derived from opium.

oendorphinseNeurotransmitters that help relieve pain and reduce emotional tension. They are sometimes referred fo as the body s own opioids.

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Substance Misuse and Depressants

The misuse of substances (or drugs) may lead to temporary changes such as intoxi- cation. Long-term and high use can lead to substance abuse or substance depen- dence. People who become dependent on a drug may develop a tolerance for it, experience unpleasant withdrawal symptoms when they abstain from it, or both.

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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 pu- pils"), and constipation.

Heroin Abuse and Dependence Heroin use exemplifies the kinds of problems posed by opioids. After taking heroin repeatedly for just a few weeks, users may become caught in a pattern of abuse:The drug interferes significantly with their social and occupational functioning. In most cases, heroin abuse leads to a pattern of dependence as well, and users soon cen- ter their lives on the substance, build a tolerance for it, and experience a withdrawal reaction when they stop taking it (Kreek, 2008). At first the withdrawal symptoms are anxiety, restlessness, sweating, and rapid breath- ing; 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 withdrawal can either wait out the symptoms or end withdrawal by taking heroin again.

People who are dependent on heroin soon need the drug 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.The individuals 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" (Allen, 2005).

Surveys suggest that close to 1 percent of adults in the United States become addicted to heroin or other opioids at some time in their lives (APA, 2000). The rate of such de- pendence dropped considerably during the 1980s, rose in the early 1990s, fell in the late 1990s, and now seems to be relatively high once again (NSDUH, 2008). The number of persons currently addicted to these drugs is estimated to be as much as 323,000. The actual number may be even higher, however, given the reluctance of many people to admit an illegal activity.

What Are the Dangers of Heroin Abuse? The most immediate danger of heroin use is an overdose, which closes down the respiratory center in the brain, almost paralyzing breathing and in many cases causing death. Death is particularly likely dur- ing sleep, when a person is unable to fight this effect by consciously working to breathe. People who resume heroin use after having avoided it for some time often make the fatal mistake of taking the same dose they had built up to before. Because their bodies have been without heroin for some time, however, they can no longer tolerate this high level. Each year approximately 2 percent of persons dependent on heroin and other opioids die under the drug's influence, usually from an overdose (Theodorou & Haber, 2005; APA, 2000).

Users run other risks as well. Often the heroin they purchase has been mixed 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 (Batki & Nathan, 2008). In some areas of the United States the HIV infection rate among persons dependent on heroin is reported to be as high as 60 percent (APA, 2000).

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ecocaineoAn addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.

Depressants are substances that slow the activity of the central nervous system. Long-term and excessive use of these substances can lead to a pattern of abuse or dependence.

Alcoholic beverages contain ethyl alcohol, which is carried by the blood to the central nervous system, depressing its function. Intoxication occurs when the concentration of alcohol in the bloodstream reaches 0.09 percent. Among other actions, alcohol increases the activity of the neurotransmitter GABA at key sites in the brain. 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. They all reduce tension and pain and cause other reactions. Opioids operate by binding to neurons that ordinarily receive endorphins.

*Stimulants Stimulants are substances that increase the activity of the central nervous system, result- ing in increased blood pressure and heart rate, greater 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.

Cocaine Cocaine —the central active ingredient of the coca plant, found in South America—is the most powerful natural stimulant now known. The drug was first separated from the plant in 1865. Native people of South America, however, have chewed the leaves of the plant since prehistoric times for the energy and alertness the drug offers. Processed cocaine is an odorless, white, fluffy powder. For recreational use, it is most often snorted so that it is absorbed through the mucous membrane of the nose. Some users prefer the more powerful effects of injecting cocaine intravenously or smoking it in a pipe or cigarette.

For years people believed that cocaine posed few problems aside from intoxication and, on occasion, temporary psychosis. Only later did researchers come to appreciate its many dangers.Their insights came after society witnessed a dramatic increase in the drug's popularity and in problems related to its use. In the early 1960s an estimated 10,000 persons in the United States had tried cocaine. Today 28 million people have tried it, and 2.4 million—most of them teenagers or young adults—are using it currently (NSDUH, 2008). In fact, 2 percent of all high school seniors have used cocaine within the past month ( Johnston et al., 2007).

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 sup- plies of the neurotransmitter dopamine at key neurons throughout the brain (Haney, 2008; Kosten et al., 2008) (see Figure 10-2). Excessive amounts of dopamine travel to receiving neurons throughout the central

efree-baseoA 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.

ocrackGA powerful form of ready-to- smoke free-base cocaine.

nervous system and overstimulate them. In addition, cocaine appears to increase the activity of the neurotransmitters norepinephrine and serotonin in some areas of the brain (Haney, 2008; Ksir et al., 2008).

High doses of the drug produce cocaine intoxication, whose symptoms are poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and confusion. Some people experience hallucinations, delusions, or both, a condition known as cocaine-induced psychotic disorder (APA, 2000).

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, 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 experiences a depression-like let- down, popularly called crashing, a pattern that may also include headaches, dizziness, and fainting (Doweiko, 2006). 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 individuals may sink into a stupor, deep sleep, or, in some cases, coma.

Cocaine Abuse and Dependence Regular use of cocaine may lead to a pat- tern of abuse in which the person remains under its effects much of each day and func- tions poorly in social relationships and at work. Regular use may also cause problems in short-term memory or attention (Kubler et al., 2005). Dependence may also develop, so that cocaine dominates the person's life, higher doses are needed to gain the desired ef- fects, and stopping it results in depression, fatigue, sleep problems, irritability, and anxiety (Barry et al., 2009).These withdrawal symptoms may last for weeks or even months after drug use has ended.

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. Since 1984, however, the availability of newer, more powerful, and sometimes cheaper forms of cocaine has produced an enormous increase in abuse and dependence. Currently, close to 1 percent of all people over the age of 11 in the United States display cocaine abuse or dependence in a given year (NSDUH, 2008). Many people now ingest cocaine by free -basing, a technique in which the pure co-

caine basic alkaloid is chemically separated, or "freed," from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe. Millions more use crack, a powerful form of free-base cocaine that has been boiled down into crystalline balls. It is smoked with a special pipe and makes a crackling sound as it is inhaled (hence the name). Crack is sold in small quantities at a fairly low cost, a practice that has resulted in crack epidemics among people who previously could not have afforded cocaine, primarily those in poor urban areas (Acosta et al., 2005).Almost 2 percent of high school seniors report having used crack within the past year ( Johnston et al., 2007).

What Are the Dangers of Cocaine? Aside from cocaine's harmful effects on behavior, the drug poses serious physical dangers (Kosten et al., 2008). Its growing use in powerful forms has caused the annual number of cocaine-related emergency room incidents in the United States to multiply by more than 100 times since 1982, from around 4,000 cases to 450,000 (SAMHSA, 2007). In addition, cocaine

296 ://CHAPTER 10

A CI °SEP iflOK •

Tobacco, Nicotine, and Addiction

'most 30 percent of all Americans over the age of 11 regularly smoke

tobacco (NSDUH, 2008). Surveys also suggest that 22 percent of all high school seniors have smoked in the past month (Johnston et al., 2007). At the same time, 440,000 persons in the United States die each year as a result of smoking. Smok- ing is directly tied to high blood pressure, coronary heart disease, lung disease, cancer, strokes, and other deadly medical problems (George & Weinberger, 2008; Hymowitz, 2005). Nonsmokers who inhale cigarette smoke from their environment have a higher risk of lung cancer and other diseases. And the 16.4 percent of all pregnant women who smoke are more likely than nonsmokers to deliver premature and underweight babies (Ksir et al., 2008; NSDUH, 2008).

So why do people continue to smoke? Because nicotine, the active substance in tobacco and a stimulant of the central nervous system, is as addictive as heroin,

perhaps even more so (Ksir et al., 2008; Report of the Surgeon General, 1988). Indeed, the World Health Organization estimates that 1.1 billion people worldwide are addicted to nicotine (Hasman & Holm, 2004). Regular smokers develop a toler- ance for nicotine and must smoke more and more in order to achieve the same results. When they try to stop smoking, they experi- ence withdrawal symptoms—irritability, in- creased appetite, sleep disturbances, slower metabolism, cognitive difficulties, and crav- ings to smoke (Brandon et al., 2009; APA, 2000). As a stimulant, nicotine acts on the same neurotransmitters and reword center in the brain as amphetamines and cocaine (George & Weinberger, 2008).

The declining acceptability of smoking in our society has created a market for products and techniques to help people kick the habit. A fairly helpful behavioral treatment for nicotine addiction is aversion therapy. In one version of this approach, known as rapid smoking, the smoker sits in

a closed room and puffs quickly on a ciga- rette, as often as once every six seconds, until he or she begins to feel ill and cannot take another puff. The feelings of illness become associated with smoking, and the smoker develops an aversion to cigarettes (George & Weinberger, 2008).

Several biological treatments have also been developed. A common one is the use of nicotine gum, an over-the-counter product that contains a high level of nico- tine that is released as the smoker chews. Theoretically, people who obtain nicotine by chewing will no longer feel a need to smoke. A similar approach is the nico- tine patch, which is attached to the skin like a Band-Aid. Its nicotine is absorbed through the skin throughout the day, sup- posedly easing withdrawal and reducing the smoker's need for nicotine. Studies find that both nicotine gum and the nicotine patch help people to abstain from smok- ing (George & Weinberger, 2008; Grilly, 2006). Still other popular biological prod.

ucts are nicotine lozenges, nicotine nasal spray, and the antidepressant drug bupropion (brand names Zyban and Wellbutrin).

The more one smokes, the harder it is to quit. On the positive side, however, former smokers' risk of disease and death decreases steadily the longer they continue to avoid smoking. This assurance may be a powerful motivator for many smokers, and, in fact, around 46 percent of

regular smokers want to stop and are even- tually able to stop permanently (NSDUH, 2008). In the meantime, more than 1,000 people die of smoking-related diseases each day.

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use has been linked to as many as 20 percent of all suicides by men under 61 years of age (Garlow, 2002).

The greatest danger of cocaine use is an overdose. Excessive doses have a strong ef- fect 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 (Ksir et al., 2008). In addition, pregnant women who use cocaine run the risk of

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having a miscarriage and of having children with abnormalities in immune functioning, attention and learning, thyroid size, and dopamine and serotonin activity in the brain (Kosten et al., 2008).

Amphetamines The amphetamines are stimulant drugs that are manufactured in the laboratory. Sonic 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 seek- ing 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.

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; 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, nor- epinephrine, and serotonin throughout the brain, although the actions of amphetamines differ somewhat from those of cocaine (Haney, 2008; Rawson & Ling, 2008).

Tolerance to amphetamines builds very quickly, so users are at great risk of becom- ing dependent (Acosta et al., 2005). People who start using the drug to reduce their appetite and weight, for example, may soon find they are as hungry as ever and increase their dose in response. Athletes who use amphetamines to increase their energy may also find before long that larger and larger amounts of the drug are needed. So-called speed freaks, who pop pills all day for days at a time, have built a tolerance so high that they now take as much as 200 times their initial amphetamine dose.When people who depend on the drug stop taking it, they may plunge into a deep depression and extended sleep identical to the withdrawal from cocaine. Around 0.4 percent of adults

display amphetamine abuse or dependence each year (NSDUH,2008).As many as 2 percent become dependent on amphetamines at some point in their lives (APA, 2000; Anthony et al., 1995).

One kind of amphetamine, methamphetamine (nicknamed crank), has had a major surge in popularity in recent years and so warrants special discus- sion. Almost 6 percent of all persons over the age of 11 in the United States have used this stimulant at least once.Around 0.3 percent use it currently (NSDUH, 2008). It is available in the form of crystals, also known by the street names ice and crystal meth, which are smoked by users.

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 safer location (Ksir et al., 2008). Such laboratories have increased eightfold over the past decade. A major health concern is that they expel dangerous fumes and residue (Burgess, 2001).

Since 1989, when the media first began reporting about the dangers of smoking methamphetamine crystals, the rise in usage has been dramatic.At this point, 15 million Americans have tried this stimulant at least once (NSDUH, 2008). Until recently, use of the drug was much more prevalent in western parts of the United States, but its use has now spread east as well (NSDUH, 2007). Similarly, methamphetamine-linked emergency room visits are rising in hospitals throughout all parts of the country (DAWN, 2008).

Methamphetamine is about as likely to be used by women as men. Around 40 percent of current users are women. The drug is particularly popular today among biker gangs, rural Americans, and urban gay communities and has gained wide use as a "club drug," the term for those drugs that regularly find their way to all-night dance parties, or "raves" (Fchevarry & Nettles, 2009).

DON'T LET DRUG DEALERS CHANGE THE FACE OF YOUR NEIGHBOURHOOD. Call CrIrnestoppers anonymously on 0800 555111.

Stimulan

Stimulants are substances that increase the activity of the central nervous system. They may lead to intoxication, abuse, and dependence, including a withdrawal pattern marked by depression, fatigue, and irritability. Cocaine and amphetamines produce their effects by increasing the activity of dopamine, norepinephrine, and serotonin in the brain.

Substance-Related Disorders :11 299

Like other kinds of amphetamines, methamphetamine increases activity of the neu- rotransmitters dopamine, serotonin, and norepinephrine, producing increased arousal, attention, and related effects (Rawson & Ling, 2008). It can have serious negative effects on a user's physical, mental, and social life (NSDUH, 2007). Of particular concern is that it damages nerve endings (Rawson & Ling, 2008). But users focus more on meth- amphetamine's immediate positive impact, including perceptions by many that it makes them feel hypersexual and uninhibited ( Jefferson, 2005). Such perceived effects have contributed to several societal problems. For example, one-third of all men who tested positive for HIV in Los Angeles in 2004 reported having used this drug. In the area of law enforcement, one survey of police agencies had 58 percent of them reporting that methamphetamine is the leading drug they battle today.

oarnphetaminegA stimulant drug that is manufactured in the laboratory.

omethomplietamine.A powerful amphetamine drug whose surge in popu- larity in recent years has posed major health and law enforcement problems.

ehallucinogenGA substance that causes powerful changes primarily in sensor), perception, including stronger percep- tions, illusions, and hallucinations. Also called psychedelic drug.

eLSD (lysergic add diethylarnide)GA hallucinogenic drug derived from ergot alkaloids.

*Hallucinogens, Cannabis, and Combinations of Substances Other kinds of substances may also cause problems for their users and for society. Hallu- cinogens produce delusions, hallucinations, and other sensory changes. Cannabis substances produce sensory changes, but they also have depressant and stimulant effects, and so they are considered apart from hallucinogens in DSM-IV-TR. And many individuals 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, and MDMA (Ecstasy). Many of these substances come from plants or animals; others are laboratory-produced.

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 persons turned to the drug as a way of expanding their experience. Within two hours of being swallowed, LSD brings on a state of hallucinogen intoxication, sometimes called hallucinosis, marked by a general strengthening of perceptions, particularly visual perceptions, along with psychological changes and physical symptoms. People may focus on small details—the pores of the skin, for example, or individual blades of grass. Colors may seem enhanced or take on a shade of purple. Illu- sions may be experienced in which objects seem distorted and may 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.

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What Are the Dangers of Using Ecstasy? As MDMA has gained wider and wider use, the drug has received increasing research scrutiny. As it turns out, the mood and energy lift produced by MDMA comes at a high price (Ksir et al., 2008; Weaver & Schnoll, 2008; Wiegand et al., 2008). The problems that the drug may cause in- clude the following:

Immediate psychological problems such as confusion, depression, sleep difficulties, severe anxiety, and para- noid thinking. These symptoms may also continue for weeks after ingestion of MDMA.

Significant impairment of memory and other cognitive skills.

Physical symptoms such as muscle ten- sion, nausea, blurred vision, faintness, and chills or sweating. MDMA also causes many people to clench and grind their teeth for hours at a time.

Increases in heart rate and blood pres- sure, which place people with heart disease at special risk.

Reduced sweat production. At a hot, crowded dance party, taking Ecstasy can even cause heat stroke, or hyper- thermia. Users generally try to fix this problem by drinking lots of water, but since the body cannot sweat under the drug's influence, the excess fluid intake can result in an equally danger- ous condition known as hyponafremia, or "water intoxication."

Potential liver damage. This may happen when users take MDMA in combination with other drugs that are broken down by the same liver en- zyme, such as the cheaper compound DXM, which is commonly mixed in with Ecstasy by dealers.

How Does MDMA Operate in the Brain? MDMA works by causing the neurotransmit- ters serotonin and (to a lesser extent) dopa- mine to be released all at once throughout the brain, at first increasing and then de- pleting a person's overall supply of the neu- rotransmitters (Ksir et al., 2008; Malberg &

Bonson, 2001). MDMA also interferes with the body's ability to produce new supplies of serotonin. With repeated use, the brain eventually produces less and less serotonin (Baggot & Mendelson, 2001).

Ecstasy's impact on these neurotransmit- ters accounts for its various psychological effects—and associated problems. High levels of serotonin, such as those produced after one first ingests MDMA, produce feel- ings of well-being, sociability, and even euphoria. Conversely, abnormally low sero- tonin levels are associated with depression and anxiety. This is why "coming down" off a dose of Ecstasy often produces those psychological symptoms (Malberg & Bon- son, 2001). Moreover, because repeated use of Ecstasy leads to long-term serotonin deficits, the depression and anxiety may be long-lasting. Finally, serotonin is linked to our ability to concentrate; thus the re- peated use of Ecstasy may produce prob- lems in memory and learning (Zakzanis et al., 2007).

End of the Honeymoon? The dangers of MDMA do not yet seem to outweigh its pleasures in the minds of many individuals. In fact, use of the drug is still expanding to many social settings beyond raves, dance clubs, and college scenes (Weaver & Schnoll, 2008). Clearly, despite the research indications listed here, the honeymoon for this drug is not yet over.

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by its common street name, Ecstasy. It is also known as X, Adam, hug, beans, and love drug. This laboratory-produced drug is technically a stimulant, similar to amphet- amines, but it also produces hallucinogenic effects and so is often considered a hal-

lucinogenic drug. MDMA was developed as far back as 1910, but only in the past two decades has it gained life as a "club drug"—one of the drugs that are extremely popular at all-night techno-dance parties known as "raves." Today, in the United States alone, consumers collectively take hundreds of thousands of doses of MDMA weekly despite the drug's illegal status (Weaver & Schnoll, 2008; McDowell, 2005). Altogether, 12 million Americans over the age of 11 have tried MDMA at least once in their lifetimes, 2 million in the past year (NSDUH, 2008). Around 6.5 percent of all high school seniors have used it within the past year (Johnston et al., 2007).

What is Ecstasy's allure? As a stimulant and hallucinogen, it helps to raise the mood of many partygoers and provides them with an energy boost that enables them to keep dancing and partying. How- ever, it also turns out to be a dangerous drug, particularly when taken repeatedly.

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Hallucinosis may also cause one to hear sounds more clearly, feel tingling or numb- ness 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 percep- tion of time may slow dramatically. Long-forgotten thoughts and feelings may resurface. Physical symptoms can include sweating, palpitations, blurred vision, tremors, and poor coordination. All of these effects take place while the user is fully awake and alert, and they wear off in about six hours.

It seems that LSD produces these symptoms primarily by binding to some of the neurons that normally receive the neurotransmitter serotonin, changing the neurotrans- mitter's activity at those sites (Julien, 2008; Ksir et al., 2008). These neurons ordinarily help the brain send visual information and control emotions (as you saw in Chapter 7); thus LSD's activity there produces various visual and emotional symptoms.

More than 14 percent of all persons in the United States have used LSD or another hallucinogen at some point in their lives. Around 0.4 percent are currently using it (NSDUH, 2008). 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—an experience called a "bad trip." Reports of LSD users who injure themselves or others usually involve a reaction of this kind:

A 2 I-year-old woman was admitted to the hospital along with her lover. He had had a number of /..SD experiences and had convinced her to take it to make her less constrained sexually. About half an hour after ingestion of approximately 200 microgm., she noticed that the bricks in the wall began to go in and out and that light affected her strangely. She became frightened when she realized that she was unable to distinguish her body from the chair she was sitting on or from her lover's body. Her fear became more marked after she thought that she would not get back into herself At the time of admission she was hyper- active 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 (Weaver & Schnoll, 2008). Some users eventually develop psychosis or a mood or anxiety disorder. And some have flashbacks—a recurrence of the sensory and emotional changes after the LSD has left the body (Halpern, 2003). Flashbacks may occur days or even months after the last LSD experience.

Cannabis Cannabis sativa, the hemp plant, grows in warm climates throughout the world. The drugs 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_ Of the several hundred active chemicals in cannabis, tetrahydrocannabi- nol (THC) appears to be the one most responsible for its effects.The greater the THC content, the more powerful the cannabis.

When smoked, cannabis produces a mixture of hallucinogenic, depressant, and stimu- lant 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,

*cannabis drugseDrugs produced from the varieties of the hemp plant Cannabis sativa. They cause a mixture of hallucino- genic, depressant, and stimulant effects.

• morijuanocOne of the cannabis druas, derived from buds, leaves, and floweringtops of the hemp plant Cannabis sativa.

oteirahydracannabinol (THC GI - he main active ingredient of cannabis substances.

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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 dizzi- ness. Some people become drowsy and may fall asleep.

In high doses, cannabis produces odd visual experiences, changes in body image, and hallucinations. Smokers may be- come confused or impulsive. Some worry that other people are trying to hurt them. Most of the effects of cannabis last two to six hours. The changes in mood, however, may con- tinue longer.

Marihuana Abuse and Dependence Until the early 1970s, the use of marijuana, the weak form of cannabis, rarely led to a pattern of abuse or dependence.Today, however, many people, including large numbers of high school students, are caught in a pattern of marijuana abuse, getting high on mari- juana regularly and finding their social and occupational or academic lives greatly affected (see Figure 10-3). Many regular users also become physically dependent on marijuana. They develop a tolerance for it and may experience finlike symp- toms, restlessness, and irritability when they stop smoking

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(Chen et al., 2005).Around 1.7 percent of all persons in the United States have displayed marijuana abuse or dependence in the past year; as many as 5 percent fall into one of these patterns at some point in their lives (NSDUH, 2008).

Why have patterns of marijuana abuse and dependence increased in the last three decades? Mainly because the drug 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 THC content of today's marijuana is, on average, 8 percent, compared to 2 percent in the late 1960s (APA, 2000). Marijuana is now grown in places with a hot, dry climate, which increases the THC content.

is Ma ri Pia na Dangerous? As the strength and use of marijuana have increased, re- searchers have discovered that smoking it may pose certain dangers. It occasionally causes panic reactions similar to the ones caused by hallucinogens, and some smokers may fear they are losing their minds (Doweiko, 2006).Typically such reactions end in three to six 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 (Ramaekers et al., 2006). Furthermore, people on a marijuana high often fail to remember informa- tion, 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 (Lundqvist, 2005).

One study compared blood flow in the brain arteries of chronic marijuana users and nonusers (Herning et al., 2005). After one month of abstinence from smoking mari- juana, chronic users continued to display higher blood flow than nonusers.Though still higher than normal, the blood flow of light marijuana users (fewer than 16 smokes per week) and of moderate users (fewer than 70 smokes per week) had improved somewhat over the course of the abstinence month. The blood flow of heavy users, however, had shown no improvement.This lingering effect may help explain the memory and think- ing problems of long-term heavy users of marijuana.

There are indications that regular marijuana smoking may also lead to long-term health problems (Deplanque, 2005). It may, for example, contribute to lung disease.

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Studies show that marijuana smoking reduces the ability to expel air from the lungs even more than tobacco smoking does (Tashkin, 2001). In addition, marijuana smoke contains more tar and benzopyrene than tobacco smoke (Ksir et al., 2008). Both of these substances have been linked to cancer. Another concern is the effect of regular marijuana smoking on human reproduction. Studies since the late 1970s have discov- ered lower sperm counts in men who are chronic smokers of marijuana, and abnormal ovulation has been found in female smokers (Schuel et al., 2002).

Efforts to educate the public about the growing dangers of repeated marijuana use appeared to have a major impact throughout the 1980s.The percentage of high school seniors who smoked the substance on a daily basis decreased from 11 percent in 1978 to 2 percent in 1992 ( Johnston et al., 1993). Today, however, 5 percent of high school seniors smoke marijuana daily, and 45 percent do not believe that regular use can be harmful (Johnston et al., 2007).

Cannabis and Society: A Redly 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 twen- tieth 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 il- legal 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 (Mack & Joy, 2001), such as its use in treating glaucoma, a severe eye disease. Cannabis was also found to help patients with chronic pain or asthma, to reduce the nausea and vomiting of cancer patients in chemotherapy, and to improve the appetites of AIDS patients and so combat weight loss in people with that disorder.

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 re- sisted this movement, saying that prescriptions for pure THC serve all needed medical functions. But the battle between advocates and opponents of the legalization of mari- juana for medical purposes was just beginning, and, in fact, that battle has continued to the present day.

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In 2005, the U.S. Supreme Court ruled 6 to 3 that medically ill marijuana smokers and those who help them grow or obtain marijuana can be prosecuted, even if their physicians prescribe it and even if they live in one of the 14 states where medical mari- juana use has been declared legal. Although this ruling was initially considered a blow to the medical marijuana cause, proponents fought 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.

In the meantime, the Canadian government has taken a different tack. Based on re- search and trial programs, Health Canada, the country's health care regulator, now legally permits the medical use of marijuana by individuals who are suffering from severe and debilitating illnesses, and it allows the sale of medical marijuana in select pharmacies, making Canada the second country in the world, after the Netherlands, to do so.

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. When different drugs are in the body at the same time, they may multiply, or potentiate, each other's effects. The combined impact, called a synergistic effect, is often greater than the sum of the effects of each drug taken alone:A small dose of one drug mixed with a small dose of another can produce an enormous change in body chemistry.

One kind of synergistic effect occurs when two or more drugs have similar actions. For instance, alcohol, benzodiazepines, barbiturates, and opioids—all depressants—may severely depress the central nervous system when mixed (Ksir et al., 2008). Combin- ing them, even in small doses, can lead to extreme intoxication, coma, and even death. A young man may have just a few alcoholic drinks at a party, for example, and shortly afterward take a moderate dose of barbiturates to help him fall asleep. He believes he has acted with restraint and good judgment—yet he may never wake up.

A different kind of synergistic effect results when drugs have opposite, or antagonistic, actions, Stimulant drugs, for example, interfere with the liver's usual disposal of barbitu- rates and alcohol. Thus people who combine barbiturates or alcohol with cocaine or

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Hallucinogens, such as LSD, are substances that cause powerful changes primarily in sensory perception. Perceptions are intensified and illusions and hallucinations can occur. LSD apparently causes such effects by disturbing the release of the neu- rotransmitter 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 and excessive use con lead to abuse and dependence.

Many people take more than one drug at a time, and the drugs interact. The use of Iwo or more drugs at the same time—polysubstance use—has become in- creasingly common. Similarly, polysubstance-related disorders have also become a major problem.

Substance-Related Disorders :fi 305

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, 2007). Sometimes the cause is carelessness or ignorance. Often, however, people use multiple drugs precisely because they enjoy the synergistic effects. In fact, polysubstance -related disorders are becoming as common as individual substance-related disorders in the United States, Canada, and Europe (Rosenthal & Levounis, 2005). As many as 90 percent of persons who use one illegal drug are also using another to some extent.

Fans still mourn the deaths of many celebrities who have been the victims of poly- substance use. Elvis Presley's balancing act of stimulants and depressants eventually killed him. Janis Joplin's mixtures of wine and heroin were ultimately fatal.And John Belushi's and Chris Farley's liking for the combined effect of cocaine and opioids ("speedballs") also ended in tragedy.

*What Causes Substance-Related Disorders? Clinical theorists have developed sociocultural, psychological, and biological explana- tions for why people abuse or become dependent on various substances. No single explanation, however, has gained broad support. Like so many other disorders, exces- sive and long-term drug use is increasingly viewed as the result of a combination of these factors.

Sociocuitural Views A number of sociocultural theorists propose that people are most likely to develop pat- terns of substance abuse or dependence when they live under stressful socioeconomic conditions. In fact, studies have found that regions with higher levels of unemployment have higher rates of alcoholism. Similarly, lower socioeconomic classes have substance- abuse rates that are higher than those of the other classes (Franklin & Markarian, 2005; Khan et al., 2002). In a related vein, more than 18 percent of unemployed adults cur- rently use an illegal drug, compared to around 9 percent of full-time and part-time employed workers (NSDUH, 2008).

Other sociocultural theorists propose that substance abuse and dependence are more likely to appear in families and social environments where substance use is valued, or at

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epolysubstance - related disordereA long-term pattern of maladaptive behav- ior centered on abuse of or dependence on a combination of drugs.

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least accepted. Researchers have, in fact, found 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 (Ksir et al., 2008; Lieb et al., 2002). Moreover, lower rates of alcohol abuse are found among Jews and Protestants, groups in which drinking is typically acceptable only as long as it remains within clear limits, whereas alcoholism rates are higher among the Irish and Eastern Europeans, who do not, on average, draw as clear a line (Ksir et al., 2008; Ledoux et al., 2002).

Psychodynarnic Views Psychodynamic theorists believe that people who abuse substances have powerful dependency needs that can be traced to their early years (Lightdale et al., 2008; Stetter, 2000). They claim 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 and patient interviews have in fact indi- cated that people who abuse or depend on drugs tend to be more dependent, antisocial, impulsive, novelty-seeking, and depressive than other people (Ksir et al., 2008; Coffey et al., 2003). These findings are correlational, however, and do not clarify whether such personality traits lead to drug use or whether drug use causes people to be dependent, impulsive, and the like.

In an effort to establish clearer causation, one longitudinal study measured the per- sonality traits of a large group of nonalcoholic young men and then kept track of each man's development ( Jones, 1971, 1968).Years later, the traits of the men who developed alcohol problems in middle age were compared with the traits of those who did not. The men who developed alcohol problems had been more impulsive as teenagers and continued to be so in middle age, a finding suggesting that impulsive men are indeed more prone to develop alcohol problems. Similarly, in one laboratory investigation, "impulsive" rats—those that generally had trouble delaying their rewards—were found to drink more alcohol when offered it than other rats (Poulos, Le, & Parker, 1995).

A major weakness of this line of argument is the wide range of personality traits that have been tied to substance abuse and dependence. In fact, different studies point to different "key" traits. Inasmuch as some people with a drug addiction 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 substance-related disorders (Chassin et al., 2001).

Cognitive-Behavioral Views According to behaviorists, operant conditioning may play a key role in substance abuse (Bradizza & Stasiewkz, 2009; Higgins et al., 2004).They argue that the temporary reduc- tion of tension or raising of spirits produced by a drug has a rewarding effect, thus in- creasing the likelihood that the user will seek this reaction again. Similarly, the rewarding effects of a substance may eventually lead users to try higher dosages or more powerful methods of ingestion. In addition, cognitive theorists argue that such rewards eventu- ally produce an expectancy that substances will be rewarding, and this expectation helps motivate individuals to increase drug use at times of tension (Chassin et al., 2001).

In support of these behavioral and cognitive views, studies have found that many people do in fact drink more alcohol or seek heroin when they feel tense (Ham et al., 2002). In one study, as participants worked on a difficult anagram task, a confederate planted by the researchers unfairly criticized and belittled them (Marlatt et al., 1975). The participants were then asked to participate in an "alcohol taste task," supposedly

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to compare and rate alcoholic beverages. The individuals 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 ex- pect higher rates of drug abuse among people who suffer from anxiety, depression, and other such problems. And, in fact, more than 22 percent of all adults who suffer from psychological disorders have been dependent on or abused alcohol or other substances within the past year (NSDUH, 2008).

A number of behaviorists have proposed that classical conditioning may also play a role in substance abuse and dependence (Haney, 2008). Objects present in the environment at the time drugs are taken 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 hypo- dermic needle, drug buddy, or regular supplier, for example, has been known to comfort people who abuse heroin or amphetamines and to relieve their withdrawal symptoms. In a similar manner, objects that are present during withdrawal distress may produce withdrawal-like symptoms. One man who had formerly been dependent on heroin experienced nausea and other withdrawal symptoms when he returned to the neighbor- hood where he had gone through withdrawal in the past—a reaction that led him to start taking heroin again (O'Brien et al., 1975). Although classical conditioning certainly ap- pears to be at work in particular cases or aspects of drug abuse and dependence, research has not found it to be the key factor in such patterns probes et al., 2001).

Biological Views In recent years researchers have come to suspect that drug misuse may have biological causes. Studies on genetic predisposition and specific biochemical processes have pro- vided some support for these suspicions.

Genetic Predisposition For years breeding experiments have been conducted to see whether certain animals are genetically predisposed to become dependent on drugs (Kreek, 2008; Li, 2000). In several studies, for example, investigators have first identi- fied 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 pref- erence for alcohol (Melo et al., 1996).

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Similarly, some research with human twins has suggested that people may inherit a predis- position to abuse substances (Ray & Hutchi- son, 2009). One classic study found that if one identical twin abused alcohol, the other twin also abused alcohol in 54 percent of the cases, whereas among fraternal twins, the rate was only 28 percent (Kaij, 1960). Other stud- ies have found similar twin patterns (Tsuang et al., 2001). 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 abuse and dependence comes from studies of alcoholism rates in people adopted shortly after birth (Walters, 2002; Cadoret et al., 1995; Goldstein, 1994). These studies have compared adoptees whose biological parents are dependent on alcohol with adoptees whose biological parents are not. By adulthood, the individuals whose biological parents are dependent on alcohol typically show higher rates of alcohol abuse than those with nonalcoholic biological parents.

Genetic linkage strategies and molecular biology techniques provide more direct evi- dence in support of a genetic explanation (Gelernter & Kransler, 2008). One line of investigation has found an abnormal form of the so-called dopamine-2 (D2) receptor gene in a majority of research participants with alcohol, nicotine, or cocaine dependence but in less than 20 percent of nondependent participants (Preuss et al., 2007; Blum et al., 1996, 1990). Other studies have tied still other genes to substance-related disorders (Gelernter & Kranzler, 2008; Kreek, 2008).

Biochemical Factors Over the past few decades, researchers have pieced together several biological explanations of drug tolerance and withdrawal symptoms (Kleber & Galanter, 2008; Koob, 2009, 2008). According to one of the leading explanations, when a particular drug is ingested, it increases the activity of certain neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or increase alertness. When a person keeps on taking the drug, the brain apparently makes an adjustment and reduces its own production of the neurotransmitters. Because the drug is increasing neurotransmit-

ter activity, release of the neurotransmitter by the brain is less necessary. As drug in- take increases, the body's production of the neurotransmitters continues to decrease, leaving the person in need of more and 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 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.

Which neurotransmitters are affected depends on the drug used. Repeated and excessive use of alcohol or benzodiazepines may lower the brain's production of the

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According to the sociocultural view, the people most likely to abuse drugs are those living in stressful socioeconomic conditions or whose families value or accept drug use. In the psychodynamic view, people who turn to substance abuse have

Substoraelated Disorders :1/ 309

°reward centereA dopamine-rich path- way in the brain that produces feelings of pleasure when activated.

oreward - deficiency syndromeeA condition, suspected to be present in some individuals, in which the brain's reward center is not readily activated by the usual events in their lives.

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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 produc- tion of dopamine (Haney, 2008;Volkow et al., 2004, 1999). In addition, researchers have identified a neurotransmitter called anandamide that operates much like THC; excessive use of marijuana may reduce the production of this neurotransmitter (Hitti, 2004; Johns, 2001).

This theory helps explain why people who regularly take substances experience tolerance and withdrawal reactions. But why are drugs so rewarding, and why do certain people turn to them in the first place? A number of brain-imaging studies suggest that many, perhaps all, drugs eventually activate a reward center, or "pleasure pathway," in the brain (de Wit & Phan, 2010; Haney, 2008).A key neurotransmitter in this pleasure pathway app ears to be dopamine (Koob, 2009; Volkow et al., 2004). When dopamine is activated along the pleasure pathway, a person experiences pleasure. Music may activate dopamine in the reward center. So may a hug or a word of praise. And so do drugs. Some researchers believe that other neurotransmitters may also play important roles in the reward center.

Certain drugs apparently stimulate the reward center directly. Remember that cocaine and amphetamines directly increase dopamine activity. Other drugs seem to stimulate it in roundabout ways.The biochemical reactions triggered by alcohol, opioids, and marijuana probably set in motion a series of chemical events that eventually lead to increased dopamine activity in the reward center. A number of theorists suspect that people who abuse drugs suffer from a reward-deficiency syndrome: Their reward center is not readily activated by the usual events in their lives, so they turn to drugs to stimulate this pleasure pathway (Blum et al., 2000).

31 0 ://CHAPTER 10

excessive dependency needs traceable to the early stages of life. Some psychody- namic theorists also believe that certain people have a substance-abuse personality that makes them prone to drug use. The leading behavioral view proposes that drug use is reinforced initially because it reduces tensions and raises spirits, and the lead- ing cognitive view holds that such reductions of tension then lead to an expectancy that drugs will be comforting and helpful.

The biological explanations are supported by twin, adoptee, genetic linkage, and molecular biology studies, suggesting that people may inherit a predisposition to substance dependence. Researchers have also learned that drug tolerance and withdrawal symptoms may be caused by cutbacks in the brain's production of par- ticular neurotransmitters during excessive and repeated drug use. Finally, biologi- cal studies suggest that many, perhaps all, drugs may ultimately lead to increased dopamine activity in the brain's reward center.

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*How Are Substance-Related Disorders Treated? Many approaches have been used to treat substance-related disorders, including psycho- dynamic, behavioral, cognitive-behavioral, and biological approaches, along with several sociocultural therapies. Although these treatments sometimes meet with great success, more often they are only moderately helpful (Myrick & Wright, 2008).Today the treat- ments are typically used on either an outpatient or inpatient basis or a combination of the two (Carroll, 2008, 2005; Weiss et al., 2008) (see Figure 10-4).

Psychodynamic Therapies Psychodynamic therapists first guide clients to uncover and work through the underly- ing needs and conflicts that they believe have led to the disorder.The therapists then try to help the individuals change their substance-related styles of living (Lightdale et al., 2008). Although often applied, this approach has not been found to be particularly effective in cases of substance-related disorders (Cornish et al., 1995). It may be that drug abuse or dependence, regardless of its causes, eventually becomes a stubborn in- dependent problem that must be the direct target of treatment if people are to become drug-free. Psychodynamic therapy tends to be of greater help when it is combined with

other approaches in a multidimensional treatment program (Lightdale et al., 2008).

Behavioral Therapies A widely used behavioral treatment for substance-related disorders is aversion therapy, an approach based on the principles of classical conditioning. Individuals are repeatedly presented with an unpleasant stimulus (for example, an elec- tric shock) at the very moment that they are taking a drug. After repeated pairings, they are expected to react negatively to the substance itself and to lose their craving for it.

Aversion therapy has been applied to alcohol abuse and dependence more than to other substance-related disorders. In one version of this therapy, drinking behavior is paired with drug-induced nausea and vomiting (Owen-Howard, 2001; Welsh & Liberto, 2001). The pairing of nausea with alcohol is expected to produce negative responses to alcohol itself. Another version of aversion therapy requires people

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with alcoholism to imagine extremely upsetting, repulsive, or frightening scenes while they are drinking (Cautela, 2000; Kassel et al., 1999). Here the pairing of the imagined scenes with liquor is expected to produce negative responses to liquor. Here are the kinds of scenes 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 realise that you have swallowed some of them and you're very aware of the taste in your mouth. You feel very sick and wish you'd never reached for the glass and had the drink at all.

(Clarke & Saunders, 1988, pp. 143-144)

A behavioral approach that has been effective in the short-term treatment of people who abuse cocaine and some other drugs is contingency management, which makes in- centives (such as cash, vouchers, prizes, or privileges) contingent on the submission of drug-free urine specimens (Barry et al., 2009; Kosten et al., 2008). In one pioneering study, 68 percent of cocaine abusers who completed a six-month contingency training program achieved at least eight weeks of continuous abstinence (Higgins et al., 1993).

Behavioral interventions for substance abuse and dependence have usually had only limited success when they are the sole form of treatment (Carroll, 2008).A major problem is that the approaches can be effective only when individuals are motivated to continue with them despite their unpleasantness or demands (DiClemente et al., 2008). Generally, behavioral treatments work best in combination with either biological or cognitive approaches (Higgins & Silverman, 2008).

°aversion therapyoA treatment in which clients are repeatedly presented with unpleasant stimuli while performing undesirable behaviors such as taking a drug.

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*behavioral self-control training (BSCT)®A cognitive-behavioral approach to treating alcohol abuse and depen- dence in which clients are taught to keep track of their drinking behavior and to apply coping strategies in situations that typically trigger excessive drinking.

orelapse-prevention training°An approach to treating alcohol abuse that is similar to BSCT and also has clients plan ahead for risky situations and reactions.

odetoxificationeSystematic and medi- cally supervised withdrawal from a drug.

*antagonist drugs*Drugs that block or change the effects of an addictive drug.

Cognitive-Behavioral Therapies Two popular approaches combine cognitive and be- havioral techniques to help people gain control over their substance-related behaviors (Carroll, 2008). In one, behavioral self-control training (BSCT), applied to alcoholism in particular, therapists first have clients keep track of their own drinking behavior (Bishop, 2008; Miller et al., 1992; Miller, 1983). Writing down the times, locations, emotions, bodily changes, and other cir- cumstances of their drinking, they become more aware of the situations that place them at risk for excessive drinking. They are then taught coping strategies to use when such situations arise. They learn, for example, to set limits on their drinking, to recognize when the limits are being approached, to control their rate of drinking (perhaps by spacing their drinks or by sipping them rather than gulping), and to practice relaxation tech- niques, assertiveness skills, and other coping behaviors in situations in which they would otherwise be drinking. Approximately 70 percent of the people who complete

this training apparently show some improvement, particularly younger drinkers who are not physically dependent on alcohol (Deas et al., 2008; Ksir et al., 2008).

In a related cognitive-behavioral approach, relapse-prevention training, heavy drinkers are assigned many of the same tasks as clients in BSCT (Blume et al., 2009; Witkiewitz & Marlatt, 2007, 2004). They are also taught to plan ahead of time how many drinks are appropriate, what to drink, and under what circumstances. The ap- proach often lowers the frequency of intoxication, although the majority of clients achieve success only after repeated relapse-prevention treatments. The approach has also been used, with some success, in the treatment of marijuana and cocaine abuse as well as with other kinds of disorders such as sexual paraphilias (see Chapter 11).

Biological Treatments Biological approaches may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without further increases. As with the other forms of treatment, biological approaches alone rarely bring long-term improve- ment, but they can be helpful when combined with other approaches.

•• • Detoxi f ication 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 offer 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 (Wright & Thompson, 2002). A second—often medically preferred—detoxification strategy is to give clients other drugs that reduce the symptoms of withdrawal (Caldeiro et al., 2009; Ksir et al., 2008). 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 (DiClemente et al., 2008). However, relapse rates tend to be high for those who fail to receive a follow-up form of treatment—psychological, biological, or sociocultural—after successful detoxification (Polydorou & Kleber, 2008).

Antagonist Drugs After successfully stopping a drug, people must avoid falling back into a pattern of abuse or dependence. As an aid to resisting temptation, some people with substance-related disorders are given antagonist drugs, which block or change the effects of the addictive drug (O'Brien & Kampman, 2008). Disulfiratn (Antabuse),

Medial HOME SEND EXPLORE

Substanceakted Disorders :1/ 313

In Real Time, Amy Winehouse's Deeper Descent BY JON PARES, NEW YORK TIMES, JANUARY 24, 2008

I. was witty ... when Amy Winehouse sang, "They tried to make me go to rehab/I said no, no, no" on her album

"Back to Black." . . . But there was nothing amusing, and barely any surprise, in Ms. Winehouse's recent, notorious and possibly inadvertent public appearance: on a video released by an Eng- lish tabloid, The Sun.

The homemade clip . . . shows Ms. Winehouse, with her recent blond hairdo, in her London apartment, using a glass pipe to smoke what The Sun says is crack. . . . Performers thrive on attention, and sometimes admit that it's an addiction; now, the Internet enables that addiction all too easily. The unintended consequence is that we can now watch stars self-destruct in real time.

Images of Ms. Winehouse looking intoxicated, disheveled, half-dressed and wild-eyed are all over the tabloids and the Internet. She has appeared to be drunk onstage, barely able to get through a song.. . . Ms. Winehouse, who writes her own lyrics, . . has often sung about harmful appetites, not just in "Rehab" but in "Addicted" (about a freeloading pot smoker) and in "Back to Black," in which she sings, "You love blow and I love puff/And life is like a pipe." .. .

Addiction might start with experiments by performers so young they feel invulnerable; it might seem to be, at first, a way to ease the stress of a peculiar lob. It might be a way to act out the old Romantic image of the artist as daredevil. And there's no shortage of temptation in a musician's work environment of bars, clubs, late nights and party people. Rock stars weren't the first musicians to drink or drug themselves to death.

What's different, in the 21st century, is that we can watch the breakdowns almost as they happen. One day there's a grainy video of Ms. Winehouse spreading across the Internet. .

In the '60s and '70s there were occasional photos of Janis Joplin hoisting a bottle of Southern Comfort, and word-of-mouth about many bands' backstage excesses or drunken exploits, but those were occasional glimpses and dispatches. Rockers dosed themselves, mostly, behind closed doors.

Now digital video and photography, coupled with the Inter- net, can odd up to near-constant surveillance.. . . There's an en- tire industry in celebrity scandal, much of it remarkably callous.

In their times the deaths of Jim Morrison and Kurt Cobain were sudden and shocking, leaving them a legacy as handsome rock martyrs. . .. But they were pre-Internet stars. Now, there's a sleazy symbiosis that connects instantaneous worldwide Hy, publicity, marketing and narcissism. Attention addicts can get their fix with a few mouse clicks.

Why, for instance, was Ms. Winehouse letting someone shoot video, in a private setting, of her puffing that pipe in the first place? Maybe it's some version of "keepin' it real," . . . Maybe it's obliviousness, ... Maybe she mistakenly trusted that whoever made the video would resist another temptation: the potential profit to be made providing it to a tabloid.

Perhaps Ms. Winehouse misunderstood what should be clear in the age of the Internet: Everything recorded can be dupli- cated and distributed. And possibly the video was, in its own bleary way, a kind of performance. She is keeping her audience informed if not exactly entertained.

Mostly, however, she's just supplying material for the sphere of celebrity interaction that only wants to see idols torn down. Her fans—those of us who believe she has more superb songs yet to write—would prefer she grow less visible and consider- ably more boring.... [S]he would do well to disappear for a while, into rehab or private recovery, and then to hole up in a recording studio and work up some new songs. (She definitely has enough ups and downs to write about, realistically or not.) In the era of total exposure Ms. Winehouse would serve herself and her listeners best by working behind closed doors.

Copyright © 2008. Reprinted by permission of PARS International Corp. on behalf of The New Ybrk Times.

[Note: Two weeks after this article was printed, Amy Winehouse won five Grammy Awards, including ones for best new artist, song of the year ("Rehab"), and best pop vocal album ("Back to Black").]

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"methadone maintenance program"An approach to treating heroin dependence in which clients are given legally and medically supervised doses of a substitute drug, methadone.

"Alcoholics Anonymous (AA)°A self- help organization that provides support and guidance for persons with alcohol abuse or dependence.

"residential treatment center®A place where people formerly dependent on drugs live, work, and socialize in a drug-free environment while undergo- ing treatment. Also called a therapeutic community.

for example, is often given to people who are trying to stay away from alcohol. By itself a low dose of this drug seems to have few negative effects, but a person who drinks al- cohol while taking disulfiram will experience intense nausea, vomiting, blushing, 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 (DiClemente et al., 2008). In addition to disulfiram, several other alcohol antagonist drugs are now being tested (De Sousa et al., 2008).

In the realm of opioid dependence, several narcotic antagonists, such as naloxone and naltrexone, are used to treat people who are addicted to drugs of that kind (Caldeiro et al., 2009). 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, con- tinued drug use becomes pointless. Although narcotic antagonists have been helpful— particularly in emergencies, to rescue people from an overdose of opioids—they can in fact be a dangerous form of treatment for opioid dependence. These antagonists must be given very carefully because of their ability to throw a person with an addiction into severe withdrawal. Recent studies indicate that narcotic antagonists may also be useful in the treatment of alcohol and cocaine dependence (Bishop, 2008; Oslin, 2006).

Drug Maintenance Therapy A drug-related lifestyle may be a greater problem than the drug's direct effects. Much of the damage caused by heroin addiction, for ex- ample, 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 & Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory opioid methadone as a substitute for heroin.Although they then become dependent on methadone, their new addiction is maintained under safe medical supervision. Unlike heroin, methadone can be taken by mouth, thus eliminating the dangers of needles, and needs to be taken only once a day.

At first, methadone programs seemed very effective, and many of them were set up 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 accept- able "solution" for substance dependence, and many persons with an addiction com- plained that methadone addiction was creating an additional drug problem that simply complicated their original one (McCance-Katz & Kosten, 2005). In fact, methadone is sometimes harder to withdraw from than heroin because the withdrawal symptoms can last longer (Ksir et al., 2008). Moreover, pregnant women maintained on methadone have the added concern of the drug's effect on their fetus.

Despite such concerns, maintenance treatment with methadone—or with buprenor- phine, another widely used substitute drug—has again sparked interest among clinicians in recent years, partly because of new research support (Strain & Lofwall, 2008) and partly because of the rapid spread of the HIV virus and the hepatitis C virus among intravenous drug abusers and their sex partners and children (Galanter & Kleber, 2008; Schottenfeld, 2008). Not only is methadone treatment safer than street opioid use, but many methadone programs now include AIDS education and other health instructions in their services (Sorensen & Copeland, 2000). Research suggests that methadone main- tenance programs are most effective when they are combined with education, psycho- therapy, family therapy, and employment counseling (Schottenfeld, 2008; O'Brien & McKay, 2002). Today thousands of clinics provide methadone treatment across the United States (MTC, 2008).

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 applied to substance-related

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disorders: (1) self-help programs, (2) culture- and gender-sensitive programs, and (3) community prevention programs (Ritvo & Causey, 2008).

Self-Help and Residential Treatment Programs Many people who abuse drugs have organized among themselves to help one another recover without profes- sional assistance.The drug self-help movement dates back to 1935, when two Ohio men suffering from alcoholism met and wound up discussing alternative treatment possibili- ties.The first discussion led to others and to the eventual formation of a self-help group whose members discussed alcohol-related problems, traded ideas, and provided support. The organization became known as Alcoholics Anonymous (AA).

Today AA has more than 2 million members in 113,000 groups across the United States and 1S0 other countries (AA World Services, 2008). It offers peer support along with moral and spiritual guidelines to help people overcome alcoholism. Different members apparently find different aspects of AA helpful (Tonigan & Connors, 2008). For some it is the peer support; for others it is the spiritual dimension. Meetings take place regularly, and members are available to help each other 24 hours a day.

By offering guidelines for living, the organization helps members abstain "one day at a time," urging them to accept as "fact" the idea that they are powerless over alcohol and that they must stop drinking entirely and permanently if they are to live normal lives (Nace, 2008). Related self-help organizations, Al-Anon and Alateen, offer support for people who live with and care about persons with alcoholism (Galanter, 2008). Self- help programs such as Narcotics Anonymous and Cocaine Anonymous have been developed for other substance-related disorders.

Many self-help programs have expanded into residential treatment centers, or therapeutic communities —such as Daytop Village and Phoenix House—where people formerly dependent on 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 (Brook, 2008; De Leon, 2008).

The evidence that keeps self-help and residential treatment programs going comes largely in the form of individual testimonials. Many tens of thousands of persons have revealed that they are members of these programs and credit them with turning their lives around. Studies of the programs have also had favorable findings, but their numbers have been limited (De Leon, 2008; Moos & Timko, 2008; Tonigan & Connors, 2008).

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Culture- and Gender-Sensitive Programs Many persons who abuse sub- stances 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 faced by drug abusers who are poor, homeless, or members of minority groups (Cabaj, 2008; Westermeyer & Dickerson, 2008). 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 (Brady & Back, 2008). Women and men often have different physical and psychological reactions to drugs, for example. In addition, treatment of women who abuse substances 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 (Finnegan & Kandall, 2008).Thus many women with such disorders feel more comfortable seeking help at gender-sensitive clinics or resi- dential programs; some such programs also allow children to live with their recovering mothers.

Community Prevention Programs Perhaps the most effective approach to substance-related disorders is to prevent them (Sloboda, 2009; Clayton et al., 2008; Ksir et al., 2008).The first drug-prevention efforts were conducted in schools.Today preven- tion programs are also offered in workplaces, activity centers, and other community settings, and even through the media (NSDUH, 2008). Over 11 percent of adolescents report that they have participated in substance use prevention programs outside school within the past year. Around 80 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.

Prevention programs may focus on the individual (for example, by providing educa- tion 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 (by public service announcements such as the "Just say no" campaign of the 1980s and 1990s). The most effective prevention efforts focus on several of these areas to provide a consistent message about drug abuse in all areas of individuals' lives (Clayton et al., 2008; Ksir et al., 2008). Some prevention pro- grams have even been developed for preschool children.

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Substance-Related Disorders :1/ 317

•

How Are Substance-Related Disorders Treated?

Treatments for substance abuse and dependence vary widely. Usually several ap- proaches are combined. Psychodynamic therapies try to help clients become aware of and correct the underlying needs and conflicts that may have led to their use of drugs. A common behavioral technique is aversion therapy, in which an unpleasant stimulus is paired with the drug that the person is abusing. Cognitive and behavioral techniques have been combined in such forms as behavioral self-control training (BSCT) and relapse-prevention training. Biological treatments include detoxification, antagonist drugs, and drug maintenance therapy. Sociocultural treatments approach substance-related disorders in a social context by means of self-help groups (for example, Alcoholics Anonymous), culture- and gender-sensitive treatments, and community prevention programs.

PUTTING IT... together New Wrinkles to a Familiar Story In some respects the story of the misuse of drugs is the same today as in the past. Sub-

stance use is still rampant, often creating damaging psychological disorders. New drugs

keep emerging, and the public goes through periods of believing, naively, that they are

"safe." Only gradually do people learn that these drugs, too, pose dangers. And treat-

ments for substance-related disorders continue to have only limited effect.

Yet there are important 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. The same kind of integrated efforts that

have helped with other psychological disorders are bringing new promise and hope to

the study and treatment of substance-related disorders.

Perhaps the most important insight to be gained from these integrated efforts is

that several of the models were already on the right track. Social pressures, personality

characteristics, rewards, and genetic predispositions all seem to play roles in substance-

related disorders, and in fact to operate together. For example, some people may inherit

a malfunction of the biological reward center and so may need special doses of external

stimulation—say, intense relationships, an abundance of certain foods, or drugs—to

stimulate their reward center. Their pursuit of external rewards may take on the char-

acter of an addictive personality (Ebstein & Kotler, 2002). Such individuals may be es-

pecially prone to experimenting with drugs, particularly when their social group makes

the drugs available or when they are faced with intense social and personal stress.

Just as each model has identified important factors in the development of substance-

related disorders, each has made important contributions to treatment. As you have

seen, 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.

These recent developments are encouraging. At the same time, however, enormous

and increasing levels of drug use continue. New drugs and drug combinations are dis-

covered almost daily, and with them come new problems and the need for new research

and new treatments. Perhaps the most valuable lesson is an old one: There is no free

lunch. The pleasures derived from these substances come with high psychological and

biological costs, some not yet even known.

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g 1. Various kinds of club drugs (e.g.,

Ecstasy and crystal meth), drugs

.0.1;

used at all-night dance parties called " raves," seem to fall in and out of favor rather quickly. Why might

Os young people readily move from one such drug to another? pp. 298-299, 300

lif: 2. What effects might the use of drugs 70--;

54

by some rock, rap, and other musical

young adults? performers hav Who has the greater e on teenagers and

42,-;

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impact on the drug behaviors of teenagers and young adults: perform-

\\\KEy TEP/S/// intoxication, p. 286

f hallucinosis, p. 286 0: substance abuse, p. 286

substance dependence, p. 286

0 tolerance, p. 286 withdrawal, p. 286

alcohol, p. 287 .?:

O.: delirium tremens (DTs), p. 289 cirrhosis, p. 291 Korsakoff's syndrome, p. 291

fetal alcohol syndrome, p. 291

sedative-hypnotic drug, p. 292

opioid, p. 293

gi endorphins, p. 293 cocaine, p. 295

417:

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ers who speak out against drugs or performers who praise the virtues of drugs? pp. 304-305, 313, 317

3 What different kinds of issues might be confronted by drug abusers from different ethnic groups or genders, and how might such issues influence their efforts at recovery? pp. 305- 306, 316

4. Popular talk show host Oprah Winfrey has revealed, with great emotion, that she was physically dependent on cocaine in the

free-basing, p. 296

crack, p. 296

amphetamine, p. 298

hallucinogen, p. 299

lysergic acid diethylamide (LSD), p. 299

cannabis drugs, p. 301

marijuana, p. 301

tetrahydrocannabinol (MC), p. 301

synergistic effect, p. 304

polysubstance-related disorder, p. 305

substance-abuse personality, p. 306

dopamine-2 (D2) receptor gene, p. 308

reward center, p. 309

aversion therapy, p. 310

contingency management, p. 311

-• • AA. ..*•,A1-.

mid-1970s. What impact might admissions like Winfrey's have on people's willingness to seek treatment for substance abuse? pp. 310-316

5. Since the major dangers of heroin come from overdose, unsterilized needles, and a criminal lifestyle, society has periodically tried legal, medically supervised use of heroin {in Great Britain) or a heroin substitute (in the United States) to combat this drug problem. In many cases, such approaches have had limited effec- tiveness. Why? p. 314

behavioral self-control training (BSCT), p. 312

relapse-prevention training, p. 312

detoxification, p. 312

antagonist drug, p. 312

disulfiram (Antabuse), p. 312

narcotic antagonist, p. 314

methadone maintenance program, p.314

self-help program, p. 315

Alcoholics Anonymous (AA), p. 315

residential treatment center, p. 315

culture- and gender-sensitive program, p. 316

community prevention program, p. 316

1. How does alcohol act on the brain and body? What are the problems and dangers of alcohol misuse? pp. 287-292

2. Describe the features and problems of the misuse of barbiturates and benzodiazepines. pp. 292-293

3. Compare the various opioids (opium, heroin, morphine). What problems may result from their use? pp. 293-294

4. List and compare two kinds of stimu- lant drugs. Describe their biological

actions and the problems caused by each of them. pp. 295-299

5. Why has cocaine use become a major problem in recent years? pp. 295-298

6. What are the effects of hallucino- gens, particularly LSD? pp. 299-301

t A 4A.1*2_A_.6*.f. A A.•

Substance-Related Disorders :// 319

What are the effects of marijuana and other cannabis substances? Why is marijuana a greater danger today than it was 30 years ago? pp. 301-304

,40,1 ,ot • •.•,•,• %•.0.

8. What special problems does polysub- stance use pose? pp. 304-305

9. Describe the leading explanations for substance-related disorders. Row well supported are these explanations? pp. 305-309

10. What are the leading treatments for substance-related disorders? How effective are they? pp. 310-316

4

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SEXUAL DISORDERS AND GENDER IDENTITY DISORDER

obert, a 57-year-old man, came to sex therapy with his wife because of his inability to get erections. He had not had a problem with erections until six months earlier, when they attempted to have sex after an evening out during which he had had several drinks.

UThey 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 o year, might be interfering with erection. . . . When they came for sex therapy, they had not attempted any sexual activity for over two months.

LoPiccolo, 1992, p. 492

Sexual behavior is a major focus of both our private thoughts and public discus- sions. Sexual feelings are a crucial part of our development and daily functioning, sexual activity is tied to the satisfaction of our basic needs, and sexual performance is linked to our self-esteem. Most people are fascinated by the abnormal sexual behavior of others and worry about the normality of their own sexuality.

Experts recognize two general categories of sexual disorders: sexual dysfunc- tions and paraphilias. People with sexual dysfunctions experience 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 activ- ity. People with paraphilias have repeated and intense sexual urges or fantasies in response to objects or situations that society deems inappropriate, and they may behave inappropriately as well. They may be aroused by the thought of sexual activity with a child, for example, or of exposing their genitals to strangers, and they may act on those urges. In addition to the sexual disorders, DSM-IV-TR includes a diagnosis called gender identity disorder, a sex-related pattern in which people persistently feel that they have been born to the wrong sex and in fact identify with the other gender.

As you will see throughout this chapter, except for gender differences, little is known about racial and other cultural differences in sexuality. This is true for normal sexual patterns, sexual dysfunctions, and paraphilias alike. Although dif- ferent 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.

TOPIC OVERVIEW 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 Applied to Particular Dysfunctions?

What Are the Current Trends in Sex Therapy?

Paraphilias

Fetishism

Transvestic Fetishism

Exhibitionism

Voyeurism

Frotteurism

Pedophilia

Sexual Masochism

Sexual Sadism

A Word of Caution

Gender Identity Disorder Explanations of Gender Identity Disorder

Treatments for Gender Identity Disorder

Putting It Together: A Private Topic Draws Public Attention

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°sexual dysfunctioneA disorder marked by a persistent inability to func- tion normally in some area of the human sexual response cycle.

°desire phaseeThe phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction to others.

°hypoactive sexual desire disordereA disorder marked by a lack of interest in sex and hence a low level of sexual activity.

°sexual aversion disordereA disorder characterized by an aversion to and avoidance of genital sexual interplay.

1'y 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. A large study suggests that as many as 31 percent of men and 43 percent of women in the United States suffer from such a dysfunction during their lives (Laumann et al., 2005, 1999; Heiman, 2002). Sexual dysfunctions are typically very distressing, and they often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems (Basson, 2007). Often these dysfunctions are interrelated; many patients with one dysfunction experience another as well. Sexual dysfunctioning will be described here for hetero- sexual couples, the majority of couples seen in therapy. Homosexual couples have the same dysfunctions, however, and therapists use the same basic techniques to treat them (LoPiccolo, 2004, 1995).

The human sexual response can be described as a cycle with four phases: desire, excite- ment, orgasm, and resolution (see Figure 11-1). Sexual dysfunctions affect one or more of the first three phases. Resolution consists simply of the relaxation and reduction in arousal that follow orgasm. Some people struggle with a sexual 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, 2000).

Disorders of Desire The desire phase of the sexual response cycle consists of an urge to have sex, sexual fantasies, and sexual attraction to others. Two dysfunctions—hypoactive sexual desire dis- order and sexual aversion disorder—affect the desire phase.A client named Clara Bryarton experiences both of these disorders:

[Randall and Clara Bryarton] have been married for 14 years and have three children, ages 8 through 12. They [complain that Clara] has never enjoyed [sex] since they have been married.

Before their marriage, although they had intercourse only twice, [Clara] had been highly aroused by kissing and petting and felt she used her attractiveness to "seduce" her husband into marriage. She did, however, feel intense guilt about their two episodes of premarital intercourse; during their honeymoon, she began to think of sex as a chore that could not be pleasing. Although she periodically passively complied with intercourse, she had almost no spontaneous desire for sex. She never masturbated, had never reached orgasm, thought of all variations such as oral sex as completely repulsive, and was preoc- cupied with a fantasy of how disapproving her family would be if she ever engaged in any of these activities.

[Clara feels] certain that no woman she respects in any older generation has [truly] enjoyed sex, and that despite the "new vogue" of sexuality, only sleazy, crude women let themselves act like "animals." These beliefs have led to a pattern of regular, but in- frequent, sex that at best is accommodating and gives little or no pleasure to her or her husband. Whenever [Clara] comes close to having a feeling of sexual arousal, numerous negative thoughts come into her mind, such as "What am I, a tramp?" "If 1 like this, he'll just want it more often." Or "How could l look myself in the mirror after something like this?" These thoughts almost inevitably are accompanied by a cold feeling and an insensitivity to sensual pleasure. As a result, sex is invariably on unhappy experience. Al- most any excuse, such as fatigue or being busy, is sufficient for her to rationalize avoiding intercourse.

Yet, intellectually [Clara] wonders, "Is something wrong with me?"

(Spitzer et al., 1994, p. 251)

322 ://CHAPTER 1 1

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Sexual Disorders and Gender Identity Disorder :// 323

People with hypoactive sexual desire disorder lack interest in sex and, in turn, display little sexual activity (see Table 11-1). Nevertheless, when these individuals do have sex, their physical responses may be normal and they may enjoy the experience. While our culture portrays men as wanting all the sex they can get, hypoactive sexual desire may be found in as many as 16 percent of men, and the number seeking therapy has increased during the past decade (Maurice, 2007; Laumann et al., 2005, 1999). It may also be found in 33 percent of women. A number of people experience normal sexual interest and arousal but choose, as a matter of lifestyle, not to engage in sexual relations. These individuals are not diagnosed as having hypoactive sexual desire disorder.

DSM-IV-TR_ defines hypoactive sexual desire as "deficient or absent sexual fanta- sies and desire for sexual activity," but it does not specify what a "deficient" level is. In fact, this criterion is difficult to define (Maurice, 2007; LoPiccolo, 2004, 1995). Age, number of years married, education, social class, and other factors may all influence the frequency of sex. In one survey, 93 happily married couples were asked to report how often they desire sexual encounters. Almost all of them said that they desire sex at least once every two weeks, and around 85 percent reported a desire rate of several times a week or more. On the basis of this survey, sexual desire would be considered hypoactive only when a person desires sex less frequently than once every two weeks.

People with sexual aversion disorder find sex distinctly unpleasant or repulsive. Sexual advances may sicken, disgust, or frighten them. Some people are repelled by a particular aspect of sex, such as penetration of the vagina; others experience a general aversion to all sexual stimuli, including kissing or touching. Aversion to sex seems to be quite rare in men and somewhat more common in women (Wincze, Bach, & Barlow, 2008; Heiman, 2002).

A person's sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of them may reduce sexual desire. Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly.

Biologica Causes A number of hormones interact toproduce sexual desire and behavior, and abnormalities in their activity can lower the sex drive (Ashton, 2007; Hyde, 2005). 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

324 ://CHAPTER 1 1

or women who have recently given birth. Long-term physical illness can also lower the sex drive (Basson, 2007; Stevenson & Elliott, 2007).The low drive may be a direct result of the illness or an indirect result because of stress, pain, or depression brought on by the illness.

e )caterns or Sexual Behavior

1 -,11,exual dysfunctions are, by definition, klifferent from the usual patterns of

sexual functioning. But in the sexual realm, what is "the usual"? Studies conducted over the past Iwo decades have provided a wealth of useful, sometimes eye-opening in- formation about sexual patterns in the "nor- mal" populations of North America (CDC, 2007; Lindau et al., 2007; McAnulty & Burnette, 2006; Smith, 2006; Kelly, 2005; Laumann et cd., 2005, 1999, 1994; Brown & Ceniceros, 2001; Seidman & Rieder, 1995; Janus &Janus, 1993).

Teenagers More than 90 percent of boys masturbate by the end of adolescence, compared to 50 percent of girls. For the vast majority of them, masturbation began by age 14. Males report masturbating an average of one to two times a week, females once a month.

Around 20 percent of teenagers have heterosexual intercourse by the age of 15, and 80 percent by age 19. Today's teen- agers are having intercourse younger than those of past generations. Most teens who are sexually experienced engage in only one sexual relationship at a time. Over the course of their teen years, however, most have at least two sex partners.

Extended periods without sex are still common, even for teenagers in a relation- ship. Half of sexually experienced adoles- cent girls have intercourse once a month or less. Sexually experienced teenage boys spend an average of six months of the year without intercourse.

Condom use by teenagers has in- creased somewhat during the past decade, partly because of warnings about AIDS. However, at most half of teenagers report having used a condom the last time they had sex. Less than a third of teenagers use condoms consistently and appropriately.

Early Adulthood (Ages 18-24) More than 80 percent of unmarried young adults have intercourse in a given year. Of those who are sexually active, around a third have intercourse two or three times a month and another third engage in it two or three times a week. Masturbation re- mains common in young adulthood: Close to 60 percent of men masturbate, a third of them at least once a week, and 36 percent of women masturbate, a tenth of them at least once a week.

Mid-Adulthood (Ages 25-59) From the ages of 25 to 59, sexual relation- ships last longer and are more monoga- mous. More than 90 percent of people in this age range have sexual intercourse in a given year. Half of the unmarried men have two or more partners in a given year, com- pared to a quarter of the unmarried women.

Among sexually active adults, close to 60 percent of men hove intercourse up to three times a week and around 60 percent of women once or twice a week. Middle- aged adults are still masturbating. Half of all middle-aged men masturbate at least

monthly. Half of all women between 25 and 50 masturbate at least monthly, but only a third of those between 51 and 64 do so.

Old Age (Over Age 60) More and more people stop having inter- course as the years go by—a total of 10 percent in their 40s, 15 percent in their 50s, 30 percent in their 60s, and 45 percent in their 70s. The decline in men's sexual activ- ity usually comes gradually as they advance in age and their health fails. Sexual activity is more likely to drop off sharply for elderly women, commonly because of the death or illness of a partner. Elderly women also seem to lose interest in sex before elderly men do. Half of the women in their 60s report limited sexual interest, compared to fewer than 10 percent of the men.

Among elderly persons who remain sexually active, those in their 60s have intercourse an average of four times a month, those in their 70s two or three times a month. Around 70 percent of elderly men and 50 percent of elderly women con- tinue to have sexual fantasies. Around half of men and a fourth of women continue to masturbate into their 90s.

• lb

Sex drive can be lowered by some pain medications, certain psychotropic drugs, and a number of illegal drugs such as cocaine, marijuana, amphet- amines, and heroin (Stevenson & Elliott, 2007). Low levels of alcohol may raise the sex drive by lowering a person's inhibitions, yet high levels may reduce it (Ksir et al., 2008).

Psychological Causes A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women (Basson, 2007). Frequently, as cognitive theorists have noted, people with hypoactive sexual desire and sexual aversion have particular attitudes, fears, or memories that contribute to their dysfunction, such as a belief that sex is immoral or dangerous (Wincze et al., 2008; LoPiccolo, 2004, 1995). Other people are so afraid of losing con- trol over their sexual urges that they try to resist them completely. And still others fear pregnancy.

Certain psychological disorders may also contribute to hypoactive sexual desire and sexual aversion. 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 (Maurice, 2007; LoPiccolo, 2004, 1995).

Sociocultu r'ol Causes The attitudes, fears, and psychological disorders that contrib- ute to hypoactive sexual desire and sexual aversion occur within a social context, and so certain sociocultural factors have also been linked to these dysfunctions. Many suffer- ers are feeling situational pressures—divorce, a death in the family, job stress, infertility difficulties, having a baby (Basson, 2007; Lau mann et al., 2005). Others may be having problems in their relationships (Wincze et al., 2008). People who are in an unhappy re- lationship, have lost affection for their partner, or feel powerless and dominated by their partner can lose interest in sex (Maurice, 2007). Even in basically happy relationships, if one partner is a very unskilled, unenthusiastic lover, the other can begin to lose interest in sex. And sometimes partners differ in their needs for closeness. The one who needs more personal space may develop hypoactive sexual desire as a way of keeping distance (LoPiccolo, 2004, 1995).

Cultural standards can also set the stage for hypoactive sexual desire and sexual aver- sion. Some men adopt our culture's double standard and thus cannot feel sexual desire for a woman they love and respect (Maurice, 2007). More generally, because our society equates sexual attractiveness with youthfulness, many middle-aged and older men and women lose interest in sex as their self-image or their attraction to their partner dimin- ishes with age (LoPiccolo, 2004, 1995).

The trauma of sexual molestation or assault is especially likely to produce the fears, attitudes, and memories found in these sexual dysfunctions. Sexual aversion is very common in victims of sexual abuse and may persist for years, even decades (Hall, 2007; Heiman & Heard-Davison, 2004). In some cases, individuals may experience vivid flashbacks of the assault during adult sexual activity.

Disorders of Excitement The excitement phase of the sexual response cycle is marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pres- sure, 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 (the folds of skin on each side of the vagina), as well as lubrication of the vagina (see Figure 11-2 on the next page). Dysfunctions affecting the excitement phase are female sexual arousal disorder (once referred to as "frigidity") and wale erectile disorder (once called "impotence").

Female Sexual Arousal Disorder Women with a female sexual arousal dis- order are persistently unable to attain or maintain proper lubrication or genital swelling during sexual activity (see Table 11-2, also on the next page). Understandably, many of

Sexual Disorders and Gender Identity Disorder :1/ 325

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female sexual arousal disorderoA female dysfunction marked by a persis- tent inability to attain sexual excitement, including adequate lubrication or genital swelling, during sexual activity.

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326 :A/CHAPTER 1 1

them also experience an orgasmic disorder or other sexual dysfunction. In fact, this disor- der is rarely diagnosed alone (Heiman, 2007). Studies vary widely in their estimates of its prevalence, but most agree that more than 10 percent of women experience it (Laumann et al., 2005, 1999,1994; Bancroft et al., 2003). Because lack of sexual arousal in women is so often tied to an orgasmic disorder, researchers usually study and explain the two prob- lems together. Correspondingly, this chapter will consider the causes of these problems together in the section on orgasmic disorder.

Ma ke Erectile Disorder Men with male erectile disorder persistently fail to attain or maintain an adequate erection during sexual activity.This problem occurs in about 10 percent of the general male population, including Robert, the man whose difficulties opened this chapter (Laumann et al., 2005, 1999; Heiman, 2002). Carlos Domera also has erectile disorder:

Carlos Domera is a 30-year-old dress manufacturer who came to the United States from Argentina at age 22. He is married to ... Phyllis, also age 30. They have no children. Mr. Domera's problem was that he had been unable to have sexual 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 sur- rounded 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 concur- rent with a tense period in his business. After several "failures" to complete intercourse, he

Sexual Disorders and Gender Identity Disorder :1/ 327

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, from both childhood masturbatory guilt and a feeling that he was "cheating" his wife. It was also noted that he had occasional firm erections upon awakening in the morning. Other than the antidepressant, the patient was taking no drugs, and he was not using much alcohol. There was no evidence of physical illness.

(Spitzer et al., 1983, pp. 105-106)

°male erectile disorder0A dysfunction in which a man repeatedly fails to attain or maintain an erection during sexual activity.

°nocturnal penile tumescence (NPT)0 Erection during sleep.

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 (Cameron et al., 2005). The disorder is experienced by 7 percent of men who are under 30 years old and increases to 50 percent of men over 60 (Rosen, 2007). 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 (Rosen, 2007). One study found that only 10 of 63 cases of this disorder were caused by purely psychosocial factors, and only 5 were the result of physical impairment alone (LoPiccolo, 1991).

BIOLOGICAL CAUSES The same hormonal imbalances that can cause hypoactive sexual de- sire can also produce erectile disorder (Hyde, 2005). More commonly, however, vascular problems—problems with the body's blood vessels—are involved (Wincze et al., 2008; Rosen, 2007) .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 the disorder. 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 (Wincze et al., 2008; Stevenson & Elliott, 2007). In addition, as is the case with hypoactive sexual desire, the use of certain medications and various forms of substance abuse, from alcohol abuse to cigarette smoking, may interfere with erections.

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 respon- sible. 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 perhaps two to three hours of penile erections. 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 erection has occurred during the night. An unbroken band indicates a lack of nigh_ttime erections and suggests that the person's general erectile problem may have a physical basis. A newer version of this device further attaches the band to a com- puter, which provides precise measurements of erections throughout the night (Wincze et al., 2008). Such devices are less likely to be used in clinical practice today than in past years. As you' 11 see later in the chapter,Viagra and other drugs for erectile disorder are typically given to patients without much evaluation of their problem (Rosen, 2007).

PSYCHOLOGICAL CAUSES Any of the psychological causes of hypoactive sexual desire can also interfere with arousal and lead to erectile disorder (Rosen, 2007). As many as 90 percent of all men with severe depression, for example, experience some degree of erectile dysfunction (Stevenson & Elliott, 2007).

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328 ://CHAPTER 11

verformance anxietyeThe fear of performing inadequately and a related tension experienced during sex.

()spectator roleoA 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.

°orgasm phaseeThe phase of the sexual response cycle during which an individual s sexual pleasure peaks and sexual tension is released as muscles in the pelvic region contract rhythmically.

orapid ejaculationoA dysfunction in which a man reaches orgasm and ejaculates before, on, or shortly after penetration and before he wishes to. Also known as premature ejaculation.

()male orgasmic disordereA male dysfunction characterized by repeated inability to reach orgasm or long delays in reaching orgasm after normal sexual excitement.

One well-supported psychological explanation for erectile disorder is the cognitive-behavioral theory developed by William Masters and Virginia Johnson (1970). The explanation emphasizes performance anxiety and the spectator role. Once a man begins to experience erectile problems, for whatever reason, he becomes fearful about failing to have an erection and worries during each sexual encounter. Instead of relaxing and enjoying the sensations of sexual pleasure, he remains distanced from the activity, watching himself and focusing on the goal of reaching erection. Instead of being an aroused participant, he becomes a judge and spectator. Whatever the initial reason for the erectile dysfunc- tion, 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.

SOCIOCULTURAL CAUSES Each of the sociocultural factors that contribute to hypoactive sexual desire has also been tied to erectile disorder. Men who have lost their jobs and are under financial stress, for example, are

more likely to develop erectile difficulties than other men (Morokoff & Gillilland, 1993). Marital stress, too, has been tied to this dysfunction (Wincze et al., 2008). Two relationship patterns in particular may contribute to it (Rosen, 2007; LoPiccolo, 2004, 1991). In one, the wife provides too little physical stimulation for her aging husband, who, because of normal aging changes, now requires more intense, direct, and lengthy physical stimulation of the penis for erection to occur. In the second relationship pattern, a couple believes that only intercourse can give the wife an orgasm. This idea increases the pressure on the man to have an erection and makes him more vulnerable to erectile dysfunction. If the wife reaches orgasm manually or orally during their sexual encounter, his pressure to perform is reduced.

Disorders of Orgasm During the orgasm phase of the sexual response cycle, an individual'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 rapid, or premature, ejaculation; male orgasmic disorder; and female orgasmic disorder

Rapid, or Premi4ure, Ejaculation Eddie is typical of many men in his experience of rapid ejaculation:

Eddie, a 20-year-old student, sought treatment after his girlfriend ended their relation- ship because his premature ejaculation left her sexually frustrated. Eddie 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 Eddie 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 geni- tals 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.

(LoPiccolo, 1995, p. 495)

A man suffering from rapid, or premature, ejaculation persistently reaches orgasm and ejaculates with very little sexual stimulation before, on, or shortly after penetration,

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Sexual Disorders and Gender Identity Disorder :1/ 329

and before he wishes to (see Table 11-3). As many as 30 percent of men in the United States experience rapid ejaculation at some time ( jannini & Lenzi, 2005; Laumann et al., 2005, 1999, 1994). The typical duration of intercourse in our society has increased over the past several decades, in turn increasing the distress of men who suffer from rapid ejaculation. Although the dysfunction is certainly experienced by many young men, research suggests that men of any age may in fact suffer from it (Althof, 2007; Laumann et al., 2005, 1999).

Psycholo gical, particularly behavioral, explanations of rapid ejaculation have received more research support than other kinds of explanations. The dysfunction is common, for example, among young, sexually inexperienced men such as Eddie, who simply have not learned Co slow down, control their arousal, and extend the pleasurable process of making love (Althof, 2007). In fact, rapid ejaculation often occurs when a young man has his first sexual encounter.With continued sexual experience, most men gain greater control over their sexual responses. Men of any age who have sex only occasionally are also prone to ejaculate rapidly.

Clinicians have also suggested that rapid ejaculation may be related to anxiety, hur- ried masturbation experiences during adolescence (in fear of being caught" by parents), or poor reco gnition of one's own sexual arousal (Althof, 2007;Westheimer & Lopater, 2005). However, these theories have only sometimes received clear research support.

There is a growing belief among some clinical theorists that biological factors may also play a key role in many cases of rapid ejaculation. Research is at the earliest of stages, but three biological theories have emerged (Althof, 2007; Mirone et al., 2001;Waldinger et al., 1998). One theory states that some men are born with a genetic predisposition to develop this dysfunction.A second argues that the brains of men with rapid ejaculation contain certain serotonin receptors that are overactive and others that are underactive. A third explanation holds that men with this dysfunction experience greater sensitivity or nerve conduction in the area of their penis, a notion that has received inconsistent research support thus far.

Male Orgasmic Disorder A man with male orgasmic disorder is repeatedly unable to reach orgasm or is very delayed in reaching orgasm after normal sexual excite- ment (see Table 11-4 on the next page). The disorder occurs in 8 percent of the male population (Hartmann & Waldinger, 2007; Laumann et al., 2005, 1999) and is typically a source of great frustration and upset, as in the case ofJohn:

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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 experi-

enced 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 differ-

ent intercourse positions, but the harder he tried, the more difficulty he hod in reaching orgasm. Because of his frustration, the couple began to ovoid sex altogether. John expe-

rienced increasing performance anxiety with each successive failure, and an increasing

sense of helplessness in the face of his problem.

(Rosen & Rosen, 1981, pp. 317-318)

A low testosterone level, certain neurological diseases, and some head or spinal cord injuries can interfere with ejaculation (Stevenson & Elliott, 2007; McKenna, 2005). Drugs that slow down the sympathetic nervous system (such as alcohol, some medications for high blood pressure, and certain psychotropic medications) can also affect ejaculation. For example, certain serotonin-enhancing antidepressant drugs appear to interfere with ejacu- lation in at least 30 percent of men who take them (Ashton, 2007; Clayton et al., 2002).

A leading psychological cause of male orgasmic disorder appears to be performance anxiety and the spectator role, the cognitive-behavioral factors also involved in male erectile disorder. 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 (Hartmann &Waldinger, 2007;Wiederman, 2001). Another psychological cause of male orgasmic disorder 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 sensa- tions and mechanics tied to those objects (Wincze et al., 2008). Finally, male orgasmic disorder may develop out of hypoactive sexual desire (Apfelbaum, 2000). A man who engages in sex largely because of pressure from his partner, without any real desire for it, simply may not get aroused enough to reach orgasm.

Female Orgasmic Disorder Stephanie and Bill, married for three years, came for sex therapy because of her lack of orgasm.

Stephanie had never had an orgasm in any way, but because of Bill's concern, she had

been faking orgasm during intercourse until recently. Finally she told him the truth, and

they sought therapy together. Stephanie 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. Stephanie 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.

(LoPircolo, 1995, p. 496)

330 ://CHAPTER 11

.female orgasmic disordereA dys- function in which a woman rarely has an orgasm or repeatedly experiences a very delayed one.

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Women with female orgasmic disorder rarely reach orgasm or generally experi- ence a very delayed one (see again Table 11-4).Around 24 percent of women apparently have this problem to some degree—including more than a third of postmenopausal women (Heiman, 2007, 2002; Laumann et al., 2005, 1999, 1994). Studies indicate that 10 percent or more of women have never had an orgasm, either alone or during inter- course, and at least another 9 percent rarely have orgasms (Bancroft et al., 2003).At the same time, half of all women experience orgasm in intercourse at least fairly regularly (LoPiccolo & Stock, 1987). Women who are more sexually assertive (Hurlbert, 1991) and more comfortable with masturbation (Kelly et al., 1990) tend to have orgasms more regularly. Female orgasmic disorder appears to be more common among single women than among women who are married or living with someone (Laumann et al., 2005, 1999, 1994)

Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning (Wincze et al., 2008). Many women instead reach orgasm with their partners by direct stimulation of the clitoris (LoPiccolo, 2002, 1995). Although early psychoanalytic theory considered a lack of orgasm during intercourse to be pathologi- cal, evidence suggests that women who rely on stimulation of the clitoris for orgasm are entirely normal and healthy (Heiman, 2007).

As you saw earlier, female orgasmic disorder typically is linked to female sexual arousal disorder, and the two tend to be studied, explained, and treated together. Once again, biological, psychological, and sociocultural factors may combine to produce these disorders (Heiman, 2007).

BIOLOGICAL CAUSES A variety of physiological conditions can affect a woman's arousal and orgasm (Wincze et al., 2008; Heiman, 2007). 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.

PSYCHOLOGICAL CAUSES The psychological causes of hypoactive sexual desire and sexual aversion, including depression, may also lead to the female arousal and orgasmic disorders (Heiman, 2007; Heard-Davison et al., 2004). In addition, as psychodynatnic theorists might predict, memories of childhood traumas and relationships have sometimes been associated with these disorders. In one large study, memories of an unhappy childhood or loss of a parent during childhood were tied to lack of orgasm in adulthood (Raboch & Raboch, 1992). In other studies, childhood memories of a dependable father, a posi- tive 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 orgasm (Heiman, 2007; Heiman et al., 1986).

SOCIOCULTURAL CAUSES For years many clinicians have believed that fe- male arousal and orgasmic disorders 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 (see Figure 11-4). In fact, many wome n with female arousal and orgasmic disorders report that they had an overly strict religious upbringing, were punished for child- hood masturbation, received no preparation for the onset of menstrua- tion, were restricted in their dating as teenagers, and were told that "nice girls don't" (LoPiccolo & van Male, 2000; LoPiccolo, 1997).

A sexually restrictive history, however, is just as common among women who function well in sexual encounters (LoPiccolo, 2002, 1997; LoPiccolo & Stock, 1987). In addition, cultural messages about female sexuality have been more positive in recent years, while the rate of female arousal and orgasmic disorders remains the same. Why, then, do some women and not others develop sexual arousal and orgasmic

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ovaginisniuseA condition marked by involuntary contractions of the muscles around the outer third of the vagina, pre- venting entry of the penis.

edyspareunia®A disorder in which a person experiences severe pain in the genitals during sexual activity.

dysfunctions? Researchers suggest that unusually stressful events or relationships may help produce the fears, memories, and attitudes that often accompany these dysfunctions (Westheimer & Lopater, 2005). For example, many women molested as children or raped as adults have arousal and orgasm dysfunctions (Hall, 2007; Heiman, 2007).

Research has also related orgasmic behavior to certain qualities in a woman's inti- mate relationships (Heiman, 2007; Metz & Epstein, 2002; Heiman et al., 1986). Studies have found, for example, that the likelihood of reaching orgasm may be tied to how much emotional involvement a woman had during her first experience of intercourse and how long that relationship lasted, the pleasure the woman obtained during the experience, her current attraction to her partner's body, and her marital happiness. Inter- estingly, the same studies have found that erotic fantasies during sex with their current partner are more common in orgasmic than in nonorgasmic women.

Disorders of Sexual Pain Two sexual dysfunctions do not fit neatly into a specific phase of the sexual response cycle. These are the sexual pain disorders, vaginismus and dyspareunia, each marked by enormous physical discomfort when sexual activity is attempted.

VaginiSMUS In vaginismus, involuntary contractions of the muscles around the outer third of the vagina prevent entry of the penis (see Table 11-5). Severe cases can prevent a couple from ever having intercourse. Estimates are that perhaps 20 percent of women occasionally experience pain during intercourse and that vaginismus occurs in less than 1 percent of all women (LoPiccolo & van Male, 2000; LoPiccolo, 1995).

Most clinicians agree with the cognitive-behavioral position that vaginismus is usu- ally a learned fear response, set off by a woman's expectation that intercourse will be painful and damaging. A variety of factors apparently can set the stage for this fear, in- cluding anxiety and ignorance about intercourse, exaggerated stories about how painful and bloody the first occasion of intercourse is for women, trauma caused by an unskilled lover who forces his penis into the vagina before the woman is aroused and lubricated, and the trauma of childhood sexual abuse or adult rape (Binik et al., 2007; Hall, 2007; Heiman & Heard-Davison, 2004).

Some women experience painful intercourse because of an infection of the vagina or urinary tract, a gynecological disease such as herpes simplex, or the physical effects of menopause. In such cases vaginismus can be overcome only if the women receive medi- cal treatment for these conditions (LoPiccolo, 2002, 1995). Many women who have vaginismus also have other sexual dysfunctions (Heard-Davison et al., 2004; Reissing et al., 2003). Some, however, enjoy sex greatly, have a strong sex drive, and reach orgasm with stimulation of the clitoris. They just fear penetration of the vagina.

Dyspareunia A person with dyspareunia (from Latin words meaning "painful mating") experiences severe pain in the genitals during sexual activity. Surveys suggest that as many as 14 percent of women and 3 percent of men suffer from this problem to some degree (Heiman, 2007, 2002; Laumann et al., 2005, 1999).As many as 8 percent of women experience painful intercourse on all or most occasions (Wincze et al., 2008). Sufferers 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.

Dyspareunia in women usually has a physical cause (Binik et al., 2007; Bergeron et al., 2002). Among the most common is an injury (for example, to the vagina or pelvic ligaments) during childbirth. Similarly, the scar left by an episiotomy (a cut often made to enlarge the vaginal entrance and ease delivery) can cause pain. Dyspareunia has also been tied to collision of the penis with remaining parts of the hymen, infections of the vagina, wiry pubic hair that rubs against the labia during intercourse, pelvic diseases, tumors, cysts, and allergic reactions to either the chemicals in vaginal douches and con- traceptive creams, the rubber in condoms or diaphragms, or the protein in semen.

Although psychological factors (for instance, heightened anxiety or overattentive- ness to one's body) or relationship problems may contribute to this disorder, psycho-

332 ://CHAPTER

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Sexual Disorders and Gender Identity Disorder 333

social factors alone are rarely responsible for it (Binik et al., 2007, 2002). In cases that are truly psychogenic, the woman is in fact likely to be suffering from hypoactive sexual desire (Steege & Ling, 1993).That is, penetration into an unaroused, unlubricated vagina is painful.

Sexual Dysfunctions

Sexual dysfunctions make it difficult or impossible for a person to have or enjoy

sexual intercourse. DSM-IV-TR lists two disorders of the desire phase of the sexual

response cycle: hypoactive sexual desire disorder and sexual aversion disorder. Bio-

logical 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 are female sexual arousal disorder and

male erectile disorder. Biological causes of male 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 relation-

ship problems.

Rapid, or premature, ejaculation, a disorder of the orgasm phase of the sexual

response cycle, has been related most often to behavioral causes, such as inappro-

priate early learning and inexperience. Male orgasmic disorder, another orgasm

disorder, can have biological causes, such as low testosterone levels, neurologi-

cal diseases, and certain drugs, and psychological causes, such as performance

anxiety and the spectator role. The dysfunction may also develop from hypoactive

sexual desire.

Female orgasmic disorder has, along with female sexual arousal disorder, 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.

In vaginismus, one of the sexual pain disorders, involuntary contractions of

the muscles around the outer third of the vagina prevent entry of the penis. In dys-

pareunia, the person experiences severe pain in the genitals during sexual activity.

Dyspareunia usually occurs in women and typically has a physical cause, such as

injury resulting from childbirth.

*Treatments for Sexual Dysfunctions The last 35 years have brought major changes in the treatment of sexual dysfunctions. For the first half of the twentieth century, the leading approach was long-term psycho- dynamic therapy. Clinicians assumed that sexual dysfunctioning was caused by failure to progress properly through the psychosexual stages of development, and they used techniques of free association and therapist interpretations to help clients gain insight about themselves and their problems. Although it was expected that broad personality changes would lead to improvement in sexual functioning, psychodynamic therapy was typically unsuccessful (Bergler, 1951).

In the 1 950s and 1960s, behavioral therapists offered new treatments for sexual dysfunctions. Usually they tried to reduce the fears that they believed were causing the dysfunctions by applying such procedures as relaxation training and systematic desensitization (Lazarus, 1965; Wolpe, 1958). These approaches had some success, but they failed to work in cases where the key problems included misinformation, negative attitudes, and lack of effective sexual technique (LoPiccolo, 2002, 1995).

334 ://CHAPTER

A revolution in the treatment of sexual dysfunctions occurred 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, along with a number of sex-specific techniques (Leiblum, 2007; Bach et al., 2001). In recent years, biological interventions, particularly drug therapies, have been added to the treatment arsenal.

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 (Wincze et al., 2008; LoPiccolo, 2002, 1995). Carlos Domera, the Argentine man with an erectile disorder whom you met earlier, responded successfully to the multiple techniques of modern sex therapy:

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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 impos- sible. The couple was advised that a brief trial of therapy, focused directly on the sexual problem, would very likely produce significant improvement within ten to fourteen sessions. They were assured that the problem was almost certainly not physical in origin, but rather psychogenic, and that therefore the prognosis was excellent.

Mr. Domera was shocked and skeptical, but the couple agreed to commence the ther- apy 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 on 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 acknowl- edged 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 humorously chastised and encouraged to try again to have sexual contact involving caressing and non-demand light genital stimula- tion, without an expectation of erection or orgasm, and to avoid intercourse.

During the second and fourth weeks [Carlos] did not achieve erections during the love play, and the therapy sessions dealt with helping him to accept himself with or without erections and to learn to enjoy sensual contact without intercourse. His wife helped him to believe genuinely that he could please her with manual or oral stimulation and that, although she enjoyed intercourse, she enjoyed these other stimulations as much, as long as he was relaxed.

[Carlos] struggled with his cultural image of what a "man" does, but he had to admit that his wife seemed pleased and that he, too, was enjoying the nonintercourse caressing techniques. He was encouraged to view his new lovemaking skills as a "success" and to recognize that in many ways he was becoming a better lover than many husbands, be- cause he was listening to his wife and responding to her requests.

By the fifth week the patient was attempting intercourse successfully with relaxed con- fidence, and by the ninth session he was responding regularly with erections. if they both

Sexual Disorders and Gender identity Disorder :// 335

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 applied in almost all cases, regardless of the dysfunction:

1. Assessment and conceptualization of 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 (Heiman, 2007; Leiblum, 2007). Sometimes proper assessment requires a team of specialists, perhaps including a psychologist, urologist, and neurologist.

2. Mutual responsibility. Therapists stress the principle of mutual responsibility. Both partners in the relationship share the sexual problem, regardless of who has the actual dysfunction, and treatment will be more successful when both are in therapy (Hall, 2007; Bach et al., 2001).

3. Education about sexuality. Many patients who suffer from sexual dysfunctions know very little about the physiology and techniques of sexual activity (Wincze et al., 2008; Rosen, 2007).Thus sex therapists may discuss these topics and offer educational materials, including instructional books, videos, and Internet sites.

4. Attitude change. Following a key principle of cognitive therapy, sex therapists help patients examine and change any beliefs about sexuality that are pre- venting sexual arousal and pleasure (Wincze et al., 2008; Heiman, 2007). Some of these mistaken beliefs are widely shared in our society and can result from past traumatic events, family attitudes, or cultural ideas.

5. 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 limit 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.

6. Increasing sexual and general communication skills. Couples are taught to use their sensate-focus skills and apply new sexual techniques and positions at home. They may, for example, try sexual positions in which the person being caressed can guide the other's hands and control the speed, pressure, and 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 man- ner ("The way you're touching me doesn't turn me on"). Moreover, couples are often given broader training in how best to communi- cate with each other (Wincze et al., 2008; Bach et al., 2001).

7. Changing destructive lifestyles and marital 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

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8. Addressing physical and medical factors. When sexual dysfunctions are caused by a medical problem, such as disease, injury, medication, or substance abuse, therapists try to address that problem (Ashton, 2007; Basson, 2007). If anti- depressant medications are causing a man's erectile disorder, for example, the clinician may lower the dosage of the medication, change the time of day when the drug is taken, or consider prescribing a different antidepressant.

What Techniques Are Applied to Particular Dysfunctions? In addition to the general components of sex therapy, specific techniques can help in each of the sexual dysfunctions.

Hypoactive Sexual Desire and Sexual Aversion Hypoactive sexual desire and sexual aversion are among the most difficult dysfunctions to treat because of the many issues that may feed into them (Maurice, 2007; LoPiccolo, 2004, 2002).Thus thera- pists typically apply a combination of techniques. 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, pa- tients receive cognitive self- instruction training to help them change their negative reac- tions to sex. That is, they learn to replace negative statements during sex with "coping statements," such as "I can allow myself to enjoy sex; it doesn't mean I'll lose control."

Therapists may also use behavioral approaches to help heighten a patient's sex drive. They may instruct clients to keep a "desire diary" in which they record sexual thoughts and feelings, to read books and view films with erotic content, and to fantasize about sex. Pleasurable shared activities such as dancing and walking together are also encour- aged (LoPiccolo, 2002, 1997).

For sexual aversion that has resulted from sexual assault or childhood molestation, additional techniques may be needed (Hall, 2007). A patient may be encouraged to remember, talk about, and think about the assault until the memories no longer arouse fear or tension. Or the individual may be instructed to have a mock dialogue with the molester in order to express lingering feelings of rage and powerlessness (LoPiccolo, 2002, 1995).

These and related psychological approaches apparently help many women and men with hypoactive sexual desire and aversion disorders eventually to have intercourse more than once a week (Heard-Davison et al., 2004; Hurlbert, 1993). However, only a few controlled studies have been conducted. 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. The interventions have received some prelimi- nary research support (Ashton, 2007; Davis, 2000, 1998).

Erectile Disorder Treatments for erectile disorder focus on reducing a man's perfor- mance anxiety, increasing his stimulation, or both, using a range of behavioral, cognitive, and relationship interventions (Rosen, 2007; Segraves & Althof, 2002). 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 caress- ing 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. In another technique, the couple may be instructed to use manual or oral sex to try to achieve the woman's orgasm, again reducing pressure on the man to perform (LoPiccolo, 2004, 2002, 1995).

Biological approaches gained great momentum with the development in 1998 of sildengfil (trade name Viagra). This drug increases blood flow to the penis within one

336 ://CHAPTER 11

Sexual Disorders and Gender identity Disorder :1/ 337

hour of ingestion; the increased blood flow enables the user to attain an erection dur- ing sexual activity. Sildenafil appears to be relatively safe except for men with certain coronary heart diseases and cardiovascular diseases, particularly those who are taking nitroglycerin and other heart medications (Stevenson & Elliott, 2007). Over the past decade, two other erectile dysfunction drugs have been approved—tadaiafit (Cialis) and vardenafil (Levitra)—and are now actively competing withViagra for a share of the lucra- tive marketplace. Collectively, the three drugs are the most common form of treatment for erectile disorder (Rosen, 2007). They effectively restore erections in 75 percent of men who use them.

Prior to the development of Viagra, Cialis, and Levitra, a range of other medical procedures -were developed for erectile disorder. These procedures are now viewed as "second-line" treatments that are applied primarily when the medications are unsuc- cessful or too risky for individuals (Rosen, 2007; Frohman, 2002). Such procedures include gel suppositories, injections of drugs into the penis, and a vacuum erection device (VED), a hollow cylinder that is placed over the penis. Here a man uses a hand pump to pump air out of the cylinder, drawing blood into his penis and producing an erection.

Male Orgasmic Disorder Like the treatments for male erectile disorder, thera- pies for male orgasmic disorder include techniques to reduce performance anxiety and increase stimulation (Hartmann & Waldinger, 2007; LoPiccolo, 2004). In one of many such techniques, a man may be instructed to masturbate to orgasm in the presence of his partner or to masturbate just short of orgasm before inserting his penis for intercourse (Marshall, 1997). This increases the likelihood that he will ejaculate during intercourse. He then is instructed to insert his penis at ever earlier stages of masturbation.

When male orgasmic disorder is caused by physical factors such as neurological damage or injury, treatment may include a drug to increase arousal of the sympathetic nervous system (Stevenson & Elliott, 2007). However, few studies have systematically tested the effectiveness of such treatments (Hartmann &Waldinger, 2007).

Rapid Eiaculation Rapid, or premature, ejaculation has been treated successfully for years by behavioral procedures (Althof, 2007; Masters & Johnson, 1970). In one such approach, the stop-start, or pause, procedure, the penis is manually stimulated until the man is highly aroused. The couple then pauses until his arousal subsides, after which the stimulation is resumed.This sequence is repeated several times before stimulation is car- ried through to ejaculation, so the man ultimately experiences much more total time of stimulation than he has ever experienced before (LoPiccolo, 2004, 1995). Eventually the couple progresses to putting the penis in the vagina, making sure to withdraw it and to pause whenever the man becomes too highly aroused.According to clinical reports, after two or three months many couples can enjoy prolonged intercourse without any need for pauses (Althof, 2007; LoPiccolo, 2004, 2002).

Some clinicians treat rapid ejaculation with SSRIs, the serotonin-enhancing antide- pressant drugs. Because these drugs often reduce sexual arousal or orgasm, the reasoning goes, they may be helpful to men who experience rapid ejaculation. Many studies report positive results with this approach (Althof, 2007, 1995; Ashton, 2007). The effect of this approach is consistent with the biological theory, mentioned earlier, that serotonin re- ceptors in the brains of men with rapid ejaculation may function abnormally.

Female Arousal and Orgasmic Disorders Specific treatments for female arousal and orgasmic dysfunctions include cognitive-behavioral techniques, self- exploration, enhancement of body awareness, and directed masturbation training (Heiman, 2007, 2002, 2000; LoPiccolo, 2002, 1997) .These procedures are especially use- ful for women who have never had an orgasm under any circumstances. Biological treat- ments, including hormone therapy, have also been tried, but research has not found such interventions to be consistently helpful (Heiman, 2007).

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 use of diagrams and reading material, private self-stimulation, erotic

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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 women learn to have an orgasm during masturbation, about 80 percent during caressing by their partners, and about 30 percent during intercourse (Heiman, 2007; LoPiccolo, 2002, 1997).

As you read earlier, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and can reach orgasm through caressing, either by her partner or by herself. For this reason some therapists believe that the wisest course is simply to educate women whose only concern is lack of orgasm during intercourse, informing them that they are quite normal.

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aginismus Specific treatment for vaginismus, involuntary contractions of the muscles around the vagina, typically takes two approaches (Kabakci & Batur, 2003). 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 increas- ingly large dilators in her vagina at home and at her own pace and eventually ending with the insertion of her partner's penis (Binik et al., 2007; Rosenbaum, 2007). Most women treated for vaginismus with such procedures eventually have pain-free intercourse (ter Kuile et al., 2009; Heiman, 2002). In recent years, some medical interventions have also been applied. For example, several clinical investigators have injected the problematic vaginal muscles with Bo tox to help reduce spasms in those muscles (Ghazizadeh & Nikzad, 2004; Romito et al., 2004). However, studies of this approach have been unsystematic.

Dyspareunia As you saw earlier, the most common cause of dyspareunia, genital pain during intercourse, is physical, such as pain-causing scars, lesions, or infection after- effects.When the cause is known, pain management procedures (see pages 333-334) and sex therapy techniques may be tried, including helping a couple to learn intercourse positions that avoid putting pressure on the injured area. Medical interventions—from topical creams to surgery—may also be tried, but they must still be combined with other sex therapy techniques to overcome the years of sexual anxiety and lack of arousal (Binik et al., 2007; Heard-Davison et al., 2004). Many experts believe that most cases of dyspareunia (and for that matter, vaginismus) are best assessed and treated by a team of professionals, including a gynecologist, physical therapist, and sex therapist or other men- tal health professional (Rosenbaum, 2007).

What Are the Current Trends in Sex Therapy? Sex therapists have now moved well beyond the approach first developed by Masters and Johnson. For example, today's sex therapists regularly treat partners who are living together but not married. They also treat sexual dysfunctions that arise from psychologi- cal disorders such as depression, mania, schizophrenia, and certain personality disorders (Leiblum, 2007; Bach et al., 2001). In addition, sex therapists no longer screen out clients with severe marital discord, the elderly, the medically ill, the physically handicapped, gay clients, or individuals who have no long-term sex partner (Nichols & Shernoff, 2007; Stevenson & Elliott, 2007). Sex therapists are also paying more attention to excessive sexuality, sometimes called hypersexuality or sexual addiction (Kafka, 2007, 2000).

Many sex therapists have expressed concern about the sharp increase in the use of drugs and other medical interventions for sexual dysfunctions, particularly for hypo- active sexual desire and male 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 (Leiblum, 2007; Rosen, 2007). 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.

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oparaphiliasuDisorders characterized by recurrent and intense sexual urges, fantasies, or behaviors involving nonhu- man objects, children, nonconsenting adults, or experiences of suffering or humiliation.

Treatments Sexud Dysfunctions

In the 1970s the work of William Masters and Virginia Johnson led to the develop- ment of sex therapy. Today sex therapy combines a variety of cognitive, behavioral, couple, and family systems therapies. It generally includes features such as care- ful 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 dysfunc- tions, The use of biological treatments for sexual dysfunctions is also increasing.

oParaphilias ParaphiIias are disorders in which individuals repeatedly have intense sexual urges or fantasies or display sexual behaviors that involve nonhuman objects, children, non- consenting adults, 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.

According to DSM-IV-TR, a diagnosis of paraphilia should be applied only when the urges, fantasies, or behaviors last at least six months (see Table 11-6 on the next page). For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or interfere with one's social life or job performance in order for a diagnosis to be applied (APA, 2000). For certain paraphilias, however, DSM-IV-TR clarifies that performance of the sexual behavior indicates a disorder even if the individual experiences no distress or impairment (APA, 2000). People who initiate sexual contact with children, for ex- ample, warrant a diagnosis of pedophilia regardless of how troubled the individuals may or may not be over their behavior.

Some people with one kind of paraphilia display others as well (Marshall et al., 2008). Relatively few people receive a formal diagnosis of paraphilia, but the large Inter- net and consumer market in paraphilic pornography leads clinicians to suspect that the patterns may be quite common (APA, 2000). People whose paraphilias involve children or nonconsenting adults often come to the attention of clinicians when they get into legal trouble (Maletzky & Steinhauser, 2004).

340 ://CHAPTER 1 1

Although theorists have proposed various explanations for paraphilias, there is little formal evidence to support them (Abramowitz, 2008). Moreover, none of the many treatments applied to paraphilias have received much research or proved clearly effective (Roche & Quayle, 2007; McConaghy, 2005). Psychological and sociocultural treatments for paraphilias have been available the longest, but today's professionals are also using biological interventions. Some practitioners administer drugs called a fitiandrogens that lower the production of testosterone, the male sex hormone, and reduce the sex drive (Marshall et al., 2008). Although antiandrogens do indeed reduce paraphilic patterns, several of them disrupt normal sexual feelings and behavior as well.Thus the drugs tend to be applied primarily when the paraphilias are of danger either to the individuals themselves or to other people. Clinicians are also increasingly administering SSRIs, the serotonin-enhancing antidepressant medications, to treat persons with paraphilias, hop- ing that the drugs will reduce these compulsion-like sexual behaviors just as they help reduce other kinds of compulsions (Wright & Hatcher, 2006). In addition, of course, a common effect of the SSRIs is to lower sexual arousal.

Fetishism Key features of fetishism are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other stimuli. Usually the disorder, which is far more common in men than in women, begins in adolescence. Almost anything can be a fetish; women's underwear, shoes, and boots are particularly common (APA, 2000). Some people with fetishism commit thievery 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 indi- vidual may ask a partner to wear the object when they have sex (Marshall et al., 2008). Several of these features are seen in the following case:

ofetishismeA paraphilia consisting of recurrent and intense sexual urges, fanta- sies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other stimuli,

°masturbatory satiation0A behav- ioral 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 bore- dom that in turn becomes linked to the object.

°orgasmic reorientation0A proce- dure for treating certain paraphilias by teaching clients to respond to new, more appropriate sources of sexual stimulation.

otransvestic fetishismoA paraphilia consisting of repeated and intense sexual urges, fantasies, or behaviors that involve dressing in clothes of the oppo- site sex. Also known as transvestism or cross-dressing.

A 32-year-old, single male . related that although he was somewhat sexually attracted by women, he was far more attracted by "their panties."

To the best of the patient's memory, sexual excitement began at about age 7, when he came upon a pornographic magazine and felt stimulated by pictures of partially nude women wearing "panties." His first ejaculation occurred at 13 via masturbation to fan- tasies of women wearing panties. He masturbated into his older sister's panties, which he had stolen without her knowledge. Subsequently he stole panties from her friends and from other women he met socially. He found pretexts to "wander" into the bedrooms of women during social occasions, and would quickly rummage through their possessions until he found a pair of panties to his satisfaction. He later used these to masturbate into, and then "saved them" in a "private cache." The pattern of masturbating into women's under-wear had been his preferred method of achieving sexual excitement and orgasm from adolescence until the present consultation.

(Spitzer et al., 1994, p. 247)

Researchers have not been able to pinpoint the causes of fetishism. Behaviorists propose that fetishes are acquired through classical conditioning (Roche & Quayle, 2007; Akins, 2004). 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 experi- ences similarly occur in the presence of particular objects, perhaps the stage is set for development of fetishes.

Behaviorists have sometimes treated fetishism with aversion therapy Wright & Hatcher, 2006; Krueger & Kaplan, 2002). In one study, an electric shock was administered to the arms or legs of participants with fetishes while they imagined their objects of desire

Sexual Disorders and Gender Identify Disorder :1/ 341

(Marks & Gelder, 1967).After two weeks of therapy all men in the study showed at least some improvement. In another aversion technique, people with fetishism are guided to imagine the pleasurable object and repeatedly to pair this image with an imagined aversive stimulus until the object of sexual pleasure is no longer desired.

Another behavioral treatment for fetishism is masturbatory satiation (Wright & Hatcher, 2006). 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.

Yet another behavioral approach to fetishism, also used for other paraphilias, is orgasmic reorientation, which teaches individuals to respond to more appropriate sources of sexual stimulation (Wright & Hatcher, 2006). People are shown conventional stimuli while they are responding to unconventional objects.A person with a shoe fetish, for example, may be instructed to obtain an erection from pictures of shoes and then to begin masturbating to a picture of a nude woman. If he starts to lose the erection, he must return to the pictures of shoes until he is masturbating effectively, then change back to the picture of the nude woman. When orgasm approaches, he must direct all attention to the conventional stimulus.

Transvestic Fetishism Transvestic fetishism, also known as transvestism or cross-dressing, is a recurrent need or desire to dress in clothes of the opposite sex in order to achieve sexual arousal. In the following passage, a 42-year-old married father describes his pattern:

1 have been told that when I dress in drag, at times I look like Whistler's Mother [laughs], especially when I haven't shaved closely. I usually am good at detail, and I make sure when I dress as a woman that 1 have my nails done just so, and that my colors match. Honestly, it's hard to pin o date on when I began cross dressing. . . . If pressed, I would have to say it began when I was about 10 years of age, fooling around with and putting on my mom's clothes.. . . / was always careful to put everything back in its exact place, and in 18 years of doing this in her home, my mother never, 1 mean never, suspected, or questioned me about putting on her clothes. I belong to a transvestite support group . . . , a group for men who cross dress. Some of the group are homosexuals, but most are not. A true transvestite—and 1 am one, so 1 know—is not homosexual. We don't discriminate against them in the group at all; hey, we have enough trouble getting acceptance as nor- mal people and not just a bunch of weirdos ourselves. They are a bunch of nice guys . . . , really. Most of them are like me.

Most of [the men in the group] have told their families about their dressing inclina- tions, but those that are married are a mixed lot; some wives know and some don't, they just suspect. I believe in honesty, and told my wife about this before we were married. We're separated now, but I don't think it's because of my cross dressing. . . . Some of my friends, when I was growing up, suggested psychotherapy, but I don't regard this as a problem. If it bothers someone else, then they have the problem. . . I function perfectly well sexually with my wife, though it took her some time to be comfortable with me wear- ing feminine underwear; yes, sometimes I wear it while making love, it just makes it more exciting.

(Janus &Jamts, 1993, p. 121)

Like this man, the typical person with transvestism, almost always a heterosexual male (Marshall et al., 2008), begins cross-dressing in childhood or adolescence (Langstrom & Zucker, 2005; Doctor & Neff; 2001). He is the picture of characteristic masculinity

342 :1/CHAPTER 1 1

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 transvestism involve their wives in their cross-dressing behavior (Kolodny et al., 1979). The disorder is often confused with gender identity disorder, but, as you will see, they are two separate patterns that overlap only in some individuals.

The development of transvestic fetishism sometimes seems to follow the behavioral principles of operant conditioning. In such cases, parents or other adults may openly encourage the individuals to cross-dress as children or even reward them for this behavior. In one case, a woman was delighted to discover that her young nephew enjoyed dressing in girls' clothes. She had always wanted a niece, and she proceeded to buy him dresses and jewelry and sometimes dressed him as a girl and took him out shopping.

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°exhibitionism®A paraphilia in which persons have repeated sexually arousing urges or fantasies about exposing their genitals to another person, and may act upon those urges.

ovoyeurismeA paraphilia 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 may act upon these desires.

afrotteurismoA parophilia consisting of repeated and intense sexual urges, fan- tasies, or behaviors that involve touching and rubbing against a nonconsenting person.

opedophiliaeA paraphilia in which a person has repeated and intense sexual urges or fantasies about watching, touch- ing, or engaging in sexual acts with prepubescent children and may carry out these urges or fantasies.

Exhibitionism A person with exhibitionism has recurrent urges to expose his genitals to another per- son, almost always a member of the opposite sex, or has sexually arousing fantasies of doing so. He may also carry out those urges but rarely attempts to initiate sexual activity with the person to whom he exposes himself (Maletzky, 2002, 2000; APA, 2000). More often, he wants to provoke shock or surprise. 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 (Langstrom & Seto, 2006).Yet between one-third and one-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 typi- cally becomes stronger when the person has free time or is under significant stress.

Generally the disorder begins before age 18 and is most common in males (APA, 2000). Some studies suggest that persons with exhibitionism are typically immature in their dealings with the opposite sex and have difficulty in interpersonal relationships (Marshall et al., 2008; Murphy & Page, 2006). Around 30 percent of them are married and another 30 percent divorced or separated; their sexual relations with their wives are not usually satisfactory (Doctor & Neff, 2001). Many have doubts or fears about their masculinity, and some seem to have a strong bond to a possessive mother. As with other paraphilias, treatment generally includes aversion therapy and masturbatory satiation, pos- sibly combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy (Marshall et al., 2008; Murphy & Page, 2006).

Voyeurism A person who engages in voyeurism has recurrent and intense urges to secretly observe unsuspecting people as they undress or to spy on couples having intercourse.The person may also 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. This disorder usually begins before the age of 15 and tends to persist (APA, 2000).

The vulnerability of the people being observed and the probability that they would feel humiliated if they knew they were under observation are often part of the individu- al's enjoyment. In addition, the risk of being discovered often adds to the excitement.

Voyeurism, like exhibitionism, is often a source of sexual excitement in fantasy; it can also play a role in normal sexual interactions, but in such cases it is engaged in with the consent or understanding of the partner. The clinical disorder of voyeurism is marked by the repeated invasion of other people's privacy. Some people with voyeur- ism are unable to have normal sexual relations; others, however, have a normal sex life apart from their voyeurism.

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Sexual Disorders and Gender Identity Disorder :11 343

Many psychodynamic clinicians propose that people with voyeurism are seeking by their actions to gain power over others, possibly because they feel inadequate or are sexually or socially shy (Metzl, 2004). Behaviorists explain the disorder as a learned be- havior that can be traced to a chance and secret observation of a sexually arousing scene. If such observations are repeated on several occasions while the onlooker masturbates, a voyeuristic pattern may develop.

Froiteurism A person who develops frotteurism has repeated and intense sexual urges to touch and rub against a nonconsenting person or has sexually arousing fantasies of doing so. The person may also act on the urges. Frottage (from French frotto; "to rub") is usually com- mitted in a crowded place, such as a subway or a busy sidewalk (Horley, 2001; Krueger & Kaplan, 2000). 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 person reaches the age of about 25, the acts gradually decrease and often disappear (APA, 2000).

Pedophilia A person with pedophilia gains sexual gratification by watching, touching, or engaging in sexual acts with prepubescent children, usually 13 years old or younger. Some people with this disorder are satisfied by child pornography (Linz & lmrich, 2001) or seemingly innocent material such as children's underwear ads; others are driven to actually watch, fondle, or engage in sexual intercourse with children (Durkin & Hundersmarck, 2008). Some people with pedophilia are attracted only to children; others are attracted to adults as well (Roche & Quayle, 2007; APA, 2000). Both boys and girls can be pedophilia victims, but there is evidence suggesting that two-thirds of them are girls (Doctor & Neff, 2001; Ross & Heslet, 1992).

People with pedophilia usually develop their disorder during adolescence. Some were themselves sexually abused as children, and many were neglected, excessively pun- ished, or deprived of genuinely close relationships during their childhood (McAnulty, 2006; Berlin, 2000). It is not unusual for them to be married and to have sexual dif- ficulties or other frustrations in life that lead them to seek an area in which they can be masters. Often these individuals are immature: Their social and sexual skills may be underdeveloped, and thoughts of normal sexual relationships fill them with anxiety (McAnulty, 2006).

Some people with pedophilia also exhibit distorted think- ing, such as, "It's all right to have sex with children as long as they agree" (Roche & Quayle, 2007; Abel et al., 2001, 1984). Similarly, it is not uncommon for pedophiles to blame the chil- dren for adult-child sexual contacts or to assert that the children benefited from the experience (Durkin & Hundersmarck, 2008; Lanning, 2001).

While many people with pedophilia believe that their feel- ings 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 individuals. Indeed, there is now a range of websites, newsgroups, chat rooms, and discussion forums centered on pedophilia and adult-child sex (Durkin & I-lundersmarck, 2008).

Studies have found that most men with pedophilia also display at least one additional psychological disorder (McAnulty,

cvfigiM 1,0

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THERAPY: VIE POSSIBILITY

OF CHANCING . BEIVAVIOR

would more carefully weigh the potential conse-

quences of research publications.

344 ://CHAPTER 11

Serving fine Public Good

i 4s clinical practitioners and re-

searchers conduct their work,

should they consider the potential

impact of their decisions on society?

Many people, including a large

number of clinicians, believe that the

answer to this question is a resound-

ing yes. A decade ago two important

clashes between the clinical field and

the public interest—each centering on

the disorder of pedophilia—brought this issue to life.

In 1994, the then-newly published

DSM-IV ruled that people should re-

ceive a diagnosis of pedophilia only

if their recurrent fantasies, urges, or

behaviors involving sexual activity

with children cause them significant

distress or impairment in social, occu-

pational, or other spheres of function-

ing. Critics worried that this criterion

seemed to suggest that pedophilic

behavior is acceptable, even normal,

as long as it causes no distress or

impairment. Even the U.S. Congress

condemned the DSM-IV definition.

In response to these criticisms,

the American Psychiatric Association

clarified its position in 1997, stating,

"An adult who engages in sexual

activity with a child is performing

a criminal and immoral act which

never can be considered moral or

socially acceptable behavior." In

2000 the Association went further

R ... • • .•

still and changed the criteria for

pedophilia in its newly published

DSM-IV-TR; the disorder is now diag-

nosed if persons act on their sexual

urges, regardless of whether they

experience distress or impairment

(APA, 2000). Similarly, acting on

one's recurrent sexual urges or fanta-

sies warrants a diagnosis in cases of

exhibitionism, voyeurism, frotteurism,

and sexual sadism.

Another clash between the clinical

field and public sensibilities occurred

in 1998 when a review article in

the prestigious journal Psychological Bulletin concluded that the effects of child sexual abuse are not as long-

lasting as usually believed. The study

set off a firestorm, with critics arguing

that the conclusion runs counter to

evidence from a number of studies.

Furthermore, many people worried

that the article's conclusions could be

used to legitimize pedophilia. After a

groundswell of criticism, the American

Psychological Association, publisher

of the journal, acknowledged that

it should have given more thought

to how the study would be received

and should have either presented the

article with an introduction outlining

the Association's stance against child

sexual abuse or paired it with articles

offering different viewpoints. The As-

sociation also said that in the future it

2006). In recent years, some theorists have proposed that pedophilia may be related to a biochemical or brain structure abnormality (Cantor et al., 2004; Maes et al., 2001), but clear biological factors have yet to emerge in research.

Most pedophilic offenders are imprisoned or forced into treatment if they are caught (Stone et al., 2000). After all, they are committing child sexual abuse when they take any steps toward sexual contact with a child. Moreover, 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 (Sandler et al., 2009).

Treatments for pedophilia include those already mentioned for other paraphilias, such as aversion therapy, masturbatory satiation, orgasmic reorientation, cognitive- behavioral therapy, and antiandrogen drugs (Krueger & Kaplan, 2002; LoPiccolo,

Sexual Disorders and Gender Identify Disorder :// 345

1992). One widely applied cognitive-behavioral treatment for pedophilia, relapse- prevention training, is modeled after the relapse-prevention programs used in the treat- ment of sub-stance dependence (Wright & Hatcher, 2006; Marques et al., 2005) (see page 312). 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 the situations or coping with them more ef- fectively. Relapse-prevention training has sometimes, but not consistently, been of help in pedophilia and in certain other paraphilias (Marshall et al., 2008).

Sexual Masochism A person with sexual masochism is intensely sexually aroused by the act or thought of being humiliated, beaten, bound, or otherwise made to suffer. 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 disor- der 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, 2000).

An industry of products and services has arisen to meet the desires of people with sexual masochism. Here a 34--year-old woman describes her work as the operator of a sadomasochism house:

•

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. . . . Remember, these are businessmen, and they are not only buying my time, but they have to get back to work, so time is important.

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 hire, that he knows he deserves worse, and I begin to list his sins. It works every time. Hey, I'm not nuts, I know what I'm doing. I act very tough and hard, but I'm really a very sensitive woman. But you have to watch out for a guy's health ... you must not kill him, or have him get a heart attack. . . . I know of other places that have had guys die there. I've never lost a customer to death, though they may have wished for it during my "treatment." Remember, these are repeat customers. I have a clientele and a reputation that 1 value.

(Jarvis &Janus, 1993, p. 115)

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In one form of sexual masochism, hypoxyphilia, people strangle or smother them- selves (or ask their partner to strangle them) in order to enhance their sexual pleasure. There have, in fact, been a disturbing number of clinical reports of autoerotic asphyxia, in which individuals, 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, but it is at least sometimes accompanied by other acts of bondage (Blanchard & Hucker, 1991).

Most masochistic sexual fantasies begin in childhood. However, the person does not act out the urges until later, usually by early adulthood.The disorder typically continues

°sexual masochism®A poraphilia characterized by repeated and intense sexual urges, fantasies, or behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer.

346 ://C HAPTER H

osexuai sadismeA paraphilia chorea,. terized by repeated and intense sexual urges, fantasies, or behaviors that involve inflicting suffering on others.

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for many years. Some people practice more and more dangerous acts over time or dur- ing times of particular stress (Santtila et al., 2006, 2002; APA, 2000).

In many cases sexual masochism seems to have developed through the behavioral process of classical conditioning (Akins, 2004).A classic case study tells of a teenage boy with a broken arm who was caressed and held close by an attractive nurse as the physi- cian set his fracture, a procedure done in the past without anesthesia (Gebhard, 1965). The powerful combination of pain and sexual arousal the boy felt then may have been the cause of his later masochistic urges and acts.

Sexual Sadism A person with sexual sadism, usually male, is intensely sexually aroused by the thought or act of inflicting suffering on others by dominating, restraining, blindfolding, cutting, strangling, mutilating, or even killing the victim (Marshall & Kennedy, 2003). The label is derived from the name of the famous Marquis de Sade (1740-1814), who tortured others in order to satisfy his sexual desires. People who fantasize about 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. Some, however, act out their urges on nonconsenting victims (Marshall et al., 2008; Marshall & Hucker, 2006).A number of rapists and sexual mur- derers, for example, exhibit sexual sadism. 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 child- hood ( Johnson & Becker, 1997); the sadistic acts, when they occur, develop by early adulthood (APA, 2000). The pattern is long-term. Sadistic acts sometimes stay at the same level of cruelty, but often they become more and more severe over the years (Santtila et al., 2006, 2002). Obviously, people with severe forms of the disorder may be highly dangerous to others.

Some behaviorists believe that classical conditioning is at work in sexual sadism (Akins, 2004). While inflicting pain, perhaps unintentionally, on an animal or person, a teenager may feel intense emotions and sexual arousal. The association between in- flicting pain and being aroused sexually sets the stage for a pattern of sexual sadism. Behaviorists also propose that the disorder may result from modeling, when adolescents observe others achieving sexual satisfaction by inflicting pain. The many Internet sex sites, sexual magazines, books, and videos in our society make such models readily avail- able (Seto et al., 2001).

Both psychodynamic and cognitive theorists suggest that people with sexual sadism 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 (Doctor, 2003; Rathbone, 2001). Alternatively, certain biologi- cal studies have found signs of possible abnormalities in the endocrine systems of persons with sadism (Langevin et al., 1988). None of these explanations, however, has been thoroughly investigated.

Sexual sadism has been treated by aversion therapy. The public's view of and distaste for this procedure have been influenced by Anthony Burgess's novel (later a movie) A Clockwork Orange, which describes simultane- ous presentations of sadistic 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. However, relapse-prevention training, used in some criminal cases, may be of value (Wright & Hatcher, 2006; Maletzky, 2003, 2002).

• Se):. c 11.

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Sexual Disorders and Gender Identity Disorder :ll 347

A Word ®f Caution The definitions of the paraphilias, like those of sexual dysfunctions, are strongly in- fluenced by the norms of the particular society in which they occur. Some clinicians argue that except when people are hurt by them, many paraphilic behaviors should not be considered disorders at all. At the very least, we need to be extremely careful about applying these labels to others or to ourselves. Keep in mind that for years clinicians considered homosexuality a paraphilia, and their judgment was used to justify laws and even police actions against gay individuals (Kirby, 2000). Only when the gay rights movement helped change society's understanding of and attitudes toward homosexual- ity did clinicians stop considering it a disorder. 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.

omosexuality is not new; it has al- ways existed in all cultures, as has

the controversy that surrounds it. While most cultures do not openly advocate homosexuality, over the course of history few have condemned it more fiercely than Western culture has (Kauth, 2006). Never- theless, research shows that a society's ac- ceptance or rejection of gay people does not affect the rate of homosexuality.

Before 1973, the DSM listed homosexu- ality as a sexual disorder. Protests by gay activist groups and many psychotherapists eventually led to its elimination from the diagnostic manual as a sexual disorder (Robertson, 2004). Most clinicians in the Western world now view homosexuality as a variant of normal sexual behavior, not a disorder (Crary, 2007).

Psychologists do continue to debate one issue: whether homosexuality is the result of psychological factors (for example, cog- nitive and emotional factors) or biological factors (for example, genetic predisposi- tions or events that occur in the uterus). The debate has been fueled by a range of find- ings that both support and contradict these various factors (Kauth, 2006; Hyde, 2005; Savic et al., 2005). Given such mixed results, several interactionist theories have also been proposed, but these have yet to be tested systematically (Kauth, 2006, 2000; Diamond, 2003).

Gay people are found in every socio- economic group, every race, and every

profession. It is impossible to identify a characteristic that consistently separates them from the rest of the population other than their sexual orientation. The gay com- munity argues that since sexual orienta- tion is the only variable that consistently separates homosexual from heterosexual couples, gay couples should have the same rights as heterosexual ones. In certain states, marriages are now performed for same-sex couples. Furthermore, gay cou- ples are increasingly asserting their rights in areas such as spousal health insurance coverage, housing opportunities, tax and inheritance laws, and social security ben- efits; recent court decisions have endorsed a number of these rights.

A consistent 4 to 7 percent of all Ameri- cans continue to identify themselves as gay. Now that most psychologists agree that homosexuality is not a disorder, a key issue remains: How will society react to a significant proportion of its population that typically differs from the rest in but one way—their sexual orientation? So far, Western society cannot claim to have dealt very effectively or fairly with this question, but at least a trend toward understand- ing and equality seems to be unfolding. Research suggests that through continued education and exposure, people of differ- ent sexual orientations can often learn to accept and work with one another (Guth et al., 2004).

3.48 :if/CHAPTER 1

YAV-A P4 \ I

Sex and the Law, Take 2

, I .1 :;:ff

•

Paraphilias

Paraphilias are disorders marked by recurrent and intense sexual urges, fantasies, or behaviors involving either nonhuman objects, children, nonconsenting adults, or experiences of suffering or humiliation. The disorders are found primarily in men. The paraphilias include fetishism, transvestic fetishism (transvestism), exhibi- tionism, voyeurism, frotteurism, pedophilia, sexual masochism, and sexual sadism. Although various explanations have been proposed for these disorders, research has revealed little about their causes. A range of treatments have been tried, including aversion therapy, masturbatory satiation, orgasmic reorientation, and relapse-prevention training.

*Gender Identity Disorder As children and adults, most people feel like and identify themselves as males or females—an identity that is consistent with the gender to which they are born. But society has come to appreciate that many people do not experience such gender clar- ity. Instead, they have transgender experiences— a sense that their actual gender identity is different from the gender category to which they were born physically or that it lies outside the usual male versus female categories (Carroll, 2007). Many people with such transgender experiences come to terms with their gender inconsistencies, but others experience gender dysphoria— unhappiness with their given gender—and often seek treatment for their problem. DSM-IV-TR categorizes these latter individuals as having gender identity disorder, a disorder in which people persistently feel that a vast mis- take has been made and they have been born to the wrong sex (see Table 11-7).

The DSM-IV-TR categorization of gender identity disorder has become contro- versial in recent years. Many people believe that transgender experiences reflect alter- native—not pathological—ways of experiencing one's gender identity. Moreover, they argue, even transgender experiences that bring unhappiness, such as those called gender dysphoria, should not be considered a disorder. At the other end of the spectrum, many argue that gender identity disorder is in fact a medical problem that often produces per- sonal unhappiness.They hold that gender identity disorder should not be categorized as a psychological disorder, just as kidney disease and cancer, medical conditions that may also produce unhappiness, are not categorized as psychological disorders. Although one of these views may eventually prove to be an appropriate perspective, this chapter largely will follow DSM-IV-TR's current position that gender identity disorder represents more than a variant lifestyle and is also far from a clearly defined medical problem, and it will examine what clinical theorists believe they know about the pattern.

People with gender identity disorder would like to get rid of their primary and secondary sex characteristics—many of them find their own genitals repugnant—and acquire the characteristics of the other sex (APA, 2000). Men with gender identity dis- order outnumber women by around 2 to 1. People with the problem often experience anxiety or depression and may have thoughts of suicide (Hepp et al., 2005; Bradley, 1995). Such reactions may be related to the confusion and pain brought on by the dis- order itself, or they may also be tied to the prejudice typically experienced by individuals who display this pattern (Sanchez &Vilain, 2009). Studies also suggest that some people with gender identity disorder further manifest a personality disorder (Hepp et al., 2005). For most of today's clinicians, the term "gender identity disorder" has replaced the old term transsexualism, although the label "transsexual" is still commonly applied to those individuals who desire and seek full gender change.

Sometimes gender identity disorder emerges in children (Carroll, 2007; Zucker, 2005). Like adults with this disorder, the children feel uncomfortable about their assigned sex

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Sexual Disorders and Gender Identity Disorder :1/ 349

and yearn to be members of the opposite sex. This childhood pattern usually disappears by adolescence or adulthood, but in some cases it develops into adult gender identity dis- order (Cohen-Kettenis, 2001).Thus adults with this disorder may have had a childhood gender identity disorder, but most children with the disorder do not become adults with the disorder. Surveys of mothers indicate that about 1.5 percent of young boys wish to be girls, and 3.5 percent of young girls wish to be boys (Carroll, 2007; Zucker & Bradley, 1995).Yet, considerably less than 1 percent of adults manifest gender identity disorder. This age shift in the prevalence of gender identity disorder is, in part, why today's leading experts on the disorder strongly recommend against any form of physical treatment for this pattern until individuals are at least 16 years of age (HBIGDA, 2001).

Explanations of Gender Identity Disorder Various theories have been proposed to explain gender identity disorder (Carroll, 2007; Gehring & Knudson, 2005), but research to test these views has been limited and gener- ally weak. Many clinicians suspect that biological—perhaps genetic or prenatal—factors play a key role in the disorder (Henningsson et al., 2005).

Consistent with a genetic explanation is evidence that the disorder sometimes runs in families (Green, 2000). In addition, one biological study has received considerable at- tention (Zhou et al., 1997, 1995). Dutch investigators autopsied the brains of six people who had changed their sex from male to female. They found that a cluster of cells in the hypothalamus called the bed nucleus of stria terniinalis (BSI) was only half as large in these people as it was in a control group of "normal" men. Usually, a woman's BST is much smaller than a man's, so in effect the men with gender identity disorder were found to have a female-sized BST. Recent studies tell a similar story (Swaab, 2005). Scientists do not know for certain what the BST does in humans, but they know that it helps regulate sexual behavior in male rats. Thus, it may be that men who develop gender identity disorder have a key biological difference that leaves them very uncomfortable with their assigned sex characteristics.

Treatmen h for Gender Identity Disorder In order to more effectively assess and treat those with gender identity disorder, clini- cal theorists have tried to distinguish the most common patterns of gender dysphoria encountered in clinical practice.

°gender identity disorder®A disor- der in which a person persistently feels extremely uncomfortable about his or her assigned sex and strongly wishes to be a member of the opposite sex.

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350 :A/CHAPTER 1 1

Types of Gender Dysphoria Clients Richard Carroll (2007), a leading theorist on gender dysphoria, has described the three patterns of gender identity disorder for which individuals most commonly seek treatment: (1) female-to-male gender dysphoria, (2) male-to-female gender dysphoria: androphilic type, and (3) male-to-female gender dysphoria: antogynephilic type.

FEMALE-TO-MALE GENDER DYSPHORIA People with a female-to-male gender dysphoria pat- tern are born female but appear or behave in a stereotypically masculine manner from early on—often as young as 3 years of age or younger. As children they always play rough games or sports, prefer the company of boys, hate "girlish" clothes, and state their wish to be male. As adolescents, they become disgusted by their physical changes of puberty and are sexually attracted to females. However, lesbian relationships do not feel like a satisfactory solution to them because they want other women to be attracted to them as males, not as females.

MALE-TO-FEMALE GENDER DYSPHORIA: ANDROPHILIC TYPE People with an androphilic type of male-to-female gender dysphoria are born male but appear or behave in a stereo- typically female manner from birth. As children, they are viewed as effeminate, pretty, and gentle; avoid rough games; and hate to dress in boys' clothing. As adolescents, they become sexually attracted to males, and they often come out as gay and develop gay relationships (the term "androphilic" means attracted to males). But by adulthood, it be- comes clear to them that gay relationships do not address their gender dysphoric feelings because they want to be with heterosexual men who are attracted to them as women.

MALE-TO-FEMALE GENDER DYSPHORIA: AUTOGYNEPHILIC TYPE People with an autogynephilic type of male-to-female gender dysphoria are not sexually attracted to males within their pattern of gender dysphoria; rather, they are attracted to the fantasy of themselves being females (the term "autogynephilic" means attracted to oneself as a female). Like males with the paraphilia transvestic fetishism (see pages 341-342), persons with this form of gender dysphoria behave in a stereotypically masculine manner as children, start to enjoy dress- ing in female clothing during childhood, and, after puberty, become sexually aroused when they cross-dress. Also, like males with transvestic fetishism, they are attracted to females during and beyond adolescence. However, unlike individuals with transvestic fetishism, these persons have fantasies of becoming female which become stronger and stronger during adulthood. Eventually, they are consumed with the need to be female.

In short, cross-dressing is characteristic of both men with the paraphilia transvestic fetishism and men with this type of male-to-female gender dysphoria. But the former

Sexual Disorders and Gender Identity Disorder :ll 351

HOME }—°. SEND )•••-• EXPLORE ''''''' •"" " " — """ " '"""'"'""" °"""

Battling a Culture of Shame BY MARTIN ABBUGAO, AGENCE FRANCE-PRESSE, SEPTEMBER 10, 2007

he loves children and her lifelong dream is to be a wife and a mother, but the raspy voice and masculine frame be-

tray the fact that Leona Lo was born a man. Unlike many other transsexuals in Asia who prefer to live

privately because of the social stigma of sex change, the British- educated,. Singaporean transsexual woman has chosen to live a normal life, but in public. Smart, confident and articulate, the communications specialist who heads her own public relations company has embarked on a mission to help turn around the "culture of shame" surrounding transsexuals in Singapore and the region. "Somewhere out there, not just in Singapore but throughout Asia, there are lots of young people who are suffering the way I suffered years ago," Leona, 32, [says] in an interview.

In her former life as a man, she was called Leonard. These days, she draws on her experiences of gender identity crisis, rejection and discrimination to challenge social mores on behalf of the so-called silent community. . . . While a few trans- sexuals are gaining prominence in Asia most continue to live in silence....

Slim and taller than the average local woman, Leona packs charm and gets animated when talking about children. But her lipsticked mouth creases into a pensive smile when she says: "I can't bear children. I have to be on hormones for life and I have this body structure of a guy." The hormone treatment has "feminised" the former man. While traces of masculinity are evident, Leona says she has already come to terms with being a woman— although a transsexual one. "I can't deny that biologically I'm different," says Leona, wearing a blue dress, the muscles on her shoulders and arms clearly visible.

Discrimination is the biggest challenge faced by transsexuals, she says, recalling repeated rejection by prospective employers in Singapore despite her academic credentials. "Singapore may be a cosrnospolitan city but many things are still swept under the carpet," Leona says. .. . "It's because a lot of transsexual women face discrimination at work and experience failure of re- lationships that a lot end up in suicide, depression. They end up on the streets as prostitutes," she says.

This is why she has taken time away from her thriving public relations consultancy promoting beauty products to wage her campaign. After much persuasion, one local university allowed her to speak to an audience of students but she is finding it hard to pry open a window to share her thoughts in the corporate world. . . . On September 14 she is to launch her autobiogra- phy, "From Leonard to Leona—A Singapore Transsexual's Jour- ney to Womanhood.".

As early as 10, Leonard had already started developing feel- ings for boys. But he was forced to remain silent because of a

dearth of information about transsexual- ism and for fear his traditional Chinese family would be scandalized. "I did not think I was gay, I just felt that I was a woman trapped in a man's body," says Leona, who has a younger sister. At age 15, Leonard discovered a book about transsexualism. . . . "I discovered that book in the library and I said 'Oh my God! There are actually people like me!" she reminisces. "That changed my life and I discovered that I could go for the sex change operation." . .

After military service, Leonard in 1996 went to study in Britain, where a more tolerant university environment allowed him to cross-dress for a year as part of his preparation for sex-change surgery. In 1 997, Leonard flew with his tuition money from Britain to Bangkok, where he walked into a clinic for the life-altering operation. "I was afraid. I could go in and I could die. But I knew at that point that I was going to change my life for- ever," she recalls. "1 had carried that bur- den within me for so long and I couldn't

live anymore without doing it." Leona endured a lot of pain dur- ing the procedure . . . but the feeling of having a new identity was "wonderful, euphoric!" ..

What is her dream now? "To be a wife and a mother," she says. "I look forward to a fulfilling relationship with a loving man, getting married and adopting three children. . . . I'm [also] more self-assured and finally able to lay to rest the painful aspects of my past and move confidently as a woman."

Copyright 0 2007 Agence France-Presse. Reprinted by permission.

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*sex-change surgeryeA surgical procedure that changes a person's sex organs, features, and, in turn, sexual identity. Also known as sexual reassign- ment surgery.

individuals cross-dress strictly to become sexually amused, whereas the latter develop much deeper reasons for cross-dressing, reasons of gender identity.

Types of Treatment for Gender Identify Disorder Many people with gender identity disorder receive psychotherapy (Affatati et al., 2004), but a large number of them further seek to address their concerns through biological interventions. For example, many adults with this disorder change their sexual characteristics by means of hormone treatments (Andreasen & Black, 2006). Physicians prescribe the female sex hormone estro- gen for male patients, causing breast development, loss of body and facial hair, and change in body fat distribution. Similar treatments with the male sex hormone testosterone are given to women with gender identity disorder.

Hormone therapy and psychotherapy enable many persons with this disorder to lead a satisfactory existence in the gender role that they believe represents their true identity. For others, however, this is not enough, and they seek out one of the most controversial practices in medicine: sex-change, or sexual reassignment, surgery (Andreasen & Black, 2006).This surgery, which is preceded by one to two years of hor- mone therapy, involves, for men, amputation of the penis, creation of an artificial vagina, and face-changing plastic surgery. For women, surgery may include bilateral mastectomy and hysterectomy. The procedure for creating a functioning penis, called phalloplaso; is performed in some cases, but it is not yet perfected (Doctor & Neff, 2001). Doctors have, however, developed a silicone prosthesis that gives the patient the appearance of having male genitals. Studies in Europe suggest that 1 of every 30,000 men and 1 of every 100,000 women seek sex-change surgery (Carroll, 2007; Bakker et al., 1993). In the United States, more than 6,000 persons are estimated to have undergone this surgi- cal procedure (Doctor & Neff, 2001).

Clinicians have debated heatedly whether sexual reassignment is an appropriate treatment for gender identity disorder. Some consider it a humane solution, perhaps the most satisfying one to people with the pattern. Others argue that sexual reassignment is a "drastic nonsolution" for a complex disorder. Either way, sexual reassignment surgery appears to be on the increase (Olsson & Moller, 2003).

Research into the outcomes of gender reassignment surgery points in favorable di- rections, although most such studies have key methodological flaws (Carroll, 2007). In the studies, the majority of patients—both female and male—state satisfaction with the outcome of the surgery and report improvements in self - satisfaction and interpersonal interactions (Michel et al., 2002). Improvements in sexual functioning after surgery, however, are often lacking (Schroder & Carroll, 1999).

352 :IICHAPTER 1 1

Landmark Case

The rate of "poor" sexual reassignment outcomes appears to be at least 8 percent (Carroll, 200 7;Abramowitz, 1986). Female-to-male patients consistently show the most favorable psychosocial outcomes. Those who display the autogynephilic type of gender dysphoria (that is, those whose problems seem to begin as transvestic fetishism) are more likely than those with the other types of gender dysphoria to later regret sexual reas- signment surgery and to have poor outcomes. Finally, patients with serious pretreatment psychological disturbances (for example, a personality disorder) are particularly likely to regret the surgery and are more likely than others to later attempt suicide. All of this argues for very careful screening prior to surgical interventions and, of course, for continued research to better understand both the patterns themselves and the long-term impact of the surgical procedures.

r,--71 •

Gender k]enli;y Disorder

People with gender identity disorder persistently feel that they have been assigned to the wrong sex. In recent years, a number of theorists have criticized the categoriza- tion of such gender identity patterns as clinical disorders. Men with gender identity disorder apparently outnumber females by around 2 to 1. Its causes are not well understood. Hormone treatments and psychotherapy have been used to help some people adopt the gender role they believe to be right for them. Sex-change opera- tions have also been performed, but the appropriateness of surgery as a form of "treatment" has been debated heatedly.

PUTTING IL. together A Private Topic Draws Public Attention

For all the public interest in sexual disorders, clinical theorists and practitioners have only recently begun to understand their nature and how to treat them. As a result of research done over the past few decades, people with sexual dysfunctions are no longer doomed to a lifetime of sexual frustration. At the same time, however, insights into the causes and treatment of other kinds of sexual disorders—paraphilias and gender identity disorder—remain limited.

Studies o f sexual dysfunctions have pointed to many psychological, sociocultural, and biological causes. Often the various causes may interact to produce a particular dys- function, as in erectile disorder and female orgasmic disorder. For some dysfunctions, however, one cause alone is dominant, and integrated explanations may be inaccurate and unproductive. Dyspareunia, for example, usually has a physical cause.

Recent work has also yielded important progress in the treatment of sexual dysfunc- tions, and people with such problems are now often helped greatly by therapy. Sex therapy today is usually a complex program tailored to the particular problems of an individual or couple. Techniques from the various models may be combined, although in some in- stances the particular problem calls primarily for one approach (Bach et al., 2001).

One of the most important insights to emerge from all of this work is that educa- tion about sexual dysfunctions can be as important as therapy. Sexual myths are still taken so seriously that they often lead to feelings of shame, self-hatred, isolation, and hopelessness—feelings that themselves contribute to sexual difficulty. Even a modest amount of education can help persons who are in treatment.

In fact, most people can benefit from a more accurate understanding of sexual functioning. Public education about sexual functioning—through appropriate websites, books, television and radio, school programs, group presentations, and the like—has be- come a major clinical focus. It is important that these efforts continue and even increase in the coming years.

Sexual Disorders and Gender Identity Disorder :1/ 353

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Sexual Census • • •:: • •• ::••• ••:

354 :I/CHAPTER 11

• •

\\\ GRITIPJAL TH001-11 1-5///i 7A 1. Why do you think the clinical field

has been so slow to investigate pos-

7: sible cultural and racial differences in sexual behaviors, sexual dysfunc-

.??' tions, and paraphilias across the 3 United States? p. 321

2. Prevalence rates for sexual behavior 71: are typically based on surveys of the VA,: 7A

general population. However, many people feel that sex is private and

47: refuse to participate in such surveys,

.512. and those who do respond tend 4 to be more liberal, sexually expe-

rienced, and unconventional than the norm. What problems might this cause for sex researchers? pp. 324, 322-333

Some theorists cite performance anxiety and the spectator role as contributing factors in certain sexual dysfunctions. Are there other areas of dysfunction in life that might also be explained by performance anxiety and the spectator role? pp. 328, 330

A key technique in sex therapy is to have a couple explore and caress

each other's body (sensate focus) while resisting orgasm or intercourse. Why might people become more aroused during sexual caressing if they are prohibited from reaching orgasm or having intercourse? p. 335

5. Sex is one of the topics most com- monly searched on the Internet. Why might it be such a popular search topic? Is the availability of sex chat groups and other sexual material on the Internet psychologically healthy or damaging? pp. 343, 321-346

.1/

• \\\ KEY l'EPMS/// 4,04. le: sexual dysfunction, p. 322

desire phase, p. 322

.5) hypoactive sexual desire, p. 323

sexual aversion disorder, p. 323

/re,: excitement phase, p. 325

female sexual arousal disorder, p. 325

male erectile disorder, p. 326 d,e7jj

nocturnal penile tumescence (NPT), p. 327

#.,..?" performance anxiety, p. 328

spectator role, p. 328

orgasm phase, p. 328

rapid, or premature, ejaculation, p. 328

male orgasmic disorder, p. 329

female orgasmic disorder, p. 331

vaginismus, p. 332

dyspareunia, p. 332

sex therapy, p. 334

sensate focus, p. 335

sildenafil (Viagra), p. 336

directed masturbation training, p. 337

paraphilia, p. 339

fetishism, p. 340

aversion therapy, p. 340

masturbatory satiation, p. 341

orgasmic reorientation, p. 341

transvestic fetishism, p. 341

exhibitionism, p. 342

voyeurism, p. 342

frotteurism, p. 343

pedophilia, p. 343

relapse-prevention training, p. 345

sexual masochism, p. 345

sexual sadism, p. 346

transgender experiences, p. 248

gender dysphoria, p. 248

gender identity disorder, p. 248

androphilic type, p. 350

autogynephilic type, p. 350

hormone treatments, p. 352

sex-change surgery, p. 352

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...7'. 1. What sexual dysfunctions are i' associated with the desire phase of the sexual response cycle? How common are they, and what causes

4 ,71 them? pp. 322-325 /..7) 2. What are the symptoms and preva-

lence of female sexual arousal ii:„...#': disorder and male erectile disor-

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der? To which phase of the sexual response cycle are they related? pp. 325-328

3. What are the possible causes of male erectile disorder? pp. 326-328

4. Which sexual dysfunctions seem to involve performance anxiety and the spectator role? pp. 328, 330

5. What are the symptoms, rates, and leading causes of rapid ejaculation, male orgasmic disorder, and female orgasmic disorder? To which phase of the sexual response cycle are they related? pp. 328-332

6. Identify, describe, and explain the sexual pain disorders. p. 332

Sexual Disorders and Gender Identity Disorder :1/ 355

7. What are the general features of dmodern sex therapy? What particu-

lar techniques are further used to treat specific sexual dysfunctions?

pp. 334-338

8. List, describe, and explain the lead- / ing paraphilias. pp. 339-346 " a: .... .. Zae2,:gY 4./.:',.4".0

9. Describe the treatment techniques of aversion therapy, masturbatory satiation, orgasmic reorientation, and relapse-prevention training. Which paraphilias have they been used to treat, and how successful are they? pp. 340-346

10. Distinguish transvestic fetishism from gender identity disorder. What are the various types of gen- der identity disorder, and what are today's treatments for this disorder? pp. 341-342, 348-353

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SCHIZOPHRENIA CHAPTER

That ... does schizophrenia mean to me? ft means fatigue and confusion, it means I trying to separate every experience into the real and the unreal and sometimes not

being aware of where the edges overlap. It means trying to think straight when there

is a maze of experiences getting in the way, and when thoughts are continually being sucked out of your head so that you become embarrassed to speak at meetings. It means feel-

ing sometimes that you are inside your head and visualizing yourself walking over your brain, or

watching another girl wearing your clothes and carrying out actions as you think them. it means

knowing that you are continually "watched," that you con never succeed in life because the laws ore all against you and knowing that your ultimate destruction is never far away.

Rollin, 1980, p. 162

Does it surprise you to see such a coherent firsthand description of how it feels to suffer from schizophrenia? People who have this disorder, though they previ- ously functioned well or at least acceptably, deteriorate into an isolated wilderness of unusual perceptions, odd thoughts, disturbed emotions, and motor abnormalities. They 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.They may have hallucinations (false sensory perceptions) or delusions (false beliefs), or they may withdraw into a private world. As you saw in Chapter 10, taking LSD or abusing amphetamines or cocaine may produce psychosis. So may injuries or diseases of the brain. Most commonly, however, psychosis appears in the form of schizophrenia.

Approximately 1 of every 100 people in the world suffers from schizophrenia during his or her lifetime (APA, 2000).An estimated 24 million people worldwide are afflicted with this disorder, 2.5 million in the United States (Lambert & Kinsley, 2005). Its financial cost is enormous, and the emotional cost is even greater. In addition, sufferers have an increased risk of suicide and of physical—often fatal— illness (Casey & Hansen, 2009). As you read in Chapter 8, it is estimated that at least 15 percent of people with the disorder attempt suicide (Heisel, 2008).

Although schizophrenia appears in all socioeconomic groups, it is found more frequently in the lower levels (see Figure 12-1 on the next page), leading some theorists to believe that the stress of poverty is itself a cause of the disorder. However, it could be that schizophrenia causes its victims to fall from a higher to a lower so- cioeconomic level or to remain poor because they are unable to function effectively (Priebe & Fakhoury, 2008). This is sometimes called the downward drift theory.

Equal numbers of men and women receive a diagnosis of schizophrenia (Seeman, 2008). The average age of onset for men is 21 years, compared to 27 years for women (Folsom et al., 2006). Almost 3 percent of all those who are divorced or separated suffer from schizophrenia sometime during their lives, compared to 1 percent of married people and 2 percent of people who remain single. Again, however, it is not clear whether marital problems are a cause or a result (Softer et al., 2004; Keith et al., 1991).

People today, like those of the past, show great interest in schizophrenia, flocking to plays and movies that feature the disorder.Yet, as you will read, all too many people with schizophrenia are neglected in our country, their needs almost

TOPIC OVERVIEW The Clinical Picture of Schizophrenia What Are the Symptoms of Schizophrenia? What Is the Course of Schizophrenia? Diagnosing Schizophrenia

How Do Theorists Explain Schizophrenia? Biological Views Psychological Views Sociocultural Views

How Are Schizophrenia and Other Severe Mental Disorders Treated? Institutional Care in the Past Institutional Care Takes a Turn for the Better

Antipsychotic Drugs Psychotherapy The Community Approach

Putting It Together: An Important Lesson

Annual Prevalence of Schizophrenia

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oschizophreniaoA psychotic disorder in which personal, social, and occupa- tional functioning deteriorate as a result of strange perceptions, unusual emotions, and motor abnormalities.

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entirely ignored. Although effective treatments have been developed, most sufferers live without adequate care and without nearly fulfilling their potential as human beings (Ritsner & Gibel, 2007).

3.-The Clinical Picture of Schizophrenia The symptoms of schizophrenia vary greatly, and so do its triggers, course, and respon- siveness to treatment (APA, 2000). In fact, a number of clinicians believe that schizo- phrenia is actually a group of separate disorders that happen to have some features in common (Tamminga et al., 2008). To see the variety of forms schizophrenia may take, consider two people who were diagnosed as suffering from it.The cases are taken from the files of Silvano Arieti (1974), a famous theorist on the disorder.

Laura, 40 years old: Laura's desire was to become independent and leave home fin Austria] 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 provincial 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 down- stairs. 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; in the butcher shop, the butcher had purposely served her last, although she was in the middle of the line. During the next few days she felt that people were planning to harm either her or her husband. . . In the

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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.

(pp. 165-168)

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 dress- ing 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 tor- tured 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.

(pp. 153-155)

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*positive symptomsoSymptoms of schizophrenia that seem to be excesses of or bizarre additions to normal thoughts, emotions, or behaviors.

edelusionoA strange false belief firmly held despite evidence to the contrary.

*formal thought disorderoA disturb- ance in the production and organization of thought.

*loose associations0A common thinking disturbance in schizophrenia, characterized by rapid shifts from one topic of conversation to another. Also known as derailment.

*hallucination*The experiencing of sights, sounds, or other perceptions in the absence of external stimuli.

What Are the Symptoms of Schizophrenia? Laura and Richard both deteriorated from a normal level of functioning to become ineffective in dealing with the world. Each experienced 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 oth- ers by negative ones, although both kinds of symptoms are typically present (Vahia & Cohen, 2008). In addition, around half of people with schizophrenia display significant difficulties with memory and other kinds of cognitive functioning ( Leavitt & Gold- berg, 2009; Julien, 2008).

Positive Symptoms Positive symptoms are "pathological excesses," or bizarre addi- tions, 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.

DELUSIONS Many people with schizophrenia develop delusions, ideas that they believe wholeheartedly but have no basis in fact. Some people hold a single delusion that domi- nates their lives and behavior, whereas others have many delusions. Delusions of persecution are the most common in schizophrenia (APA, 2000). People with such delusions believe they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized. Laura believed that her neighbors were trying to irritate her and that other people were trying to harm her and her husband.

People with schizophrenia may also experience 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 who experience delusions of grandeur believe themselves to be great inventors, religious saviors, or other specially empowered persons. And those with delusions of control believe their feelings, thoughts, and actions are being controlled by other people.

DISORGANIZED THINKING AND SPEECH People with schizophrenia may not be able to think logically and may speak in peculiar ways. These formal thought disorders can cause the sufferer great confusion and make communication extremely difficult. Often they take the form of positive symptoms (pathological excesses), as in loose associations, neo- logisms, perseveration, and clang.

People who have loose associations, or derailment, the most common formal thought disorder, rapidly shift from one topic to another, believing that their incoher- ent statements make sense. 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. l 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 individual stated, 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 ..." (Vetter, 1969, p. 189). Others may display 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 dis-

360 ://CHAPTER 12

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organized speech or thinking may appear long before a full pattern of schizophrenia unfolds (Covington et al., 2005; Metsanen et al., 2005).

HEIGHTENED PERCEPTIONS AND HALLUCINATIONS The perceptions and attention of some people with schizophrenia seem to intensify. 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:

Everything seems to grip my attention. . . I am speaking to you just now, but I can hear noises going on next door and in the corridor. I find it difficult to shut these out, and it makes it more difficult for me to concentrate on what I am saying to you.

(McGhie and Chapman, 1961)

Laboratory studies repeatedly have found problems of perception and attention among people with schizophrenia (Savla et A, 2008; Rogers et al., 2007). Such problems may develop years before the onset of the actual disorder (Cornblatt & Keilp, 1994). It is also possible that these difficulties further contribute to the memory impairments that are experienced by many individuals with the disorder (Fuller et al., 2009).

Another kind of perceptual problem in schizophrenia consists of hallucinations, perceptions that occur in the absence of external stimuli. People who have auditory hal- lucinations, by far the most common kind in schizophrenia, hear sounds and voices that seem to come from outside their heads (Waters, Badcock, & Maybery, 2007).The voices may talk directly to the hallucinator, perhaps giving commands or warning of dangers, or they may be experienced as overheard:

The voices . .. were mostly heard in my head, though I often heard them in the air, or in different parts of the room. Every voice was different, and each beautiful, and generally, speaking or singing in a different tone and measure, and resembling those of relations or friends. There appeared to be many in my head, I should say upwards of fourteen. I divide them, as they styled themselves, or one another, into voices of contrition and voices of joy and honour_

("Perceval's Narrative," in Batesoit, 1974)

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 (Woodruff, 2004). One line of research measured blood flow in Broca's area, the region of the brain that helps people produce speech (Waters et al., 2007; McGuire et al., 1996).The investigators found more blood flow in Broca's area while patients were experiencing auditory hallucinations.A related study instructed six men with schizophrenia to press a button whenever they experienced an auditory hallucination (Silbersweig et al., 1995). PET scans re- vealed increased activity near the surfaces of their brains, in the brain's hearing center, when they pressed the button.

Hallucinations and delusional ideas often occur together (Bach, 2007). A woman who hears voices issuing commands, for example, may have the delu- sion that the commands are being placed in her head by someone else.A man with delusions of persecution may hallucinate the smell of poison in his bed- room or the taste of poison in his coffee. Might one symptom cause the other? Whatever the cause and whichever comes first, the hallucination and delusion eventually feed into each other:

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einappropriate affecteDisplay of emo tions that are unsuited to the situation; a symptom of schizophrenia.

enegative symptomseSymptoms of schizophrenia that seem to be deficits in normal thought, emotions, or behaviors.

oaioyl aeA decrease in speech or speech content; a symptom of schizo- phrenia. Also known as poverty of speech.

°flat affectoA marked lack of expressed emotions; a symptom of schizophrenia.

ocataiania0A pattern of extreme psy- chomotor symptoms found in some forms of schizophrenia, which may include catatonic stupor, rigidity, or posturing.

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. / 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. 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. During a tender conversation with his wife, for example, a man with schizophrenia suddenly started yelling obscenities at her and complaining about her inadequacies.

In at least some cases, these emotions may be merely a response to other features of the disorder. Consider a woman with schizophrenia who smiles when told of her husband's serious illness. She may not actually be happy about the news; in fact, she may not be understanding or even hearing it. She could, for example, be responding instead to another of the many stimuli flooding her senses, perhaps a joke coming from an auditory hallucination.

362 :1/CHAPTER 12

NegatiVe SyMpiOniS Negative symptoms are those that seem to be "pathologi- cal deficits," characteristics that are lacking in an individual. Poverty of speech, blunted and

flat affect, loss of volition, and social withdrawal are commonly found in schizophrenia. Such deficits greatly affect one's life and activities.

POVERTY OF SPEECH People with schizophrenia often display 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 man- age to convey little meaning.

BLUNTED AND FLAT AFFECT Many people with schizophrenia have a blunted affect—they show less anger, sadness, joy, and other feelings than most people. And some show al- most no emotions at all, a condition known as flat affect. Their faces are still, their eye contact is poor, and their voices are monotonous. In some cases, people with these problems may have anhedonia, a general lack of pleasure or enjoyment. In other cases, however, blunted or flat affect may reflect an inability to express emotions as others do.

One study had participants view very emotional film clips. The participants with schizophrenia showed less facial expression than the others; however, they reported feeling just as much positive and negative emotion and in fact displayed greater skin arousal (Kring & Neale, 1996).

LOSS OF VOLITION Many people with schizophrenia experience avo- lition, 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, individuals with the disorder may display ambivalence, or conflicting feelings, about most things. The avolition and am- bivalence 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

DSM Checklist

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Schizophrenia :11 363

fantasies. 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 (Kurtz & Mueser, 2008; Tenhula & Bellack, 2008).

Psychomotor Symptoms People with schizophrenia sometimes experience psychomotor symptoms, for example, awkward movements or repeated grimaces and odd gestures.These unusual gestures often seem to have a private purpose—perhaps magical.

The psychomotor symptoms of schizophrenia may take certain ex- treme forms, collectively called catatonia (Weder et al., 2008). 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 who display cata- tonic 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 who display catatonic excite- ment, a different form of catatonia, move excitedly, sometimes with wild waving of arms and legs.

What Is the Course of Schizophrenia? Schizophrenia usually first appears between the person's late teens and mid-30s (APA, 2000). Although its course varies widely from case to case, many sufferers seem to go through three phases—prodromal, active, and residual (Hafner & an der Heiden, 2008). During the prodromal phase, symptoms are not yet obvious, but the individuals are begin- ning to deteriorate. They may withdraw socially, speak in vague or odd ways, develop strange ideas, or express little emotion. During the active phase, symptoms become ap- parent. Sometimes this phase is triggered by stress in the person's life. For Laura, the middle-aged woman described earlier, the immediate trigger was the loss of her cher- ished dog. Finally, many people with schizophrenia eventually enter a residual phase, in which they return to a prodromal-like level of functioning. The striking symptoms of the active phase lessen, but some negative symptoms, such as blunted emotions, may re- main.Although one-quarter 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 & Carpenter, 2008; Roe & Davidson, 2008).

Each of these phases may last for days or for years. A fuller recovery from schizo- phrenia is more likely in persons who functioned quite well before the disorder (had good premorbid functioning) or whose disorder was initially triggered by stress, came on abruptly, or developed during middle age (Conus et al., 2007). Relapses are apparently more likely during times of life stress (Bebbington & Kuipers, 2008).

Diagnosing Schizophrenia DSM-IV-TR calls for a diagnosis of schizophrenia only after symptoms of the disorder continue for six months or more. In addition, people suspected of having this disorder must show a deterioration in their work, social relations, and ability to care for them- selves (see Table 12-1).The DSM distinguishes five types of schizophrenia: disorganized, catatonic, paranoid, undifferentiated, and residual.

The central symptoms of disovnized type of schizophrenia are confusion, incoherence, and flat or inappropriate affect.Attention and perception problems, extreme social with- drawal, and odd mannerisms or grimaces are common. The central feature of catatonic type of schizophrenia is a psychomotor disturbance of some sort. Some of the people in this category spend their time in a catatonic stupor, others in the throes of catatonic excitement. Richard, the unemployed young man who became mute and statue-like, might receive a diagnosis of this type of schizophrenia.

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People with paranoid type of schizophrenia have an organized system of delusions and auditory hallucinations that may guide their lives. Laura would receive this diagnosis. She believed people were out to get her (delusions of persecution) and that people on television were stealing her ideas (delusions of reference). In addition, she heard noises from the apartment downstairs and felt "funny sensations" that confirmed her beliefs.

When people with schizophrenia do not fall neatly into one of the other categories, they are diagnosed with undifferentiated type of schizophrenia. Because this category is somewhat vague, it has been assigned to a wide assortment of unusual patterns over the years. Many clinicians believe that it is in fact overused.

When the symptoms of schizophrenia lessen in strength and number yet remain in a residual form, the patient's diagnosis is usually changed to residual type of schizophrenia. As you saw earlier, people with this pattern may continue to display blunted or inap- propriate emotions, as well as social withdrawal, eccentric behavior, and some illogical thinking.

Apart from these DSM-IV categories, many researchers believe that a distinction between so-calledType I andType II schizophrenia helps predict the course of the disor- der. People with Type I schizophrenia are thought to be dominated by positive symptoms, such as delusions, hallucinations, and certain formal thought disorders (Crow, 2008, 1995, 1985, 1980). Those with Type II schizophrenia largely display negative symptoms, such as flat affect, poverty of speech, and loss of volition. Type I patients generally seem to have a greater likelihood of improvement.

The Clinical Picture of Schizophrenia

Schizophrenia is a disorder in which functioning deteriorates as a result of disturbed thought processes, distorted perceptions, unusual emotions, and motor abnormali- ties. Approximately 1 percent of the world's population suffers from this disorder. Its symptoms 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, blunted and flat affect, loss of volition, and social withdrawal. The disorder 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. DSM-IV-TR identifies five patterns of schizophrenia: disorganized, catatonic, paranoid, undif- ferentiated, and residual. Moreover, it is not uncommon for some patients to be dominated by positive symptoms and others to display more negative ones.

Do Theorists Explain Schizophrenia? As with many other kinds of disorders, biological, psychological, and sociocultural theo- rists have each proposed explanations for schizophrenia. So far, the biological explana- tions 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 will develop schizophrenia only if certain kinds of events or stressors are also present (Prasad et al., 2009; Glatt, 2008; Tamminga et al., 2008).

Biological Views Perhaps the most enlightening research on schizophrenia during the past several decades has come from genetic and biological studies (Downar & Kapur, 2008; Glatt, 2008). These studies have revealed the key roles of inheritance and brain activity in the

364 :4/CHAPTER 12

General population

Spouse

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development of this disorder and have opened the door to important changes in its treatment.

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 (Glatt, 2008). The genetic view has been supported by studies of (1) relatives of people with schizophrenia, (2) twins with this disorder, (3) people with schizophrenia who are adopted, and (4) genetic linkage and molecular biology.

ARE RELATIVES VULNERABLE? Family pedigree studies have found repeatedly that schizophrenia (and other psychotic disorders) is more common among relatives of people with the disorder (Tamminga et al., 2008; Higgins & George, 2007). And the more closely related the relatives are to the person with schizo- phrenia, the greater their likelihood of developing the disorder (see Figure 12.2).

IS AN IDENTICAL TWIN MORE VULNERABLE THAN A FRATERNAL TWIN? Twins, who are among the closest of relatives, have received particular study by schizophrenia researchers. If both members of a pair of twins have a particular trait, they are said to be concor- dant 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 this disorder than fraternal twins (who share only some genes). This expectation has been supported consistently by research (Higgins & George, 2007; Gottesman, 1991). Studies have found that if one identical twin develops schizophrenia, there is a 48 percent chance that the other twin will do so as well. If the twins are fraternal, on the other hand, the second twin has approximately a 17 percent chance of developing the disorder.

ARE THE BIOLOGICAL RELATIVES OF AN ADOPTEE VULNERABLE? Adoption studies look at adults with schizophrenia who were adopted as infants and compare them with both their biological and their adoptive relatives. Because they were reared apart from their bio- logical relatives, similar symptoms in those relatives would indicate genetic influences. Conversely, similarities to their adoptive relatives would suggest environmental influ- ences. Repeatedly, researchers have found that the biological relatives of adoptees with schizophrenia are more likely to experience schizophrenia or a related disorder (see Table 12-2 on the next page) than their adoptive relatives (Andreasen & Black, 2006; Kety, 1988, 1968).

WHAT DO GENETIC LINKAGE AND MOLECULAR BIOLOGY STUDIES SUGGEST? As with bipolar dis- orders (see Chapter 7), researchers have run studies of genetic linkage and molecular biology to pinpoint the possible genetic factors in schizophrenia (Glatt, 2008;Walsh et al., 2008). In one approach, they select large families in which schizophrenia is very common, take blood and DNA samples from all members of the families, and then compare gene fragments from members with and without schizophrenia. Applying this procedure to families from around the world, various studies have identified possible gene defects on chromosomes 1, 6, 8, 10, 13, 15, 18, and 22 and on the X chromosome, each of which may help predispose individuals to develop schizophrenia (Folsom et al., 2006; Harrison & Weinberger, 2005).

These varied findings may indicate that some of the suspected gene sites are cases of mistaken identity and do not actually contribute to schizophrenia. Alternatively, it may be that different kinds of schizophrenia are linked to different genes. It is most

Disorder

Schizophrenia

Brief psychotic disorder

Lifetime Duration Prevalence

6 months or more 1.0%

Less than 1 month Unknown

Key Features

Various psychotic symptoms such as delusions, hallucinations, disorganized speech, flat or inappropriate affect, and catatonia

Various psychotic symptoms such as delusions, hallucinations, disorganized speech, flat or inappropriate affect, and catatonia

No minimum length Unknown

such No minimum length Unknown

Psychotic disorder due to a Hallucinations or delusions caused by a medical illness or general medical condition brain damage

Substance-induced Hallucinations or delusions caused directly by a substance, psychotic disorder as an abused drug

An Array of Psychotic Disorders

Various psychotic symptoms such as delusions, hallucinations, 1 to 6 months 0.2% disorganized speech, flat or inappropriate affect, and catatonia

Marked symptoms of both schizophrenia and a mood disorder 6 months or more Unknown

Persistent delusions that are not bizarre and not due to schizophrenia; persecutory, jealous, grandiose, and somatic delusions are common

Person adopts delusions that are held by another individual, such as a parent or sibling; also known as Idle a deux

Schizoaffective disorder

Delusional disorder

Shared psychotic disorder

1 month or more 0.1%

No minimum length Unknown

Schizophreniform disorder

366 ://CHAPTER 12

table:

likely, however, that schizophrenia, like a number of other disorders, is a polygenic disorder, caused by a combination of gene defects (Tamminga et al., 2008).

How might genetic factors lead to the development of schizophrenia? Research has pointed to two kinds of biological abnormalities that could conceivably be inherited— biochemical abnormalities and abnormal brain structure.

odopamine hypothesisoThe theory that schizophrenia results from excessive activity of the neurotransmitter dopamine.

oantipsychotic drugsoDrugs that help correct grossly confused or distorted thinking.

ophenothiazinesoA group of antihista- mine drugs that became the first group of effective antipsychotic medications.

Biochemical Abnormalities As you have read, the brain is made up of neurons whose electrical impulses (or "messages") are transmitted from one to another by neu- rotransmitters.After an impulse arrives at a receiving neuron, it travels down the axon of that neuron until it reaches the nerve ending.The nerve ending then releases neurotrans- mitters that travel across the synaptic space and bind to receptors on yet another neuron, thus relaying the message to the next "station."This neuron activity is known as "firing."

Over the past four decades, researchers have developed a dopamine hypothesis to explain their findings on schizophrenia: Certain neurons that use the neurotransmitter dopamine fire too often and transmit too many messages, thus producing the symptoms of the disorder (McGowan et al., 2004). This hypothesis has undergone challenges and adjustments in recent years, but it is still the foundation for present biochemical ex- planations of schizophrenia. The chain of events leading to this hypothesis began with the accidental discovery of antipsychotic drugs, medications that help remove the symptoms of schizophrenia. The first group of antipsychotic medications, the pheno- thiazines, were discovered in the 1950s by researchers who were looking for better antihistamine drugs to combat allergies.Although phenothiazines failed as antihistamines, their effectiveness in reducing schizophrenic symptoms became obvious, and clinicians began to prescribe them widely.

Researchers soon learned that these early antipsychotic drugs often produce trouble- some 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

Schizophrenia :11. 367

A CLOSE OCA

Postpartum Psychosis: The Case of Andrea Yates

In the morning of June 20, 2001, the (nation's television viewers watched

in horror es 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 develop. ing correctly" and because she "realized [she had not been] a good mother to them." Homicide sergeant Eric Mehl described how she 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 7 you observed 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 depres- sion. 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.

Postpartum psychosis affects about 1 to 2 of every 1,000 mothers who have re- cently given birth. The symptoms apparently are triggered by the enormous shift in hor- mone levels that occur after delivery (Black- more et al., 2008; Nonacs, 2007, 2002). Within days or at most a few months of childbirth, the woman develops signs of losing touch with reality, such as delusions (for example, she may become convinced that her baby is the devil); hallucinations (perhaps hearing voices); extreme anxiety, confusion, and disorientation; disturbed sleep; and illogical thoughts (for example, thoughts about killing herself or her child).

Women with a history of bipolar dis- order, schizophrenia, or depression are particularly vulnerable to the disorder (Read & Purse, 2007; Sit et al., 2006). In addition, women who have previously experienced postpartum depression or postpartum psychosis have an increased

likelihood of developing this disorder after subsequent births (Nonacs, 2007; Ruta & Cohen, 1998). Andrea Yates, for example, had developed signs of postpartum depres- sion (and perhaps postpartum psychosis) and attempted suicide after the birth of her fourth child. At that time, however, she ap- peared to respond well to a combination of medications, including antipsychotic drugs, and so she and her husband later decided to conceive a fifth child. Although they were warned that she was at risk for serious postpartum symptoms once again, they believed that the same combination of medications would help if the symptoms were to recur (King, 2002).

After the birth of her fifth child, the symptoms did in fact recur, along with fea- tures 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.

Most clinicians who are knowledgeable about this rare disorder agree that Yates was indeed a victim of postpartum psy- chosis. Although only a fraction of women with the disorder actually harm their chil-

dren (estimates run as high as 4 percent), the Yates case reminds us that such an outcome is indeed possible (Read & Purse, 2007; Dobson & Sales, 2000). The case also reminds us that early detection and treatment are critical.

On March 13, 2002, a Texas jury found Andrea Yates guilty of murdering her children and she was sentenced to life in prison. She had pleaded not guilty by rea- son of insanity during her trial, but the jury concluded within hours that despite her profound disorder, she did know right from wrong. The verdict itself stirred debate throughout the United States, but clinicians and the public alike were united in the be- lief that, at the very least, the mental health system had tragically failed this woman and her five children.

A Texas appeals court later reversed Yates's conviction, citing the inaccurate testimony of a prosecution witness, and on July 26, 2006, after a new trial, Yates was found not guilty by reason of insanity and was sent to a high-security mental health facility for treatment. In 2007, she was transferred to a low-security state mental hospital where she continues to receive treatment today.

368 ://CHAPTER 12

eatypical antipsychotic drugsoA rela- tively new group of antipsychotic drugs whose biological action is different from that of the traditional antipsychotic drugs.

reason for their uncontrollable shaking. If antipsychotic drugs produce Parkinsonian symptoms in persons with schizophrenia while removing their psychotic symptoms, perhaps the drugs reduce dopamine activity. And, scientists reasoned further, if lowering dopamine activity helps remove the symptoms of schizophrenia, perhaps schizophrenia is related to excessive dopamine activity in the first place.

Since the 1960s, research has supported and helped clarify the dopamine hypoth- esis. It has been found, for example, that some people with Parkinson's disease develop schizophrenia-like symptoms if they take too much L - dopa, a medication that raises dopamine levels in patients with that disease (Grilly, 2002).The L-dopa apparently raises the dopamine activity so much that it produces psychosis. Support has also come from research on amphetamines, drugs that, as you saw in Chapter 10, stimulate the central nervous system by increasing dopamine 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.

Researchers have located areas of the brain that are rich in dopamine receptors and have found that phenothiazines and other antipsychotic drugs bind to many of these receptors (Burt et al., 1977; Creese et al., 1977).Apparently the drugs are dopamine an- tagonists— drugs that bind to dopamine receptors, prevent dopamine from binding there, and so prevent the neurons from firing (Iversen, 1975). Five kinds of dopamine receptors have been identified throughout the brain—called the D-1, D-2, D-3, D-4, and D-5 receptors. Phenothiazines bind most strongly to the D- 2 receptors ( Julien, 2008).

These and related findings suggest that in schizophrenia, messages traveling from dopamine-sending neurons to dopamine receptors on other neurons, particularly to

It's when I was bitten by a rabid dog. . . When I'm emotionally upset, I feel as if I am turning into something else: my fingers go numb, as if I had pins and needles right in the middle of my hand; I can no longer control myself. . I get the feeling I'm becoming a wolf. I look at myself in the mirror and I witness my transformation. It's no longer my face; it changes completely. I store, my pupils dilate, and I feel as if hairs are growing all over my body, as if my teeth are getting longer. . . feel as if my skin is no longer mine.

(BENEZECH, EIEWITTE, & BOURGEOIS, 1989)

l ycanthropy, the delusion of being — an animal, is a rare psychological

syndrome (Nejad, 2007). The word "lycanthropy" comes from the Greek lykos, "wolf," and anthropos, "man." Accounts have been found all over the world of people who take on the characteristics and behavior of wolves or other animals. Belief in these tales has persisted for centuries.

Mention of lycanthropy continues to produce an image of a werewolf baring its fangs at a terrified villager on a fog- shrouded moor. The legend was that the

former had been bitten by another werewolf in an unbroken chain that passes on the legacy. But there are now more reasonable explanations for this type of behavior. One explanation is that some people afflicted with lycan- thropy actually suffer from congenital generalized hypertrichosis, an extremely rare disease marked by excessive amounts of hair on the face and upper body (Kemp, 2000; Mough, 1995). Others may suffer from porphyria, an inherited blood disease whose victims sprout extra facial hair and are sensitive to sunlight (Osterweil, 2003). Still another current explanation ties lycanthropy to a disturbance in the activity of the temporal lobe of the brain, which is close to areas of the brain that may be responsible for visual hallucinations.

Despite these rational explanations, be- liefs in werewolves as supernatural beings are likely to continue for the foreseeable fu- ture. Tales of demonic possession are more alluring than histories of congenital disease or temporal lobe abnormalities. Nor are publishers or movie producers likely to

say good-bye to such good friends. Old explanations of lycanthropy may be flawed scientifically, but the profits they produce are far from a delusion.

Schizophrenia :ill 369

the D-2 receptors, may be transmitted too easily or too often. This theory is appealing because certain dopamine neurons are known to play a key role in guiding attention (Sikstrom & Soderlund, 2007). People whose attention is severely disturbed by exces- sive dopamine activity might well be expected to suffer from the problems of attention, perception, and thought found in schizophrenia.

Though enlightening, the dopamine hypothesis has certain problems. The greatest challenge to it has come with the discovery of a new group of antipsychotic drugs, referred to as atypical antipsychotic drugs, which are often more effective than the traditional ones. The new drugs bind not only to D-2 dopamine receptors, like the traditional antipsychotic drugs, but also to many D-1 receptors and to receptors for other neurotransmitters such as serotonin (Goldman-Rakic et al., 2004). Thus, it may be that schizophrenia is related to abnormal activity or interactions of both dopamine and serotonin and perhaps other neurotransmitters as well, rather than to abnormal dopa- mine activity alone (Bach, 2007).

Abnormal Brain Structure During the past decade, researchers also have linked schizophrenia, particularly cases dominated by negative symptoms, to abnormalities in brain structure (Eyler, 2008;Weyandt, 2006). Using brain scans, they have found, for ex- ample, that many people with schizophrenia have enlarged ventricles— the brain cavities that contain cerebrospinal fluid (Cahn et al., 2002; Lieberman et al., 2001). In addition to displaying more negative symptoms and fewer positive ones, patients who have enlarged ventricles tend to experience a poorer social adjustment prior to the disorder and greater cognitive disturbances (Bornstein et a1.,1992).

It may be that enlarged ventricles are actually a sign that nearby parts of the brain have not developed properly or have been damaged, and perhaps these problems are the ones that help produce schizophrenia. In fact, studies suggest that some patients with the disorder also have smaller temporal lobes and frontal lobes than other people, smaller amounts of cortical gray matter, and, perhaps most important, abnormal blood flow— either reduced or heightened—in certain areas of the brain (Tamminga et al., 2008; Higgins & George, 2007). Still other studies have linked schizophrenia to structural abnormalities of the hippocampus, amygdala, and thalamus (see Figure 12-3).

Viral Problems What might cause the biochemical and structural abnormalities found in schizophrenia? Various studies have pointed to genetic factors, poor nutrition, fetal development, birth complications, immune reactions, and toxins (Mum & Cannon, 2008; Bach, 2007). In addition, some investigators suggest that the brain abnormalities may result from exposure to viruses before birth. Perhaps the viruses enter the fetus's brain and interrupt proper brain development, or perhaps the viruses remain quiet until puberty or young adulthood, when, activated by changes in hormones or by another viral infection, they help to bring about schizophrenic symptoms (Lambert & Kinsley, 2005;Torrey, 2001, 1991).

Some of the evidence for the viral theory comes from animal investigations, and other evidence is circumstantial, such as the finding that an unusually large number of people with schizo- phrenia are born during the winter. The winter birth rate among people with schizophrenia is 5 to 8 percent higher than among other persons (Tamminga et al., 2008).This could be because of an increase in fetal or infant exposure to viruses at that time of year. More direct evidence comes from studies showing that mothers of individuals with schizophrenia were more likely to have been ex- posed to the influenza virus during pregnancy than were mothers of people without schizophrenia (Brown et al., 2004; Limosin et al., 2003). And, finally, studies have found antibodies to certain viruses in the blood of 40 percent of research participants with schizo- phrenia (Leweke et al., 2004; Torrey et al., 1994). The presence of

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370 . //CHAPTER 12

such antibodies suggests that these people had at some time been exposed to those particular viruses.

Together, the biochemical, brain structure, and viral findings are shed- ding much light on the mysteries of schizophrenia. At the same time, it is important to recognize that many people who display these biological abnormalities never develop schizophrenia.Why not? Possibly, as you read earlier, because biological factors merely set the stage for schizophrenia, while key psychological and sociocultural factors must be present for the disorder to appear.

Psychological Views When schizophrenia investigators began to identify genetic and biologi- cal factors during the 1950s and 1960s, many clinicians abandoned the psychological theories of the disorder. During the past decade, however, the tables have been turned and psychological factors are once again being considered as important pieces of the schizophrenia puzzle. The leading

psychological theories come from the psychodynamic and cognitive perspectives.

The Psychodynarnic Explanation Freud (1924, 1915, 1914) believed that schizophrenia develops from two psychological processes: (1) regression to a pre-ego stage and (2) efforts to reestablish ego control. He proposed that when their world is extremely harsh or withholding—for example, when parents are cold or unnurturing—people who develop schizophrenia regress to the earliest point in their development, to the pre-ego state ofprimary narcissism, in which they recognize and meet only their own needs.Their near-total regression leads to self-centered symptoms such as neologisms, loose associa- tions, and delusions of grandeur. Once people regress to such an infantile state, Freud continued, they then try to reestablish ego control and contact with reality.Their efforts give rise to yet other schizophrenic symptoms.Auditory hallucinations, for example, may be an individual's attempt to substitute for a lost sense of reality.

Years later, noted psychodynamic clinician Frieda Fromm-R.eichmann (1948) elab- orated on Freud's notion that cold or unnurturing parents may set schizophrenia in motion. She described the mothers of people who develop this disorder as cold, domi- neering, and uninterested in their children's needs. According to Fromni-Reichmann, these mothers may appear to be self-sacrificing but are actually using their children to meet their own needs. At once overprotective and rejecting, they confuse their children and set the stage for schizophrenic functioning. She called them schizophrenogenic (schizophrenia-causing) mothers.

Fromm-Reichrnann's theory, like Freud's, has received little research support (Willick, 2001). The majority of people with schizophrenia do not appear to have mothers who fit the schizophrenogenic description. Most of today's psychodynamic theorists have, in fact, rejected the views of Freud and Fromm-Reichmann. Although the theorists may retain some of the early notions (Karon, 2008; Spielrein, 1995), more and more of them believe that biological abnormalities leave certain persons particularly prone to extreme regression or other unconscious acts that may contribute to schizophrenia (Berzoff, Flanagan, & Hertz, 2008).

The Cognitive Explanation A leading cognitive explanation of schizophrenia agrees with the biological view that during hallucinations and related perceptual diffi- culties the brains of people with schizophrenia are actually producing strange and unreal sensations—sensations triggered by biological factors.According to the cognitive expla- nation, however, further features of the disorder emerge when the individuals attempt to understand their unusual experiences (Tarrier, 2008;Waters et al., 2007). When first confronted by voices or other troubling sensations, these people turn to friends and rela- tives. 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 (Perez-

Sthizophrenia :ft 371

Alvarez et al., 2008; Bach, 2007). In short, according to this theory, people with schizo- phrenia 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 of them have hallucinations, for example, and most have trouble keeping their attention focused. But researchers have yet to provide clear, direct support for the cognitive notion that misinterpretations of such sensory problems actually produce a syndrome of schizophrenia.

Sociocultural Views Sociocultural theorists, recognizing that people with mental disorders are subject to a wide range of social and cultural forces, claim that multicultural factors, social labeling, and family dysfunctioning all contribute to schizophrenia. At the same time, research has yet to clarify what the precise causal relationships might be.

Muiticult r l Factors Rates of schizophrenia appear to differ between racial and ethnic groups, particularly between African Americans and white Americans. As many as 2.1 percent ofAfrican Americans receive a diagnosis of schizophrenia, compared with 1.4 percent of white Americans (Lawson, 2008; Folsom et al., 2006). Similarly, studies suggest that African Americans with schizophrenia are overrepresented in state hospitals (Lawson, 2008; 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 (Lawson, 2008; Barnes, 2004).

It is not clear why African Americans have a higher likelihood than white Americans of receiving this diagnosis. One possibility is that African Americans are more prone to develop the disorder. Another possibility is that clinicians from majority groups are unintentionally biased in their diagnoses of African Americans or misread cultural dif- ferences as symptoms of schizophrenia (Lawson, 2008; Barnes, 2004).

Yet another explanation for the difference between African Americans and white Americans may lie in the economic sphere. On average, African Americans are more likely than white Americans to be poor, and, indeed, 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 Ameri- cans, who are, on average, also economically disadvantaged, also appear to have a higher likelihood of receiving a diagnosis of schizophrenia than white Americans, although their diagnostic rate is not as high as that of African Americans (Blow et al., 2004).

It also appears that schizophrenia differs from country to country in key ways. Al- though 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. Accord- ing to a 10-country study conducted by the World Health Organization (WHO), the 25 million schizophrenic patients who live in developing countries have better recovery rates than schizophrenic patients in Western and other developed countries (Vahia & Vahia, 2008; Jablensky, 2000). During a two-year observation period, the schizophrenic patients from developing countries were more likely than those in devel- oped countries to recover from their disorder and less likely to experience continuous symptoms, be socially impaired, re- quire heavy antipsychotic drugs, or require hospitalization.

Some clinical theorists believe that the psychosocial en- vironments of developing countries tend to be more sup- portive and therapeutic than those of developed countries, leading to more favorable outcomes for people with schizo- phrenia (Vahia & Vahia, 2008; Jablensky, 2000). Developing countries, for example, seem to provide more family and social support to people with schizophrenia, make available more relatives and friends to help care for the individuals, and

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act less judgmental and critical toward persons with schizophrenia. The Nigerian culture, for example, is generally more tolerant of the presence of voices than are Western cultures (Matsumoto & Juang, 2008).

Social Labeling Many sociocultural theorists believe that the features of schizophrenia are influenced by the diagnosis itself (Modrow, 1992). In their opin- ion, 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 leads to 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. They also reported that staff members 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 investigation demonstrates that the label "schizophrenic" can itself have a negative effect not just on how people are viewed but on how they themselves feel and behave.

Family Dysfunctioning Many studies suggest that schizophrenia, like a number of other mental disorders, is often linked to family stress (Boye et al., 2002; Schiffinan et al., 2002, 2001). Parents of people with this disorder often (1) display more conflict, (2) have greater difficulty communicating with one another, and (3) are more critical of and overinvolved with their children than other parents.

Family theorists have long recognized that certain 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. Individuals 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 (Ritsner & Gibel, 2007; Nomura et al., 2005). Do such findings mean that family dysfunctioning helps cause and maintain schizophrenia? Not necessarily. It is also the case that indi- viduals with schizophrenia greatly disrupt family life. In so doing, they themselves may help produce the family problems that clinicians and researchers continue to observe (Barrowclough & Lobban, 2008).

Although the sociocultural causes of schizophrenia, like the psychological causes, have yet to be fully understood, many clinicians currently believe that such factors play an important role in the disorder. As we have seen, most hold a diathesis-stress view of schizophrenia, believing that biological factors set up a predisposition to the disorder, but that certain kinds of personal, family, or social stress are needed for the syndrome to spring to life.

How Do Theorists Explain Schizophrenia?

The biological explanations of schizophrenia point to genetic, biochemical, brain

structure, and viral factors. The leading biochemical explanation holds that the brains of people with schizophrenia experience excessive dopamine activity. Brain- imaging techniques have also detected abnormal brain structures in many people

with schizophrenia, including enlarged ventricles and abnormal blood flow in

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Schizophrenia :1/ 373

certain parts of the brain. Finally, some researchers believe that schizophrenia is related to a virus that settles in the fetus and perhaps lies quiet until adolescence or young adulthood.

The leading psychological explanations for schizophrenia come from the psy- chodynamic and cognitive models. In influential psychodynamic explanations, Freud held that schizophrenia involves regression to a state of primary narcissism and Fromm-Reichmann proposed that schizophrenogenic mothers help produce this disorder. Today's psychodynamic theorists believe, however, that the disorder is caused by a combination of biological and psychodynamic factors. Cognitive theorists hold that when people with schizophrenia try to understand their strange biological sensations, they develop delusional thinking.

One sociocultural explanation holds that multicultural differences may influence the rate and character of schizophrenia, as well as recovery from this disorder. An- other sociocultural explanation argues that society expects persons who are labeled as having schizophrenia to behave in certain ways and that these expectations actually lead to further symptoms. Still other sociocultural theorists point to family dysfunctioning as a cause of schizophrenia.

Most clinical theorists now agree that schizophrenia can probably be traced to a combination of biological, psychological, and sociocultural factors. However, the biological factors have been more precisely identified.

JziM-low Are Schizophrenia and Other Severe Mental Disorders Treated?

They call us insane—and in reality they are as inconsistent as we are, as flighty and changeable. This one in particular. One day he derides and ridicules me unmercifully; the next he talks to me sadly and this morning his eyes misted over with tears as he told me of the fate ahead. Damn him and all of his wisdom!

He has dinned into my ears a monotonous dirge—"Too Egotistical—too Egotistical— too Egotistical. Learn to think differently. "—And how can I do it? How—how—can 1 do it? How the hell can I do it? I have tried to follow his suggestions but have not learned to think a bit differently. It was all wasted effort. Where has it got me?

(Jefferson, 1948)

With these words, Lara Jefferson, a young woman with schizophrenia, described her treatment experience in the 1940s. Her pain and frustration were typical of those expe- rienced by hundreds of thousands of similar patients during that period of time. In fact, for much of human history, persons with schizophrenia were considered beyond help.The disorder is still extremely difficult to treat, but clinicians are much more successful today than they were in the past (Roe & Davidson, 2008). Much of the credit goes to antipsychotic drugs, medica- tions that help many people with schizophrenia think clearly and profit from therapies that previously would have had little effect on them.

To better convey the plight of people with schizophrenia, this chapter will proceed 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 schizo- phrenia, it is important to keep in mind that the label "schizophrenia" was assigned to most people with psychotic symptoms throughout the twenti- eth century. Clinical theorists now realize, however, that a number of people

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with psychotic symptoms are in fact displaying a severe form of bipolar disorder or major depressive disorder and that many such individuals were in past times inaccurately given a diagnosis of schizophrenia. Thus, our discussions of past treatments for schizo- phrenia, particularly the failures of institutional care, are as applicable to those other severe mental disorders as they are to schizophrenia. Indeed, any disorder that includes psychotic features presents formidable obstacles to treatment, and so even some of our

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Hypochondriacs no longer thought they were going to die, would-be suicides found life acceptable, sufferers from persecution complex forgot the machinations of imaginary conspirators. Prefrontal lobotomy, as the operation is called, was made possible by the localization of fears, hates, and instincts lin the prefrontal cortex of the brain]. It is fitting, then, that the Nobel Prize in medicine should be shored by Hess and Moniz. Surgeons now think no more of operations on the brain than they do of removing an appendix.

We now know that the lobotomy was hardly a miracle treatment. Far from "cur- ing" people with mental disorders, the procedure left thousands upon thousands extremely withdrawn, subdued, and even stuporous. The first lobotomy was per- formed by Portuguese neuropsychiatrist Egas Moniz in 1935 (Tierney, 2000). His particular procedure, called a prefrontal leukotomy, 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 could be changed by cutting the nerve pathways that carried such thoughts from one part of the brain to another. In the 1940s Walter Freeman and his surgi- cal partner, James Watts, developed a second kind of psychosurgery 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.

Altogether, an estimated 50,000 peo- ple in the United States alone received lobotomies (Johnson, 2005). Why was the procedure so enthusiastically accepted by the medical community in the 1940s and 1950s? Neuroscientist Elliot Valenstein

(1986) points first to the extreme over- crowding in mental hospitals at the time. This crowding was making it difficult to maintain decent standards in the hospitals. Valenstein also points to the personali- ties of the inventors of the procedure as important factors. Although these indi- viduals were gifted and dedicated physi- cians, Valenstein also believes that their professional ambitions led them to move too quickly and boldly in applying the procedure. Indeed, in 1949 Moniz was awarded the Nobel Prize for his work.

The prestige of Moniz and Freeman was so great and the field of neurology was so small that their procedures drew little criticism. 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 (Swayze, 1995; Valenstein, 1986).

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 coordi- nation, partial paralysis, incontinence, endocrine malfunctions, and very poor intellectual and emotional responsiveness. Finally, the discovery of effective antipsy- chotic drugs put an end to this inhumane treatment for mental disorders (Mashour et al., 2005).

Today's psychosurgical procedures are greatly refined and hardly resemble the lobotomies of 50 years back. Moreover, such procedures are considered experimen- tal and are used only as a last resort in the most severe cases of obsessive-compulsive disorder and depression (McNeely et al., 2008; Anderson & Booker, 2006). Even so, many professionals believe that any kind of surgery that destroys brain tissue is inappropriate and perhaps unethical and that it keeps alive one of the clinical field's most shameful and ill-advised efforts at cure.

Lobotomy: How Could It Happen?

In 1949 a New York Times article I reported on a medical procedure

that appeared to offer hope to sufferers of severe mental disorders:

Schizophrenia :1/ 375

discussions about current approaches to schizophrenia, such as the community mental health movement, apply to other severe mental disorders as well.

Institutional Care in the Past For more than half of the twentieth century, most people diagnosed with schizophrenia were institutionalized in a public mental hospital. Because patients with this disorder failed to respond to traditional therapies, the primary goals of these establishments 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 Bicetre asylum and began the practice of "moral treatment." For the first time in centuries, patients with severe disturbances were viewed as human beings who should be cared for with sympathy and kindness.As Pinel's ideas spread throughout Europe and the United States, they led to the creation of large mental hospitals rather than asylums to care for those with severe mental disorders (Goshen, 1967).

These new mental hospitals, typically located in isolated areas where land and labor were cheap, were meant to protect patients from the stresses of daily life and offer them a healthful psychological environment in which they could work closely with thera- pists (Grob, 1966). States throughout the United States were even required by law to establish public mental institutions, state hospitals, for patients who could not afford private ones.

Eventually, however, the state hospital system encountered serious problems. Be- tween 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 em- phasis shifted from giving humanitarian care to keeping order. In a throwback to the asylum period, difficult patients were restrained, isolated, and punished; individual atten- tion 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 (Hafner & an der Heiden, 1988). The back wards were in fact 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.

ostate huspitaisoPublic mental hos- pitals in the United States, run by the individual states.

therapy®A humanistic approach to institutional treatment based on the belief that institutions can help patients recover by creating a climate that promotes self-respect, responsible behavior, and meaningful activity.

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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 pa- tients, problem areas that had been worsened by institutionalization. The approaches were soon adopted by many institutions and are now standard features of institutional care.

Milieu Therapy In 1953, Maxwell Jones, a London psychiatrist, converted a ward ofpatients with various psychological disorders into a therapeutic community, the first application of milieu therapy in a hospital setting.The principle behind milieu therapy is that institu- tions can help individuals by creating a social climate, or milieu, that builds productive activity, self-respect, and a sense of responsibility. In

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°token economy programeA behav- ioral 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.

oneuroleptic drugseConventional antipsychotic drugs, so called because they often produce undesired effects similar to the symptoms of neurological disorders.

376 :Ai/CHAPTER 12

such settings, patients are often given the right to run their own lives and make their own decisions. They may take part in community government, working with staff members to set up rules and decide penalties. The atmosphere is one of mutual respect, support, and openness. Patients may also take on special projects, obs, and recreational activities. In short, their daily schedule is designed to resemble life outside the hospital.

Since Jones's pioneering effort, milieu-style programs have been set up in institu- tions 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 staff, to keep patients active, and to raise patients' expectations of what they can accomplish.

Research over the years has shown that patients with severe mental disorders in milieu hospital programs often improve and that they leave the hospital at higher rates than patients in programs offering primarily custodial care (Paul, 2000; Paul & Lentz, 1977). Many of these persons remain impaired, however, and must live in sheltered set- tings after their release. Despite its limitations, milieu therapy continues to be practiced in many institutions, often combined with other hospital approaches (Gunter, 2005). Moreover, you will see later in this chapter that many of today's halfway houses and other community programs for individuals with severe mental disorders are run in ac- cordance with the principles of milieu therapy.

The Token Economy In the 1950s, behaviorists discovered that the systematic appli- cation of operant conditioning techniques on hospital wards could help change the be- haviors of patients with schizophrenia and other severe mental disorders (Ayllon, 1963; Ayllon & Michael, 1959). Programs that applied these techniques were called token economy programs.

In token economies patients are rewarded when they behave acceptably and are not rewarded when they behave unacceptably.The immediate rewards for acceptable behav- ior are often tokens that can later be exchanged for food, cigarettes, hospital privileges, and other desirable items, thus creating a "token economy"Acceptable behaviors likely to be targeted include 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 (Combs et al., 2008; Dickerson et al., 2005). In one early program, Gordon Paul and Robert Lentz (1977) set up a hospital token economy for 28 patients diag- nosed with long-term schizophrenia, most of whom improved greatly. After four and a half years, 98 percent of the patients had been released, mostly to sheltered-care facilities, compared with 71 percent of patients treated in a milieu program and 45 percent of patients who received custodial care only.

Despite the effectiveness of token economies, some clinicians have questioned the quality of the improvements made under such programs. Are behaviorists 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 (Coiner, 1973). Whenever he spoke, he spoke as the government. "We are happy to see you....We need people like you in our service. . . . We are carrying out our activities in John's body." When John's hospital ward was made into a token economy, the staff members targeted his delusional statements and required him to identify himself properly to earn tokens. After a few months on the token economy program, ohn stopped referring to himself as the government.When asked his name, he would say,"John."Although staff members were 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?"

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Today, we were desperate for a smoke and went to Simpson, the damn nurse, and she made us do her bidding. "Tel/ 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 ciga- rettes. 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)

Critics of the behavioral approach would argue that John was still delusional and therefore as psychotic as before. Behaviorists, however, would argue that at the very least, John's judgment about the effects of his behavior had improved.

Token economy programs are no longer as popular as they once were, but they are still used in many mental hospitals, usually along with medication, and in many commu- nity residences as well (Kopelowicz et al., 2008). The approach has also been applied to other clinical problems, including mental retardation, delinquency, and hyperactivity, as well as in other fields, such as education and business (Spiegler & Guevremont, 2003).

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 this disorder. These drugs eliminate many of its symptoms and today are almost always a part of treatment.

As we have observed, the discovery of antipsychotic medications dates back to the 1940s, when researchers were developing 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. Laborit suspected that the drugs might also have a calming effect on persons with severe psychological disorders. One of the phenothiazines, chlorpromazine, was eventually tested on six patients with psychotic symptoms and found to reduce their symptoms sharply. In 1954, chlorpromazine was approved for sale in the United States as an antipsychotic drug under the trade name Thorazine.

Since the discovery of the phenothiazines, other kinds of antipsychotic drugs have been developed. The ones developed throughout the 1960s, 1970s, and 1980s are now referred to as "conventional" antipsychotic drugs in order to distinguish them from the "atypical" antipsychotics (also called "second generation" antipsychotic drugs) that have been developed in recent years.The conventional drugs are also known as neuroleptic drugs because they often produce undesired movement effects similar to the symptoms of neurological diseases. As you saw earlier, the conventional drugs reduce psychotic symptoms at least in part by blocking excessive activity of the neurotransmitter dopamine, particularly at the brain's dopamine D-2 receptors (Combs et al., 2008; Julien, 2008).

How Effective Are Antipsychotic Drugs? Re- search repeatedly has shown that antipsychotic drugs reduce symptoms in at least 65 percent of patients di- agnosed with schizophrenia ( Julien, 2008). 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 (May,Tuma, & Dixon, 1981; May & Tuma, 1964). In most cases, the drugs produce the maximum level of improvement within the first six months of treatment (Kutscher,

378 ://CHAPTER 12

oextrapyramidal effectse Unwanted movements, such as severe shaking, bizarre-looking grimaces, twisting of the body, and extreme restlessness, sometimes produced by conventional antipsychotic drugs.

otardive dyskinesia.Extrapyramidal effects that appear in some patients after they have taken conventional antipsy- chotic drugs for an extended time.

2008); however, symptoms may return if patients stop taking the drugs too soon (Saba et al., 2007). The antipsychotic drugs, particularly the conventional ones, reduce the positive symptoms of schizophrenia, such as hallucinations and delusions, more com- pletely, or at least more quickly, than the negative symptoms, such as flat affect, poverty of speech, and loss of volition (Combs et al., 2008; Julien, 2008).

Although antipsychotic drugs are now widely accepted, patients often dislike the powerful effects of the drugs—both intended and unintended—and some refuse to take them (Saba et at., 2007; Gilmer et al., 2004). But like this man, many are greatly helped by the medications.

In my case it was necessary to come to terms with a specified drug program. 1 am a legal- ized addict. My dose: 100 milligrams or Thorazine and 60 milligrams of Stelazine daily. don't feel this dope at all, but 1 have been told it is strong enough to flatten a normal per- son. It keeps me—as the doctors agree—sane and in good spirits. Without the brain candy, as f call it, I would go—zoom—right back into the bin. I've made the institution scene enough already to be familiar with what it's like and to know! don't want to go back.

(Snow, 1976)

s you saw in Chapter 7, depressed

African Americans in the United

States are less likely than depressed

white Americans to be prescribed second-

generation antidepressant drugs, the

newer antidepressants that have fewer

side effects than tricyclics and MAO in-

hibitors (see page 202). Unfortunately, a

similar pattern appears to be at work in

cases of schizophrenia when people are

prescribed atypical antipsychotic medica- tions, the second-generation antipsychotic medications that are often more effective

and have fewer undesired effects than con-

ventional antipsychotic medications. The

following racial prescription patterns have

emerged in several studies:

African Americans and Hispanic Americans with schizophrenia and other psychotic disorders are signifi-

cantly less likely than white Americans to be prescribed atypical antipsychotic drugs (Herbeck et al., 2004; Covell

et al., 2002).

African Americans and Hispanic Americans with schizophrenia are much more likely than white Ameri- cans to be prescribed conventional antipsychotic drugs (Herbeck et al., 2004; Covell et al., 2002).

In turn, African American and His- panic American patients are less likely to be helped by their antipsychotic medications and more likely to experi- ence tardive dyskinesia and extrapy-

ramidal effects in response to their medications for schizophrenia.

One reason for this racial disparity

may be economic. On average, Afri- can American and Hispanic American patients are less likely than white Americans to have private health insur- ance or any health insurance at all (Ni & Cohen, 2004). Schizophrenic patients without private insurance are more likely to be prescribed con-

ventional antipsychotic medications, which are much cheaper than atypical

antipsychotics (Herbeck et al., 2004).

Another explanation for this racial disparity points to the kind of practitio-

ners seen by patients. In general, Afri- can American and Hispanic American patients with severe mental disorders are more likely to have a family physi- cian rather than a psychiatrist pre- scribe their psychotropic drugs (Mark et al., 2002; Pingitore et al., 2001). It turns out that many family physi- cians are more inclined to prescribe conventional antipsychotic drugs than atypical antipsychotic drugs (Mark et

al., 2003, 2002).

First Dibs on Atypical Antipsychotic Drugs?

Schizophrenia :1/ 379

The Unw. nted Effects of Conventional Antipsychotic Drugs In addition to reducing psychotic symptoms, the conventional antipsychotic drugs sometimes produce disturbing movement problems ( Julien, 2008). 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.

The most common extrapyramidal effects are Parleinsonian symptoms, reactions that closely resemble the features of the neurological disorder Parkinson's disease. At least half of patients on conventional antipsychotic drugs experience muscle tremors and muscle rigidity at some point in their treatment; they may shake, move slowly, shuffle their feet, and show little facial expression (Combs et al., 2008). Some also display bizarre movements of the face, neck, tongue, and back, and a number experience great restless- ness and discomfort in the limbs.

Whereas most undesired 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 conven- tional antipsychotic drugs for more than a year.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 10 percent of the people who take the conventional drugs for an extended time develop tardive dyskinesia to some degree, and the longer the drugs are taken, the greater the risk becomes ( Julien, 2008; APA, 2000). Patients over 50 years of age seem to be at greater risk. Tardive dyskinesia can be dif- ficult, sometimes impossible, to eliminate (Combs et al., 2008). The longer patients are on the conventional antipsychotic drugs, the less likely it is that their tardive dyskinesia will disappear, even when the drugs are stopped ( Julien, 2008).

Today clinicians are more knowledgeable and more cautious about prescribing conventional antipsychotic drugs than they were in the past. Previously, when patients did not improve with such a drug, their clinicians would keep increasing the dose (Kane, 1992); today a clinician will typically stop the drug. Similarly, today's clini- cians try to prescribe the lowest effective dose for each patient and to gradually reduce or even stop medication weeks or months after the patient begins functioning normally (Addington Sc Addington, 2008; Kutscher, 2008).

New Antipsychotic Drugs As we saw earlier, "atypical" anti- psychotic drugs have been developed in recent years (see Table 12-3). The most effective and widely used of these new drugs are clozapine (trade name Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). As you have read, the drugs are called atypical because their biological operation differs from that of the conventional antipsychotic medica- tions:The atypicals are received at fewer dopamine D-2 receptors and snore D-1,D -4, and serotonin receptors than the others ( Julien, 2008).

In fact, atypical antipsychotic drugs appear to be more effective than the conventional drugs, helping as many as 85 percent of persons with schizophrenia, compared with the 65 percent helped by most of the conventional drugs ( Julien, 2008). Unlike the conventional drugs, the new drugs reduce not only the positive symptoms of schizophre- nia, but also the negative ones (Combs et al., 2008). Another major benefit of the atypical antipsychotic drugs is that they cause fewer extrapyramidal symptoms and do not seem to produce tardive dyski- nesia, although some of them produce significant undesired effects of their own (Edlinger et al., 2009; Dolder, 2008). Given such advantages,

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Trade Name

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Vesprin

Mellaril

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Stelazine

Prolixin, Permitil

Trilafon

Tindal

Taractan

Navane

Haldol

Loxitane

Mohan, Lidone

Orap

Antipsychotic Drugs

Class/Generic Name

Conventional antipsychotics

Chlorpromazine

Triflupromazine

Thioridazine

Mesoridazine

Trifluoperazine

Fluphenazine

Perphenazine

Acetophenazine

Chlorprothixene

Thiothixene

Haloperidol

Loxapine

Molindone hydrochloride

Pimozide

Atypical antipsychotics Risperidone

Clozapine

Olanzapine

Quetiapine

Ziprasidone

Aripiprazole

Risperdal

Clozaril

Zyprexa

Serociuel

Geodon

Abirify

380 :// CHAPTER 12

it is not surprising that over half of all medicated patients with schizophrenia now take the atypical drugs and that these drugs are considered the first line of treatment for the disorder (Combs et al., 2008; Sajatovic et al., 2008). Moreover, many patients with bi- polar or other severe mental disorders also seem to be helped by several of the atypical antipsychotic drugs ( Julien, 2008).

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 (Kopelowicz et al., 2008). By helping to relieve thought and perceptual disturbances, antipsychotic drugs allow people with schizophrenia to learn about their disorder, participate actively in therapy, think more clearly, and make changes in their behavior (Rosenberg & Mueser, 2008; Beck et al., 2009). The most helpful forms of psychotherapy include

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Can You Live with the Voices in Your Head? BY DANIEL B. SMITH, NEW YORK INES, MARCH 25, 2007

,ngelo, a London-born scientist in his early 30s ... vividly recalls the day he began to hear voices. It was Jan. 7,

2001, and he had recently passed his Ph.D. oral exams in chem- istry at an American university. . . . Angelo was walking home from the laboratory when, all of a sudden, he heard two voices in his head. "It was like hearing thoughts in my mind that were not mine," he explained recently. "They identified themselves as Andrew and Oliver, two angels." ... What the angels said, to Angelo's horror, was that in the coming days, he would die of a brain hemorrhage. Terrified, Angela hurried home and locked himself into his apartment. For three long days he waited out his fate, at which time his supervisor drove him to a local hospital, where Angelo was admitted to the psychiatric word. It was his first time under psychiatric care. He had never heard voices be- fore. His diagnosis was schizophrenia with depressive overtones.

Angelo remembers his time at the hospital as the deepening of a nightmare. . . Angelo did not react well to the antipsy- chotic he'd been prescribed. . . . His voices remained strong and disturbing. . . . Several days into his stay, Angelo's parents flew to the United States from London and took him back home.

More than six years later, Angelo still lives at his parents' house. He currently takes a cocktail of antidepressants and antipsychotics, with tolerable side effects. . . . The pills help Angelo to manage his voices, but they have not been able to eradicate them. . . . Despite these setbacks, Angelo. . . is eager to discover new ways to combat his voices. Not long ago, he found one. In November, his psychologist informed him of a local support group for people who hear voices, from which he thought Angelo might benefit. Angelo began to attend the group late last year.

I first met Angelo at a meeting of the group in mid-January. (I was given permission to sit in on the condition that I not divulge the participants' last names.). . . The gathering was small but eclectic. In addition to the group's facilitators—Jo Kutchinsky, an occupational therapist, and Liana Kaiser, a social-work student— five men and women assembled in a circle. . . . Besides Angelo, there was Stewart, . . . Jenny, ... Michelle, . . . and David. .

. . . When Kutchinsky opened the meeting by asking each member to discuss the previous week's experience hearing voices, . . . most of the members spoke of their voices in the way that comedians speak of mothers-in-law: burdensome and irritating, but an inescapable part of life that you might as well learn to deal with. When David's name was called, he lifted his head and discussed his struggle to accept his voices as part of his consciousness. "I've learned over time that my voices can't be rejected," he said. "No matter what I do, they won't go away. I have to find a way to live with them." Jenny discussed how keeping busy quieted her voices; she seemed to have taken a remarkable number of adult-education courses. Michelle ex- pressed her belief that her voices were nothing more exotic than powerfully negative thoughts. "Negative thoughts are universal," she said. "Everyone has them. Everyone. What matters is how you cope with them: that's what counts."

. . . Afterward I pulled [Angelo] aside and asked him what he thought. "It's interesting to hear people's stories," he said. "Before I started coming, I hadn't realized just how long some people have suffered. I've heard voices for six years. Some people have heard them for 15 or 20. . It was comforting, he said, to speak at last with people who understood.

The meeting that I attended in London is one of dozens like it affiliated with a small but influential grass-roots organization known as Hearing Voices Network. . . . H.V.N. groups must

Schizophrenia :1/ 381

cognitive-behavioral therapy and two sociocultural interventions—family therapy and social therapy. Often the various approaches are combined.

Cognitive-Behaviorai Therapy As you read earlier, the cognitive explanation for schizophrenia starts with the premise that people with this disorder do indeed actually hear voices (or experience other kinds of hallucinations) as a result of biologically trig- gered sensations. According to this theory, the journey into schizophrenia takes shape when individuals 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 an- other such notion.These misinterpretations are essentially delusions.

With this view of hallucinations and delusions in mind, an increasing number of clinicians now employ a cognitive-behavioral treatment for schizophrenia that seeks to change how individuals react to their hallucinatory experiences (Morrison, 2008; Tarrier, 2008). The therapists believe that if individuals can be guided to interpret such experiences in a more accurate way, they will not suffer the fear and confusion produced

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"And only you can hear this whistle?"

accept all interpretations of auditory hallucinations as equally valid. If an individual comes to a group claiming that he is hear- ing the voice of the queen of England, and he finds this belief useful, no attempt is made to divest him of it, but rather to figure out what it means to him....

. H.V.N.'s brief „ . can be boiled down to two core posi- tions. The first is that many more people hear voices, and hear many more kinds of voices, than is usually assumed. The second is that auditory hallucination—or "voice-hearing," H.V.N.'s more neutral preference—should be thought of not as a pathological phenomenon in need of eradication but as a meaningful, inter- pretable experience... .

The concept of "coping" is central to H.V.N., based on its be- lief that people feel better not when their voices are extinguished but when the person hearing voices learns to listen to his halluci-

nations without anguish. Jacqui Dillon, the national chairwoman of H.V.N. . .. has heard voices for more than 30 years. . . But she no longer heeds their commands or allows them to bother her.. .

It was just before noon on a mild Friday in January when the . . . hearing-voices group reconvened after a 15-minute cof- fee break. . . . The participants were asked to . . . discuss [how they cope with the voices in their heads]. . . . The coping strate- gies that followed were ... commonsensical lifestyle suggestions geared toward improving one's frame of mind, or sanding down the edges of the experience's effects. Liana chose "Exercise"; Jenny chose "Religious Activities"; David chose "Pamper Your- self." ... The most novel strategy, and the only one that seemed to cause the group's members to perk up, came under the heading of "Mobile Phones." If you have the temptation to yell at your voices in public, one suggestion went, you should do so with a phone to your ear. That way you can feel free to let loose, and no one who sees you will think you're crazy. Chris in particular seemed to cozy to the suggestion. "I sometimes talk to my voices in public," he said matter-of-factly. "It's very upsetting. I have to bite my knuckles to suppress the urge."

Participants in H.V.N.'s self-help groups take comfort from strategies like these.... As for Angelo, his concern is not to choose one option over another—but only to recover. "I have found the group interesting," Angelo wrote via e-mail three weeks after we met. "It has made me realize that many voice-hearers have had the problem for many yeors, and that many . . . are able to hold down a job despite the voices. I hope to do this myself. Perhaps the right combination of drugs will make this possible."

Copyright © 2007 New York Times. All rights reserved. Used by permission.

by 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. They help clients learn more about the "comings and goings" of their own hallucinations and delusions. The individuals learn, for example, to track which kinds of situations trigger the voices in their heads.

3. The therapists challenge their clients' inaccurate ideas about the power of their hallucinations, such as their notions that the voices are all-powerful, uncontrollable, and must be obeyed.The therapists also have the clients con- duct behavioral experiments to put such notions to the test.What happens, for example, if the clients occasionally resist following the orders from their hallucinatory voices?

4. The therapists teach clients to more accurately interpret their hallucinations. Clients may, for example, adopt alternative conclusions such as, "It's not a real voice, it's my illness."

5. The therapists teach clients techniques for coping with their unpleasant sen- sations (hallucinations).The clients may learn ways to reduce the physical arousal that accompanies hallucinations--applying special breathing and re- laxation techniques, for example. Similarly, they may learn to distract them- selves whenever hallucinations occur (Veiga-Martinez et al., 2008).

These behavioral and cognitive techniques often help schizophrenic individuals gain more control over their hallucinations and reduce their delusional ideas. But they do not eliminate the hallucinations. Can anything be done further to lessen the hallucinations' unpleasant impact? Yes, say new - wave cognitive - behavioral therapists, including practitioners of Acceptance and Commitment Therapy.

As you read in Chapter 2, new-wave cognitive-behavioral therapists believe that the most useful goal of treatment is often to help clients accept their streams of problem- atic thoughts rather than to judge them, act on them, or try to change them (Hayes et al., 2004; Hayes, 2002). The therapists, for example, help highly anxious individuals to become simply mindful of the worries that overrun their thinking and to accept such negative thoughts as but harmless events of the mind (see page 50). 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 un- usual sensations and accepting of them—while the individuals otherwise move forward with the events of their lives (Bach, 2007).

Studies indicate that the various forms of cognitive-behavioral treatment for schizo- phrenia are often very helpful to clients (Morrison, 2008; Tarrier, 2008). Many clients who receive such treatments report feeling less distressed by their hallucinations and

display fewer delusions. Indeed, the individuals are often able to shed the diagnosis of schizophrenia. Rehospitalizations decrease by 50 percent among clients treated with cognitive-behavioral therapy.

Family Ther py Over 50 percent of persons who are recovering from schizophrenia and other severe mental disorders live with their families: parents, siblings, spouses, or children (Barrowclough & Lobban, 2008). Such situations create special pressures; even if family stress was not a factor in the onset of the disorder, a patient's recovery may be influenced greatly by the reactions of his or her relatives at home.

Generally speaking, persons with schizophrenia who feel positively toward their relatives do better in treatment (Camacho et al., 2005). As you saw earlier, recovered patients living with relatives who display high levels of expressed emotion — that is, relatives who are very critical, emotion- ally overinvolved, and hostile-----often have a much higher relapse rate than those living with more supportive relatives (Ritsner & Gibel, 2007; Janicak

382 :// CHAPTER 12

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Schizophrenia :1/ 383

et al., 2001). Moreover, for their part, family members may be upset greatly by the social withdrawal and unusual behaviors of a relative with schizophrenia (Barrowclough & Lobban, 2008).

To address such issues, clinicians now commonly include family therapy in their treatment of schizophrenia, providing family members with guidance, training, practi- cal advice, psychoeducation about the disorder, and emotional support and empathy (Kopelowicz et al., 2008; Smerud & Rosenfarb, 2008). In family therapy, relatives de- velop more realistic expectations and become more tolerant, less guilt-ridden, and more willing to try new patterns of communication. Family therapy also helps the person with schizophrenia cope with the pressures of family life, make better use of family members, and avoid 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 go down (Barrowclough & Lobban, 2008).

The families of persons with schizophrenia and other severe mental disorders may also turn to family support groups and family psychoeducational programs for encouragement and advice (Jewell et al., 2009; Powder, 2004). In such programs, family members meet with others in the same situation to share their thoughts and emotions, provide mutual support, and learn about severe mental dysfunctioning.

Socid Therapy Many clinicians believe that the treatment of people with schizo- phrenia should include techniques that address social and personal difficulties in the clients' lives.These clinicians offer practical advice; work with clients on problem solving, decision making, and social skills; make sure that the clients are taking their medications properly; and may even help them find work, financial assistance, appropriate health care, and proper housing (Ridgway, 2008; Sherrer & O'Hare, 2008). Research finds that this practical, active, and broad approach, called social therapy or personal therapy, does indeed help keep people out of the hospital (Hogarty, 2002).

The Community Approach The broadest approach for the treatment of schizophrenia and other severe mental dis- orders is the community approach. In 1963, partly in response to the terrible conditions in public mental institutions and partly because of the development 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 provided that patients with psychological disorders were to receive a range of mental health services—outpatient therapy, inpatient treatment, emergency care, preventive care, and aftercare—in their communities rather than being transported to institutions far from home. The act was aimed at a variety of psychological disorders, but patients diagnosed with schizophrenia, especially those who had been institutionalized for years, were affected most. Other countries around the world put similar community treatment programs into action shortly thereafter (Wiley-Exley, 2007).

Thus began four 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 only around 60,000 patients reside in those set- tings (Salzer et al., 2006; Torrey, 2001). Clinicians have learned that patients recovering from severe mental disorders can profit greatly from community programs. As you will see, however, the actual quality of community care for these people has often been in- adequate throughout the United States. The result is a "revolving door" syndrome for many patients: They are released to the community, readmitted to an institution within months, released a second time, admitted yet again, and so on, over and over (Sadock & Sadock, 2007; Torrey, 2001).

What Are the Features of Effective Comrnunily Care? People recovering from schizophrenia and other severe mental disorders need medication, psychotherapy, help in handling daily responsibilities, guidance in making decisions, training in social

odeinstitutionalizationoThe discharge of large numbers of patients from long- term institutional care so that they might be treated in community programs.

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skills, residential supervision, and vocational counseling—a combination of services sometimes called assertive community treatment (DeLuca, Moser, & Bond, 2008; Coldwell & Bender, 2007).Those whose communities help them meet these needs make greater progress than those living in other communities. Some of the key features of effective community care programs are (1) coordination of patient services, (2) short-term hos- pitalization, (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 a community mental health center, a treatment facility 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 dis- orders often make significant progress (Rapp & Goscha, 2008). Coordination of services is particularly important for mentally ill chemical abusers (MICAs), patients with psychotic disorders as well as substance-related disorders (Buckley & Meyer, 2009).

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 (Addington & Addington, 2008). If this ap- proach fails, short- term hospitalization that lasts a few weeks (rather than months or years) may be tried (Soliman et al., 2008). Soon after the patients improve, they are released for aftercare, a general term for follow-up care and treatment in the community.

PARTIAL HOSPITALIZATION People's needs may fall between full hospitalization and outpa- tient therapy, and so some communities offer day centers or day hospitals, all-day programs in which patients return to their homes for the night.The day centers provide

patients with daily supervised activities, therapy, and programs to improve social skills. People recovering from severe mental disor- ders in day centers often do better than those who spend extended periods in a hospital or in traditional outpatient therapy (Mayahara & Ito, 2002; Yoshimasu et al., 2002). Another kind of institution that has become popular is the semihospital, or residential crisis center: Semihospitals are houses or other structures in the community that provide 24-hour nursing care for people with severe mental disor- ders (Soliman et al., 2008; Torrey, 2001).

SUPERVISED RESIDENCES Many people do not require hospitalization but, at the same time, are unable to live alone or with their families. Halfway houses, also known as crisis houses or group homes, often serve individuals well (Levy et al., 2005). Such residences may shel- ter between one and two dozen people.The live-in staff usually are paraprofessionals— lay people who receive training and ongoing su- pervision from outside mental health professionals. The houses are usually run with a milieu therapy philosophy that emphasizes mu- tual 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 (Hanson et al., 2002; McGuire, 2000).

OCCUPATIONAL TRAINING Paid employment provides income, inde- pendence, self-respect, and the stimulation of working with others. It also brings companionship and order to one's daily life. For these reasons, occupational training and placement are important services for people with severe mental disorders (Becker, 2008; DeLuca et al., 2008).

Many people recovering from such disorders receive occupa- tional training in a sheltered workshop—a supervised workplace

384 ://CHAPTER 12

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for employees who are not ready for competitive or complicated jobs. For some, the sheltered workshop becomes a permanent workplace. For others, it is an important step toward better-paying and more demanding employment or a return to a previous job (Becker, 2008; Chalamat et al., 2005). In the United States, however, occupational training is not consistently available to people with severe mental disorders (Honberg, 2005; Blyler, 2003).

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 (Lehman et al., 2004; McGuire, 2000). 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 (Wang et al., 2002;Torrey, 2001).Two factors are primarily responsible: poor coordination of services and shortage of services.

POOR COORDINATION OF SERVICES The various mental health agencies in a community often fail to communicate with one another (Leshner et al., 1992). There may be an opening at a nearby halfway house, for example, and the therapist at the community mental health center may not know about it. In addition, even within a community agency a patient may not have continuing contacts with the same staff members and may fail to receive consistent services. Still another problem is poor communication between state hospitals and community mental health centers, particularly at times of hospital discharge (Torrey, 2001).

It is not surprising, then, that a growing number of community therapists have be- come case managers for people with schizophrenia and other severe mental disorders (Rapp & Goscha, 2008; Sherrer & O'Hare, 2008). Like the social therapists described earlier, they offer therapy and advice, teach problem-solving and social skills, ensure that medications are being taken properly, and keep an eye on possible health care needs. In addition, they try to coordinate available community services, guide clients through the community system, and, perhaps most importantly, help protect clients' legal rights. Many professionals now believe that effective case management is the key to success for a community program.

SHORTAGE OF SERVICES The number of community programs—from community mental health centers to halfway houses and sheltered workshops—available to people with severe mental disorders falls woefully short ( Julien, 2008). In addition, the community

°community mental health center° A treatment facility that provides medi- cation, psychotherapy, and emergency care for psychological problems and coordinates treatment in the community.

eaftercarecA program of posthospital- ization care and treatment in the community.

oday center°A program that offers hospital-like treatment during the day only. Also known as a day hospital.

Gila way house°A residence for peo- ple with schizophrenia or other severe problems, often staffed by paraprofes- sionals. Also known as a group home or crisis house.

°sheltered workshop0A supervised workplace for people who are not yet ready for competitive jobs.

case managereA community thera- pist who offers a full range of services for people with schizophrenia or other severe disorders, including therapy, advice, medication, guidance, and pro- tection of patients' rights.

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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 some improvement. The discovery of anti- psychotic 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 of antipsychotic drugs operate

officials continue to press to make it more available. In addition, a number of national in- terest groups have formed in countries around the world that push for better community treatment (Frese, 2008; Archibald, 2007; Torrey, 2001). In the United States, for example, the NationalAiliance on Mental Illness began in 1979 with 300 members and has expanded to around 220,000 members in more than 1,100 chapters (NAMI, 2008). Made up largely of relatives of people with severe mental disorders, this group has become both a source of support for its members and a powerful lobbying force in state legislatures; additionally, it has pressured community mental health centers to treat more persons with schizophrenia and other severe mental disorders.

Today community care is a major feature of treatment for people recovering from severe mental disorders in countries around the world (Wiley-Exley, 2007). Both in the United States and abroad, well-coordinated community treatment is seen as an impor- tant part of the solution to the problem of severe mental dysfunctioning (DeLuca et al., 2008; Rapp & Goscha, 2008).

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by reducing excessive dopamine activity in the brain. These "conventional" anti- psychotic drugs reduce the positive symptoms of schizophrenia more completely, or more quickly, than the negative symptoms.

The conventional antipsychotic drugs can also produce dramatic unwanted effects, particularly movement abnormalities. One such effect, tardive dyskinesia, apparently occurs in more than 10 percent of the people who take conventional antipsychotic drugs for an extended time and can be difficult or impossible to eliminate. Recently, "atypical" antipsychotic drugs have been developed, which seem to be more effective than the conventional drugs and to cause fewer or no extrapyramidal effects.

Today psychotherapy is often used successfully in combination with antipsy- chotic drugs. Helpful forms include cognitive-behavioral therapy, family therapy, and social therapy.

A community approach to the treatment of schizophrenia and other severe mental disorders began in the 1960s, when a policy of deinstitutionalization in the United States brought about a mass exodus of hundreds of thousands of patients from state institutions into the community. Among the key elements of effective community care programs are coordination of patient services by a community mental health center, short-term hospitalization (followed by aftercare), day centers, halfway houses, and occupational training. However, the quality and funding of community care for people with schizophrenia and other severe mental disorders have been inadequate throughout the United States, often resulting in a "revolving door" syndrome. One result is that many people with such disorders are now home- less or in jail.

Schizophrenia :1/ 389

PUTTING IT... together An important Lesson

Schizophrenia—a bizarre and frightening disorder—was studied intensively throughout the twentieth century. Only since the discovery of antipsychotic drugs, however, have clinicians acquired practical insight into its causes. As with most other psychologi- cal disorders, clinical theorists now believe that schizophrenia is probably caused by a combination of factors. At the same time, researchers have been far more successful in identifying the biological influences than the psychological and sociocultural ones. While biological investigations have closed in on specific genes, abnormalities in brain biochemistry and structure, and even viral infections, most of the psychological and sociocultural research has been able to cite only general factors, such as the roles of family conflict and diagnostic labeling. Clearly, researchers must identify psychological and sociocultural factors with greater precision if we are to gain a full understanding of the disorder.

The treatment picture for schizophrenia and other disorders marked by psychosis has also improved in recent decades.After years of frustration and failure, clinicians now have an arsenal of weapons to use against these disorders—medication, institutional programs, psychotherapy, and community programs. It has become very clear that anti- psychotic medications can open the door for recovery, but in most cases other kinds of treatment are also needed to help the recovery process along. The various approaches must be combined in a way that meets each individual's specific needs.

Working with schizophrenia and other severe mental disorders has taught clinicians an important lesson: No matter how compelling the evidence for biological causa- tion may be, a strictly biological approach to the treatment of psychological disorders is a mistake more often than not. Largely on the basis of pharmacological discoveries, hundreds of thousands of patients with schizophrenia and other severe mental disorders

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were released to their communities beginning in the 1960s. Little attention was paid to the psychological and sociocultural needs of these individuals, and many of them have been trapped in their pathology ever since. Clinicians must remember this lesson, espe- cially 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 such indi- viduals show improvement. Certainly the clinical field has advanced considerately since Kraepelin's day, yet it still has far to go. It is unacceptable that the majority of people with this and other severe mental disorders receive few or none of the effective community interventions that have been developed, worse still that tens of thousands have become homeless. It is now up to clinical professionals, along with public officials, to address the needs of all people with schizophrenia and other severe mental disorders.

1. The psychodynamic explanations of

: schizophrenia reflect a long-standing

ce: tradition in the clinical field and in

404 society of pointing to parents as key causes of mental disorders, even in cases where evidence is lacking. Why are parents and family life so likely to be blamed? p. 370

7;1 than white Americans to receive a

.5- diagnosis of schizophrenia and to be hospitalized for the disorder. Some

/•• theorists suggest that bias by diag-

7: nosticians may contribute to these

patterns. How and why specifically might bias produce such race-linked diagnostic and treatment differences? pp. 371 -372

3. Why have more people with schizophrenia than people with other disorders been the victims of mistreatment (lobotomy or dein- stitutionalization, for example)? pp. 373-388

4. Although both cognitive-behavioral therapists and self-help programs such as Hearing Voices Network believe that people who hallucinate

should "accept" the voices that spring forth from their brains, there are differences between the role and meaning that they each assign to hallucinations. What are these differ- ences, and why are they important? pp. 380-382

5. The public often perceives people with schizophrenia as dangerous and violent even though most persons with this disorder are far from dan- gerous. Why does the public hold such a perception, and how can it be changed? pp. 389, 371

_•••• ■•••••••

2. African Americans are more likely

OF. 1 • • .6" n • • p w• • .• 00 000 . :• e. • ,• • • 4,..• • • • • ;* a; • ...A •

\\■ KEY TEPIS/// schizophrenia, p. 357

psychosis, p. 357

positive symptom, p. 360

delusion, p. 360

formal thought disorder, p. 360

loose associations, p. 360

hallucination, p. 361

inappropriate affect, p. 362

negative symptoms, p. 362

alogicr, p. 362

flat affect, p. 362

avolition, p. 362

psychomotor symptom, p. 363 • •, •, * • • • •

catatonia, p. 363

diathesis-stress relationship, p. 364

polygenic disorder, p. 366

dopamine hypothesis, p. 366

Parkinson's disease, p. 366

schizophrenogenic mother, p. 370

expressed emotion, p. 372

milieu therapy, p. 375

token economy program, p. 376

conventional antipsychotic drugs, p. 377

atypical antipsychotic drugs, p. 377

extrapyramidol effects, p. 379

tardive dyskinesia, p. 379 P ....off

social therapy, p. 383

deinstitutionalization, p. 383

assertive community treatment, p. 384

community mental health center, p. 384

mentally ill chemical abuser (MICA), p. 384

aftercare, p. 384

day center, p. 384

halfway house, p. 384

sheltered workshop, p. 384

case manager, p. 385

Schizophrenia 391

0.."

7,2 ...-A,

/A! 7-, 2. What are the positive, negative, A ../..,. and psychomotor symptoms of

/7".",... schizophrenia? pp. 360-363 3. What are the five types of schizo-

es: phrenia identified by DSM-1V-TR? pp. 363-364

40:. 7f. 4. Describe the genetic, biochemical,

Fe. brain structure, and viral explana- tions of schizophrenia, and discuss how they have been supported in

.47.0 research. pp. 364-370

pp. 370-372 6. Describe institutional care for

people with schizophrenia and other severe mental disorders over the course of the twentieth century. How effective are the token econ- omy and milieu treatment programs? pp. 373-377

7. How do antipsychotic drugs oper- ate on the brain, and how effective are they in the treatment of schizo-

phrenia? What are the unwanted effects of these drugs? pp. 377-380

8. What kinds of psychotherapy seem to help people with schizophrenia and other disorders marked by psychosis? pp. 3 8 0-3 83

9. What is deinstitutionalization? What features of community care seem critical for helping people with schizophrenia and other severe mental disorders? pp. 383-385

10. How and why has the community mental health approach been inadequate for people with severe mental disorders? pp. 3 85-3 8 8

74: V/2;70121."; " • ""e5.07” ,-, •

1. What is schizophrenia, and how 5. What are the key features of the prevalent is it? What is its rela- psychodynamic, cognitive, multicul- tion to socioeconomic class and tural, social labeling, and family gender? pp. 357-358 explanations of schizophrenia?

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